International Archives of Integrated Medicine

11-19

Authors: Prajapati J, Parmar H

Background: Spinal anesthesia is most frequently used for transurethral prostatectomy (TURP), because it permits early recognition of transurethral resection of prostate (TURP) syndrome and bladder perforation. In this study, we compared the effects of low dose bupivacaine (5 mg) with fentanyl (25µg) and conventional dose of bupivacaine (7.5 mg) in elderly patients undergoing TURP. This comparative study was conducted to evaluate the efficacy of addition of fentanyl 25 µg intra thecally to bupivacaine 5 mg and bupivacaine 7.5 mg alone for transurethral prostatectomy. Material and methods: The patients were randomly allocated into 2 groups, each having 30 patients. Group-A: Inj. Bupivacaine 5 mg (0.5%) (1ml) + Inj. Fentanyl 25 µg (0.5 ml). Group-B: Inj. Bupivacaine 7.5 mg (0.5%) (1.5 ml). A standard subarachnoid block was performed in L2-L3 / L3-L4 Space in sitting / lateral position with 22G/23G BD spinal needle (Quinky type, 3.5 inch long) under all aseptic and antiseptic precautions after local infiltration of skin and subcutaneous tissue with 2 cc 2 % lignocaine. Drugs were injected after checking of free flow of CSF and according to group selected. All the observations were recorded and all the results were analyzed statistically. Results: The mean time of onset sensory blockade was significantly shorter in group A than group B. Group A took less time to reach the peak sensory level (3.57 min) as compared to group B (5.8 min). Onset of motor blockade was delayed in group B as compared to group-A, and the differences were statistically significant. Changes in pulse rate of all groups are statically not significant and comparable. The incidence of hypotension and shivering was significantly higher in group B as compared to group A. Conclusion: It was observed that intra thecal bupivacaine 5 mg combined with fentanyl 25 µg provided adequate anesthesia for TURP in elderly patients and is associated with lower incidence of hypotension and shivering than a conventional dose of bupivacaine. The addition of fentanyl improves the quality of block, increases duration of sensory block and makes the blockade hemodynamically more stable than conventional dose of bupivacaine.

26-32

Authors: Patel P, Parmar H, Vaghela G

Background: Although incidence of ureteric stricture, in general population, is not known, proper evaluation of and treatment is essential to preserve the renal function and rule out malignancy. Strictures of the upper urinary tract are either congenital or acquired. With the exception of primary UPJ obstruction, most ureteral strictures are acquired and usually are iatrogenic. Before the development of endourological instruments and techniques, ureteral strictures were managed by open repair. The management of ureteric stricture has changed dramatically over the last decade in conjunction with new developments in endourology. Material and methods: This bi-directional study was performed on 30 patients, diagnosed as a benign ureteric stricture by various modalities of diagnosis, which underwent open or laparoscopy surgical procedures. Data, with respect to patient’s demographic information, etiology, mode of presentation, stricture location and length, diagnostic modalities, operative procedures and their follow-up were recorded, analyzed and plotted on master chart. Various surgical treatment modalities are used according to length and location of strictures like: Upper and mid-ureteric stricture: Ureteroureterostomy 2-3 cm, Uretero calycostomy/ pyeloureterostomy for long upper ureteric stricture, 4-5 cm with intra renal or scarred pelvis, Buccal mucosal graft ureteroplasty. Lower ureter: Ureteroneocystostomy 4-5 cm, Psoas hitch 6-10 cm, Boari flap 12-15 cm, Ileal ureter replacement for long segment defect > 10-15 cm, in every patient, we keep closed drainage system. Usually, drain was removed after 72 hours. We were keeping double j stent in every patient, which were removed after 1 month. Follow up the patient after 21 days of double j stent removal and thereafter 6 monthly for 2 years, then every yearly for 5 years. Results: Among 30 patients, main causes are genitourinary TB 8 (26.66%), Iatrogenic 8 (26.66%). 46% strictures involve, lower ureter with length >3-5 cm, which correlates with characteristics of tuberculosis, involving multiple sites and long segment of ureter, 54% stricture involving upper ureter are < 3-5 cm which correlates with iatrogenic and impacted ureteric calculus related strictures. Among 30 patients, with 33 renal units 2 patient’s surgery failed, among which one required nephrectomy, and another required redo surgery, one patient who lost follow up was also considered as a failure. Conclusion: In era of endourology and minimal invasive surgery, open reconstructive surgery has its own place.

40-46

Authors: Rathod VJ, Patel P, Patel N

Background: Over 50% of patients with upper limb paresis resulting from stroke face long-term impaired arm function and ensuing disability in daily life. The incidence of stroke increases dogmatically with age, doubling in the decade after 65 years of age. Early rehabilitation treatment in the first phase of stroke is currently advice in clinical guidelines and little evidence is available on such treatment for improving arm/hand function in the same period. Unfortunately, the number of effective treatments aimed at improving arm function due to stroke is still low. Aim: This study aimed to evaluate a new therapy for improving upper extremity function in sub-acute stroke patients based on mental practice theories and functional task-oriented training, and to study the predictors for a positive treatment result. Material and methods: 30 sub-acute stroke patients with upper limb paresis were selected by simple random sampling in this study. The experimental group undertook 12 week, individually tailored therapy regime focused on improving upper extremity function using mental practice. Primary outcome measures assessed upper extremity functioning with Action Research Arm Test, Fugl Meyer Test, and Modified Asworth Scale. ANOVA was used in this study. Null hypothesis with alpha level was set at 0.05. Conclusion: Mental imagining training resulted in significant improvement in upper extremity function in sub acute stroke patient. However the improvement obtained in upper extremity function found no significant difference after mental imagining training between the groups.

51-60

Authors: Shah RR

Background: Individuals with HIV infection are at increased risk for tuberculosis (TB) and other respiratory tract infections (RTIs). The altered CD4 T-cell homeostasis induced by HIV infection may play a key role in the development of respiratory tract infections in HIV-infected patients. Aim: Finding out of mean CD4 count of HIV patients at which they were at higher risk of developing various RTI and accordingly when HAART is to be started in this part of the world. Material and methods: All the 961 HIV infected patients and 300 HIV sero-negative patients’ three early morning sputum were screened for routine bacterial and fungal pathogens and even examined for AFB and few of the samples were even cultured on LJ medium. All sputum samples’ smears were also examined for PMNLs in Gram’s staining. Results: Out of all these 961 HIV patients, in 349 patients with probable viral RTI etiology, the mean CD4 count was found to be 474.62 + 114.89, followed by mixed polymicrobial RTI (80 patients) with mean CD4 about 392.26 + 87.14. The patients with pure fungal etiology (66), the mean CD4 count was found to be 377.29 + 268.29 followed by 466 patients with pure monomicrobial bacterial RTI the mean CD4 count was about 223.07 + 83.21. Conclusion: Very vague co-relationship between pattern of RTIs and CD4 counts had been attempted. Only Fungal and Bacterial RTIs were seen first to establish in even HIV infected patients at very high mean CD4 counts of about 377 + 268.29 and 223.07 + 83.21 respectively, but in both very high prevalence rate had been observed when compared with HIV non-infected patients with probability values of <0.05 and <0.001 respectively. Probable viral etiology of RTI was significantly high in HIV-non infected subjects when compared to HIV-infected RTI patients with probability value P < 0.001.

65-69

Authors: Vijaya Sekhar MV, Ramprasad KV, Kavita K

The incidence of head injuries is increasing worldwide. The associated skull fractures are also increasing with rise in vehicular traffic. In the present study, a total of 214 cases of head injuries which were admitted into a Rangaraya Medical College Hospital from the time period of 2 years, were taken for the study. Out of them 124 cases presented with skull fractures ranging from simple linear to stellate, depressed, comminuted, compound and compound comminuted depressed fractures. Some fractures were extending to the base of skull and some to the vault and some were associated with facio-maxillary injuries. 17 cases out of the 124 open skull fractures, presented with cerebro-spinal fluid leak and brain matter seen directly herniating through the wound. The wounds in all the cases were contaminated, with many cases harboring hair, sand particles etc. Majority of them were secondary to road traffic accidents, but assaults and some directly hitting injuries under the influence of alcohol were also included. As there was an evident CSF leak and brain matter already present in the wounds, all the cases were taken up for emergency surgery. In spite of the grossly contaminated wounds, thorough wound debridement and closure of defects and duraplasty wherever feasible, resulted in very good improvement in all the cases. No mortality or procedure related morbidity was observed in any of these cases.

77-81

Authors: Vijaya Sekhar MV, Giri Rao DK, K. Babji

Ventriculo-Peritoneal shunt is the most commonly performed surgery for hydrocephalus, universally. Many complications are reported, of which the shunt malfunction and infection are most commonly encountered. These common complications can be minimized, by precautions like – senior surgeons operating shunt cases, as the first case in the operation, with minimal personnel in the operation and thoroughly scrubbing the part for minimum five minutes. However, in few cases, – even in the experienced hands and with all precautions, some rare complications like extrusion of the lower end through anus, vagina, into scrotum were described. In our experience of over 15 years, wide range of complications was seen apart from malfunction and infection. Exposure of the part of shunt system, with excoriation of overlying skin, peritubal leaks, disconnection of shunt system with CSF leaking out, loculation in between the loops of bowel/ omentum, extrusion of the lower end through anus etc. were encountered and probable factors for these unusual complications were discussed.

88-93

Authors: Y. Umasatyasri, I.Vani, P. Shamita

Serum LDH is abnormal in a host of disorders, therefore the total serum LDH is highly sensitive but nonspecific test. In preeclampsia also LDH may be elevated and can indicate the prognosis for both mother and fetus. The present study was intended to assess the prognostic significance of the value of serum LDH as a marker of preeclampsia – eclampsia and its severity. Higher serum LDH levels were associated with increased incidence of maternal complications like abruption placenta, renal failure HELLP syndrome, cerebrovascular accidents etc. in the present study. There was an increase in maternal morbidity with increasing serum LDH levels. To conclude high serum LDH levels have significant association with severity of disease and maternal and fetal outcomes in patients of preeclampsia and eclampsia and can be considered as a supportive prognostic tool from early third trimester.

102-110

Authors: Manjunath SM, Nagesh Raju G, Srinivas TR, Someswara GM

Background: Pharmacology, like any other branch of medicine, is progressing by leaps and bounds. Consequently, reforms in undergraduate teaching are the need of the hour. Objectives: To determine the medical students’ perception and receive feedback on teaching and learning of pharmacology in our institution. Material and Methods: This was a cross-sectional study based on the questionnaire. A pre-validated, predesigned questionnaire containing 23 points was administered to fifth term medical students. Results: 73.43% wanted the faculty members to make more use of Audio-Visual aids for effective learning. 98.43% students wanted to include case based learning in the curriculum and 90.62% students wanted more of the clinical pharmacology to be introduced in the curriculum. 70% participants wished recent advances to be included in the curriculum and almost 80% were in favour of MCQs to be included in assessment of their academic performance. Only 26% participants felt rabbit eye experiments was appropriate and relevant to the present days of practical pharmacology reflecting a need for reforms. Only 10.93% students were willing to consider pharmacology as one of the subject for post-graduation. About 25% students felt the ideal teaching method for learning pharmacology was didactic lectures and group discussions and 81% thought the ideal teaching/learning media for pharmacology was the combination of LCD projector and blackboard. The most difficult system to understand was Autonomic Nervous System (53%). Conclusion: The study revealed the perception and feedback of the students regarding learning pharmacology were positive and constructive. It also revealed the priority areas for improvement.

116-118

Authors: Pawar CA

A 64 years postmenopausal woman approached emergency department due to acute abdominal pain and vomiting. Gynecological history of mild postmenopausal bleeding and increased vaginal discharge was noted since 10 days. Per abdomen was very tender distended, muscle rigidity. Emergency Explorative laparotomy was performed under the diagnosis of perforation of gastrointestinal (GI) tract. The uterus was found to have posterior wall perforation of 2x1 cm dimension and purulent material exuding from the uterine cavity was identified. Thus was diagnosed as perforated uterus due to pyometra. A total abdominal hysterectomy with bilateral salpingo-oophorectomy was done uneventful. Patient recovered completely without any complications and was discharged. Perforation of uterus due to pyometra can cause the peritonitis in postmenopausal females with signs of acute abdomen as an unusual but serious condition.

124-128

Authors: Kandukuri Mahesh Kumar, V. Indira, V. Hari Shanker

Kikuchi-Fujimoto disease (KFD) is also known as histiocytic necrotizing lymphadenitis. It is a benign, systemic lymphadenitis, self limiting disease first described independently by Japanese Pathologists Kikuchi and Fujimoto in Japan in 1972. The incidence of KFD is unknown. KFD is up to 4 times commoner in women. It presents as lymphadenopathy mainly involving the posterior cervical region, but can occur in any lymph node and even in extra nodal sites. Fever is associated with lymph node enlargement in half of the cases. Though viral and autoimmune cause is suggested by some studies, the exact etiology remains uncertain. There have also been reports of a relation between KFD and systemic lupus erythematosus. Most of the preoperative diagnostic tests are inconclusive. Definitive diagnosis depends on the histopathological examination of the lymph node biopsy. Clinically it has to be differentiated from other lesions like malignant lymphoma, mononucleosis tuberculosis and SLE as treatment and prognosis differs. Here we submit a case of Kikuchi-Fujimoto disease in an inguinal lymph node in a young adult auto driver.

135-140

Authors: Pandey V, Kandukuri Mahesh Kumar, V. Indira, V. Hari Shanker

Primary caecal lymphoma or the colonic lymphoma is a rare tumor of the gastrointestinal (GIT) tract and comprises only 0.2-1.2% of all colonic malignancies, both in adults and pediatric age group. The most common variety of colonic or caecal lymphoma is Non-Hodgkin’s Lymphoma (NHL) which arises from the lymphoid elements of the intestine. GIT is the most frequently involved site, accounting for 50-60% of all extra nodal lymphomas, and most of them are NHL. In adults, the stomach is the most common location of GIT lymphomas, followed by the small intestine, but the most common GI site of NHL in children is the terminal ileum and the ileo-caecal region. Diagnosis is difficult since lymphoma presents with vague abdominal pain with loss of weight and appetite. It may present as lump abdomen with complications such as intestinal obstruction, bleeding, perforation and peritonitis and intussusseption. Histologically it is B or T cell type with small or large cell variation, but frequently encountered is diffuse large B- cell lymphoma (DLBCL). DLBCL has low incidence but favorable outcome in young adults, lesions localized to one area or organ and children below 5 years of age, but has an aggressive course in children between 10-15 years of age and also in adults above 55 years of age. DLBCL or GIT Lymphomas in general have male preponderance. We present a rare case of caecal lymphoma (DLBCL) involving appendix and right ovary in a 12 year old girl who presented with vague symptoms of abdominal pain and abdominal mass. Clinically and radiologically, provisional diagnosis of Ileo-caecal tuberculosis with possibility of adhesions leading to a mass lesion was considered. Histopathological examination (HPE) revealed the diagnosis and prognosis of the case.

144-147

Authors: Billakanti Prakash Babu, Huban Thomas

During routine dissection in Anatomy Department, KMC Manipal, anomalous origin of superior laryngeal artery arising from external carotid artery was observed on the right side in an adult male cadaver. Superior laryngeal artery normally is a branch of superior thyroid artery. It supplies laryngeal muscles, mucosa and glands. The origin of lingual and facial arteries from external carotid artery was normal. The courses of nerves in the carotid triangle are also normal. No variations were observed in the left carotid arterial system. Variations in the origin of the superior laryngeal artery are very rare. It may arise from lingual, facial, ascending pharyngeal, external carotid artery or even from the common carotid artery. There are reports of rare variation of the common trunk of origin of superior laryngeal and inferior thyroid artery from the external carotid artery at the same level as origin of common linguofacial trunk. Though embryogenesis of this variation is not clear, but may be important for reconstruction surgery of the larynx, laryngeal transplantation and it will also be useful to the surgeons in minimizing the post-operative complications in a bloodless surgery. Clinicians must be aware of these variations in the super selective intra arterial chemotherapy for laryngeal and hypo laryngeal cancers.

152-156

Authors: Khatawkar AV, Awati SM

Multi-nodular goiter is a common endocrine disorder worldwide. It is endemic in certain populations. It is more common in women and presents mainly in 4th and 5th decades of life. Various factors have been implicated for the development of multi-nodular goiter, most common being Iodine deficiency. Nodular goiter results from uni or multifocal hyperplasia of follicular cells which may have autonomy of growth and autonomy of function. The process can be divided into five stages which result in the classic appearance and histology of multi-nodular goiter. Present article deals with epidemiology, etiology, pathogenesis and pathology of multi-nodular goiter based on relevant articles searched on pubmed.

165-171

Authors: Khatawkar AV, Awati SM

Thyroid gland is an important endocrine organ. Its hormone thyroxine is essential for life. The structure and function of thyroid gland were discovered during 17th to 20th centuries. Thyroid surgery is being done since early 19th century, perfected by Theodre Kocher in early 20th century. Thyroid is the first endocrine gland to develop in embryo and is endodermal origin. The surgically important anatomical relations of thyroid are recurrent laryngeal nerve, parathyroid glands and external laryngeal nerve with variations. Thyroid gland secretes thyroxine hormone which contains Iodine. Thyroxine has effects on all organs of body and its secretion is regulated by Pituitary. Present article throws light on some historical aspects, embryology, anatomy and physiology of thyroid gland based on relevant articles and textbooks.