International Archives of Integrated Medicine

1-7

Authors: Hrituraj Singh, C. Raychaudhuri

Background: A solitary pulmonary nodule is defined as a discrete, well - marginated, rounded opacity less than or equal to 3 cm in diameter that is completely surrounded by lung parenchyma, does not touch the hilum or mediastinum , and is not associated with adenopathy, atelectasis or pleural effusion. Lesions larger than 3 cm are considered masses and are treated as malignancies until proven otherwise. It is not uncommon for a patient who currently has or has previously had extra pulmonary neoplasm to develop a solitary pulmonary nodule. Such a nodule may be detected with chest radiography or computed tomography performed as part of the work - up or follow - up of the known extra pulmonary malignancy. The determination of the etiology of such a nodule is usually important to direct the appropriate therapy. Aim and objectives: To evaluate the Chest Radiographs and CT characteristics of solitary lung nodule with a primary extra pulmonary neoplasm and to determine the presence and/or frequency of single lung metastasis , primary lung cancer and benign lesions in patients with solitary lung nodule and a primary extra pulmonary neoplasm. Materials and methods: A retrospective analysis of CT and Chest Radiographs of 9 patients with an extra pulmonary malignant neoplasm and a solitary pulmonary nodule, done in our Dhiraj General Hospital. Images were reviewed for the presence of solitary lung nodule. If present, the following nodular characteristics were recorded: Distribution, CT attenuation, Shape, Size, Margins and Calcification. The histological characteristics of the nodule were correlated with those of the extra pulmonary neoplasm and with patient age and smoking history. Results: Out of total number of 9 patients that were included in this study showed different pathologies and those were then those were evaluated in detail and showed: benign pulmonary nodule (1 case), metastatic deposit (1 case), primary bronchogenic carcinoma with brain metastasis (1 case), lung metastasis (1 case), lung carcinoma in upper lobe of left lung (1 case), actinomycosis (1 case), lung metastasis with renal cell carcinoma (1 case), oesophageal carcinoma with primary bronchogenic carcinoma (1 case), primary bronchogenic carcinoma with bony metastasis (1 case). Conclusion: Solitary lung nodule in patients with extra pulmonary malignancies showed a variety of patterns on CT. Nearly half of the non – calcified solitary pulmonary nodules identified in this series were malignant. The likelihood of a spread depends on the histological characteristics of the extra pulmonary neoplasm and the patient's smoking history. Lung cancer was more common than metastatic disease.

13-16

Authors: Akanksha Narula, Jayesh Shah, C. Raychaudhuri

Introduction: Imperforate anus is a defect that is present from birth (congenital) in which the opening to the anus is missing or blocked. In female infants, imperforate anus is typically characterized by the rectum, bladder and vagina sharing one large opening called a cloaca. The condition develops in utero during the 5th to 7th weeks of pregnancy. This condition often happens in conjunction with other defects of the rectum. Incidence is 1 in 5000. It is more common in males. Diagnosis is usually made shortly after birth. Aims and objectives: To study the presentation of imperforate anus using various radiological modalities. Materials and methods: 10 cases of either strong suspicion or symptoms related to imperforate anus were evaluated who came to Dhiraj hospital with different radiological modalities like plain radiograph lateral invertogram, cross table lateral radiograph, erect radiograph and contrast studies (MCUG). Results: Out of total number of 10 patients who were diagnosed and evaluated for imperforate anus 3 i.e. 33.3 % were diagnosed with plain radiograph lateral invertogram, 2 i.e. 20 % were diagnosed with prone cross table lateral radiograph, 2 i.e. 20 % were diagnosed with abdominal erect radiograph and 2 were found to have recto-vesical fistula with the help of micturating cystourethrogram. Conclusion: It was concluded that plain radiograph lateral invertogram proves to be the most important modality in diagnosing imperforate anus. It is followed by prone cross table lateral radiograph and abdominal erect radiograph. Micturating cystourethrogram proves to be important in diagnosing associated anomalies such as recto-vesical fistula.

21-25

Authors: Modiya S, Shah J, C. Raychaudhuri

Background: Acute disseminated encephalomyelitis is an acute demyelinating disorder of the central nervous system and is characterised by multifocal white matter involvement. Diffuse neurological signs with multifocal lesions in brain and spinal cord characterise the disease. It do not invade central nervous system. Aim: To evaluate role of MRI in acute disseminated encephalomyelitis. Materials and methods: A prospective study of 10 cases which was conducted in the pediatric department in Dhiraj hospital. MRI brain was done on 1.5 Tesla MRI machine. Results: ADEM can be distinguished from acute viral encephalitis because the disease is not the result of primary tissue invasion by an infectious organism. It was thought to be immune-mediated and is characterized neuropathologically by perivenular inflammation and demyelination. Conclusion: ADEM is more common in female and more associated with previous infection as compared to previous vaccination. Neurological deficit is mostly associated with it. CSF showed raised protein in almost cases. It showed hyperintense lesion on T2W and FLAIR sequences. Periventricular area of brain is commonly associated.

31-36

Authors: B. Bheeshma, B.S. Nithyananda, Sumaiyya Fatima, Fatima Anjum

Background: Placenta accreta is a severe pregnancy complication and is currently the most common indication for peri partum hysterectomy. It is becoming an increasingly common complication mainly due to the increasing rate of cesarean delivery. Placenta accreta is considered a severe pregnancy complication that may be associated with massive and potentially life-threatening intrapartum and postpartum hemorrhage. It has become the leading cause of emergency hysterectomy. Maternal morbidity had been reported to occur in up to 60% and mortality in up to 7% of women with placenta accreta. In addition, the incidence of perinatal complications is also increased mainly due to preterm birth and small for gestational age fetuses. Placenta cretas are defined as abnormal adherences and/or ingrowths of the placenta to the uterine wall. Placenta creta is currently classified according to the depth of abnormal adhesion and invasion of the chorionic villi to the myometrium in the absence/deficiency of decidualization. The incidence of placenta accreta, defined as the abnormal adherence of the placenta to the uterine wall, has been increasing alarmingly in the developed as well as the developing world.. The exact pathogenesis of placenta accreta is unknown. Generally, placenta accreta has been diagnosed on hysterectomy specimens when an area of accretion showed chorionic villi in direct contact with the myometrium and an absence of decidua or in placental basal plate. Aim: The aim of this study was to determine the incidence of placentas cretas in our hospital and to profile the associated risk factors. Materials and Methods: The patients who underwent gravid hysterectomies for placenta creta at Modern Government Maternity Hospital from 2013 to 2016 were included in study. A total of 25 cases during 4 year period were included out of 33063 deliveries. The indications for hysterectomy in majority of cases were heavy bleeding after removal of placenta or inability to remove the placenta manually either partially or totally. The specimens received in pathology department were thoroughly examined grossly and the representative sections were taken from all the specimens after proper fixation which was submitted for tissue processing and H&E stained sections were studied for final diagnosis. Results: Amongst 33093 deliveries which occurred at our institute from January 2013 to December 2016, there were a total of 25 patients with placenta accreta diagnosed by histopathology, which was a rate of 0.7% cases per 1,000 . This total included 2 cases of focal placenta accreta (8%), 10 cases of placenta accreta vera (40%), 9 cases of placenta increta (36%), and 4 cases of placenta percreta (16%). Conclusion: The incidence is considerably higher in women with both a previous caesarean delivery and placenta praevia. Therefore it is important to have a high index of suspicion in such cases. Women with a placenta previa overlying a uterine scar should be evaluated for the potential diagnosis of placenta accreta and arrangements should be made for delivery accordingly to reduce maternal and fetal morbidity and mortality.

45-51

Authors: Lodha R, Nepalia R

Background: Diabetes mellitus is one of the most common endocrine disorders affecting about 6% of the world’s population. Diabetes mellitus is the leading cause of end stage renal disease (ESRD), a major cause of non-traumatic amputations, responsible for preventable blindness and a leading cause of cardiovascular mortality. Objective: The objective of the study was to assess the glycemic control by estimation of glycated hemoglobin (HbA1c), and lipid profile in patients of Diabetes mellitus without complications and in Diabetes mellitus with complications like neuropathy, retinopathy and nephropathy and compare with controls. Material and methods: The present study comprised of 100 clinically diagnosed and confirmed cases of type 2 Diabetes mellitus attending and admitted in RNT Medical College and Hospital, Udaipur, Rajasthan, India. Glycosylated hemoglobin (HbA1c), Total Cholesterol, Triglycerides, HDL-Cholesterol, LDL-Cholesterol and VLDL-Cholesterol were calculated in all groups using Friedewald’s formula. Result: Our study showed that HbA1c levels were significantly higher (p<0.01) in all groups of patients as compared to controls. The increase in Serum Cholesterol, Triglyceride, LDL-Cholesterol, VLDL-Cholesterol and decrease in HDL-Cholesterol levels were statistically significant (p<0.01) in Diabetic retinopathy and Diabetic nephropathy group as compared to controls, whereas in Diabetic neuropathy group and in Diabetes mellitus without complication, the increase in Serum Cholesterol, Triglyceride, LDL-Cholesterol, VLDL-Cholesterol and decrease in HDL-Cholesterol levels was not statistically significant as compared to controls. Conclusion: Our study revealed that poor glycemic control and dyslipidemia are associated with Diabetic complications like neuropathy, retinopathy and nephropathy. Estimation of glycosylated hemoglobin and lipid profile helps in predicting the development of microvascular complications. Therefore intensive glycemic control and aggressive treatment of dyslipidemia can help in reducing Diabetes mellitus associated complications.

56-60

Authors: Patel K, Zala S, C. Raychaudhuri

Background: Neurocutaneous syndromes encompass a group of disorders that affect the embryonic ectodermal plate, which includes the central and peripheral nervous systems, as well as the overlying skin. Materials and methods: All patients were known case of neurofibromatosis type 1. All patients for this study had undergone MRI whole spine with brain screening. Conventional radiographs were also taken when and where needed after taking informed consent. Results: In our study we found that 15 (60%) patients having lumbar neurofibromas, 7 (28%) patients having cervical neurofibromas, 2 (8%) patients having thoracic neurofibromas and 1 (4%) patients having sacral neurofibromas. Conclusion: MRI allows non-invasive detection of spinal neurofibromas and helps determine intrdural or extradural origin and their relationship to the neural foramina, spinal canal, and thecal sac and spinal cord. The target sign (bright on T2, with dark collagen centrally) is highly suggestive of a peripheral neurofibroma on MRI.

79-87

Authors: Pereira EM, Tambekar MY, Sahu S, Dhar R

Background: Carcinoma of the breast is a leading cause of death in women and needs to be evaluated at an early stage. FNAC helps in rapid diagnosis of breast lesions and their management. Objective: To study the diagnostic efficacy of FNAC in breast lesions. Materials and methods: Three year retrospective study of 105 cases of breast lump was conducted which included cases, where FNAC and histopathological correlation was available. The cytological diagnosis was classified as inflammatory lesions, benign, atypical probably benign, suspicious for malignancy and malignant. Results: On cytology out of 105 cases, 57 were benign, 7 inflammatory lesions, 34 malignant and 7 were inadequate. Fibroadenoma was the most common benign lesion noted in age group of 21-30 years and infiltrating ductal carcinoma was the most common malignant lesion in 31-40 years age group. Diagnostic accuracy, sensitivity and specificity of this study were 96.93%, 91.89% and 100% respectively. Conclusion: FNAC of breast lesions is a simple, safe and effective modality in pre-operative assessment of benign and malignant lesions and shows high accuracy, sensitivity and specificity.

98-102

Authors: S. Appandraj, V. Sivgamasundari

Background: Non-steroidal anti-inflammatory drugs (NSAIDs) including aspirin are among the most frequently prescribed drugs worldwide and are available ‘Over-The-Counter’ (OTC) also. Though reasonably safe in most cases in prescribed dosages and for short durations, these drugs cause serious gastrointestinal toxicity in a large number of cases. They can affect all segments of the gastrointestinal tract causing ulcers, severe bleeding, perforation, and obstruction. Aim: To study the endoscopic abnormalities in fifty cases of drug induced UGI bleeding. Materials and methods: Fifty patients (32 males and 18 females) admitted with drug-induced hematemesis and or malena were studied with respect to age group, number of bouts of hematemesis, approximate quantity of total blood loss, causative drug responsible for UGI bleeding, risk factors of GI bleeding, number of individual risk factors in each patients. Thorough clinical and laboratory investigations were done. UGI scopy was done for all patients. Results: NSAIDs were the commonest cause for UGI bleeding. Age > 50 years (66%) was the commonest risk factor for UGI bleeding. It was observed that ten patients were having normal endoscopic study, twenty five patients were having lesions in stomach only, ten patients were having lesions in duodenum only and five were having lesions in both stomach and duodenum. None of the patients studied, had lesions in the esophagus. It was found that ulcers were more common than erosions. Conclusion: Stomach is the commonest site affected (50%) and ulcers (64%) were common than erosion.

111-116

Authors: Rana-Khara R, Lakhani SJ, Vasava S, Panjwani D

Background: Sepsis is one of the most common clinical conditions that cause substantial morbidity and mortality all over the world. Blood culture is considered to be the gold standard for the identification of bacteria as a cause of sepsis along with the pattern of antibiotic susceptibility that helps clinicians to choose the appropriate empirical antibiotic. E. coli, belonging to the family Enterobacteriaceae, is a very important pathogen causing infections in humans. It causes a number of important clinical conditions like urinary tract infections, diarrhea, peritonitis, visceral abscesses, endovascular infections, septicemia pneumonia, meningitis, osteomyelitis, wound and soft tissue infections. Due to increased resistance to drugs and ability to produce variety of beta-lactamase enzymes (extended-beta lactamases) poses a difficulty in treating infections caused due to E. coli. Objectives: Objectives of this study were (a) to detect ESBL production amongst the E.coli isolated from the blood cultures of patients with sepsis and (b) to determine its effect on the outcome of sepsis patients from a rural based tertiary hospital in Vadodara district of Gujarat. Materials and methods: A total of 48 E. coli isolates were obtained from the blood culture of 46 patients with clinically diagnosed sepsis. These 48 E. coli isolates were tested for detection of ESBL production according to the CLSI guidelines using phenotypic screening & confirmatory methods. Results: From a total of 48 E. coli isolates obtained from blood culture of 46 clinically diagnosed sepsis, 24 were female patients (as 2 patients had 2 blood samples cultured) and 22 were males. Of the total 48 E. coli isolates tested for ESBL production, 23 (47.91%) isolates from 23 (50%) patients were found to be producing ESBL and 25 (52.08%) isolates from other 23 (50%) patients did not produce ESBL. Of the 23 patients with ESBL producing E. coli, 14 (60.86%) patients did not survive the episode of sepsis, whereas 7 (30.43%) survived and for 2 (8.69%) patients the outcome was not known as they took discharge against the medical advice. Amongst the 23 patients with 25 blood samples yielding non-ESBL producing E. coli, 8 (34.78%) did not survive, 14 (60.86%) survived and for 1(4.34%) patient the outcome was not known. Thus the mortality was more in patients with sepsis due to ESBL producing E. coli as compared to patients with non-ESBL producing E.coli. Also the urinary tract/kidneys were the common source of infection and kidneys were the organ affected. The ESBL producing E. coli showed a higher resistance to most of the antibiotics used but a higher susceptibility to Imipenem and Ertapenem. Conclusion: The findings of our study suggests a higher prevalence of ESBL producing E. coli, which exhibit a higher resistance to most of the antibiotics, are associated with greater mortality and pose a real challenge in the management of patients with sepsis.

122-127

Authors: K. Padma Malini, Tami Arasi, K. Sudha, O. Shravan Kumar

Background: Blood Transfusion plays a vital role in patient management and is lifesaving in many instances. It plays a pivotal role as a specialized modality of treatment and saves millions of lives worldwide each year and reduces morbidity. It is well known to be associated with a large number of complications, some of them trivial while others are life threatening, demanding for meticulous pre transfusion testing and screening. The priority objective of BTS is to ensure safe, adequate accessible efficient blood supply at all times. The magnitude of TTI varies from country to country and depends directly on the TTI load of society and also effective screening of donors at blood bank. Materials and methods: A retrospective study was conducted in our hospital blood bank from 2014-1016, to study the sero- prevalence and trends in TTI, including HIV, HBV, HCV, VDRL, and malaria. The total number of voluntary and replacement donors increased steadily in 3 years. Results: The sero- prevalence of HBV, HCV and HIV decreased steadily over 3 years, whereas incidence of syphilis increased steadily. HBV was noted to be more in voluntary donors than in replacement donors. Blood unit utilization index was calculated and ranged from 90.9% in 2014 to 88.9% in 2015 and 91.6% in 2016. Most common cause for discard of the blood units was TTI followed by expiry of products. Conclusion: Strict selection of blood donors is mandatory and is recommended to ensure safe blood supply. Voluntary blood donations need to be increased to decrease the incidence of TTI.

133-139

Authors: Porika Ram Mohan Lal, V. Dhananjay

Background: It describes a spectrum of conjunctival and corneal epithelial neoplasia, manifesting as Dysplasia, Carcinoma in Situ and Ocular squamous cell neoplasia (OSSN). Aim: To study the association between human immunodeficiency virus and ocular surface squamous neoplasia. Materials and methods: It was a prospective interventional study on total 60 eyes of 60 patients with Ocular squamous cell neoplasia (OSSN) was included in this study diagnosed Histopathologically. Bilateral and recurrent OSSN cases, which were diagnosed by repeat excision biopsy and HPE were included only once to exclude HIV statistics. Results: A total of 72 patients of clinical OSSN attended, the OP Department of Occuloplastics. 3 patients did not consent for surgery and were dropped from the study (2 HIV reactive 1 HIV non-reactive). 9 patients HPE negative for OSSN and were dropped from the study. 60 eyes of 60 patients were included in the study all had histopathologically confirmed diagnosis of OSSN. Minimum age was 6 years and maximum age was 80 years. HIV reactive and HPE positive OSSN was 12. 1 patient had lower lid palpabral conjunctival tumor OSSN – A typical presentation. CD4+ T lymphocytes of the patients were around 250 cells / cuml and below in all HIV positive patients. OSSN can occur from 6 years to 80 years Common age group for affection was 51 - 60 years i.e. above 50 years but it can affect any age group. This disease has male preference. HIV association was 20% of cases. Neglected old patients reported late i.e. 3.3% had radical surgery. Recurrence of the tumour was 3.3% so regular follow up is needed. OSSN develops when the CD4 counts were less than 250cell/cu ml. Conclusion: It can be concluded from the study that there is an association between HIV infection and OSSN.

143-145

Authors: Jain A, Patel N, Chandra Raychaudhuri, Dashore S

Nasal septal lesions are relatively common. Although most manifest with symptoms of nasal destruction, some are incidentally found. Acquired septal lesions may appear due to chronic inflammation and relative ischemia induced by repeated trauma due to nose picking. Because their imaging features often are nonspecific, the diagnosis usually is based also on the clinical history. Rhinotillexomania is a common and generally benign habit in adolescents and adults and only rarely leads to mutilating self-injury. Chronic self-mutilation with resultant loss of body parts occurs most often in schizophrenic and severely obsessive-compulsive patients. The most common symptoms produced by such lesions include nasal obstruction, nasal discharge, epistaxis, facial swelling, and pain. If a physical examination confirms the presence of a trauma, both MR imaging and CT may be used to characterize the finding.