Indian Medical Association - Kerala State Branch
Giant Left Atrial Myxoma Causing Mitral Inflow and Pulmonary Venous Obstruction
Introduction and Objective: Atrial myxomas are the most common primary cardiac tumors. Here we report a giant left atrial myxoma with mitral inflow and pulmonary venous obstruction and treated successfully by surgical resection Case report: a large left atrial (LA) myxoma of size 9x3.4 cm occupying almost the entire LA with prolapse into the mitral inflow during atrial systole. The soft lobulated tumor was excised with a wide cuff of IAS circumferentially through a bi-atrial approach (Trans right atrial (RA) and LA). CABG was also performed using Left Internal mammary artery Discussion: Once a cardiac myxoma is diagnosed it requires surgical excision, and in the event of a large mass, RA access alone does require significant tumor manipulation and may not permit radical resection Conclusion: bi-atrial approach ensures good exposure and enables radical excision of the tumor.
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Amniotic Fluid Embolism - A Survival Story
Introduction and objective: Amniotic fluid embolism is an obstetric catastrophe which occurs in 1 in 8000-80,000 deliveries and carries 80% mortality even in developed countries. It is postulated that amniotic fluid, fetal cells, hair, or other debris enter the ma- ternal circulation, and causes cardio respiratory collapse. A case of amniotic fluid embolism with successful recovery is described in this case report Case report: There was sudden hypotension and tachycardia 10 minutes after the delivery of the baby and uterine atony followed 2 minutes later. Coagulopathy also set in while the uterus was being closed 20 minutes after the delivery of the baby, which was proven by the lab parameters. The survival of the patient is due to the immediate measures taken to correct the hypotension metabolic acidosis, coagulation abnormalities replacement of necessary blood products Discussion: Strong clinical suspicion of amniotic fluid embolism and team work of the Anesthetists, Obstetricians, Intensivists and the blood bank officers with all the supportive staff helped in the survival Conclusion: Good antenatal care, institutional delivery, strong instinct for diag- nosis and prompt supportive measures are the key factors in bringing down the mortality rate.
Vitamin D has important benefits in reducing the risk of many conditions and diseases. In addition to its well-known effects on rickets, osteomalacia and osteoporosis vitamin D influences muscle function, cardiovascular homeostasis, nervous function, and the immune response. Those diseases for which the benefits are well supported and that have large economic effects include many types of cancer, cardiovascular diseases, diabetes mellitus, several bacterial and viral infections, and autoimmune diseases such as multiple sclerosis. The prevalence of vitamin D deficiency/ insufficiency is high throughout the world. The currently recommended daily vitamin D intake of 5-15µg is too low to achieve an adequate vitamin D status in individuals with only moderate skin synthesis. Thus, there is a need to recommend a vitamin D intake that is effective for achieving adequate circulating 25-hydroxyvitamin D concentrations (>75 nmol/L).
Prevalence of Self Reported Diabetes, Knowledge, Attitude and Practice on Diabetes and Diabetes Care in a Rural Community in Malaysia
Background/Objective: Diabetes is a global public health challenge with high economic burden. Diabetes is increasing not only in the urban but also in the rural settings. This study was conducted to study the prevalence of self reported diabetes, risk factors, complications, knowledge, attitude and practice on diabetes among adults above 40 years in a village in Kinta district, Malaysia Methodology: Cross-sectional study conducted on 194 villagers of Kampung Seri Jaya, who were aged 40 years and above, con- ducted during May-July, 2013 Results: The prevalence of reported diabetes with documented evidence was 20.1% (95% CI 15.07 to 26.3) among the par- ticipants. Prevalence among males was 18.7% (95% CI 11.46 to 28.93) and among females was 21% (95% CI 14.65 to 29.18). Prevalence of diabetes was significantly higher in higher age groups. A positive family history was a significant risk factor among diabetics (p&lt;0.05). Knowledge and attitude regarding importance of exercise, weight reduction and checking of glycosylated hemoglobin was less Conclusion: More intensive interventions on lifestyle changes in the rural population is needed to control this alarmingly high occurrence
Gender and Antibiotic Resistance Pattern of Uropathogen in a Tertiary Care Level
Background: Antibiotic therapy for UTI has become more difficult in the recent years, due to the widespread emergence of drug resistance (especially multi-drug resistance) among urinary pathogens. This study was designed to analyse the impact of the sex of the patient on antibiotic resistance. Materials and Methods: A retrospective study, based on laboratory data on the bacterial isolates from urine samples submitted for culture and antibiotic susceptibility to the department of microbiology during the period of 2008 to 2011. Result: Out of 1239 bacterial isolates included in this study, 745 (60.1%) were obtained from in-patients, while 494 (39.9%) were obtained from out-patients. 494 (39.87%) of the total isolates were from males, while 745 (60.13%) were from females. Higher susceptibility rates to all antibiotics tested, except for ciprofloxacin, were seen in females. This was found to be statistically significant, except with cotrimoxazole. The difference in susceptibility rates among in-patients and out-patients (higher susceptibility rates for all antibiotics, except ciprofloxacin) were statistically significant for all antibiotics, except with ampicillin, cotrimoxazole and ciprofloxacin. Conclusion: Antibiotic resistance is more likely in urinary isolates from male patients and from in-patients. Greater caution is warranted in selecting antibiotics to treat these patients and should ideally be guided by urine culture and antibiotic susceptibility results.
Asymptomatic Bacteriuria in Patients with Diabetes Attending a Tertiary Care Level – A Descriptive Study
Background: Most of the major cancer centres have adopted sentinel lymph node biopsy (SNLB) as standard means of axillary nodal assessment as an alternative to axillary lymph node dissection (ALND) in clinically node negative early breast cancers. The benefits of SNLB is to reduce the functional disability which is a potential consequence of ALND. A major pitfall of SNLB is the potential of false negative rate which will increase the risk of an axillary recurrence. Methods: This is a pilot study of forty one cases of clinically NO. T1 and T2 tumors for whom sentinel lymph node mapping was done using methylene blue dye to detect occult metastasis. This was validated by complete ALND in all cases. Results: The calculated accuracy of the frozen section analysis was 97.5%, sensitivity was 85.7% and specificity was 100%. Positive predictive value was 100%, negative predictive value was 97.14% and false negative rate was 2.86% Discussion & Conclusion: This study demonstrates a high sensitivity and specificity for frozen sections of SNLB with an ac- curacy of 96%.
Research and Problem Solving: Practitioner's Need to Think?
Scientific research is a marker of success for all professionals in health science. It is not merely writing something irrelevantly. It does not matter how pleased an author might be to have converted all the right data into wordings; it matters only whether a large majority of the reading audience accurately perceives what the author had in mind. In modern medicine evidence based practice is truly scientific and also ethical. Most of the medical professionals are reluctant to do research and publishing, especially in developing countries. This reluctance is not only because of their lack of knowledge but also due to the absence of some statutory body to monitor the development in terms of promoting scientific research. Scientific writings are always influenced not only by academic interests and knowledge, but also by extracurricular talents and life experiences. This is one of the principal reasons why medical professionals in renowned institutions are working in clinically orientated medical research.
A Case of Protein losing Enteropathy - Intestinal Lymphangiectasia
Primary intestinal lymphangiectasia (PIL) is a rare disorder of unknown etiology characterized by diffuse or localized dilation and eventual rupture of the enteric lymphatic vessels in mucosa, submucosal, and/or subserosa. The main symptom is variable degrees of pitting edema of bilateral lower limbs.
Giant Adrenal Cyst : Epithelial Variant, A Rare Entity
Adrenal cystic lesions are a rare entity encountered in clinical practice. They can be classified into 4 types endothelial, pseudocyst, epithelial and parasitic. It is mostly asymptomatic and non-functional. Lack of definite laboratory and radiological diagnostic criteria makes it difficult to establish their diagnosis preoperatively and excision is needed in most cases. Laparoscopic adrenalectomy is the treatment of choice although small, benign, asymptomatic, non functional lesions can be aspirated or put on surveillance. Epithelial cyst is one of the rare types of adrenal cyst comprising only 9% of all adrenal cysts with most of the benign cysts less than 7 cm. Hereby illustrating a rare case of incidentally diagnosed giant epithelial adrenal cyst, the incidence of which has been less than hundred in the literature reported so far
Unusual Presentation of Multiple Myeloma
64 years old diabetic male presented with 2 months history of back ache, associated with restriction of movements, involving paraspinal muscles. Investigations showed pancytopenia, high ESR, bone marrow examination was suggestive of multiple myeloma. Serum electrophoresis showed no abnormal band. And the patient was diagnosed to have non secretory myeloma presenting as polymyalgia rheumatica
Prospective Observational Study of Adverse Reactions following Intravesical BCG in Bladder Cancer Patients in Tertiary Hospital in Kerala
Intravesical BCG instillation is standard treatment for NMIBC following TURBT for specific indications. The presence of adverse effects following BCG instillation in bladder cancer patients has been a matter of study by several researchers. Though a common treatment protocol prospective studies in this area based in India are less common. In this prospective observational study this has been studied in detail. The adverse effects were classified based on the Cleveland classification and managed accordingly. The findings were analysed. Several conclusions were reached upon
Risk Factors for Poor Asthma Control and Breakthrough Attacks
Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals. Prevalence is increasing in many countries, especially in children. Asthma is a major cause of school and work absence. Health care expenditure on asthma is very high. Asthma' symptoms may be triggered by factors which are well known such as viral infections, allergens, tobacco smoke, exercise and stress.
Frozen Section Evaluation of Methylene Blue Dye based Sentinel Lymph Node Biopsy in Early Breast Cancer - A Feasibility Pilot Study in a Tertiary Cancer Centre
Background: Most of the major cancer centres have adopted sentinel lymph node biopsy (SNLB) as standard means of axillary nodal assessment as an alternative to axillary lymph node dissection (ALND) in clinically node negative early breast cancers. The benefits of SNLB is to reduce the functional disability which is a potential consequence of ALND. A major pitfall of SNLB is the potential of false negative rate which will increase the risk of an axillary recurrence. Methods: This is a pilot study of forty one cases of clinically N0, T1 and T2 tumors for whom sentinel lymph node mapping was done using methylene blue dye to detect occult metastasis. This was validated by complete ALND in all cases. Results: The calculated accuracy of the frozen section analysis was 97.5%, sensitivity was 85.7% and specificity was 100%. Positive predictive value was 100%, negative predictive value was 97.14% and false negative rate was 2.86% Discussion & Conclusion: This study demonstrates a high sensitivity and specificity for frozen sections of SNLB with an accuracy of 96%.
Economic Impact of Needle Sticks Injuries
Background: Needle stick injuries (NSI)s involve loss of economy at different levels to an institution which is often not addressed in many of the related studies. An assessment of such issues in terms of the money involved can actually help in planning cost effective strategies in preventing them by policy makers and hence we decided to conduct this study Objectives: We attempted to find out the direct and indirect costs involved in managing the occupational exposures by the institution during a 2 year period Materials and Method: This was a retrospective observational study on all the reported cases of occupational exposures (OEs) to health care workers (HCWs) that had occurred during the study period. Direct and indirect costs involved were calculated as per the CDC definition. Results: We found that on an average each occupational exposure costs INR 4791 to the in-stitution in total which include INR 3556 and INR 1235 as direct and indirect costs respectively. Discussion: The economic burden on the institution in managing occupational exposures to HCWs is considerable and warrants implementation of effective preventive strategies to minimize this loss. The results of the present study represent issues faced by any similar establishment in a developing country and can be used to plan cost effective intervention strategies
Health Consequences of the Massive Floods: Immediate and Long Term
Kerala is a narrow strip of land about 500 kms long extending from Kaliyikkavila in the south to Manjeswaram in the north extending from the Western Ghats to the Arabian Sea about 150 kms broad. It has varied topographical features from the mountainous terrain to the hilly and flat plains. The state receives heavy rainfall approximately 200 cms yearly spread across two monsoons the South West beginning May end to September and the North Eastern from October to mid-December is drained by 44 rivers that take the water rapidly to the sea. Numerous dams harness these waters for generation of electricity, irrigation, flood control and water supply. Since time immemorial this state had protection from major natural disasters like floods, earthquakes and cyclones and manmade disasters like war and major communal flare-ups.
Coronary artery septic embolisation resulting in acute myocardial infarction is a rare complication of infective endocarditis. Diagnosis requires high clinical suspicion, echocardiography, coronary angiography and cultures of peripheral blood and/or embolic material. Optimal therapy is unknown. We report a case of 27 yr old male who had recently been diagnosed with IE later presented with AMI.
RS3PE is a rare inflammatory arthritis which can occur idiopathically or as a paraneoplastic manifestation of an underlying malignancy. We present a case presented with remitting seronegative symmetrical synovitis with pitting oedema finally diagnosed with Adenocarcinoma Lung.
A case of neuropathy complicating horse bite is presented. Neuropathy is reversible.
NIPAH Virus Infection - A Review Article
Nipah virus (NiV) is an emerging zoonotic disease with high case fatality rate. Infection is spread to humans from the natural reservoir host (bats) through intermediate hosts like pig or through fruits contaminated by bat saliva or urine. Currently there is no treatment and vaccine for the disease. So early identification of the outbreak, and personal protective measures are important to prevent the transmission of the disease.
Evaluation of Perinatal outcomes of High Risk Pregnant Mothers who undergo Caesarean Section
Background: Rising caesarean rates above the recommended 10% has shown to worsen the perinatal outcome, especially with reference to developing countries. Early detection of perinatal outcomes followed by special intensive care can significantly alter perinatal mortality rates. The study was undertaken with the objective of evaluating the perinatal outcomes of high risk cases undergoing caesarean section. Objective: To evaluate perinatal outcome in high risk pregnant mother who undergo caesarean section Methods: This is a prospective cohort study. The sample size was calculated to be 125 each in cohort and control. A total of 357 women from SAT Hospital, Thiruvananthapuram were interviewed which included those posted for elective caesarean and others. They were categorised according to Coopland's scoring system into high risk and low risk groups and 250 women who underwent caesarean section were followed up on the 4th day of their confinement and their perinatal outcomes assessed. Result: The mean age of women who took part in the study was 26.45 years (SD-4.693) and the mean gestational age was 261 days (SD-14.181). It was found that 39.2% of women had a history of previous caesarean section, 26.8% and 18% of women had gestational diabetes-mellitus and hypertension during their present pregnancy respectively. The relative risk for significant neonatal outcomes in high risk group when compared to low risk group are: respiratory-distress syndrome-11.965(CI 1.51-94.144, P=0.03), neonatal-hyperbilirubinemia -14.393(Cl 1.853 to 111.795, P=0.001), prematurity-2.042 (CI 1.101-3.785, P=0.022), neonatal hypoglycaemia-4.125(CI 1.329-12.805, P=0.009). Conclusion: Our study found that neonates of high risk women had a greater risk of respiratory-distress syndrome, neonatal-hyperbilirubinemia, prematurity and neonatal-hypoglycaemia. We suggest a timely care and referral of high risk women and a targeted treatment plan for their neonates.
Article Title: Medical Ethics - the Evolving Paradigms in India
Though India has a strong and enviable legacy of ethics related to patient care, the discipline of Bioethics is still in its infancy in the country. Bioethics, an integral part of modern medical practice and research, is gradually percolating to the fields of medical education, research and practice, though not at a commendable pace. The Medical Council Regulation Act that guides the medical practice in the country and the Guidelines on biomedical research involving human participants are yet to gain widespread popularity among the practitioners as well as researchers. The Medical Council Regulation Act, drafted almost two decades back, with modifications instituted several times, still remains to be modified or even rewritten to suit the current situation. The medical profession during this period has undergone a sea of changes and the demarcation line between 'profession' and 'healthcare industry' is fast thinning out due to various reasons including the growth of 'profit oriented non-government and corporate sectors in healthcare. Added to this is the growing menace of attacks on hospitals and healthcare providers. Medical Council Regulations, drafted with 'single doctor- single patient' and their one-to-one relations in mind is fast losing its relevance and needs to be revisited. Similarly, institutional mechanisms for overseeing research involving human participants needs to be strengthened. Ethics education needs to take a centre-stage in Medical Education and Ethics Committees, both clinical as well as research need to have more professionals trained in Bioethics. The Medical Councils at the Centre as well as at the regional levels need to have more ethics professionals and the existing situation demands for paradigm shifts in ethics related to medical practice and research in India
Ethics in Organ Transplantation - Some Facts and Thoughts
Successful transplantations give patients with otherwise untreatable degenerative diseases a new lease on life, or enable them to lead a more fulfilling or productive existence
Hypocalcaemia evaluation is very important, as it may be seen most often in practice. We are reporting a case Pseudohypoparathyroidism Type la, which is one of the very rare causes of hypocalcaemia. The patients present with distinctive skeletal and developmental defects (Albright's hereditary osteodystrophy) along with decreased calcium, hyperphosphatemia and high parathyroid hormone levels.
Primary myelofibrosis is a clonal disorder of a multipotent hematopoietic stem cell of unknown etiology and is one of the least common myeloproliferative neoplasms (MPN). It primarily affects men in their sixth decade or later. We are presenting a young lady who presented with anemia and massive splenomegaly diagnosed as Primary myelofibrosis.
Association of Non-Alcoholic Fatty Liver Disease with Renal Stone Disease detected on Computed Tomography
Introduction: Non-alcoholic fatty liver disease (NAFLD) has been recognized as a liver manifestation of the metabolic syndrome. NAFLD is defined as the presence of at least 5% of the fat component in the liver without any other liver disease. Recent studies concluded that NAFLD has no direct association with renal function and mild renal function abnormality may have similar risk factors or disease process. Recently, we noticed a concomitant diagnosis of both fatty liver and renal stones disease in same patient on the basis of computed tomography (CT) finding in routine daily practice. Literature reviews by using Pubmed articles demonstrate only two recent studies were performed and revealed the association between fatty liver and renal stone disease. Objective: To evaluate the association between Non-alcoholic fatty liver disease (NAFLD) with renal stone disease detected on computed tomography (CT). Materials and Method: A total 250 patients who underwent abdomen-pelvis CT in 2016-17 were included in this study. All of the studies were performed on the same Dual Source CT. Fatty liver and nephrolithiasis were determined based on ultrasound and CT scan findings. The statistical significance of the association between NAFLD and renal stone disease was assessed using Chi Square Test. The Odds ratios and 95% Cl were calculated to assess the propensity of renal stones disease for NAFLD by using Logistic Regression analysis. Result: Among the 250 cases, there were 200 men (80%) and 50 women (20%). Association of fatty liver and stone was higher in men (28%) compare to female (12%). The association between NAFLD and nephrolithiasis was more prominent in cases less than 50 years of age than in those older than 50 years (p for interaction&lt;0.001). Conclusion: The present study indicates that the prevalence of Urolithiasis is significantly higher in the NAFLD than healthy subjects. This result suggests that NAFLD may be involved in the mechanism of onset of Urolithiasis
Retrospective Analysis of Dengue Fever Outbreak in 2017 - An Observational Study from General Hospital, Thiruvananthapuram
Background: Dengue epidemics are a serious public health concern world over. Similar epidemics are reported from various parts of India also. The recent outbreak in Kerala in 2017 had high morbidity. The present study is aimed to evaluate the epidemiological features, clinical profile, laboratory features and outcome in dengue patients. Materials and Methods: It is a hospital based observational study where retrospective data analysis of patients with dengue during the peak epidemic period (from May 2017 to July 2017) was done. Results: Of the 578 patients 277 (47.9%) were males and 301 (52.1%) were females. Mean age of the patients was 37.28 +-15.765.Out of 578 patients, 515 (89.1%) had thrombocytopenia and 522 (90.3%) had raised liver enzymes. Mean haematocrit was 41.44+ 4.18 in males and 37.55+_4.28 in females. Among all patients 225 (38.9%) developed any kind of bleeding manifestations. Out of 578 patients, 510(88.2%) had either NS1Ag or IgM positivity. Of the total MICU admission, 40 had severe dengue with co morbidities. Conclusion: In our study significant number of patients had thrombocytopenia and raised liver enzymes but complications and mortality were less. Early recognition of warning signs, prompt intervention, supportive treatment and monitoring can save lives.
Adverse events following Live JE Vaccination – An Observational Study
Objectives: To study the safety profile of live JE vaccine. To analyse the possible risk factors for development of adverse events. Methods: 1500 children aged 1 year to 15 years, vaccinated with live JE vaccine during a mass vaccination campaign, were followed up for a period of 6 months from the time of vaccination. Outcome measures were major and minor adverse events during the first two weeks and any neurological events thereafter. Results: No serious adverse reactions were noted in the 1st two weeks following vaccination. 22.3% reported minor events like fever, headache, upper respiratory symptoms, vomiting, rashes and local reactions. Those with a personal or family history of atopy showed an increased risk of adverse events. No significant correlation between age, sex, or nutritional status and risk for development of adverse events were noted. None of the vaccine recipients experienced any major neurological events within next 6 M. Conclusion: Live attenuated JE vaccine is safe in children below 15 years. Those with a history of atopy have a higher risk of developing minor adverse events following the vaccine.
Hospital Violence The Causes, the Response and the Way Forward
Any behaviour that is responsible for physical or emotional harm to the healthcare persons is violence. Violence against doctors is seriously threatening. It is an effect of unwell, pathetically backed healthcare system. The hospitals cannot be allowed to become war zones as sick people need a peaceful environment and the Doctors also need a stable and peaceful ambience for delivering 100% selfless quality care. Because of violence doctors have started practising defensive medicine. Finally, the stressful hospital environment is making doctors as well as patients suffer the brunt.
Swap Donation: New Hope for Transplant Patients
The quest for transplantable organs is upmost in the minds of any patient with irreversible organ failure when they are placed in the transplant list. There is a huge demand supply mismatch that makes this problem a real concern for the potential recipient and the family and well-wishers. The supply of organs comes from related live donors, unrelated live donors and deceased donors from brain dead donors. In India the potential renal recipients are nearly 1.5 lakhs yearly whereas the annual kidney transplant rate is probably ten thousand. The ratio is more alarming when liver transplant is considered.
A Case of Classic PAN Presenting as Bilateral Foot Drop
Classic Poly Arteritis Nodosa (PAN or c-PAN) is a systemic vasculitis characterized by necrotizing inflammatory lesions that affect medium-sized and small muscular arteries and most commonly affects skin, joints, peripheral nerves, the gut, and the kidney. Peripheral neuropathy develops in as many as 60% of patients. Vasculitic neuropathy is often asymmetrical and presents as (1) mononeuritis multiplex, (2) distal polyneuropathy, or (3) cutaneous neuropathy. It can take the form of a pure motor, pure sensory or mixed sensorimotor polyneuropathy. Here we present a case of a 58 year old male manual labourer who presented with progressively worsening difficulty in walking. He was evaluated in detail. Several rare manifestations were noted. A final diagnosis of Poly arteritis Nodosa was made which presented with Mononeuritis Multiplex (with the involvement of Right Median nerve and Bilateral Lateral popliteal nerve) and Sero negative Vasculitis. He was initiated on Corticosteroids and IV Cyclophosphamide. The case is presented for its rare manifestations.