International Archives of Integrated Medicine

1-6

Authors: Vijaya Nirmala B, Ramana P.V.

Back ground: Pancytopenia is a common haematological finding in clinical practice. It is a striking feature of many serious and life-threatening illnesses, ranging from simple drug-induced bone marrow hypoplasia, megaloblastic anaemia to fatal bone marrow aplasias and leukaemia. The severity of Pancytopenia and the underlying pathology determine the management and prognosis. Thus, identification of the correct cause will help in implementing appropriate therapy .Pancytopenia is a common haematological finding for which bone marrow aspiration is conducted. Aim: To study the bone marrow aspiration smears in Pancytopenia cases and correlating with peripheral smear and clinical findings to arrive at a diagnosis. Materials and methods: This was a study conducted at Department of Pathology, Gandhi Medical College on 148 cases of Pancytopenia presenting over a period of 2 years. Clinical findings, complete blood counts and peripheral smear findings were recorded and Bone marrow aspiration was done. Smears were stained with Leishman stain. Perls’ stain was done in all cases. Special stains like MPO, PAS, Reticulin staining was done if needed. Results: Out of 148 cases of Pancytopenia 67 cases were males and 81 were females. Most of the cases were in the age group of 10-20 followed by 20-30. Megaloblastic Anaemia was found to be the most common cause of Pancytopenia followed by hypoplastic marrow. Conclusion: A thorough Evaluation of bone marrow smears can diagnose underlying pathology in most cases of Pancytopenia. Correlating bone marrow features with clinical and haematological findings aid in diagnosing and management of most cases of Pancytopenia.

14-20

Authors: K. Babu Raj, R. Prabhakaran

Background: The etiology of diabetes in India is multifactorial and includes genetic factors coupled with environmental influences such as obesity associated with rising living standards, steady urban migration, and lifestyle changes. It is a chronic disease, and as it prolongs it has many serious effects on multiple organs of the body. Keeping a view of the above-said problem, there arises a need for rigorous control of diabetes mellitus. However, rigorous control of diabetes leads to more incidence of hypoglycemia in elderly diabetic patients. Hypoglycemia has serious complications leading to various morbidity and mortality. Aim and objective: To study the risk factors associated with the development of hypoglycemia in elderly diabetic patients, to study about the symptoms occurring during the hypoglycemic episodes. Materials and methods: The study included 100 patients: Group –A 50 diabetics and Group B controls. Age and sex-matched diabetic patients >60 years admitted during the same period in RMMCH. Details of the hypoglycemic episode (symptoms, severity, glucose level, risk factors identified, treatment and outcome), comorbidities, polypharmacy, alcohol use and assessment of functional status Assessment of the functional status was done using Katz score. Results: Functional status of patients were assessed with KATZ index only 10 out of 50 study patients had poor (Katz score=0) functional status. 52% patients had their episodes during night time. 34 patients (68%) had come to the hospital with hypoglycemia and the rest of the patients developed hypoglycemia in-hospital stay. 70% of patients had symptoms and 30% had no symptoms. Neuroglycopenia was predominant in most patients. Conclusion: Asymptomatic hypoglycemia was common in the elderly diabetics. In symptomatic patients, neuroglycopenic symptoms were more commonly encountered than autonomic symptoms. The mean duration of diabetes mellitus was longer in the group of study patients with no symptoms of hypoglycemia as compared to patients who were symptomatic for hypoglycemia.

28-33

Authors: K. Babu Raj, B. Nageswaran

Background: The etiology of posterior circulation ischemia has been thought to be primarily due to local arterial atherosclerosis (large artery disease) and penetrating artery disease (lacunes). However, there is increasing evidence that cardiogenic embolization is more common than previously suspected and is responsible for 20-50% of posterior circulation strokes. Aim and objective: To study the clinical manifestations, risk factor profile, and prognosis in this sample of patients. Materials and methods: 54 cases of posterior circulation strokes, admitted to the Department of Medicine, Rajah Muthiah Medical College, and Hospital, Chidambaram, during the period from September 2016 to October 2017, who fulfilled the inclusion criteria, were taken up for the study. Results: Out of 54 patients, 48.1% had hypertension, 37.0% had diabetes, 37.0% had tobacco abuse, 37.0% had alcohol abuse, 40.7% had dyslipidemia, 7.4% had TIA/Stroke, 11.1% had RHD, 27.8% had IHD and 7.4% had MVP as predisposing factors. Majority of the patients had hypertension as a risk factor followed by dyslipidemia. Many patients had multiple predisposing factors. 46.3% had their consciousness impaired, 59.3% had speech disturbances, 13.0% had cranial nerve involvement, 55.6% had motor disturbances, 13.0% had sensory disturbances, 48.1% had cerebellar signs, 37.0% had nystagmus and 44.4% had fundal changes. Majority of the patients had speech disturbances on clinical examination. Conclusion: Majority of the patients had Hypertension (48.1%) as a risk factor followed by Dyslipidemia (40.7%). Many patients had multiple predisposing factors. There is an increased association between coronary artery disease and posterior circulation strokes in our study (27.8%). Infratentorial lesions (50%) were more common than supratentorial lesions (38.9%) and both combined (11.1%). The mortality associated with posterior circulation strokes in our study is 16.7%. Majority of the patients had no disability (22.2%) or slight disability (18.5%).

39-43

Authors: V. Sivangagai Lakshmi

Background: Smoking harms nearly every organ of the body and diminishes a person’s overall health. Millions and millions of peoples have health problems due to the habit of smoking. It is now a burden worldwide because smoking addiction of teenagers increasing immensely. Globally, smoking is not only a leading cause of cancer as well as various heart diseases. Smoke contains several carcinogenic pyrolytic products like Polycyclic Aroma0tic Hydrocarbons (PCAH), acrolein etc. are irreversible binds to DNA, causes genetic mutation and cancer. Aim: To evaluate the effect of smoking on Blood biochemistry parameters. Materials and methods: Totally 68 subjects were included in the study. 34 current smokers who came from in and around Chidambaram to the RMMC and Hospital who fulfilled the inclusion criteria were selected as an experimental group. Another 34 non-smokers of the same age group were included separately in this study as a control group. So a total of 68 respondents were contacted for the study. The primary data were collected during the 2016-2017 period of around one year. biochemical parameters such as blood glucose, blood urea, and lipid profile were analyzed using standard methods. Results: While comparing the mean Blood sugar, Serum Cholesterol, Triglycerides, HDL, and LDL values, it was found to be more in smokers compared to that of non-smokers and this was significant at 5% level for Blood sugar and at 1% level for other values like cholesterol, TGL, HDL, and LDL. The mean Blood urea value had no significant association with smoking. Conclusion: Subchronic and acute exposure to tobacco smoke and various tobacco smoke constituents have been shown to elicit a wide variety of cardiovascular effects in animal models. These effects include decreased oxygen-carrying capacity, resulting in ischemia, platelet activation, endothelial damage, altered lipoprotein levels and increased arterial wall thickness which can promote atherosclerosis, and thrombosis. Ischaemia, atherosclerosis, and thrombosis increase the risk of myocardial infarction and other serious cardiovascular effects.

48-53

Authors: Mirunalini S

Background: Perinatal asphyxia is a major cause of acute mortality and chronic neurologic disability amongst survivors, and is a complication that occurs between 2-10% of deliveries. No single parameter can define perinatal asphyxia, rather a combination of parameters like fetal distress, meconium-stained liquor, low Apgar score, umbilical cord blood pH and clinical features of hypoxic-ischemic encephalopathy (HIE) can predict it. Aim: To study the correlation between nucleated red blood cell count (NRBC), fetal acidosis and clinical markers of asphyxia. Materials and methods: 52 pregnant women with fetal distress as a study group and 51 pregnant women without distress as a control the ed group were selected and their cord blood was analyzed for pH and nucleated RBCs. The results were analyzed. Result: Higher NRBC count was detected in the study group with signs of asphyxia (Thick MSAF, Non-Reassuring FHR Pattern, Low APGAR score). Conclusion: NRBC count is a simple bedside test to diagnose fetal asphyxia. Since it is cost-effective and does not require any special expertise or any high-tech facilities, it may be a useful, reliable, inexpensive and easily available markan er to evaluate perinatal asphyxia, especially in a resource-poor country like ours, where blood gas analysis facilities are not available in the majority of place.

58-62

Authors: R. Manimozhi Malathi, S. Ramesh, D. Rajkumar

Background: Malnutrition is an important factor that influences the course of pregnancy and fetal development. It is a serious international problem which leads to a deficiency of metals, trace elements, vitamins, and proteins. Much attention has been given to the effects associated with protein deficiency. Nowadays the effects due to the deficiency of trace elements have been given much importance. Trace elements are essential for life. Deficient intake- leads to impairment of some functions. The impairment may be corrected by intake of the element in physiological amount. With the deficiency of these elements, the organisms can neither grow nor complete its life cycle. Death of an organism results when there is an absolute deficiency. Aim: To compare serum iron and zinc level in term and preterm babies. Materials and methods: Sixty pregnant women who came from in and around Chidambaram who fulfilled the inclusion criteria during the period from July 2001 to March 2002 were included in this study. Among them, 50 delivered at term (37 to 42 weeks) and the rest delivered prematurely (< 37 weeks). Serum iron and zinc level were estimated by standardized technique. The results are analyzed accordingly. Results: The estimated mean iron value for the term babies was found to be 114.34 μg/dl with the standard deviation of 34 μg/dl. In case of preterm babies, the estimated mean value for iron was found to be 97.35 μg/dl with the standard deviation of 46 μg/dl. The mean zinc value of term babies was found to be 76.26 μg/dl with the standard deviation of 23 μg/dl. For preterm babies mean zinc value was found to be 56.53 μg/dl with the standard deviation of 29 μg /dl. Conclusion: Preterm birth deprives the fetus of a significant accumulation of iron in storage that occurs beyond 32nd week, total body iron deposits in tissues, Hb and zinc are low in premature babies. Iron deficiency affects perinatal growth, maturation, and function of multiple organ systems including the heart, skeletal muscle, gastrointestinal tract, and brain. Anemia of prematurity has been defined as low hematological constant levels of hemoglobin (Hb), hematocrit (Ht), serum iron, number of erythrocytes, the reticulocytes.

67-73

Authors: M. Agila Saravanan, S. Geetha

Background: Reduced production of thyroid hormone is the central feature of the clinical state termed Hypothyroidism. Hypothyroidism is associated with bradycardia, a decreased cardiac output, increased vascular resistance and perhaps a decreased sensitivity of the sympathoadrenal system. Aim and objective: To assess the cardiovascular functions in diagnosed hypothyroidism patients. Materials and methods: A total number of 70 hypothyroid patients were enrolled in this study. The clinical features, cardiovascular manifestations were studied by ECG, ECHO, chest X-ray lipid profiles. Results: Most of the cases fell in the age group of 31-40 years at a percentage of 52.9%. On analysis of 70 cases, 41% of cases were in moderate hypothyroidism group. On analyzing the pulse rate of 34% of the cases had bradycardia (PR <60/min). Mean BP- 131/84 mm Hg (Range: 118-166/66 – 102 mm Hg). Most of the patients fell into the pre-HT group which was around 66%. 24% of hypothyroid patients were hypertensive (BP >140/90 mm Hg). Lipid analysis in hypothyroid patients showed an increase in total cholesterol. 54.3% of patients had hypercholesterolemia (> 300 mg/dL). On analyzing the ECG changes in hypothyroid patients the most common finding was sinus bradycardia. It was found in 39% of cases. Next was low voltage complex which is around 34%. Normal ECG was found in 14% of patients. Least common findings were ST-T changes, RBBB and LBBB. Out of 70 cases, 12 (17.14%) patient showed enlarged cardiac silhouette (cardiomegaly). 34% of the patients had pericardial effusion. 30 % of the patients had diastolic dysfunction. Systolic dysfunction occurred in 4.3% of them, while IVST and LVPWT were seen in 14.3% and 12.9% respectively. Conclusion: Any unexplained diastolic dysfunction or pericardial effusion should be screened for hypothyroidism. Early detection of hypothyroidism and proper replacement therapy found to reverse the cardiovascular complications and thereby can decrease the morbidity and mortality.

83-90

Authors: E. Rajesh Goud, M. Muralidhar, M. Srinivasulu

Background: The advances in diagnosis and treatment, in the management of breast cancer have led to excellent cure rates for tumors detected in early stage. Even patients with stage III disease have 5 years survival rates in the range of 50-70%. The search for predictive and prognostic factors in breast cancer represents a major challenge. It is important to distinguish prognostic factors from predictive factors. Aim: The aim of the surgery was to compare the immunohistochemical expression of estrogen, progesterone and Her-2 receptor status in breast cancer before and after neo-adjuvant chemotherapy. Materials and methods: In this study, the total of 50 cases of locally advanced breast cancers was included. Cases of carcinoma breast requiring preoperative chemotherapy from January 2015 to January 2017 were recruited in to the study after informed consent. Results: In this study, the total of 50 cases of locally advanced breast cancers was included. Among them most of the cases belonged to the age group of 40 to 60. The extremes of ages (<30 and >60) comprised of only 14 % of the cases. In total of 50 cases 32 patients were pre-menopausal which was accounting for 64% of cases, and remaining patients were post-menopausal. Out of 20 cases of triple negative in this study complete response was seen in 6 cases accounting for about 30%. In our study there were a total of 24 changes in the receptor status post chemotherapy altogether out of which 11 changes were seen in Her2neu group. Changes in the ER and PR group accounted for 8 and 5 cases respectively. Out of 14 cases of ER positive before chemotherapy, conversion was seen in 8 cases accounting for change in ER status of 57%. Similarly 5 changes were seen in PR receptor expression accounting for 62% of change. All the changes found were loss of expression of receptor after NACT means receptor positive cases became receptor negative. Conclusion: Breast cancer subtypes are associat¬ed with the response to NACT. The response rates for the HE and TN subtypes were significantly higher than for the luminal subtypes. So it is mandatory for a patient with breast cancer who is scheduled for NACT should be assessed for the subtype of breast cancer before NACT, by using IHC, for planning treatment. This study also revealed that change in receptor status did occur after neo-adjuvant chemotherapy.

99-104

Authors: Shriraj Kane, Shikhar Bajpai, T K Biswas

Background: Chronic Obstructive Pulmonary Disease (COPD) is defined as a preventable and treatable lung disease with some significant extra-pulmonary effects. Pulmonary component is characterized by airflow limitation that is not fully reversible, usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles and gases. Elderly patients are more prone to COPD due to the reduction in the immune power along with the muscle weakness of the chest wall and bone weakness. Aim and objectives: To study the COPD in elderly with reference to HRCT chest and PFT, to study the pattern of pulmonary involvement in COPD in elderly. Materials and methods: It was Prospective observational study. Study population was elderly patients (age ≥60 years) detected having COPD (both in-patient and out-patient) attending MGM Hospital for treatment. Detailed history was taken from patient, particularly history of symptoms like fever, cough, shortness of breath, weight loss, night sweat etc. Thorough physical examination of all the systems with special emphasis on respiratory system was done. Results: Total 50 patients were enrolled in the study. Majority of the patients (44%) were in the age group of 60-70 years followed by 32% in the age groups of 70-80 years and 24% patients in the age group of >80 years. The mean age of the patients was 72.76±7.58 years. There was male preponderance (72%) in the study. Majority of the male patients were smokers (61%). Dyspnoea (76%), cough (68%), sputum production (64%) were the common symptoms. Centriacinar emphysema (34%) was mostly observed. FEV1/FVC ratio ranged from 38-89% (mean 62.9+/-18.52%) preinhalation, ranged from 45% to 90% (mean 69.26±15.08) post-inhalation. Conclusion: HRCT showed regional assessment of compartment involved and has greater sensitivity than chest radiography in early diagnosis of emphysema.

118-121

Authors: Bhavik Shah, S.S. Goswami

Testicular neoplasms are common cause of morbidity in both pediatric age group as well as adult. In testicular teratomas various types of tissues are present which represent the different germ layers (endoderm, mesoderm and ectoderm).Typically they appear at any age, but are usually much more common in pediatric patients, where they comprise up to 30% of all tu¬mors. In most of the reports, mature testicular teratomas likely to be diagnosed in a younger age group. Here, we report a mature testicular teratoma of the testis in a 55-year-old man which was quite rare especially in old age.

125-128

Authors: Vaibhavi Chaudhari, Jigna Patel

Malignant melanoma is a highly malignant tumor that is derived from melanocytes. The incidence of malignant melanoma has risen markedly over the last decade. Malignant melanoma mostly occurs in the skin, mucous membranes and the choroid. The cases of primary mela¬noma of the breast are quite rare. Observation of the clinical pathological features, immunohistochemical staining methods and tissue origin are required to identify primary malignant melanoma of the breast. This case report of primary malignant melanoma is presented because of its rarity.

133-142

Authors: Latifa Alanazi, Ghada Alhindi, Yara Alanazi, Sarah Alseneidi, Bashayer Alanazi, Dalal Alshagha, Munira Alghufaily

Langerhans cell histiocytosis (LCH), a rare proliferative disorder of cells that share phenotypic characteristics with dermal Langerhans cells, has long been considered an “orphan,” or neglected disease. Prior to its current designation, LCH was known as Hand–Schuller–Christian disease, Letterer–Siwe disease, or eosinophilic granuloma, which was combined under the umbrella designation of Histiocytosis X. The pathogenesis of LCH has remained unclear since the initial reports approximately 100 years earlier, and gene expression studies have demonstrated that these tumors do not originate from dermal Langerhans cells. It remains unclear whether LCH is reactive or neoplastic, although these tumors manifest a unique self-healing phenomenon that is rare among malignancies. The clinical presentation of LCH varies according to the involved organ/system, including common manifestations such as otitis media or pneumothorax or unusual manifestations such as diabetes insipidus. Accordingly, LCH cases are classified according to the number of involved organs/systems and sites, as well as the involvement of so-called “risk organs”. This review aimed to highlight recent insights as a better understanding of LCH will lead to more effective therapies.

1-8

Authors: K. Babu Raj, G. Sivachandran

Background: Cardiovascular disease (CVD) has emerged as the dominant chronic disease in many parts of the world. At the beginning of the twenty-first century, CVD accounts for nearly half of all deaths in the developed world and 25% in the developing world. Diabetes mellitus (DM) refers to a group of common metabolic disorders that share the phenotype of hyperglycemia. Vascular diseases account for most morbidity and mortality in patients with DM. Aim and objectives: To study the clinical profile of type 2 diabetic patients presenting with Acute Coronary Syndrome (ACS) with reference to HbAlc level. Materials and methods: After selecting appropriate samples for the study based on the inclusion criteria, a detailed history was elicited and clinical examination was done as per the proforma. The necessary investigations were done as per the proforma. The clinical profile of these patients was then analyzed and correlated with reference to HbAlc level and statistical analysis performed using paired’ test. Results: The prevalence of microvascular diabetic complications was high with nephropathy amounting to 62% and retinopathy amounting to 58%. Neuropathy was not documented. About 32% of patients were free of microvascular complications. Other macrovascular diabetic complications were not documented. Among complications of ACS, 24% developed hypotension and no other complication was noted. Remaining 76% did not suffer any complications. No mortality was documented. Patients with systolic dysfunction constituted 82% and diastolic dysfunction 66%. The percentage of patients with HbA1c >7% constituted 62% which was very high and only 32% of patients had their HbA1c level in the control range. Conclusion: A majority of diabetic patients developing acute coronary syndrome have poor glycaemic control as reflected by their HbAlc levels. The coronary event is likely to occur sooner after the detection of diabetes if good glycaemic control is not achieved. Exercise, in the form of regular day to day activities, does not achieve satisfactory glycaemic control and cannot prevent the development of adverse complications of diabetes.

17-29

Authors: Maskuri Soujanya, Nama Nagarjuna Chakravarthy, G. Venkateshwarlu

Introduction: Laparoscopic surgery is a routinely performed surgery and it is desirable to have stable intra-operative hemodynamic states by avoiding hypertension and tachycardia. Various drugs have been employed to attenuate this hemodynamic response. No single drug is satisfactory. Thus there is a need to find a simple efficient and reliably consistent method. Aim: The present study was undertaken to evaluate the comparison of Dexmedetomidine and Esmolol on perioperative hemodynamic response during laparoscopic cholecystectomy. Materials and methods: Prospective, randomized, controlled, single blinded trial comparing dexmedetomidine (alpha 2- agonist) and esmolol (beta 1-antagonist) done by allocating into two groups. It was conducted in 60 patients of both sex, belong to ASA I and ASA II of age group 20-60 years admitted for laparoscopic surgery from 2016-2017. They were randomly divided into two groups of 30 patients each. The Heart rate (HR), Systolic blood pressure (SBP), Diastolic blood pressure (DBP), Mean arterial pressure (MAP) were recorded prior to induction, after the induction, after the intubation, 15 min, 30 min, 45 min, 60 min after creation of pneumoperitoneum, post pneumoperitoneum, after extubation. Results: Heart rate and systolic blood pressure were significantly lower in Group A after induction, after intubation, and maintained throughout intraoperative and postoperative period compared to Group B. Diastolic blood pressure were significantly lower in Group A after intubation, and maintained throughout intraoperative period and at extubation compared to Group B. Diastolic blood pressure was not significant after induction, at postoperative period. Mean blood pressure were significantly lower in Group A after induction, after intubation, and maintained throughout intraoperative period and at extubation compared to Group B. Mean blood pressure were not significant at postoperative period. Conclusion: Dexmedetomidine is more effective agent than esmolol in maintaining stable hemodynamics during and after pneumoperitoneum in laparoscopic cholecystectomy.

41-46

Authors: Bhuvanesh Kumar Kahar, Sushma Pandey, Ankush Agrawal, Darab Singh, Ravindra Kumar Sharma

Background: Diabetes mellitus is one of the six primary risk factors identified for MI, others being dyslipidaemia, smoking, hypertension, male gender, and family history of atherosclerotic arterial disease. Diabetics have been shown to have poor outcome after post-thrombolysis in acute STEMI compared to non-diabetics. Objective: To Compare, Post Myocardial Infarction in Hospital Patients Prognosis After Thrombolytic Therapy In Diabetics versus Non-Diabetics. Materials and methods: This was a prospective cross sectional study done at Jhalawar Medical College and Hospital, Jhalawar on 139 patients from October 2016 to September 2017. Consecutive patients with ST segment elevation MI, who were not treated with primary angioplasty, but were thrombolysed with Streptokinase were recruited at the time of arrival in emergency department. ECG was taken at baseline and 2 hour after STK administration. Patients were divided in two groups A) Non-diabetics B) Diabetics. Total 139 patients 85 are diabetics and 54 are non-diabetics. Results: In non-diabetic group (54), ST segment resolution occurred in 77.76 % patients as compared to diabetic group (85) in which only 31.76% patients had ST segment resolution. Diabetics had more complications such as recurrent chest pain, heart failure, arrhythmias, death as compared to non-diabetics. Conclusion: Diabetics with acute myocardial infarction have worse prognosis as predicted by incomplete ST segment resolution in ECG after thrombolysis.

55-63

Authors: Roobal Behal, Suhail Majid Jan, Huda Hussain

Background: Patient compliance plays a decisive role in the outcome of periodontal therapy. Although a number of reports have studied patient compliance and its variables during supportive periodontal therapy, there is a paucity of literature on factors affecting compliance to active periodontal therapy. Moreover, as health beliefs largely stem out of social/religious/ethnic convictions, population specific compliance studies are highly relevant. It is foreseeable, that early identification of compliance-affecting variable will enable institution of a timely and personalized patient education/ motivation programme. Aim: To elucidate factors which affect patient compliance during active periodontal therapy in patients visiting Government dental college and hospital, Srinagar. Materials and methods: 150 patients were included in the study for performance of active periodontal therapy (scaling and root planing) over 3-5 visits every 5 days. They were subjected to pre-validated questionnaire to assess their sociodemographic factors, oral health awareness (OHA) and treatment satisfaction (TS). Results: Sociodemographic factors (education, emplyoyment and gender), OHA and most of all TS were found to influence patient compliance in the given population. Conclusion: Certain sociodemographic factors have a bearing on patient compliance and may be assessed as predictors of compliance to therapy. As treatment satisfaction has a profound effect on the patient’s willingness to return for treatment, it should be an objective of the overall clinical practice. Pertinently, the crucial role of the periodontist in patient education and management should be realized and utilized to achieve predictable compliance.

72-80

Authors: Rahul Sudan, Mehroz Ahmed, Imtiyaz Ahmed Wani, Muzaffar Maqsood Wani, Khurshid Ahmed Banday, Gunjan Gupta

Background: Chronic Kidney Disease (CKD) is one of the most common causes of morbidity and mortality due to renal causes. There are multiple causes of CKD with diabetes, hypertension and chronic glomerulonephritis among the most common causes. All of these causes gradually lead to the final common pathway of End stage renal disease (ESRD). Chronic Kidney Disease (CKD) is defined as Kidney damage for ≥3 months, as defined by structural or functional abnormalities of the kidney, with or without decreased GFR or GFR <60 mL/min/1.73m2 for ≥3 months, with or without kidney damage. Aim: To study the profile of Chronic Kidney disease (CKD) patients presenting in a tertiary care center. Materials and methods: This study was conducted at Sher I Kashmir Institute of Medical Sciences (SKIMS), a tertiary care center in Srinagar, Jammu and Kashmir, India, from July 2013 to January 2016. All the patients of CKD visiting our institute were enrolled in this study. This included patients on follow up at the Out Patient Department (OPD), patients presenting to emergency with complications of CKD, patients referred from other departments who were detected in initial stages of CKD during the routine investigations. A total of 300 patients were enrolled in this study. Results: In our study, a total of 300 patients were enrolled. CKD was more common in males. The most common aetiology of CKD was diabetic nephropathy which was seen in 102 patients (34%) followed by chronic glomerulonephritis seen in 80 patients (27%). Volume overload was the most common cause of morbidity in these patients. Patients in the initial stages of CKD were managed with symptomatic treatment and 230 patients (76.66%) received peritoneal dialysis at some stage of their management. It was in the stage of ESRD that patients were offered some definitive form of renal replacement therapy in the form of renal transplantation or hemodialysis. Out of 160 patients of ESRD, only 12 patients (7.5%) received renal transplantation and the remaining 148 patients (92.5%) were managed with hemodialysis. Conclusion: CKD is one of the leading causes of morbidity and mortality due to renal causes. The early stages of CKD which are managed by conservative methods gradually lead to the development of ESRD. It is therefore necessary to diagnose the patients of CKD in the early asymptomatic stages. At these stages it is feasible to slow down the loss of nephrons by controlling the underlying factors like diabetes and hypertension but once the stage of ESRD sets in, renal transplantation is the preferred modality of renal replacement therapy.

86-92

Authors: Anand Vachhani, Shashvat Modia, Varun Garasia, Deepak Bhimani, 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. Aim and objectives: To determine the frequency of single lung metastasis, primary lung cancer and benign lesions in patients with solitary lung nodule and a primary extrapulmonary neoplasm, to evaluate the Chest Radiographs and CT characteristics of solitary lung nodule with a primary extrapulmonary neoplasm, to develop a statistical model to guide clinicians regarding choice of patient for diagnostic biopsy. Materials and methods: A retrospective analysis of CT and Chest Radiographs of 50 patients with an extrapulmonary malignant neoplasm and a solitary pulmonary nodule, done in our Dhiraj General Hospital over a 6 – month period. Results: 50 patients of Extrapulmonary neoplasms were evaluated; out of these patients were diagnosed and evaluated for Primary Bronchogenic Carcinoma, lung metastases, benign nodule. Conclusion: Solitary lung nodule in patients with extrapulmonary 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 extrapulmonary neoplasm and the patient's smoking history. Lung cancer was more common than metastatic disease.

100-106

Authors: K. Selvarju, Kondreddi Narayana Prasad, Ajay Kumar Reddy Bobba

Background: Laryngoscopy and endotracheal intubation, which are a basic and integral part of general anesthesia (GA), are associated with reflex sympathetic stimulation, manifested by tachycardia and hypertension. Aim: The aim was to compare the effect of dexmedetomidine and clonidine on the pressor response among patients undergoing tracheal intubation in elective surgeries under general anesthesia. Materials and methods: A prospective and randomized control study conducted in 80 adult patients of age 18-55 years in ASA I and II were included in this study. Patients were divided into Group D and Group C of 40 patients each. Results: Mean SBP, DBP and MAP in the dexmedetomidine group remained close to the baseline throughout the study period showing a significant difference from clonidine groups following the induction interval. In present study after intubation heart rate, SBP, and DBP was increased in all patients but the increase was more in patients of clonidine group when compared to dexmedetomidine group. There was statistically significant difference in heart rate between the two groups at 1, 3 and 4 min interval after intubation (p value<0.05). No significant changes in peripheral oxygen saturation (SpO2) and cardiac rhythm (ECG) were observed in any patients of both groups. Bradycardia (HR<50/min) was observed in one patient of dexmedetomidine group and two patients in clonidine group, five minutes after intubation. Intraoperative hypotension was observed in one patient of dexmedetomidine group and in two patients of clonidine group. Conclusion: Premedication with dexmedetomidine can safely be recommended for attenuation of provided more stable hemodynamics response to endotracheal intubation.

1-7

Authors: Anil Kumar, Madhuri Meena, Y.K. Sanadhya

Background: A simple clinical scale of intracerebral hemorrhage, comprising the Glasgow Coma Scale score, age, Infratentorial origin, ICH volume, and Intraventricular hemorrhage, was recently shown to predict 30-day mortality. We studied how well the original ICH Score would predict morbidity and mortality. Materials and methods: We did a retrospective study, in which records of all the patients with acute intracerebral hemorrhage were reviewed. Components of the ICH Score were recorded along with other clinical characteristics. Outcome was analyzed using modified ranking scale. Results: The mean age was 69  15 years with 45.4% males and 54.6% females. Common risk factors were smoking, diabetes mellitus and hypertension. Supratentorial lesions were 93.25% and Infratentorial lesions were 6.74 %. The overall 30 day mortality rate for ICH was 29.03%. Important predictors of mortality were, GCS score on admission (P<0.0001), hematoma volume >30ml (P <0.0001), Intraventricular extension (P <0.0001), and ICH score (P <0.0001). Conclusion: The study shows ICH score is very useful in prognostication. The overall mortality rate with ICH is similar to the previously published studies.

17-23

Authors: Vigna Sai Potula

Background: Gallstones are one of the commonest medical problems leading to surgical intervention. There is recent rise in the incidence of cases due to westernization of diet. This study intends to know the various modes of presentation, its complications and various treatment modalities with their outcomes. The aim of the study is to study the prevalence of cholelithiasis and to evaluate the advantages and disadvantages of laparoscopic versus open cholecystectomy surgical procedures. Material and methods: This was a prospective study conducted at tertiary care centre for a period of two years. 100 consecutive cases of cholelithiasis were admitted, investigated and operated during this period and results analysed. Results: Cholelithiasis was common in the 4th decade with majority of cases occurring in females. The commonest clinical presentation was pain abdomen. All the cases were diagnosed on ultrasonography abdomen. The diet consumed was mixed diet. Laparoscopic cholecystectomy was done in 72 cases and 28 cases underwent open cholecystectomy. The conversion rate was 4%. The complications were minimal. Mean operating time for open cholecystectomy was 96 minutes and laparoscopic cholecystectomy was 90 minutes. Mean duration of hospital stay was 9 days for open cholecystectomy and 4 days for laparoscopic cholecystectomy. Conclusion: Laparoscopic cholecystectomy is a safe and effective treatment in most of the patients with symptomatic cholelithiasis. In cases of adhesions and inflammation, open cholecystectomy is preferred.

29-32

Authors: A. Usha Murugan

The diabetic foot is a group of syndromes in which ischemia, neuropathy and infection leads to tissue breakdown resulting in morbidity and possible lower extremity amputation. The diagnosis is based on clinical criteria investigations. It is imperative that such patients are managed by a team of Physician, Surgeon, Social care worker, Physiotherapist and a Podiatrist. In this study we included 100 diabetic foot patients in the age group of 30 to 80 years. The study was done for a period of one year. 47% of our patients had Meggit Wagner grade 3 and 10% had grade 5. 27% of the patients had renal failure and 30% had anemia. These patients were subjected to non-enteric culture of blood under sterile precautions. 80% of our patients showed positive culture. The organisms commonly isolated were Staphylococcus aureus, beta haemolytic Streptococcus and Klebsiella pneumoniae. Less commonly isolated were Citrobacter species, Proteus mirabilis and anaerobes. 40% of patients with positive culture went on to have lower extremity amputation. Thus we concluded that non enteric culture in diabetic foot disease has prognostic significance and the spectrum of infection in diabetic foot disease is polymicrobial in nature and at par with the literature.

38-44

Authors: Katadi Venkata Sudha Madhuri, Kolati Srinivas Rao

Background: Abnormal uterine bleeding (AUB) is any heavy or unusual bleeding from the uterus (through your vagina). It can occur at any time during your monthly cycle, including during your normal menstrual period. Aim: This study aimed to compare the accuracy of TVUS and SIS in relation to hysteroscopy in assessing the uterine cavity and in detecting ER and PR in endometrium and their relation with endometrial polyps in women with peri and postmenopausal bleeding. Materials and methods: The present study was a prospective study which included 120 patients with AUB who were attending the department of gynaecology at Gandhi Medical College, Hyderabad from July 2012 to November 2015. Results: 120 patients were selected in this study. Patients suffering from endometrial polyp were 40 (33.34%), endometrial hyperplasia were 25 (20.83%), endometrial atrophy were 19 (15.83%), normal endometrium were 19 (15.83%) and submucous fibroid were 17 (14.17%). Age was shown in mean±SD and p-value was 0.39 and it was statistically non- significant. Parity was shown in mean±SD and p-value was 0.283 and it was statistically non-significant. SIS had 4 false negative results by missing 2 cases with endometrial polyps, 4 false positive result by diagnosing a case of 4 endometrial hyperplasia as polypi. SIS had 8 false negative results (by missing 6 cases), 8 false positive results (3 cases was found to have polypi and 5 cases were normal). Mean endometrial thickness in mm in various diagnosis by TVUS as follows; endometrial polyp had 15.49±10.98, endometrial hyperplasia had 8.19±5.55, endometrial atrophy had 4.55±2.97 and normal endometrium had 12.68±6.80. Conclusion: Especially with intra-cavitary lesions, sonohysterography is superior to ultrasound and very close to hysteroscopy. Hysteroscopy remains the reliable standard for uterine cavity assessment, but cannot replace the histopathology. In the pathogenesis of endometrial polyps and endometrial hyperplasia, the expression of endometrial steroid receptors is crucial.

50-55

Authors: Ayyasami Revathi, Tharmaraj Ramesh Kumar

Background: Gestational diabetes mellitus, as a metabolic disorder affects 1%-28% of pregnancies. History of gestational diabetes is an important predictor of various metabolic disturbances later in life. This study was intended to observe the impact of the various predictors over persistence of abnormal glucose tolerance at post-partum and its association with metabolic risk factors. Materials and methods: This was a prospective study of 216 GDM women diagnosed by 75 g oral glucose tolerance test (OGTT) during index pregnancy attending diabetology OPD in Institute of social obstetrics and Kasturba Gandhi general hospital between January 2016 to March 2018. At 6-12 weeks post-partum, 75 g - 2 hr-OGTT was done to assess their glycemic status. Data for predictors and metabolic risk factors were obtained from history, clinical examination and personal records. Plasma glucose was measured by glucose-oxidase method. The results were calculated using SPSS software and expressed in percentage. Results: Of the 216 women only 173 patients came for postpartum follow up at 6- 12 weeks. Normal glucose tolerance (NGT) was seen in 58.9% and abnormal glucose tolerance (AGT) in 41.1%. The frequency of abnormal glucose intolerance includes IFG: 0.9%, IGT: 24.5%, DM: 15.7%. Gestational age <20 week at detection of GDM, higher parity, insulin use during pregnancy, previous history of GDM, higher glucose levels on the diagnostic OGTT, hypertension were significantly higher in the AGT group. However positive family history of diabetes and BMI showed no statistically significant correlation. Conclusion: It is concluded that advanced age, higher parity, previous history of GDM, earlier gestational age at diagnosis of GDM and use of insulin during pregnancy are important predictors for AGT during post-partum period and hypertension as a metabolic risk factor was strongly associated with AGT. Need for early postpartum screening and implementation of various intervention program to prevent type 2 diabetes in high risk GDM women.

62-66

Authors: R. Maheshwari, Rakesh Fernando

Background: Post-operative complications which follows appendicectomy are not common and it reflect the level of peritonitis that is present during the time of surgery and the diseases which may be predisposed to complications. There are various types of complications that occurred after the appendicectomy surgery. Of them, the commonest complications are fever and surgical site infection. Post-operative complications of appendicectomy have wide range of presentation from fever to fecal fistula. In this study, the patients presenting with features of post-operative complications of appendicectomy will undergo detailed history taking, clinical examination & investigations like complete blood count, blood sugar, urea and lipid profile, serum creatinine, X-ray chest and wound pus culture sensitivity. The study purpose was to assess the age distribution, sex distribution & to discuss various types of complication. Materials and methods: 100 cases that had presented with features of post-operative complications of appendicectomy in the department of surgery, Tirunelveli Medical College and Hospital were evaluated during the study period from April 2012 to October 2013. Results: Our study of 100 randomly selected patients who presented with postoperative complications of appendicectomy. The commonest post-operative complications of appendicectomy were fever (73%), followed by surgical site infection (37%). Most common age group, in which post-operative complications seen, was > 20 years, followed by the 20-30 age group. The surgical site infections were most commonly due to E.coli (64.86%) and Klebsiella species (8.1%). The common day of presentation of fever was 2nd POD with 57.3% cases. In this study 97% case of postoperative complications of appendicectomy occurred after emergency surgeries. Conclusion: Major complications were rare in elective appendicectomies which may reflect the reduced virulence of organisms in those cases.

81-87

Authors: K.B. Chandrabhanu, R. Ashok, K. Haridev Kumar

Introduction: Infective Keratitis is most common cause of corneal blindness in Rural India. Agricultural farmers are more at risk. Fungi and Bacteria are the main cause for this ocular ailment. Early diagnosis and treatment may prevent the corneal blindness. Aim: To evaluate common etiological factors causing Infective Keratitis in the region of Northern Telangana. Materials and Methods: This study was conducted at Tertiary Eye Care Hospital, Regional Eye Hospital, Warangal, Telangana State. Fifty patients were admitted with infective keratitis were clinically evaluated. Each case was analysed and results were recorded as per etiology, clinical symptoms and signs, complications and visual outcome. Results: Age group greater than 40 years (58%) were more common with male predominance (54%) was observed. People living rural area (72%) were affected more than urban areas. Agricultural labour (52%) was mostly seen with infective keratitis. Most of the cases were with trauma (62%) with vegetative matter was mostly seen. Most of the cases were acute (78%) in origin. Fungi were most common organism isolated from the cultures. Staphylococcus and Streptococcus (62%) were common species isolated from bacterial origin and they were antibiotic sensitive (92%). Aspergillous was common fungus isolated Diffuse Corneal ulcer was most common complication. Malnutrition was main cause in systemic illness. Most of the patients before treatment were with no passage of light after treatment visual acuity has prognosis to 6/18 vision. Conclusion: Early diagnosis and treatment may improve the visual prognosis and prevent Corneal blindness due to Infective Keratitis.

94-98

Authors: R. L. Sharma, Rekha Sharma

Hailey–Hailey disease also known as Familial benign chronic pemphigus is a relatively uncommon disease characterized by painful erosions, vesicles, pustules and scaly erythematous plaques on the neck, axillae, groins and perineum. A case of 27 years old male with history of recurrent, itchy, erythematous, papules and vesicles over the groins presented to the dermatology OPD. A clinical diagnosis of Hailey – Hailey disease was made which was confirmed later by histopathological examination. He was treated with tacrolimus ointment and showed a remarkable improvement.

1-4

Authors: Allwin James, Prem Kumar Karunakaran, Rabindranath Eswaran, Venkateswaran A R.

Introduction: Choledochal cyst is a type congenital anomaly in which there is dilatation of the intra or extrahepatic biliary tree. Choledochal cysts are classified into five types based on location or shape of the cysts. Materials and methods: A prospective analytical study was conducted from January 2015 to June 2017 at Madras Medical College, Chennai, India. All patients who underwent ERCP and had finding of choledochal cyst on cholangiogram were included in the study. Patients were assessed on their demographic data, clinical findings, presentation, and complications. Results: The incidence of symptomatic choledochal cyst was 2.5%. Type 1C was the most common type of choledochal cyst with obstructive jaundice due to large CBD stones as the most common presentation in this study. None had 30 day post-operative mortality. Conclusion: Type IC is the most common type among symptomatic choledochal cyst in south India. As it is a premalignant condition management includes endoscopic retrograde cholangiography followed by surgery with good clinical outcome.

14-19

Authors: Rama Ashok, K Haridev Kumar, K.B. Chandra Bhanu

Background: Congenital cataracts present very important ophthalmological and socio economic problem. It is one of the causes of blindness continuous to receive emphasis as a school health problem throughout the world. Aim: Clinical evaluation and visual outcome following surgery in congenital cataract. Materials and methods: It was a clinical study on the patients who have attended out-patient department of Ophthalmology for a period for a period of 2 year. 50 cases under the age of 12 years who were operated by SICS with PCIOL (PMMA) and Phaco with foldable IOLs were included in study. All the cases were followed for a period of 3 months. Results: Among the 50 cases, positive family history of congenital cataract was present in 6%. Systemic and ocular abnormalities were present in 3 (6%) and 10 (20%) cases of congenital cataract. Majority of children presented with visual acuity of PL. Majority of children got vision between 6/36 to 6/24. 48% presented with total cataract followed by lamellar cataract 36%. Most of the children had amblyopia followed by squint and optic atrophy. Most of the intra operative complications were posterior capsular rupture followed by premature rupture, hyphema and iridodialysis. Posterior capsular opacification was common followed by iritis, shallow AC and corneal edema. IOL implantation was done in 90% of congenital cataract cases and in 5 % of cases secondary IOL is implanted. Mean IOL power calculated was + 18.00D. Conclusion: Early diagnosis and meticulous management of congenital cataract may give satisfactory vision with minimal complications.

27-37

Authors: Kamera Sateesh Kumar, Veena Narisetty, Changala Praveen

Background: Idiopathic epilepsy is defined as disorder in which there is no underlying cause or structural pathology other than a possible hereditary predisposition for generating seizures which can be generalized or focal in nature. Objective: To study the occurrence of executive dysfunction in patients with idiopathic epilepsy and its association with age, gender, seizure type, duration of epilepsy, age at seizure onset, antiepileptic drug therapy and seizure control &the association of the interictal EEG pattern. Materials and methods: 100 cases of epileptic patients with normal CT scan brain / MRI brain were studied. Frontal Assessment Battery &The Executive Interview (EXIT) were used to assess the executive functions. Results: The FAB score were normal in 46% and abnormal in 54% of the cases. Executive dysfunction as per the FAB score was mild in 32% and moderately severe in 22% of the cases. Impairment in Executive function as per EXIT score was mild in 84% and moderate in 16 % of the cases. Executive Dysfunction was more in cases with either primary or secondarily generalized seizures, cases with a higher seizure frequency, longer duration of epilepsy, uncontrolled epilepsy and seen in 17.5% with normal and 10% cases with an abnormal EEG. Conclusion: Our study found a significant proportion of patients with idiopathic epilepsy have Executive Dysfunction, which adds to the seizure burden by reducing the capacity of an individual to successfully engage in self-care, social, academic and occupational pursuits.

44-51

Authors: P. Sivaramakrishna, Mallapu Gangadhara Reddy

Background: Transthoracic Fine Needle Aspiration Cytology is regarded as the most effective of the cytological methods for diagnosing lung cancer, in particular peripherally-located lesions. Aim: To evaluate the role of sonography in percutaneous Fine needle aspiration Cytology of peripheral pulmonary lesions. Materials and methods: This was the prospective study done in peripheral pulmonary lesions. Total number of patients in the study was 81. Results: 61 patients (75.3%) were Males, while 20 (24.6%) were Female. The Male: Female ratio was 3:1. The mean age of patients in this study was 48. The youngest patient was aged 26 years and oldest was aged 71 years giving an age range of 26 to 71 years. 54(66%) patients of this study were smokers. Only 3 female patients were smokers. The most common symptom was cough and sign was anemia. Left side and Left Upper Zone of lung was most involved area in lung. Squamous cell carcinoma was the commonest cytological type noted accounting for 60% followed by adenocarcinoma. In non-malignant lesions tuberculosis was most commonly observed in total 81 Complications of needle biopsy were 2 cases (2.4%) were with Hemoptysis and 3 cases (3.7%) were with Pneumothorax. Conclusion: It is concluded that Ultrasound Guided Transthoracic Fine Needle Aspiration cytology of peripheral pulmonary lesions abutting the chest wall is Acceptable, Simple, Safe, Quick, Accurate and Useful.

55-60

Authors: Priyanka Poonam, Preety Saha

Generally patients with breast tumors complain of lump in the breast which may be painful or painless and may be associated with nipple discharge or not. Benign tumors of the breast are common among younger age group <30 years. But the chances of malignancy increases with increasing age. Most of the cases of breast cancer are found in age group >50 years. FNAC forms the initial diagnostic method in patients with breast lump. A total of 250 patients with different breast lesions attended cytology section of our Pathology department for FNAC. Out of which 197 cases came for histopathological correlation in the study period of 2 years from January 2016 to December2017. Among these majority were benign tumors (114 cases) but an alarming number of 51cases were malignant. Next in number were benign breast diseases (24 cases). There was one case each of ductal papilloma, gynaecomastia. The commonest benign breast tumors were fibroadenoma whereas the commonest malignant tumors were infiltrating ductal carcinoma. There was one case each of lobular carcinoma in situ, infiltrating lobular carcinoma, medullary carcinoma, ductal carcinoma in male breast, inflammatory carcinoma, sarcoma breast. Hereby, we have analyzed different types of breast lesions in different age groups based on cytological evaluation followed by its histopathological confirmation.

72-76

Authors: G. Sunil, I. Ranganayakulu, R.S.V.M. Raghu Ram

Maxillary canine has a significant importance in functional and esthetic aspect of the occlusion. Clinicians must have a sound knowledge regarding the management of impacted maxillary canines as is second most common teeth prone for impaction after third molars. With early detection and timely interception and well planned orthodontic treatment the impacted canines can be successfully bought to the occlusion. This article gives an overview of etiology, diagnosis and prognosis of impacted canine.

1-7

Authors: I.D. Chaurasia, Anshul Siroliya, Manish Parihar

Introduction: CT plays a key role in accurate diagnosis and important diagnostic tool in the management of traumatic brain injury. Materials and methods: Present study was under taken in the Department of Surgery Gandhi Medical College and Hamidia Hospital, Bhopal in the duration of July 2015 to July 2016. Total 105 patients (M: 80, 76.1% and F: 25; 23.80%) with traumatic head injury were admitted and managed and were include in this study. They were followed by serial CT scan and analyzed. Results: Commonest cause of brain injury was road traffic accidents (75 cases 70%). Altered sensorium was the most common symptom in 88 cases (88.0%), followed by vomiting in 49 cases (75.38%). Contusions were the most common radiological findings in 80.95% (85 cases) followed by extradural haematoma in 18.46% and pneumocephalus in 16.92%. Out of these the most common location for contusion was frontal (14 cases), followed by parietal (12 cases) and then bilateral contusions in 10 cases. Repeat scan showed increase in volume of contusion in 29 cases (44.61%), no change in 26 cases (40.0%) and decrease in 10 cases. The increase was mainly due to edema in 18 cases (27.69%) and due to actual increase in contusion in only 11 cases. Only 4 cases needed operative intervention. Conclusions: Sequential serial CT scan results in the management changes and has role in the management even in the patients without any clinical deterioration in early stages.

14-20

Authors: Manivannan Dhanraj, Nachiappan Meenakshisundaram, Vinodh Duraisami, Vinayak Rengan

Introduction: Fistula in ano is the benign anorectal condition, but became a major problem for surgeons to cure the disease. For proper treatment of fistula in ano, a thorough knowledge of Anorectal anatomy and etiopathogenesis of the anorectal abscess is required. More than 90% cases of perianal abscess and anal fistulas occur due to cryptoglandular infections in the intersphincteric plane. Less than 10% occurs due to the complications of Crohn's disease, malignancy, Tuberculosis, and Radiation Exposure. The aim of the study: To study the different modalities of treatment for fistula in ano (Fistulotomy/ Fistulectomy/ Fibrin Glue Injection/ LIFT procedure). Materials and methods: Patients who met inclusion and exclusion criteria for the study selected and all patients discussed the nature of the disease and possible complications (recurrence, anal incontinence, and anal stricture) expected after surgery was explained. Written consent for the study and surgery was obtained. In proforma, thorough history, signs and symptoms, we identified internal opening and external opening by thorough digital rectal examination and proctoscopic examination under the adequate light were noted. Results: In our study, out of those 15 cases of Fistulectomy, 4 cases developed intraoperative bleeding, 3 cases developed sphincter injury and 3 cases had prolonged surgery more than 1 hour. Of 10 cases with Fistulotomy, 3patients developed intraoperative bleeding, 2 developed sphincter injury and 2cases had prolonged surgery more than 1 hour. Cases proceeded with Fibrin Glue Injection did not develop any obvious intraoperative complication. Conclusion: Fistulectomy has a moderate degree of intraoperative and postoperative complications with a moderate chance for stricture and incontinence and less chance for recurrence. Moreover few cases required second sitting for the completion of treatment.

27-32

Authors: Paul Praveen, Ranjini O.M., T. Murugan

Introduction: Post-operative pain and swallowing difficulty following tonsillectomy remain one of the most difficult pain states to manage in Otolaryngology. Many therapeutic modalities - ranging from non-steroidal anti-inflammatory drugs (NSAIDs) to systemic opioids, acetaminophen, and tramadol - have been used for posttonsillectomy pain control in patients. Gabapentin has been recently found to be useful for reducing acute post-operative pain when administered preoperatively. Although various dose regimens have been tried in different surgical settings, the minimum effective dose is not established. The aim of the study: To study the analgesic property of a single of dose oral Gabapentin for postoperative pain relief, to study the hemodynamic variables in patients receiving oral Gabapentin Materials and methods: A total number of, 60 patients were included in the study group between 6 to 16 years. P group (Placebo group) 30 ASA I patients for tonsillectomy receiving oral placebo, G group 30 ASA I patients for tonsillectomy receiving oral gabapentin during a 24-hour post-operative period, the outcomes of interest being postoperative pain intensity; rescue analgesic consumption; or adverse effects such as sedation, nausea and vomiting, dizziness, and headache. Results: The pain score reported by the physician during the first 8 hours, as well as the need for analgesics during 24 hours postoperatively, were significantly decreased in the gabapentinoids group versus the control group. Additionally, there was no significant difference between gabapentinoids and control groups for adverse effect during 24 hours postoperatively. Statistically, significant sedation was observed up to 4 hours in the postoperative period. After 5 hours there was no statistically significant difference in both groups. Conclusion: Oral Gabapentin is effective for postoperative pain relief, reduces the requirement of supplementary analgesics in the postoperative period. Oral Gabapentin has a better hemodynamic profile. Gabapentin is safe for use in pediatric patients.

38-44

Authors: Ranjini O.M., Paul Praveen, T. Murugan

Introduction: I-gel and the ProSeal laryngeal mask airway (PLMA) are two supra-glottic airway devices with gastric channel used for airway maintenance in anesthesia. This study was designed to evaluate the efficacy of I-gel compared with PLMA for airway maintenance in patients under general anesthesia with controlled ventilation. The aim of the study: To compare the supra-glottic airway devices, I-Gel and ProSeal Laryngeal mask airway with respect to Ease of insertion, Time taken for insertion, Airway leak pressure, Hemodynamic response during intubation. Materials and methods: A total number of, 40 patients were randomized into two groups of 20 each. After induction of anesthesia using a standardized protocol for all the patients, one of the supra-glottic airway devices was inserted. Insertion parameters, ease of gastric tube insertion, airway leak pressure, hemodynamic changes, were noted. Results: There was no significant difference in the incidence of adverse effects in both the groups. One incidence of airway trauma was noted in I-gel group. No gastric insufflations and laryngo or bronchospasm in both groups. Conclusion: Based on the result of our study we conclude that I-gel had an acceptable airway leak pressure of 23 cm H2O when compared to ProSeal whose airway leak pressure is significantly higher i-e 29 cm H2O.Both the devices provided optimal oxygenation and no fall in saturation was observed in both the groups.

51-56

Authors: S. Kalaichelvi, Daranendaranchellapa

Introduction: Diabetes is a polygenic disease characterized by abnormally high glucose levels in the blood. There is evidence that patients with diabetes have an increased risk of Urinary Tract Infections (UTIs). UTI is the most common bacterial infection in diabetic patients. They are also more often caused by resistant pathogens. Various impairments in the immune system, poor metabolic control, and incomplete bladder emptying due to autonomic neuropathy may all contribute to the enhanced risk of urinary tract infections in these patients. The aim of the study: To determine the clinical characteristics, risk factors, causative organisms and antimicrobial susceptibility in diabetics. Materials and methods: This was an observational study conducted in the medical unit of a tertiary care hospital over a period of 6 months. A total of 100 type 2 diabetic subjects were studied. History, clinical examinations, and the duration of diabetes were recorded in all patients at admission. Diabetes was diagnosed based on the WHO criteria. An immunoturbidimetric method was used to estimate glycosylated hemoglobin (HbA1CDiagnosis of UTI was made from Midstream urine samples of patients if the urine cultures have>103 to >105 colony forming units (CFU)/mL of a pathogen. A pure culture of Staphylococcus aureus was considered to be significant regardless of the number of CFUs. Results: Gram-negative bacilli were isolated from 129 (87.2%) patients which included E. coli in 75 (50.7%), Klebsiella in 30 (20.3%), Pseudomonas species in 12 (8.1%) and Citrobacter in 12 (8.1%). Gram-positive cocci were responsible for UTI in 15(10.1%) of subjects including Enterococcus in 13 (8.9%) and Staphylococcus in 2 (1.3%). Gram-negative bacilli including E. coli, the Klebsiella species, Pseudomonas and Citrobacter had a good response to piperacillin-tazobactam, cefoperazone- sulbactam, imipenam, and amikacin. Gram-positive cocci (Enterococcus and Staphylococcus) responsible for UTI showed good susceptibility to vancomycin (81 and 94% respectively) but a high resistance to ciprofloxacin and tetracyclines (68 and 57% respectively). Conclusion: There is no indication to treat diabetic patients with asymptomatic bacteriuria. Escherichia coli is the most common isolate in the community and hospital-acquired infections in non-diabetics, while Escherichia coli was common in community-acquired infection and pseudomonas was the predominant isolate in hospital-acquired the infection in diabetics.

63-68

Authors: Premlal KV

Background: Spinal dysraphism refers to a spectrum of congenital anomalies of the spine resulting in a defective neural arch through which meninges and / or neural elements herniated leading to a variety of clinical manifestations. Aim: This study aimed to evaluate the incidence, clinical presentations, and surgical outcome in spinal dysraphism patients. Materials and methods: This study was a retrospective study which consisted of 32 patients conducted in Academy of Medical Sciences, Pariyaram over a period of March 2015 to March 2017. All the patients were admitted in Department of Gynecology and Pediatrics. Results: The incidence was high in females 54.29% than males 45.71%. Spina bifida aperta (open type) was present in 44 patients (62.86%) and more common than Spina bifida occulta (closed) which was present in only in 26 patients which constituted 37.14%. The commonest site of occurrence of spinal dysraphism was the lumbo sacral region in 32 patients which constituted to 45.7%. Most common finding was myelomeningocele in 41 (58.6%) cases; myelocele was seen in 6 cases (8.6%). Lipomyelomeningocele was seen in 8 cases which was most common finding in closed type. The most common associated anomaly was hydrocephalus in 25 patients and next common was Arnold Chairi malformation type 11 in 20 cases. Motor weakness in the form of paraparesis or paraplegia present in25 patients preoperatively, out of which only 14 improved. Major cases of sensory deficits did not improved and remained static. In the majority of cases of 11 sphincter function, 6 cases remained status quo same as in the preoperative period. Conclusion: The most common congenital cause of disability in children is spinal dysraphism encountered by paediatric neurosurgeon. Open type spina bifida is more common than closed one .At peripheral centres, inadequatetreatmentshouldbeavoided.Spinaldysraphismpatientsshould be referred to higher tertiary centre where all the facilities are provided to the patients.

79-82

Authors: Veena Narisetty, Kamera Sateesh Kumar, Changala Praveen

Background: IIH is defined as an elevated intracranial pressure but no clinical, laboratory or radiological evidence of hydrocephalus, infection, tumor or vascular abnormality. Aim: To study the clinical and radiological profile of Idiopathic Intracranial Hypertension (IIH). Materials and methods: Total 31 IIH cases were studied. Patients were subjected to Fundoscopy, CT/MRI brain and CSF analysis. Results: Females were predominant and Headache was the most common presenting symptom. All patients had papilledema. Mean CSF pressure was 318.1 mm of H2O. MRI findings included prominent subarachnoid space, vertical tortuosity of optic nerves, flattening of posterior sclera. Conclusion: IIH predominantly affects women with headache being the most common symptom. Medical management and Life style medication is mostly useful. Surgical management is imperative in patients with impending vision loss.

87-91

Authors: Abirami Gunasekaran, Jayalakshmi Ramasamy, Kamatchi Karunanidhi

Introduction: Pericardial effusions can be caused by multiple disease states, including any process that results in pericarditis or myocarditis. The inflammatory reaction in these disease states can result in fluid accumulation in the pericardial space. Systemic manifestations of hypothyroidism can significantly vary according to the thyroid function, the presence of associated diseases and the duration of autoimmunity. Long-term overt hypothyroidism significantly affects growth as well as heart, liver, skin, and kidney functions, causing signs and symptoms that promptly lead to its diagnosis. The aim of the study: To analyze the important diagnostic tool ECG and X-ray finding among diagnosed pericardial effusion adult hypothyroid patients. Materials and methods: The study was conducted in 2017. Patients attending the Outpatient Clinic of the Department of Endocrinology who satisfied the inclusion criteria were registered for the study after obtaining their consent. A detailed questionnaire was used to elicit symptoms of hypothyroidism. ECG and x-ray findings were predicted accordingly. Results: Low voltage complexes were found in 17 patients (24.29%), sinus bradycardia was found in 6 patients (0.09%), the poor progression of R waves in 3 patients (0.04%). The remaining 44 patients had a normal ECG. Chest films showed Mild cardiomegaly in 20 patients (28.57%). 11 of these 20 patients had pericardial effusion on echocardiography. One patient with echo proven pericardial effusion had normal chest X-ray. So chest X-rays can be used to look for clues for pericardial effusion. Conclusion: Clinical features of pericardial effusion show statistically significant association with its presence on echocardiogram. ECG and CXR can be used to predict the presence of a Pericardial Effusion.

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Authors: Ankush Agrawal, Bhuvanesh Kahar, Sushma Pandey

Background: Malaria is a life threatening disease caused by Plasmodium parasites that are transmitted to people through the bites of infected female Anopheles mosquitoes. Aim: To study of effect of malaria parasitemia on serum electrolytes in south east Rajasthan. Materials and methods: It was a hospital based study done on malaria indoor patients from June 2017 to March 2018 in Jhalawar Medical College, Jhalawar in South East Rajasthan. The relevant history, systemic examinations and thick and thin peripheral blood smear, malaria antigen detection rapid card test was performed and serum electrolytes like sodium, potassium and calcium level were done for all patients. All patients were categorized into three groups like P.falciparum, P.vivax and mixed infection (both P.falciparum, P.vivax). Results: We observed that female was out numbered than male. Most common affected age group was 35-45 years and most of the patients came from the rural region. Severe dyselectrolytemia was noted in mixed infection (both P.falciparum and P.vivax) and P.falciparum cases. Conclusion: Serum electrolytes level are influenced by the presence of all types of malaria severely with mixed infection and P.falciparum positive cases so severe dyselectolytemia in malaria infections should be treated timely to prevent grave complications.

111-116

Authors: B.M. Monisha, G. Kannan, Muthusamy

Background: Acne is one of the most commonly prevalent skin conditions. It commonly affects the adolescents and young adult age groups. The lesions start as microcomedones and progress to nodular or inflammatory acne with post inflammatory hyperpigmentation. Although acne is not life threatening it has multiple impacts in the affected individual’s quality of life and psychological morale. Hence this study was undertaken to analyze the clinical profile of patients having acne vulgaris to facilitate better management. Materials and methods: A cross sectional observational study was conducted among patients attending the dermatological outpatient department in a tertiary care hospital. A pre-tested semi-structured questionnaire was administered to the individuals after obtaining informed written consent. Data on demographical variables, menstrual history and clinical features of acne were collected and presented. Results: A major proportion of the population was comprised of adolescents and young adults similar to previous studies. Around 13% of them had a positive family history of acne. Associated factors such as menstrual flare, increased consumption of dairy products and high glycemic index foods were also present. Almost 88% of the participants had mild acne. Half of them had post inflammatory hyperpigmentation. Conclusions: Most patients of acne vulgaris are either adolescents or young adults. This group is more prone to endocrine co-morbidities such as polycystic ovarian syndrome and impairment in quality of life. Hence considering the above factors, early diagnosis and management of acne vulgaris is essential. This is expected to yield better results in the long term in improving the quality of life in the affected persons.

121-128

Authors: Vasanthakumar M, Gnanaprakasam J

Introduction: Obesity causes reduction of Lung compliance leading to decrease in lung volumes producing mostly a restrictive type of ventilatory defect. Compression of the thoracic cage by excessive fat and increased pooling of blood in pulmonary vasculature mainly contribute towards a reduction in respiratory compliance. Deposition of fat in diaphragm causes mechanical obstruction to the descent of diaphragm thereby causing increased work of breathing and metabolic demand thereby producing breathing difficulty. The aim of the study: To measure the association of body mass index (BMI) to lung volumes assessed by a digital spirometer. Materials and methods: Apparently healthy individuals above the age group of 15 years attending Master Health Check-up OP and attenders of in-patients of wards of general medicine department, Govt. Chengalpattu Medical College, Chengalpattu of either gender were recruited. Height and weight were measured and BMI was calculated as kg/m2. Subjects were categorized as normal (BMI=18.5 to 24.9 kg/m2); overweight (BMI=25 to 29.9 kg/m2); obese Class 1 (BMI=30 to 34.9 kg/m2) and obese class 2 (BMI=35 to 39.9) on the basis of BMI. Lung volumes were measured by digital spirometer and were reported as a percentage of predicted values for forced vital capacity (FVC%), forced expiratory volume in the first second (FEV1%) and the ratio of FEV1 to FVC (FEV1: FVC). Groups were compared using t-test and ANOVA, the correlation was assessed by Pearson's 'r'. Results: Significant differences in lung volumes were found in different BMI categories. Obese subjects had significantly lower FVC% and the significant difference calculated by using One Way ANOVA F = 11.9 with p = 0.0001. Similarly, obese participants have significantly lower values of FEV1% when compared to participants of normal BMI. The significant difference calculated by using One Way ANOVA F = 6.46 with p = 0.0001. Gender and age had no significant effect on mean values of PFTs. Conclusion: Obese individuals in this sample had a significant decline in lung volumes. The presence of nutritional abundance and a sedentary lifestyle, and importantly influenced by genetic endowment, this system increases adipose energy stores and obesity develops which produces adverse health consequences.

138-145

Authors: Sreenivasu Kotagiri, Anup Kumar Songa, Mayuri Vijay Gad, Jaideep Lad

Background: The glenohumeral joint consists of dynamic and static stabilizer, which works, in concert to allow for stability and mobility through a large arc of motion, in recent years there has been significant focus on shoulder motion, particularly in overhead throwing athletes. Glenohumeral internal rotation deficits (GIRD) are common physical impairments in evaluated both adolescent and overhead sports such as baseball, cricket, and tennis. Therefore the aim of the study firstly was to determine the effectiveness of mobilization with exercise in patients with glenohumeral internal rotation deficit and secondly to determine whether mulligan internal rotation MWM with stretching in patients with glenohumeral internal rotation deficit. Materials and methods: 60 patients were included in the study which was divided into two groups; Group A and Group B, 30 patients in each group. All the subjects were randomly selected and assigned to each group. A pretest measurement with the help of two measures - Oxford Shoulder Instability Score (OSI) for disability, and inclinometer for an internal range of motion shoulder was done in each group. Subjects in Group-A were given mobilizations with stabilization exercise for capsule for a total of 12 minutes a minimum of 4 times per week over a 4-week period and Group-B were given mulligan mobilization with Posterior Capsule Stretching As follows, 1st day 3 glides, 2nd day 3 sets of six glides, 3rd day 3 sets of 10 glides were given and 4th day again 3 sets of 10 was given. A patient who failed to come for 4 days with stretching performed 3–5 repetitions each repetition was held for 30 seconds, four days a week for four weeks total 16 sessions. Results: On comparing Group A and Group B for post-treatment OSI score, results showed a significant difference (p=0.001) in improvement in terms of OSI. On comparing Group A and Group B for post-treatment inclinometer score, results showed a significant difference in improvement in terms of the inclinometer. This study showed that Mulligan MWM along with stretching exercises was more effective to that patient as compared to mobilization with strengthening exercises given to a patient with glenohumeral internal rotation deficit. Conclusion: The study showed a significant difference between both the groups when the values obtained were analysed. It indicated that Group B in Range mulligan mobilization with Posterior Capsule Stretching of Motion in internal rotation and external rotation. Their scores in Index Oxford Shoulder Instability Score (OSI) have reduced which indicates the decreased level of disability and better functional ability.

156-166

Authors: Deepak Bhimani, Varun Garasiya, C. Raychaudhuri

Introduction: Ultrasound helps by detecting lesions, give idea about its internal structure and also give opportunity to evaluate other abdominal organs. However evaluation by CT scan can give additional information, which can modify the course of treatment and prognosis of patient. Materials and methods: Study comprise of 84 patients who were evaluated with ultrasonography and CT scan of abdomen and pelvis. Ovarian pathologies were categorized with benign, malignant and metastasis and compared with histopathological diagnosis or conservative treatment follow up. Results: 84 patients were evaluated; CT scan and sonography are excellent noninvasive modality to differentiate ovarian masses from benign and malignant lesions and both imaging techniques seem to be comparable in differentiation of malignant from benign ovarian tumors. CT scan was more sensitive than ultrasonography, but sonography is more specific than CT scan in diagnosis of malignant lesions. Ultrasonography has high positive predictive value as compare to CT scan to diagnose malignant lesions. Conclusion: Ultrasound by virtue of non-invasiveness, lack of radiation hazard and by ability to demonstrate structural changes in organ is investigation of choice in ovarian pathology and it can easily detect solid to cystic lesions and characterize the size, shape and extent of lesion. Computerized Tomography is particularly useful to know the enhancement pattern of the lesion, density and extent and staging of malignancies.

174-177

Authors: Praphull Deepankar, Umashankar USA, Manish Kumar

Fibrocalculous pancreatic diabetes (FCPD) is a type of chronic calcific non-alcoholic pancreatitis. This type is reported mostly in the developing tropical and subtropical countries. Definite diagnosis of FCPD requires younger age of onset, history of malnutrition, and presence of diabetes mellitus along with extensive pancreatic calcification and ductal calculi. Pain abdomen is one of the classical clinical triad of the disease with steatorrhoea and diabetes. In this case report we are presenting a case of 17 years old girl with past history of recurrent pain abdomen for last two years. She came to casualty with complaints of generalized weakness along with pain abdomen. She was diagnosed as case of FCPD with uncontrolled hyperglycemia on subsequent investigations. Importance of this case is that patient has multiple episode of abdominal pain over two years and she consulted several practitioners for the same and she was treated symptomatically without proper work-up. However, FCPD is a rare entity but should be considered in case of recurrent abdominal pain in young patient.