International Archives of Integrated Medicine

1-4

Authors: Nilesh D. Patel, Rakesh M. Rajat, Rajesh S. Katara

Introduction: Salmonella typhi is widely prevalent in India and it causes endemic and epidemic typhoid fever. Early and proper antibiotic administration is necessary to reduce morbidity, complication and mortality of typhoid. Material and methods: A total of 1006 febrile patients, receiving treatment at Guru Govindsingh Hospital, Jamnagar, were included in this study. 1006 blood culture samples for S. typhi were collected from these patients. Blood cultures were tested for clinical bacteriology, as per standard protocol. Results: 30 blood cultures grew positive for S. typhi with the isolation rate of 2.98%. 60% S. typhi isolates were resistant to chloramphenical, ampicillin, and co-trimoxazole and hence, were multidrug resistant S. typhi. Ciprofloxacin was the most effective drug with 93.33 % sensitivity. Conclusion: Ciprofloxacin remains the drug of choice for treatment of typhoid fever. Unchecked use of ciprofloxacin antibiotic should be rationalized, since selection pressure has now emerged as ciprofloxacin resistance in S. typhi.

10-17

Authors: S. Govindu, B. Gopi Krishna, G. Ravi Prabhu

Background: The National Urban Diabetes Survey in India (2010) has reported an age standardized prevalence of diabetes to be 12.1%. The prevalence of diabetes mellitus is known to vary with lifestyle factors. Aims and objectives: The present study was conducted to find the prevalence of diabetes mellitus among adults and its association with certain life style factors like current smoking, alcohol intake, saturated fat intake and physical exercise. Material and methods: This present study was a cross sectional and analytical study carried out in 900 adults in the age group of 30 years and above during June 2014 to December 2014. A random blood sugar test was conducted among the selected study subjects and the prevalence of diabetes mellitus was estimated using the cut off level of 180 mg%. Those subjects who were already known to be diabetics with or without treatment were also classified as diabetics. The findings were analyzed using Epi-info software 7 version (CDC, Atlanta, USA). Results: The prevalence of diabetes mellitus in the present study was found to be 12.4%. Significantly higher proportion of current smoking was found in diabetics (17.0%) than in non-diabetics (6.1%). Current alcohol intake was significantly higher in diabetics than in non-diabetics (8.0% vs 2.4%); current saturated fat (ghee) intake was similar in diabetics and non-diabetics (5.4% and 5.5% respectively). Paradoxically higher proportion of physical exercise was found in diabetics (15.2%) than in non-diabetics (5.1%). Conclusion: The prevalence of diabetes mellitus showed significant association current smoking and current alcohol intake.

26-29

Authors: Vani Isukapalli, Radhika M

There is a substantial rise in diabetes complicating pregnancies in south Asian countries especially India. Until many decades, insulin eras thought to be the only management option to maintain euglycemia in these cases. But metformin can be a safe and convenient alternative in such cases. In this background we have conducted a study I 40 women with diabetes complicating pregnancies and studied the outcome of the mother and neonate in important parameters. Metformin was found to be a safe, effective and cheap alternative to insulin therapy in pregnant diabetic women.

37-42

Authors: Jignesh Jethva, Pallav Patel, Jaydeep Gadhavi, Hiren Parmar

Background: Fistula-in-ano forms a good majority of treatable benign lesions of the rectum and anal canal. 90% or so of these cases are end results of crypto glandular infections. Despite the easy of diagnosis, establishing a cure is problematic on two accounts. Firstly, many patients tend to let their ailment nag them rather than being subject to examination, mostly owing to the site of this disease. The more important second factor is that a significant percent of these diseases persist or recur when the right modality of surgery is not adopted or when the post-operative care is inadequate. Aim and objectives: To know the usefulness of investigative procedures in early and accurate diagnosis of fistula in ano. To study the efficacy of different modalities of surgical approach with reference to post-operative hospital stay and complications like pain, bleeding and sphincter incontinence and outcome in respect to persistence/ recurrence of fistulae. Material and methods: A total of 25 patients with clinically diagnosed fistula in ano were included in the study. Clinical history was obtained in all the patients. Clinical examination including per rectal examination and proctoscopy was done in all the patients. All the patients were processed by routine investigations, ECG, chest X - ray etc. prior to surgery. Patients were followed up to a period of 1 year. Results: 6 patients i.e. 24% had similar illness out of them two previously operated for fistula with recurrence, and four patients with similar illness and resolved without treatment. In this study, 72% of patients had low level of fistula and another 28% of patients had an internal opening situated above the ano rectal ring. Patients with low level fistula were treated with fistulotomy and fistulectomy and patients with high level fistula were treated with seton placement. In this study 60 % of patients underwent fistulotomy, 12 % of patients fistulectomy and another 28% seton placement. Patients with low level fistula were treated with fistulotomy and fistulectomy and patients with high level fistula were treated with seton placement. Conclusion: Fistula-in-ano is an important, commonest disease due to crypto glandular infection (anal glands) and has a complication of ano rectal abscess. It is curable disease by the treatment of surgery and higher antibiotics, local antibiotics with good post-operative wound management, like sits bath for twice a day without closing the wound.

48-55

Authors: Jignesh Jethva, Jaydeep Gadhavi, Pallav Patel, Hiren Parmar

Background: Hernia is a common surgical problem which requires good surgical skill as well as good knowledge about anatomy and various repair of hernia. Hernia is a protrusion of a viscous of part of viscous through a normal or abnormal opening in the wall of its containing cavity. Inguinal hernioplasty can be done under general anesthesia, spinal/epidural and local anesthesia. The choice of anesthesia depends upon a variety of factors viz patient's acceptance, surgeon’s wishes, safety, feasibility and cost etc. Recently there has been revival in the use of local anesthetic technique for hernioplasty. Aim: To study comparison of local anesthesia v/s spinal anesthesia for per-operative and post-operative outcome measures. Material and methods: We have done comparative study of total 100 patients (50 patients under local anesthesia and 50 patients under spinal anesthesia), with follow up period of 60 days. The present study included male patients of uncomplicated inguinal hernia with ASA grade 1 to 3. Patients were selected without bias of type (Direct/Indirect) and extent. All patients were explained about both the methods of anesthesia for hernioplasty, those who willing for local anesthesia were selected for this group and similarly spinal anesthesia group selected (Total 100, 50 in each group). Results: All patients were explained about both the methods of anesthesia for hernioplasty, those who willing for local anesthesia were selected for this group and similarly spinal anesthesia group selected (Total 100, 50 in each group). In local anesthesia group 7 (14%) patients had intra-operative discomfort in form of pain. 64% of patients of local had mild pain and 38% had moderate pain. None of the patients belonged to serve pain group. In spinal anesthesia, 6% of patient had serve pain, 22% patients had mild pain and 72% patients had moderate degree of pain. Local anesthesia was associated with less post-operative complication, in our study no patient develop complication like nausea, vomiting, urinary retention, or headache. Conclusion: hernioplasty under local anesthesia was an acceptable alternative to spinal anesthesia for hernioplasty especially with regard to operative condition, patient’s surgeon’s satisfaction, post-operative pain relief, complications and cost effectiveness.

63-71

Authors: Ravikumar Edwin, Harish Babu R, Subrahmanyam G, Ramalingam K, Mahaboob V Shaik

Background: Cardiovascular disease/Coronary artery disease (CAD), leading cause of global morbidity and mortality covers any disease of the circulatory system. In-vivo antioxidant nutrients which include vitamin C, trace elements such as Se, Zn and Cu play a crucial role in defending against oxidant damage. Objective: The aim of the present study was to investigate the changes occurring in the levels zinc (Zn), copper (Cu), and Selenium (Se) in coronary artery tissues of patients with CAD. Material and methods: Coronary artery samples collected from these patients during bypass surgery from known CAD patients. These samples were analyzed for Se, Zn, and Cu; results are expressed in terms of wet weight. Normal Healthy serum Se, Zn, and Cu levels were also analyzed to compare with coronary artery samples. Results: The levels of Zn, Cu and Se in patient’s coronary artery samples were observed to be very low when compare to Zn, Cu and Se levels of healthy person’s serum samples. In addition, our study showed that the levels of Zn and Cu in coronary artery samples were low when they compared to heart tissue Zn and Cu levels from CVD patients from other studies. Whereas, Se levels in coronary artery samples in our study are same as heart tissues samples in previous other studies. Yet, there was limited/no observational studies were published to identify levels of trace element levels in coronary artery samples. Hence our present observations interpreted the levels of Zn, Cu and Se in coronary artery samples with 20 numbers of sample size only; further, higher number of samples needed to formulate the standard reference ranges of these trace elements in setting up a newer biochemical marker in correlation/interpretation of CVD/CAD. Conclusion: The finding of our results showed that Se levels in coronary artery observed to be same as heart tissue levels from other study. The myocardial clinical manifestation seems to be due to alteration of levels of these trace elements in serum, tissue levels in patients. In our studies, however, the patients with coronary heart disease had, in general, lower concentrations of Zinc, copper in serum than the healthy controls.

79-87

Authors: SK Reddi Basha, A Penchalaiah, Y Venu Gopala Sarma

Background: Helminthic infestation is common in children because of their habits and opportunity for exposure. The present study was undertaken in the Narayana Hospital, Nellore to determine the incidence of various helminthes, the symptomatology and clinical manifestations of various helminthes and to correlate type of helminthic infestation. Material and methods: This is a prospective study, was done in 1 to 15 years children who attended O P D or admitted to the pediatric ward, Narayana Hospital, Nellore. The material for the study comprises of 500 children’s, who attended OPD or admitted to the Pediatric ward belonging to 1 to 15 years age groups. A detailed clinical examination including stool examination was done for all the 500 children. Blood examination was done for knowing the degree of anemia. Results and discussion: Out of 500 children examined in various age groups, 275 children’s were found to be positive for one or other helminthic ova in the stool samples examined giving an overall incidence of 55%. Number of stool samples examined Number of stool samples infested with Helminths. Out of 500 children examined, 235 were males and 265 were females, of which 130 males and 145 females were found to be infested for one or other helminthic ova. Out of 500 stool examples examined 275 were positive for one or other helminthic ova, 160 were positive for ascariasis, 20 were positive for Hookworm, 40 were positive for Trichuris trichura, 10 were positive for hymenolepis nana and 5 was positive for Taenia infestation. Out of 500 children studied, 130 children belong to class V Socio –economic class, 150 children belong to class IV socio – economic class, 120 children belong to class III Socio – economic class and 100 children belong to class II Socio – economic class, giving a percentage of infestation according to socio –economic class as 80% in class V, 63.3% in class IV, 41.7% in class – III and 30% in class II respectively. Anemia in hookworm infestation was of mild degree in all 15 children. Anemia in mixed infestation was of mild degree in 20 children and moderate degree in 5 children. Out of 500 children studied 300 children had normal nutritional status a nd positive percentage of helminthic infestation in them was 26.7%, 140 children had Grade – I malnutrition and positive percentage of helminthic infestation in them 96.4. 40 children had Grade-II and 20 children had Grade – III malnutrition. Positive percentage of helminthic infestation in Grade – II and Grade – III malnutrition was found to be 100%. Conclusion: This study confirms the finding of the other authors all over India regarding helminthic infestations in respect to epidemiology, clinical manifestations and relation with nutritional status. There was a high co-relation with poor nutritional status.

95-103

Authors: Sridhar Reddy S, Praveen Kumar K, Mastan Valli B, Madhav Desai

Background: Sepsis is the most common trigger for acute kidney injury (AKI) in critically ill patients. This study is to monitor changes in urine neutrophil gelatinase- associated lipocalin (uNGAL levels between septic and non-septic AKI and also to evaluate differences between septic and non-septic AKI with uNGAL. Material and methods: This was a prospective observational study of critically ill patients with acute kidney injury (AKI) Patients were evaluated for presenting complaints and on evaluation those who satisfied for SIRS criteria are taken up for study. In those patients with evidence of infection and positive for at least two criteria for SIRS are taken up as cases (n=30) and rest are taken as controls (n=30). All the patients were serially monitored for urine output, renal parameters, urine NGAL, APACHE II score and SOFA score. Patient urine was collected immediately after admission followed by 12, 24 and 48 hours for measuring NGAL. Results: Mean change in NGAL (ng/ml) at 12 hour, 24 hour and 48 hour was -12.5±5, -20.5±6.74 and -29.3±10.25 respectively in septic AKI and was -0.94±6.08, -0.92±6.31 and -0.10±6.12 respectively in non septic AKI. Within group analysis showed statistically high significance (p<0.0001) in septic AKI but not in non septic AKI group (P=0.97). On evaluating between group analysis, we found significantly high difference of NGAL in septic AKI at 12 hrs, 24 hrs and 48 hrs as compared to non septic AKI (P<0.0001) Conclusion: Septic AKI patients have higher detectable urine NGAL compared with non-septic AKI patients. These differences in NGAL values in septic AKI may have diagnostic and clinical relevance as well as pathogenetic implications.

112-120

Authors: Manjeet S Dhanda, Nadeem Ali, Abedullah Bhat, Firdous A Bangroo, Sansar C Sharma, Mehreen Maqsood, Sagar Parashar, Arti Dhingra

Background: Fractures of the proximal humerus have been a challenge to orthopaedic surgeons with treatment modalities changing from time to time. Locking plates have revolutionised the treatment of these fractures. Currently proximal humeral locking plates (PHLP) and proximal humeral interlocking osteosynthesis (PHILOS) are two types of locking plates available for fixation of these fractures. Aim of this study was to evaluate the results of proximal humeral locking plate (PHLP) for Neers’s two and three part proximal humerus fractures. Material and methods: Neer’s two and three part fractures treated by open reduction and internal fixation with proximal humeral locking plate from August 2012 to April 2014 were retrospectively evaluated for complications, time to radiological union and final functional outcome using Constant-Murley Score (CMS). Results: Twenty (12 male; 8 female) patients with 8 Neer’s 2-part and 12 Neer’s 3-part fractures managed by open reduction and internal fixation with proximal humeral locking plate (PHLP) with an average follow up of 23.2 months were evaluated. All the fractures united at an average of 16 (12 to 20) weeks. Eight complications were seen in 5 (25%) patients, namely, inadequate anatomical reduction (n = 1), superficial wound infection (n = 1), deep infection (n = 1), subacromial impingement (n = 1), axillary nerve neuropraxia (n = 1), adhesive capsulitis (n = 1) and secondary varus collapse (n = 2). There was no patient who developed avascular necrosis (AVN), non-union, primary or secondary screw perforation, implant failure and vascular injury. Average Constant-Murley Score at final follow up was 84.75 ± 11.6. 85% patients had very good and good functional results. No patient had poor functional results. Conclusion: Proximal humeral locking plate (PHLP) is an excellent implant in Neer’s two and three part fractures of the proximal humerus. Complications can be minimized by meticulous surgical technique and proper placement of screws and plate. In case of medial comminution, use of PHILOS with placement of medial support screws and bone grafting should be preferred to prevent varus collapse.

129-134

Authors: R. Sambasiva Reddy, Y. Venugopal Sarma

Objectives: To compare the demographic profile of mothers who delivered term low birth weight babies with that of mothers who delivered normal birth weight babies and study the association between the demographic variables of mother and the delivery of low birth weight babies. Material and methods: Study conducted at Department of Pediatrics and Department of Obstetrics of Narayana medical college hospital, Nellore, India. Participants were 120 postnatal mothers who delivered babies in the preceding 7days. 60 mothers who delivered term low birth weight babies and 60 mothers who delivered normal birth weight babies were include in the study. Five demographic variables: age of the mothers at the time of conception, educational status of the mothers, monthly family income, occupation of the mothers and presence or absence of consanguinity were recorded. Using chi-square test these variables are compared between two groups of mothers and association of these demographic variables with the delivery of low birth weight babies is studied. Results: Significant association was found between the family income and low birth weight (P-value 0.002) and between consanguineous marriage and low birth weight (P-value 0.000). Significant association was not found between the age of the mothers and low birth weight (P value 0.924), between occupation of the mother and low birth weight (P value 0.15) and between educational status of the mother and low birth weight babies (P value 0.062). Conclusion: Low family income and consanguineous marriage have significant association with delivery of low birth weight babies.

140-146

Authors: Ankur Mittal, Ramprasad R, Biju R, Siva Prasad Y, Ganesh Kumar Reddy M

Introduction: Risk of Nonunion, residual shoulder disability and symptomatic malunion are higher in conservative treatment of displaced midshaft clavicle fractures which are reportedly decreased by operative method but plating these fractures, however, have hardware-related problems. Low-profile anatomically precontoured plates may reduce the rates of plate prominence and hardware removal. Objective: To assess the rate of plate prominence, rate of hardware removal, rate of complications, radiological and functional outcome of a pre-contoured congruent clavicle plate in the treatment of acute, displaced, mid-shaft clavicle fractures. Materials and methods: This study presented the results of 50 patients treated with an anatomical congruent clavicle plate for acute displaced, mid-shaft fractures of the clavicle from October 2011 to December 2013 admitted in Narayana General Hospital. Results: The fracture united in all cases with minimal complications and high patient satisfaction on the Disability of the Arm and Shoulder (DASH) score, American Shoulder and Elbow Surgeons score (ASES) and Pain Visual analogue score (VAS). The results compare favorably with other published studies Conclusion: A congruent clavicle plate prove to be a better option for mid shaft clavicle fracture in terms of patient compliance, hardware complication, radiological and functional outcome.

152-155

Authors: Pankaj Chhikara, Dinesh Chillar, S K Dhattarwal

Unnatural deaths of married women amongst the total female deaths have shown an increasing trend in Indian society during the recent years. These unnatural deaths may be suicidal, homicidal or accidental but suicidal deaths are most common. In India, dowry is an persistent evil, even among educated societies, there is no escape from the brutality of in-laws if expectations are not met and some of these oppressed young women choose to commit suicide, either by burning, poisoning or by some other means. The burden of finding the cause of death lies on the shoulders of forensic experts. In this peculiar case, history and findings were confusing and inconclusive. Then as the ray of hope, flies of autopsy room came to teach us importance of patient observation in Forensic Medicine.

160-163

Authors: Bhartiya SK, Bhattacharya SK, Basu S, Srivastava A, Shukla VK

Venous aneurysm is saccular or fusiform dilatation of vein, usually congenital origin. Among acquired variety post intravenous cannulation leading to venous aneurysm is extremely rare entity. Non invasive diagnostic procedure MRI and duplex scanning are very useful modality for anatomical localization of the aneurysm. Although an ascending venogram is an invasive test and should take a backseat for diagnosis of such aneurysm. Symptometic case needs surgical management. Anatomical delineation is an important pre requisite for planning surgery. Aneurysmorrhaphy preserves the affected venous segment because it does not produce luminal compromise.

168-173

Authors: Menon Narayanankutty Sunilkumar

Parotid gland is one of the major salivary glands and when there is infection/inflammation of the parotid gland, the condition of parotitis ensues. A parotid abscess (PA) results as a complication of the primary parotitis. Literature review has revealed that it is very rare in the pediatric population and many predisposing factors are present for the formation of a PA in children. PA is seen often in the adults when compared to the paediatric subset. The management with intravenous broad spectrum antibiotics, drainage of the PA and surgery is the main stay of treatment in an adult patient. In this case report, a seven year old female child who detected to have a PA and managed only conservatively has presented and discussed.

178-182

Authors: Bhavani K, Vani Isukapalli, Nagamani T, Silpa Hasa S

Endometrial stromal tumors (EST) arise from stromal component of endometrium and are rare and common in peri or postmenopausal age group. EST are partially estrogen dependent tumors and their histopathology resemble the stromal cells of normal proliferative endometrium. They present in varied forms pathologically ranging from most benign to most malignant variants. Diagnosis essentially is by histopathology and prognosis is based on the mitotic activity of the tumor. We have presented here a case of EST presenting in a young nulliparous woman.

187-194

Authors: M.C. Songra , Sanjay Jain, Romil Jain, Rahul Ahluwalia, Naveen Patbamniya, Pragyey Nawalakhe

Catecholamine-secreting tumors that arise from chromaffin cells of the adrenal medulla and the sympathetic ganglia are referred to as pheochromocytomas and extra adrenal catecholamine-secreting paragangliomas (extra adrenal pheochromocytomas), respectively. Bladder paragangliomas are rare entities with initial non-specific presenting symptomatology. Differentiation of urinary bladder pheochromocytomas from other bladder tumors has important treatment implications. We have presented here the case of a 55 year old female who presented to our outpatient urology clinic with complains of hematuria for 3 months and headache for 1 month. Cystoscopy revealed diffusely thickened bladder wall with a well circumscribed smooth surfaced mass protruding from the right lateral wall of the bladder. Multiple biopsies were taken and sent for histopathology. After cystectomy, diagnosis of paraganglioma of bladder was done by histopathology and immunohistochemistry.

200-204

Authors: Yogesh M Borse, Rashmi V. Bengali, Rajesh D. Subhedar, S.A. Thorat

Pheochromocytoma is a rare catecholamine secreting neuroendocrine tumor. It is bilateral in 10% of cases. A 24 year lady with bilateral Pheochromocytoma operated for resection under epidural with general anesthesia. Diagnosis was confirmed with 24 hour urinary VMA levels, USG, CT scan and MIBG scan. Tumor resection was incomplete on left side so patient underwent reexploration. Preoperative BP controlled with Phenoxybenzamine and Prazocine. Intra-operative BP fluctuations managed with sodium nitropruside and esmolol. Post operative hypotension was tackled with higher doses of Dopamine and Noradrenaline due to down regulation of adrenergic receptors. Patient was discharged on oral steroids after 3 weeks.

210-212

Authors: Harish Kumar Y, Sridhar K, Srinivas MG, Thankappan KR

A 50 year female presented with dysphagia for 2 months and she denied pain during swallowing, retrosternal pain, drooling of saliva, nasal regurgitation, cough, breathlessness, hoarseness of voice, abdominal pain, vomiting, loss of weight or loss of appetite. Upper gastrointestinal (UGI) endoscopy revealed a web at 17 cm from incisors. Post endoscopy patient developed pain over the upper abdomen which worsened during swallowing and breathing. Because of rapid development of these symptoms we suspected esophageal perforation/dissection. Complete blood picture suggestive of neutrophilic leukocytosis and other parameters were normal. Thin barium study showed pseudo lumen in esophagus and confirmed the diagnosis of esophageal web with esophageal dissection. Patient was treated conservatively with nil per oral and parenteral fluids and antibiotics. Web was dilated after 2 weeks with Salivary-Gilliard dilators and procedure was uneventful and oral feeding was initiated.

218-224

Authors: Ambesh Kumar Rai, Bipin Kumar Yadav

The implementation and execution of effective infection control protocols among all health care communities cannot be overstressed. Infection control becomes even more significant in dentistry as more microorganisms are found in the oral cavity than in any other part of the body. Saliva is about half as infectious as blood, and the most likely modes of transmission in dental offices are through puncture wounds, skin abrasions, or lesions. Dental aerosols, splattering, and instrument contamination can also transmit virus, which can survive for several weeks at room temperature. With Orthodontists showing the second highest incidence of hepatitis B among dental professionals, the need of stringent infection control protocol in an orthodontic office becomes mandatory. This article discusses various sterilization protocols with their relevant scientific data keeping the instruments longevity in mind to facilitate the discerning orthodontist in make an informed decision towards their implementation.