International Archives of Integrated Medicine

1-11

Authors: Sujatha Audimulapu, M. Sudeepti

Background: AUB is a common gynecological complaint and it may involve females at any age group. 33% of women referred to gynaecology clinics have AUB and the figure rises to 69% in premenopausal and postmenopausal women. Aim: To compare the diagnostic efficacy of transvaginal ultrasonography and hysteroscopy in detecting uterine abnormalities in abnormal uterine bleeding by correlating the results with histopathological examination. Materials and methods: This was a prospective and comparative study which was conducted in Modern Government Maternity Hospital, Petlaburz, Osmania Medical College, and Hyderabad and it was conducted from November 2013 to July 2015. This study had 50 patients with AUB. Inclusion criteria: Women with abnormal uterine bleeding such as Heavy menstrual bleeding, intermenstrual bleeding, irregular and heavy bleeding, Regular, frequent and Heavy bleeding , postmenopausal bleeding , continuous bleeding , related to uterine causes. Exclusion criteria: Pelvic infection, Pregnancy, drug intake that can lead to vaginal bleeding (anticoagulants, hormonal replacement therapy, hormonal contraceptives), vaginal, vulval or cervical causes of bleeding. Informed consent was taken for all the patients, subjected to the study. Results: In the study, diagnostic hysteroscopy, transvaginal ultrasonography and hysteroscopy were done in 50 cases of abnormal uterine bleeding. Mean age of the patients enrolled in the study was 44.5±5.36 years. Most common bleeding pattern observed was Heavy flow with regular cycles (Menorrhagia) which was observed in 42% of the patients followed by Heavy flow with irregular cycles (Menometrorrhagia) which was observed in 26% of the patients in the study. With respect to parity of subjects, maximum incidence of abnormal uterine bleeding was seen in the parity of 2 (36%) followed by parity 3 (32%). Majority of patients came with 1-6 months duration of bleeding of AUB. Most common histopathology finding is Proliferative endometrium. Out of 50 cases, 38 cases (76%) of Hysteroscopy findings correlated with Histopathology and discrepancy in findings was noted in 12 cases (24%). In 26 cases (52%), TVS findings correlated with histopathology findings, and the results differed in 24 patients (48%). Sensitivity and specificity for Transvaginal ultrasonography is 62.8% and 86.6% in comparison with Sensitivity and Specificity of Hysteroscopy which is 74.3 % and 93.3 % respectively. Positive predictive value is 96.3 % and Negative Predictive value is 60.8% for hysteroscopy. Whereas, for Transvaginal ultrasonography, Positive predictive value is 91.6% and Negative Predictive Value is 50%. According to these findings, Hysteroscopy is superior to transvaginal ultrasonography in evaluating abnormal uterine bleeding because of higher sensitivity, specificity, positive predictive value, negative predictive value. Transvaginal ultrasonography is non-invasive, relatively cheap, causes minimal discomfort to the patient and can be used as the initial modality in patients with abnormal uterine bleeding. However, it has inferior diagnostic value when compared to hysteroscopy. Conclusion: In conclusion, although Transvaginal ultrasonography represents a practical approach for the initial evaluation of uterine pathologies, a hysteroscopy examination would be necessary in most of the suspicious cases. Hysteroscopy remains the best option for the assessment of AUB owing to its diagnostic performance when compared to Transvaginal ultrasonography. It allows direct visualization of the cavity and also sampling for histopathological examination.

20-32

Authors: T. Sundari Devi, Rajyalakshmi, S. Srujana, K.R.K. Prasad, O. Shravan Kumar

Background: Vaginal cytology is an efficient inexpensive and a rapid method for identifying diseases including establishing the hormonal condition of the patient. The Evaluation of the endocrinologic status of the female patient by means of the study of vaginal cells is actually one of the earliest diagnostic applications of clinical cytology. Though the vaginal cytologic characteristics of gynecologic patients have been studied throughout the world this subjected has received little attention. Vaginal cytology is useful for assessing ovarian function from puberty throughout the reproductive years, menopause and senium. Also it is used to estimate time of ovulation, to determine ovarian dysfunction, to assess placental function or dysfunction in obstetrics, to assist in selecting hormonal therapy and to follow hormonal treatment results. Aim and objectives: To ascertain the effective utilization of cost effective test of vaginal hormonal cytology as a supplement for costly biochemical hormonal estimation. A prospective study was undertaken with the following objectives: To study the normal hormonal patterns in females of different age groups and to study abnormal hormonal patterns in high risk pregnancies and in different clinical situations. Materials and methods: A prospective, hospital based study was done on vaginal smears obtained from One hundred and Sixty (160) patients, attending Gynecology and Obstetrics Out-patient department and few In-patients at Gandhi hospital, Secunderabad during the period of August 2004 to October 2006. The study group included randomly selected female patients of reproductive age groups (18 years to 35 years.);.with normal menstrual cycles; normal perimenopausal (36 years to 45 years.) and postmenopausal (above 45 years.) women, pregnant patients in the 1st, 2nd, 3rd trimesters and 1st stage of labour as well as post partum patients. The study group also included patients with primary infertility, menorrhagia, secondary oligomenorrhoea (scanty menstruation), threatened abortions, inevitable abortions, pre mature rupture of membranes, post maturity and patients with neoplastic lesion i.e. ovarian tumor. The material collected for the vaginal smear dried very rapidly during collection. Hence fixation was done within 30 sec. of spreading. The fixatives used were – 95% Ethanol or 80% Isopropyl Alcohol. Other fixatives used were ether / 95% alcohols; 100% methanol; Rapid fixative as cytospray; 2 to 10% carbowax in 95% ethanol (for mailing unstained smears). The stains used were Papanicolaou’s stain and Giemsa stain. Results: Vaginal hormonal cytology is a useful diagnostic aid in the female reproductive process. It may also provide a key to more effective conception control, as well as improvement in the treatment of menstrual disorders, anovulation, and other underlying disorders. In the present Indian scenario with lack of adequate clinical history available to the pathologist, in a rural setup as well the urban conditions; vaginal hormonal study is still a low cost diagnostic and prognostic test procedure. Hence the present study emphasizes the utility of vaginal smear study even today compared to the costly biochemical parameters available in the market which is a financial burden to poor patients. Conclusion: Vaginal smear collected between 4-11 days and 12-16 days of the normal menstrual cycle showed scattered intermediate and superficial cells. Vaginal smears collected between 17-28 days of normal menstrual cycle showed, predominately intermediate cells with folding and crowding. The KPI peak is between 12-16 days. This is extreme midzone shift, with clusters of navicular cells in all the three trimesters, of pregnancy. First stage of labour could be suspected with identification of increase in the number of superficial cells, with marked decrease in the intermediate cell values.

41-48

Authors: Karla Ravi, Nandigama Pratap Kumar, Savarapu Sai Kalyan

Background: Spondylolisthesis is defined as a displacement of one vertebra over the next lower vertebra in the sagittal plane. High-grade spondylolisthesis (HGS) is defined as greater than 50% slippage of a spinal vertebral body relative to an adjacent vertebral body as per Meyerding classification, and most common location being L5/S1 followed by L4/L5. The treatment of symptomatic high grade lumbo sacral spondylolisthesis has its own technical difficulties for surgical stabilization and fusion unlike low grade listhesis. We used single transvertebral fibular graft and implant stabilization to the vertebra one level above the pathological vertebra via posterior approach to treat the high grade spondylolisthesis of lumbo sacral spine. Materials and methods: Prospective study done from January 2012 to January 2016 for the management of High grade spondylolisthesis (Grade 3 and Grade 4), patient aged between 15-60 years. Total 15 patients were included in the study. High grade listhesis patients who were not willing for surgery were excluded from the study. All the patients were operated posteriorly with pedicle screw and rod stabilization with trans vertebral single fibular graft with posterolateral fusion was done under fluoroscopic guidance Results: Preoperative and post-operative status was analyzed in reference to the clinical symptoms and radiological evaluation. All the patients showed improvement following surgery without any implant failure. Conclusion: This procedure is technically simple, safe and effective method to treat high grade listhesis with no additional peri operative or postoperative complications.

64-67

Authors: Laxman Kumar, Prabhat Kumar Lal, Dhirendra Kumar, Jitendra Kumar, Sunil Kumar

Open defecation has many health hazards. Still, it is rampant in different parts of the country. The present study was conducted to find the prevalence of open defecation and factors associated with this behaviour among residents of rural area of Nalanda District. Open defecation was practiced by 35% of rural population. It was significantly associated with age (p=0.02), sex (p=0.01), education (p=0.00) and occupation (p=0.00). Association with caste (p=0.23), type of family (p=0.63) and type of housing (p=0.053) was not significant. Open defecation has strong roots in our culture and access/ availability of toilets poses many challenges.

72-76

Authors: Deepa Kalikavil Puthenveedu, Sundaraj Ravindran

Background: Diabetes mellitus is a major independent risk factor for cardiovascular disease (CVD). Excess abdominal fat, assessed by measurement of waist to hip ratio, is independently associated with a higher risk for cardiovascular disease. Aim and objectives: To study the fasting and post prandial lipid levels in patients with type 2 diabetes mellitus and to assess the significance of post prandial dyslipidemia with respect to fasting dyslipidemia as cardiovascular risk factor in these patients. Materials and methods: The study was conducted on 100 patients from General Medicine ward and Diabetology OPD of Government Rajaji Hospital, Madurai, and 100 age and sex matched healthy subjects as controls during the period of March 2016 To August 2016. Subjects believed to fulfil all eligibility criteria, and none of the exclusion criteria were included in the study. A predesigned proforma was used to collect the demographic and clinical details of the patients and the controls. By Clinical examination abdominal obesity was measured by waist hip ratio WHR>.90 in men and WHR>.80 in women were taken as having significant cardiovascular risk. Laboratory investigations fasting Blood Sugar, 2hr Post Prandial Blood sugar, fasting lipid profile and 6 hours post prandial were done. Comparison of various parameters were done and significance assessed by Student t test. One way ANOVA, Pearson Correlation and Chi square test and P value of < 0.05 was taken as significant. Results: Among the 100 cases of Type 2 Diabetes mellitus, by taking value of WHR 0.90 for males and 0.8 for females, the cardiovascular risk was assessed. 96 had cardiovascular risk (50 male, 46 females). By comparing with the standard reference values of the lipid profile out of the 100 diabetic subjects 53 had fasting dyslipidemia (29 males, 24 females) and 64 had post prandial dyslipidemia (23 males , 41 females). We observed a significant increase in both fasting as well as postprandial blood glucose levels in the Type 2 Diabetic subjects, as compared to those of their respective controls. Also, the postprandial blood glucose level was significantly increased as compared to that in the fasting state in the Type 2 Diabetic subjects but the HDL-cholesterol level was not significantly decreased in fasting as well as postprandial state in the Type 2 DM patients as compared to that of control subjects in our study. Conclusion: Persistent postprandial hypertriglyceridemia may result in a proatherogenic environment leading to atherosclerosis and macrovascular disease in type 2 diabetes subjects. LDL oxidation in the postprandial state seems to be affected by an acute increase in glycemia. Thus, oxidative modification of LDL may contribute to higher CVD risk among diabetic patients, and elevated levels of TG may contribute to the rapid LDL oxidation seen in Type 2 DM. Hence, it is important and beneficial to estimate the postprandial lipid profile, in addition to the fasting lipid profile, in the cardiovascular risk assessment in the patients with Type 2 DM.

81-86

Authors: Ganganesamy, S. Dharmarajan

Background: Gallstones, complex biomineralized deposits formed in the gallbladder, are still a major health problem all over the world. Cholelithiasis is common with the incidence ranging from 10% to 20% of the world population. Over the past two decades, a great deal has been learned about the epidemiology of and risk factors for gallstones. Ultrasonography has played a major role in this process, providing a rapid, risk-free method of screening large populations. Prior to the availability of ultrasound, most studies relied on highly selective autopsy data and limited oral cholecystography. Aim and objectives: To determine the Biochemical analysis of Gall stones and to study the clinical spectrum of acute cholecystitis. Materials and methods: About 50 consecutive cases were admitted, examined, investigated and diagnosed as calculus cholecystitis during the period of January 2016 to September 2016 are selected and detailed history of all the 50 cases were taken according to the proforma. Information regarding the age, nature of the symptoms, and duration of the symptoms, diet history, and history of OCP intake, Alcohol ingestion, and diabetes were obtained. All patients’ undergone detailed examination underwent investigations. Results: All cases fall between 22 and 75 years. There is an increased incidence in the 5th and 6th decade with the maximum incidence in the 5th decade. Pain abdomen was the most common presenting symptom in our study seen in 49 (98%) of the cases followed by fever in 17 (34%) cases. Dyspepsia was seen in 12 (24%) cases, 7 cases (14%) each presented with nausea/vomiting or jaundice. Among the ultrasonographic findings of cholelithiasis most common finding was thickened gall bladder wall seen in 40 cases (80%) Ultra sonogram revealed 76% (38 cases) had multiple stones and 24% (12) has solitary stone. Mass was seen in 5 cases (10%).Of the total 50 cases with cholelithiasis 38 patients (76%) had mixed stones, followed by pigment stones in 8 cases (16%) followed by cholesterol stones in remaining 4 cases (8%). Majority of the patients were in the age group 41-50 (32%) followed by the 51-60 age group (24%). Conclusion: Majority of patients underwent Laparoscopic cholecystectomy (86%) with reduced number of stay in the hospital, pain and disability as compared to open cholecystectomy. The commonest type of stone was mixed stone. Most of the gallstones were associated with grade 1 cholecystitis (78%), Grade 2 cholecystitis was seen in 20% of our study patients, Grade 3 was seen in 2% of our study patients.

91-95

Authors: P. Gunasekaran

Background: The common cause of skin infections are dermatophytes and opportunistic fungi. Aim of this study was to isolate and identify the fungal agents from clinical samples from patients with different mycoses. Superficial mycoses are among the most frequent forms of human infections, affecting more than 20–25% of the world’ population. They are predominantly caused by a group of closely related keratinophilic mycelia fungi (dermato-phytes) in the genera of Trichophyton, Microsporum, and Epidermophyton. These groups of fungi invade the stratum corneum of the skin or other keratinized tissues derived from the epidermis such as hair and nails. Aim and objectives: The present work aims at evaluation of rate of incidences of dermatophytic infections (group wise), and etiological agents with associated symptoms. In addition, we also determine to test the sensitivity of present diagnostic procedures. Materials and methods: Samples were collected from 100 patients. A portion of each sample was examined microscopically and the remaining portion of each sample was cultured onto plates of Sabouraud’s dextrose agar containing chloramphenicol with and without cycloheximide. Dermatophyte isolates were identified by studying macroscopic and microscopic characteristics of their colonies .Preliminary identification was done by conventional methods and confirmed by Polymerase Chain Reaction – Restriction Fragment length Polymorphism (PCR -RFLP) technique. Results: All over 62/100 specimens were KOH positive and 48/62 (82.7%) samples were culture positive. Of these, highest isolation rate was obtained in opportunistic mycoses such as candidiasis (29/29, 100%). Dermatophytes were isolated in 41/62 (66.3%) specimens and Trichophyton rubrum was the commonest isolate in skin samples (44/62) among the patients suffering from dermatophytosis. Phaeoannellomyces Wernicke was isolated in a patient suffering from tinea nigra. The study signifies the importance of mycological examination in the diagnosis of various mycoses for their effective management. Conclusion: Dermatophytoses are distributed worldwide with increased incidence especially in a tropical country like India. Several factors such as age, sex, illiteracy, poor hygiene and social economy influence the dermatophyte infection. In the present study we have attempted to understand the epidemological status of the dermatophytes in a tertiary care centre in Cuddalore, Tamil Nadu, India. Tinea corporis was the predominant clinical site from which dermatophytes were isolated. T. Rubrum and T. Mentagrophytes have been the major etiological agents and that has been evinced by our study.

103-107

Authors: N. Sreemani Kumari, Madhavi Parigi, Seema Afroze

Background: Rhinosporidiosis is a chronic granulomatous disease caused by Rhinosporidium seeberi which was once believed to be a sporozoan and then was included in phycomycetes, and now included under Mesomycetozoa. It is one of the common tropical diseases, most commonly affecting the mucosa of upper respiratory tract, chiefly the nose and nasopharynx. Other sites such as conjunctiva, lacrimal glands and subcutaneous tissue may also get infected. It presents as polypoidal mass. Aim and objective: To study incidence, age and gender distribution and clinicopathological features of Rhinosporidiosis. Materials and methods: A retrospective study of 20 cases was undertaken over a period of 5 years (July 2012 to June 2017) in the Department of Pathology, Government ENT Hospital, Hyderabad. The resected tissue specimens were subjected to routine processing, cutting; staining and histopathological features were studied with Hematoxylin and Eosin stain. Results: Nasal cavity was most commonly involved site, excepting in one case, where sub-glottis was involved. Males were predominantly affected i.e. 17 (85%) cases, whereas 3 (15%) cases were reported in females. Age range was between 8-70 years. (Both of them were males). Conclusion: Rhinosporidiosis most commonly presents as polypoidal mass in the nasal cavity and may also present at extra-nasal sites. Histopathology is the standard method for confirmation of diagnosis.

116-120

Authors: V. Sivagangailakshmi, D. Rajkumar

Introduction: Cigarette smoking is one of the major causes of cancer and cardiovascular diseases leading to millions of premature deaths each year all over the world. Scientists have identified about 4,000 different substances in tobacco all of which have certain degree of toxic effects. At least 43 of them are known carcinogens. Cigarette smoking is an important and independent risk factor for atherosclerosis, coronary artery disease and peripheral vascular disorders. Apart from active smokers, passive-smokers are also prone for the development of smoking related disorders. Smoking adversely affects the concentration of the coagulation profiles which causes abnormalities in circulation. Aim and objectives: This study aimed to investigate the effects of smoking on coagulation profile in chronic smoking population. Materials and methods: This present study was a case‐control study conducted among 50 smokers (subjects) and 50 non‐smokers (controls) aged 20‐50. Coagulation profile markers such as Prothrombin time (PT), activated partial thromboplastin time (APTT) and fibrinogen levels were estimated with standard methods. Results: The results showed that the mean values of PT and APTT of smokers were significantly prolonged compared to non-smokers (P < 0.05), while platelet and fibrinogen levels were significantly lowered in smokers compared to non-smokers (P < 0.05). PT and APTT were also significantly prolonged with increasing duration of smoking as well as number of cigarettes per day, while there was a relative decrease in platelet and fibrinogen levels with increasing duration and number per day. Conclusion: It was concluded that cigarette smoking alters PT, APTT, platelet and fibrinogen values, while age, duration of smoking and number of cigarettes per day were determinant factors to the extent of coagulation dysfunction in smokers.

126-132

Authors: Singh L, Garg P, Rathore S, Nishant, Singh VP, Lal BB

Background: POAG occurs in elderly, rarely seen earlier than 40 years of age and tends to run in families. Glaucoma is a neurodegenerative disease characterized by the slow, progressive degeneration of retinal ganglion cells. Aim: To study the changes, in retinal nerve fibre layer thickness in primary open angle glaucoma (POAG). Materials and methods: The present cross sectional study was carried out at a tertiary care hospital in North India. 100 patients of primary open angle glaucoma were matched with 100 controls and evaluated with the aim to assess their RNFL thickness and compare with each other. Results: The data distribution analysis of retinal nerve fibre layer thickness in different optic nerve head quadrants in POAG group in relation to overall severity of glaucoma shows that in superior quadrant maximum number of patients in preperimetric group 6 (50%) cases, in mild 9 (45%) cases and in moderate group 25 (44.6%) were in the range 100±10μm. But in severe glaucoma cases majority 7 (58.3%) cases had the RNFL thickness in the range of 60±10 μm. The temporal quadrant RNFL thickness was least in all grades of severity of glaucoma i.e. preperimetric 6 (50%), in mild cases 9 (45%), in moderate 25 (44.6%) cases and in severe 8 (66.7%) cases. Conclusion: Overall RNFL thickness variation, regardless of severity of glaucoma, follow the normal pattern of thickness being thicker in superior and inferior quadrant compared to nasal and temporal quadrant. It was interesting to note that the RNFL thickness in all the quadrants of optic nerve head area continues to become thinner as the severity of glaucoma increases.

139-142

Authors: Chandra A

The current World Health Organization classification of renal epithelial tumours recognises malignant lesions such as, clear cell, papillary, chromophobe and collecting duct renal cell carcinomas (RCCs), and benign entities such as oncocytoma and angiomyolipoma. Chromophobe renal cell carcinoma (RCC) is a rare variety of kidney neoplasm that represents approximately 5% of RCC. As the prognosis of chromophobe RCC depends upon early detection and typing of the RCC, meticulous histopathological examination of nephrectomy specimen is must.