International Archives of Integrated Medicine

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.

98-103

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.