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ABSTRACTS FROM MRC/B

Abstracts of Papers Presented at The 97th Research Meeting of
The Medical Research Centre of Bombay Hospital On Monday 10th June 2002, 2.30 Pm Sp Jain Cafeteria


1. ESTABLISHING QUALITY ASSURANCE PLAN IN AN ELECTRODIAGNOSTIC LABORATORY OF BOMBAY HOSPITAL”

Soniya Shah, KA Mansukhani

In the current health care environment, delivering high quality and high value patient care is paramount. The goal of quality assurance plan established in electrodiagnostic lab is to improve quality service using ongoing monitoring and evaluation strategies.

The Electrodiagnostic laboratory of Bombay Hospital is one of the pioneering centres in India, well equipped with pentium based state of art electromyograph machines. The department has a good infrastructure and a very good reputation to its credit. The continuous quality management is thus required to cater the quality services.
Electrodiagnostic studies performed in EDX lab are the diagnostic tests; however, without adequate history and physical examination the test has very little value. Furthermore, adequate testing of various nerves and muscles is a prerequisite for correct interpretation and diagnosis.

Common diagnoses encountered in a clinical EDX laboratory include Carpal tunnel syndrome, peripheral neuropathy, radiculopathy, plexus lesions and myopathy. Depending upon the types of patients seen in a given laboratory, certain aspects of care could be monitored.

The purpose of this study is to understand the pre-requisite for implementing quality management system for health service organizations that provide for continuous improvement, emphasizing error prevention, the reduction of variation and organizational waste.

The focus of the present study is
l To establish and implement a quality assurance plan in EDX laboratory.
l To improve patient care ad satisfaction using ongoing monitoring and evaluation strategies.
l To study the impact of Quality assurance plan on the service delivery and patient satisfaction in EDX lab using specifically designed computer software programme for effective collection and analysis of the data.
Thus, by continuous monitoring and evaluating the quality services, it can enable the community to accept it as primary centre and will automatically become benchmark for others at the national level.

2. ELECTRODIAGNOSTIC LOCALIZATION OF LONGSTANDING MONONEUROPATHIES - WITH MRI CORRELATION - 3 INTERESTING CASES
Bhavna Doshi, KA Mansukhani
Electrodiagnosis is an extremely useful test for the diagnosis of nerve lesions. It is a combination of nerve conduction studies and needle electromyographic examination, which helps to localize the exact site of nerve lesion. We present here, 3 cases of longstanding localised weakness and numbness in which MRI confirmed the electrodiagnostic localisation and in one case intraoperative confirmation was also available.

Electrodiagnostic evaluation is absolutely essential prior to surgery, close to any peripheral nerves as it gives us an objective assessment of the function of the nerve and the muscles it supplies.

3. A SERIES OF POEMS SYNDROME
Anita Narayanswamy, Jayanti Gurumukhani, JA Lalkaka, BS Singhal

POEMS Syndrome is an under recognized multisystem disorder characterized by polyneuropathy organomegaly, endocrinopathy, M-Band and skin changes. A retrospective analysis of 13 cases over a 20 year period from 1982 to 2002 was carried out.

The age group of the patients ranged from 32 years to 68 years. 11 were males and 2 were females. Polyradiculoneuropathy was present in all thirteen patients. Organomegaly in the form of hepatosplenomegaly and skin changes of hyperpigmentation was seen in eleven patients each. Diabetes and impotence was the commonest endocrinopathy. We found an M-Band suggestive of paraproteinaemia i.e. all 13 patients with bone lesions in 9 of them. They were managed with chemotherapy and radiotherapy as indicated with a good response in 10 patients.

4. UNUSUAL NEUROLOGICAL COMPLICATIONS IN AN OPERATED CASE OF THYMOMA

Jayanti Gurumukhani, Anita Narayanswamy, JA Lalkaka, BS Singhal

Mr. Anil Agarwal, a 41 year male operated for thymoma. Postoperatively he developed ophthalmoparesis and quadriplegia. Investigations revealed decremental response and elevated acetylcholine receptor antibodies. He was diagnosed to have myasthenia Gravis and treated with IV Immunoglobulins without recovery. He was also found to have hyponatraemia and MR Imaging revealed extrapontine myelinolysis. Subsequently he had repeated episodes of autonomic dysfunction in the form of hypotension and cardiac arrythmias. His repeat imaging revealed extensive signal abnormality in brainstem basal ganglia thalami and cerebral cortex. He was on ventilator for 3 months and developed critical care Neuropathy before he passed away.

Abstracts of Papers Presented at The 98th Research Meeting of The Medical Research Centre of Bombay Hospital On Monday 8th July 2002, 2.30 Pm, Sp Jain Cafeteria

1. GASTRIC ANTRAL VASCULAR ECTASIA (GAVE) SYNDROME - A RARE ENTITY - 2 CASE REPORTS
D Amarapurkar, N Patel

GAVE syndrome is an uncommon cause of chronic gastrointestinal bleeding and iron deficiency anaemia. We describe two cases of GAVE, one pernicious anaemia related and one portal hypertension related. Both the cases showing progression of multiple antral erythematous spots into linear configuration and lastly to watermelon stomach, one of the cases was treated with Tranexamic acid with good response.

2. HEPATIC SARCOIDOSIS - IS IT RARE IN INDIAN SUBCONTINENT?
D Amarapurkar, N Patel

We describe five cases of hepatic sarcoidosis. Clinical presentations included male : female = 2:3, age range 15 to 52 yrs, weight loss (100%), fever (40%), itching (40%), abnormal LFTs (100%), hepatomegaly (100%), splenomegaly (60%), abdominal lymphadenopathy (60%) and chest abnormalities on CT scan (100%). Liver biopsy was suggestive of non-caseating epitheloid granulomas in all. S. ACE level was elevated in 60%. All patients were diagnosed as hepatic tuberculosis and treated with ATT. None of them improved on ATT while some of them had significant deterioration. All responded well to corticosteroids with disappearance of symptoms and normalization of LFTs.

3. GASTRIC TUBERCULOSIS - FIVE CASE REPORTS
D Amarapurkar, N Patel

We report five cases of gastric tuberculosis in apparently immunocompetent patients. Three patients presented as gastric outlet obstruction requiring surgery for relieving obstruction as well as for Histological diagnosis. Two patients had involvement of Gastro-oesophageal junction. All responded to standard antituberculosis treatment.

4. ACUTE FLARES IN CHRONIC HEPATITIS B INFECTION (CHB)
D Amrapurkar, N Patel

Acute flares in CHB are caused by potentially identifiable and treatable causes.
To study aetiology and outcome of acute flares in CHB.

Methods : Patients of CHB with > 5 times rise in transaminases were included. Detailed clinical examination, drug history, HbeAg, Anti Hbe, HBV DNA and serology for other viruses were performed.

50 patients with acute flare were identified in 5 years.

Mean age was 38.3 ± 8.6 years. Male : female : 4:1 symptoms (30%), ascites (20%), encephalopathy (8%), 32 were asymptomatic drugs (antiepileptic, ATT, steroid, immunosuppressants) were implicated. 12% flares occurred with discontinuous of lamivudine. Interferon induced seroconversion was associated with flare in 4% whereas, Lamivudine in 10%. 4% flares were due to probable mutation on lamivudine. 2% flare were attributed to continued alcohol,.6% flares were following surgery or infection. 10% flares were associated with spontaneous precore mutation and 22% were with spontaneous abortive seroconversion.

Serconversion was seen in 36% and seroreversion in 16%. Emergence of precore mutants was noted in 10%. HbeAg remained peristent in 32%. HbsAg was cleared in 2%. 4% died because of decompensation.
Non-specific presentation was the commonest mode of presentation. It is necessary to look for drugs and superadded infections as cause of frame resulted in seroconversion in onethird of the patient.

5. STUDY OF AMOEBIC LIVER ABSTRACTS (ALA)
D Amarapurkar, N Patel

ALA is a common problem. Unfavourable outcome was in significant number in earlier series.
To study clinical profile and outcome in ALA
All patients with diagnosis of ALA in five years were studied for clinical, biochemical, radiological features, treatment and outcome.

131 patients were included.

Mean age was 44.37 ± 5.62 years. Male : female = 4.96 : 1. Mean duration of symptoms was 16.13 ± 3.33 (2-90 days). Predominant symptoms were fever (86.25%) and intercostal pain (73%) followed by vomiting (22%) and cough (21.8%). 16.03% had history of colitis. Incidence of diabetes, alcohol and HIV was 19.8%, 38.12% and 1.52% respectively.
82% had hepatomegaly (symmetrical - 92.3%, tender - 89.3%). Intercostal tenderness was in 76.33%. Pleural effusion was found in 15% and ascites in 1.52%.

Clinical jaundice was in 13.73%, mean bilirubin level was 1.5 ± 0.48% mg/dl. Elevation of alkaline phosphatase was significantly more than of transaminases (p < 0.05). Patients showed leucocytosis (TLC - 14525 ± 266.6/ cmm) and high ESR (78.81 ± 11.8 mm). Serum IHA test for amoebiasis was positive (> 1.1024) in 93.1%.

On USG/CT, 80.2% were solitary (72% - Rt lobe / 28% - Lt). 19.08% were multiple (56% - both lobes, 44% - right).
19.84% received treatment on outpatient basis. In those hospitalised, mean duration of stay was 4.25 ± 0.52 (2-20 days). Treatment with Metronidazole and chloroquine was successful in all. Therapeutic percutaneous drainage was performed in 15.26%. Mean quantity of aspirate = 156 ± 5.6 ml. Only one patient died (mortality 0.76%) due to ruptured abscess and sepsis.

Combination of ultrasonography and serology in given clinical setting gives early diagnosis. ALA is 100% sensitive to metronidazole and chloroquine. Mortality was less than 1% and mean hospital stay was < 5 days.

6. SIGNIFICANCE OF IMMUNOTHERAPY IN ALLERGIC ASTHMA AND RHINITIS

SV Joshi, DM Tripathi, HL Dhar

A significant proportion of patients having both rhinitis and asthma are allergic to multiple allergens. The treatment of allergic diseases involves reducing the severity of symptoms of immunomodulating the disease process itself. Present study deals with immunotherapy with local allergens in asthma and rhinitis.
Five hundred patients referred to the department of allergy were scrutinised for sensitivity test (Specific IgE) to different allergens. Of these 131 (rhinitis - 56, asthma - 75), those who fulfilled the criteria as per WHO guideline for allergen specific immunotherapy (SIT) and gave the consent for SIT were included in the study. Detection of specific IgE (as determined by in vivo tests) to house dust and house dust mite was highest amongst asthmatics compared to patients suffering from rhinitis. Specific IgE for pollen sensitivity was almost equal in both the groups. Number of allergens involved were more in cases of rhinitis compared to asthmatics. It was observed that tree pollens contributed maximum in causation of asthma as well as rhinitis (Asthma 66.7% and rhinitis 57.1%). However, weed pollens’s contribution was nearly half in asthma (28%) as well as in rhinitis (30.4%). Other pollens viz. grass pollens and shrub pollens were not that significant. Allergen extracts for SIT according to skin sensitivity of individual patient were prepared. All the patients completed SIT however, 21% asthmatics and 12.5% cases with rhinitis continued the maintenance dose. Majority of the patients experienced significant symptomatic relief. Improvement was assessed by way of skin sensitivity test and symptom score along with peak expiratory flow rates (PEFR). Thus the study indicates that multiple allergen immunotherapy proved equally to be effective in the management of IgE mediated asthma as well as rhinitis.

7. SLEEP DISORDERS
Kumar Menon, S Shyamsunder, HL Dhar

We present an overview of various sleep disorders with an emphasis on early detection and correlation. Sleep medicine is one of the newest branches of medicine. Specialized sleep studies like polysomnography (PSG), maintenance of wakefulness test (MWT) and multiple sleep latency test (MSLT) which measure different physiologic parameters during sleep are now available. Sleep disorders are extremely common in all age groups and contribute to daytime sleepiness and fatigue, with associated complications like poor work and school performance, depression, substance abuse as well as traffic and industrial accidents. Sleep disorders have also been linked in multiple epidemiological studies to increased morbidity such as hypertension, cardiovascular disease as well as shortened life span. We present four cases where the chief complaint was excess daytime sleepiness each of which received a different work up and final diagnosis for each case was different.

Thus we have four young patients with similar chief complaints of excess daytime sleepiness, where, with the help of a detailed sleep history and appropriately directed specialized sleep tests four different diagnoses were made and corresponding treatment given with excellent results in all cases. Mean time to presentation to our center for sleep disorders after onset of symptoms was an astounding eight years. These patients had seen a multitude of specialists and all had extensive and expensive work-ups including metabolic screen, endocrine work-up and CT and MRI of the brain, none of which led to any diagnosis. We conclude that it is time the physician community wakes up to sleep disorders and includes a sleep history in evaluating their patients, and refers such patients with suspected sleep disorders to centers where the facility and expertise exists to appropriately work-up these cases, with specialized tests.

8. EFFECT OF SARAL MEDITATION : COMPARATIVE STUDY OF SHORT AND LONG TERM PRACTICE
AH Shah, SV Joshi, Naina Potdar, HL Dhar

Meditation is a mental exercise which can be used as powerful instrument to restrain sense organ and control autonomic nervous system.

Two groups of 2nd year nursing students each of 42 students were included in the study. The following tests were performed initially on both groups.
1) Cardio pulmonary function (viz. pulse, BP, PEFR)
2) Psychomotor test including reaction time
3) Maze
4) Arithmatic ability
5) Mental status questionnaire
6) Examination results
Training of meditation was imparted for three days and then were asked to practice.
All the above tests were repeated after 18 months (Jan ‘99 to July 2000) on one group and after 2 months (Sept. 2001 to Nov. 2001) on the other group.

Cardiopulmonary functions, Maze and arithmatic ability do not show any change in both the groups.
Reaction time improves even after two months follow up. Mental status questionnaire shows significant improvement in correctness as well as time taken to complete it.

Examination results show significant improvement in a group with 18 months follow up than in a group with 2 months follow up.

Tension based on observation at intervals has been found to be reduced significantly.
Regular practice of meditation with a longer duration (18 months) caused significant improvement in intelligence and academic performance, tension and reaction time compared to non-significant improvement after two months practice and Saral Meditation.

Abstracts of Papers Presented at The 99th Research Meeting of The Medical Research Centre of Bombay Hospital On
Monday 12th August 2002, 2.30 Pm Sp Jain Cafeteria


1. AMNIOTIC MEMBRANE TRANSPLANTATION
Jayashree, Jayesh, RC Patel

The main subject of this issue is the significant contribution of AMT to a variety of severe ocular diseases which previously had no effective management and the outcome was severe loss of vision. The pioneers in this fascinating procedure were Dr. Roeth to repair Conjunctival defects in 1940 and sorsby et al in 1947 for caustic burns of the eye. This work was later revived in 1992 with Juan Battle who introduced it to Tseng Lee and Prabhasawat. In Europe this technique became a standard procedure introduced by Juan Murube.

Prof. Murube Emphasizes that in ophthal AMT is utilised for persistent or recurrent corneal defects due to, corneal perforation on melting (In cases of co perforation due to ulcer or melting (post infection, physical or chemical burns herpetic neuroparalytica, keratomalacia, severe keratoconjunctivitis sicca) as a replacement in conjunctival or cicatricial disease. It is an important adjunct to limbal SCT for resurfacing severe alkaloid burn ocular surface after dissecting the conjunctival epithelium and fibrovascular pannus).

Conjunctival reconstruction following cancer burns or pemphigoid disease
(After excision of acquired melanosis, neoplasia etc conjunctiva can be reconstructed with AMT impression cytology shows that conjunctival epithelial phenotype is recovered over the amniotic sheet).

Severe symblepharon
(In cases of pemphigoid, SJS, chemical burns etc:- where whole ocular surface is damaged, bulbar and palpebral conjunctiva can be dissected and newly created culde sac then covered with AMT. In addition LCT can also be added procedure can be completed by topical with instillation of artificial tears and cyclosporine).
Dry Eye (Lacrimal puncta can be occluded by placing a patch of AMT over it).

Large leaking filtering blebs The Effects of AMT are
It helps in reepithelization and has antiinflammatory, anticicatrical and anti neovascular effects. Increased tendency for scar tissue proliferation acts as barrier against fibroblast multiplication. Does not trigger immunological rejection, stromal matrix shows moderate antigenicity. Stimulates apoptotic death of inflammation cells. Taken up easily, nourished by simple diffusion from subjacent host tissues and creates a resistant and protective sheet covering the affected tissues that we want to heal. Tensile strength of AMT is very high. Decreased fibroblast proliferation and prevents scarring. Decreased haze after phototherapeutic keratectomy it facilitates nerve growth.

Has non specific mild antimicrobial effects both antiviral and antibacterial. At the end the pioneers come to an conclusion that it has no antigenic substances and absence of this antigen helps it. Absence of these antigens allows the cells in amniotic membrane not to be attacked by pts immunologic system. It serves as a new basement membrane over which epithelium can grow easily and secondly contain many chemical mediators or cytokines that decreases inflammation and stimulate healing.

2. NON-PENETRATING FILTERATION SURGERIES
Jayesh, RC Patel

Glaucoma is a condition in which there is an increase in Intra Ocular Pressure (exception being Normal Tension Glaucoma) with Visual Field changes and optic nerve head changes. The conventional Surgery involved post operative complication and in search led to new approaches for satisfying results.

There are various techniques developed but our technique at Bombay Hospital Institute of Medical Sciences and Research centres is improvised and one of its kind and the results are awaited.

3. POSTERIOR LAMELLAR KERATOPLASTY
Jayashree, Jayesh, RC Patel

In the history of ophthalmology keratoplasty is a boon to corneally blind People. Till 10 years back conventional methods of keratoplasty were performed.

Posterior Lamellar Keratoplasty was first practised in some scandinavian countries with specially designed instruments. Ours is a simplified technique with routine instruments improvised in Bombay Hospital Institute of Medical Sciences and Research centres.

Though we have very few cases done, as this technique is useful only in endothelial damaged layer, the results are encouraging.

4. POSTLARYNGECTOMY SPEECH
Vimal Hemani, Navneet Mukul, NK Apte

Voice : A boon seldom appreciated till lost technically we divided it as primarily voice which is produced by vibration of vocal cords and secondary voice which is produced by vibration of supraglottic vocal tract which includes pharyngeal constrictor muscles, tongue, palate and resonance of air in walls of vocal passage and air in the sinuses.
Though laryngeal carcinoma is highly curale in its early stages, treatment alters the voice or results in a complete loss of voice, this occurs irrespective of stage or type of treatment given.

There are numerous problems like emotional, psychological, physical, economical, social, surgical and communicative after total laryngectomy. Out of all problems, inability to speak is considered the greatest difficulty to the patient.
Voice restoration after total laryngectomy can be done by Artificial electrolarynx, oesophageal speech, Tracheo-oesophageal puncture and surgical methods like pharyngeal stoma called Asia’s technique and Staffieri’s operation.


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