Bhutan- carbon negative

Kingdom of bhutan, is a landlocked country in south Asia at the eastern end of the Himalayas.

It is sandwiched between two political giants and rivals India and China.

Since it's small and non controversial, it is often overlooked by the international community. 

But the country of about 750,000 keeps making the world take notice of it again and again.

Bhutan is South Asia's happiest country.

Which is not surprising since its the one country that uses Gross Happiness Index to measure its growth.

But now Bhutan is in the news for different reasons, it became the world's first carbon negative country.

This means the country’s  forests and trees absorb more carbon dioxide each year than it produces.

According to numbers the country emits around 1.5 million tonnes of carbon annually, while its forests absorb over 6 million tonnes.

The achievement is due to  Bhutan's strong environment protection policies.

72% of the country is still forested, and it's constitution guarantees at least 60% will remain that way.

Last June, a team of 100 volunteers  for planting 49,672 trees in just one hour setting a new world record.

Even this march 82,000 households planted a tree to celebrate the birth of Queen's first child.

Bhutan has already shown us a way on how to halt global warming, but are we ready to listen?

Surgery notes- breast diseases

Breast

Cystic swellings of the breast
Inflammatory
Acute bacterial mastitis

Neoplastic
Benign- phylloides tumor
Malignant- Intracystic carcinoma

Non neoplastic
Fibroadenosis
Simple cyst of breast

Retention cyst of breast- galactocele

Others
Tuberculous mastitis
Lymphatic cyst of breast
Hydratid cyst of breast
Haemotoma of breast.

Fibroadenoma

Benign tumor of the breast.
Epithelium in a fibrous stroma.
It is an aberration in the normal breast.

Types
Intracanalicular (less fibrous, deep)
Pericanalicular (nor fibrous, superficial)

1 cm or smaller -normal
1-3 cm - large
More than 3- giant

Clinical features
- peak age 20 yrs
- Usually a single lobe
- Painless
- well defined, capsule
- freely moves throughout the breast (breast mouse) -not in elderly.

Treatment -
Excision- Pericanalicular is by Peri areolar incision
Intracanalicular is by sub mamillar incision.

Complication - breast ca.

Phylloides tumor

Fibroepithelial tumors
Also called cystosarcoma fibroid

Capable of attaining massive sizes.

Types- benign, borderline, malignant.

Clinical features
30-40 yrs age
Rapid growth
Stretched skin
Engorged veins
Bosselated appearance

Diagnosis
Clinical, ultrasound, trucut biopsy

Treatment
Excision
Malignant- mastectomy may be necessary

Difference from carcinoma-

Is not attached to skin or pectorals
Can cause multiple cysts due to necrosis
No nipple retraction
Histology- blanching pattern (leaf like)

Breast abscess

Acute bacterial mastitis
Antibioma
Retro maxillary abscess
Sub areolar  abscess
Tuberculous abscess

Acute bacterial mastitis

Etiology
Lactational mastitis
Cracks or fissures in the nipple

Haematoma-
Bacteria like staphylococci can infect haemotoma, can also proliferate intraductally and clot milk.

Non lactational- anaerobic bacterial causes. Occurs in patients with ductal ectasia and subareolar mastitis.

Other factors- diabetes, HIV.

Clinical features

Stage of cellulitis- Inflamed, tender, tense, warm breast.

Stage of Abscess- fever, chills - cystic swelling develops untreated- rupture- necrosis- ulcer+ discharge.

Signs- fluctuations may be positive.

Treatment-
Stage of cellulitis
Cloxicillin, NSAIDs - ibuprofen

Stage of abscess
Incision and drainage with antibiotic cover, if both breasts are affected- boil the milk and use.
Complication- abscess, necrosis and
Antibioma- when I and C is done without antibiotic cover, it is replaced by fibrous tissue leading to a firm/hard lump, its treated by excision.

Discharge per nipple

Classification
Types of discharge
Serous- fibrocystic disease, duct ectasia.
Milk- lactation, hyper prolactinoma
Blood- duct ectasia, papiloma
Green- duct ectasia
Yellow- abscess

Site
Unilateral- duct ectasia, fibrocystic - bilateral

With mensuration- fibrocystic

With mass- tender- fibrocystic, non tender- carcinoma

Spontaneous discharge- papiloma.

Investigation and management
Ultrasound, mammogram
TSH, prolactin
Examination of discharge.
- rule out carcinoma, antibiotics, core excision.

Galactorrhea

Discharge of milk from nipples other than breast feeding

Physiological Causes- stimulation during sex

Drugs-
Oral contraceptives
Anti hypertensives

Galactocele
-sub areolar retention cyst
- due to accumulation of milk
- blocked lactiniferous ducts by epithelial debris
- rarely undergoes calcification
-treatment -multiple aspirations.
Or lastly excision

gynecomastia

Unphysiological enlargement of male breast
(Physiological- obesity, adolescence)

Causes

M- malignancy
A-anorchism- absence of testis
S-sex chromosomal anomaly klinefelter's
T-tablets- cimentidine, stibesterol
I-idiopathy
A- atrophied testis(polio, liver failure)

Clinical features- enlarged tender breast, unilateral or bilateral
Examination of testis and liver function.

Treatment- lumpectomy or mastectomy with preserved nipples.

Etiology of breast carcinoma
Sex- women (100:1)
Age- above 35
Race- white
Genes- BRCA1, BRCA2
Diet- obesity
Hormones- early puberty late menopause is a risk factors
More the lactational period lesser the risk.
Hormone replacement therapy
Chest wall radiation- multiple cheast wall

Pathogenesis of breast cell ca
Scirrhous carcinoma
60-75 percent.
Fibrous reaction.
Hard lump.
Retraction of nipple.
Fixidity to skin and chest wall.
While necrosis and calcification
Occurs.
Histology- round or polygon cells.
Sometimes causes atrophic infiltrating ca.

Medullary carcinoma breast
15% of the breast ca
Soft to firm, undifferentiated cells, lymphatic infiltration, good prognosis.

Inflammatory ca
Less than 1%,
Lymphatic infiltration is present.
Rapidly growing tumor comes under local advanced breast carcinoma.
During Lactation and pregnancy
Pain, redness and enlargement present,
different from abscess by lack of fever and presence of peau d' orange.
Worst prognosis.

Paget's disease of nipple
Misnomer.
Carcinoma of the ducts
Unilateral, affects elderly women.
Causes fissures, cracks, ulcers in the nipple, sometimes completely destroyed.
Hyperchromatic halo cell (mucopolysacchsrides or Paget's cell is present)

Colloid ca
Production of mucin
Good prognosis.

Clinical classification and grading of breast cell ca.

Clinical features

Investigations

Management

Advanced breast cell carcinoma

Mastectomy.