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Abstracts of Papers Presented at the 120th Research Meeting of The Medical Research Centre of Bombay Hospital (Convenor Dr. HL Dhar)

1. Post Transplant Renovascular Complications

H Shah, S Punamiya, S Bichu, P Namboodiri, V Dodke, UG Oza, AL Kirpalani
This is a retrospective analysis of 523 consecutive renal allograft recipients (519 live and 4 cadaver) between May 1988 and May 2003. The incidence of different types of vascular complications, the clinical profile of these patients; the diagnostic and therapeutic approach adopted and their outcome were analysed. 490 patients received azathioprine and 33 received mycophenolate while 17 patients were given IL-2 receptor antibodies as induction immunosuppression. All patients also received cyclosporine and prednisolone.

The commonest vascular complication after renal transplant was TRAS. Thrombotic complication invariably led to graft loss. The commonest site of stenosis was at the anastomosis (with an angiographic success rate of 75%) although stenosis could occur at other parts as well. The incidence of anastomotic stenosis (which could be attributable to surgical technique) was acceptably low (1.5%) and comparable to other large international series.

Abstracts of Papers Presented at the 121st Research Meeting of The Medical Research Centre of Bombay Hospital (Convenor Dr. HL Dhar)

1. Cochlear Implants - Bombay Hospital Experience

Anand K Shah
Cochlear implants are no more in the realms of research. It is now a part of our surgical armamentarium in treatment of profound deafness. Due to misconceptions amongst our colleagues very often we fail to offer this option to the patients. It is important to give every possible candidate and their relations complete information so that they can make a correct decision. Today medicine is all about informed decisions taken by patients and their relatives. We can only suggest but we cannot take the decision for them.

The first aim is to make sure that there is a good chance of improved hearing with an implant and most importantly to make sure that there is minimal chance that the patient will be worse off.

After the implant team decides that the child is a suitable candidate for implant the relatives are explained the potential benefits and told about the possible complications related to the device or the surgery. It is very important for them to meet an implanted child and parents as they are able to answer many queries. Implant is a commitment for life and it is important to be fully informed.

It is extremely important to catch these children young. There is no child that is too young to wear hearing aids and this should be done at the earliest. Implant is usually carried out when necessary between one and two years of age. When implanted early the prognosis for speech and language development is much better. At younger age they seem to be having better electrical discrimination.

2. A Different Approach to Bilateral Dermoid with Preservation of Part of Ovary

Deepak Bhenki, Daksha Bhangui, Nitin Paidhungat, S Goel, PB Paidhungat
Dermoid cyst is a benign germ cell tumour found in 15-20% of benign ovarian tumours. 15-20% of dermoids are bilateral. Laparoscopic approach for excision of bilateral big sized dermoids with preservation of part of ovary with uneventful post-op recovery was done in this case. A 26 year old female P1L1A0 was admitted with complaints of lower abdominal pain on and off since 2 months and regular menstrual cycle.

On examination, Vitals stable, PA: Soft, PV : Ut-Normal size, A/V, bilateral masses felt in fornices, mobile.

CT scan : E/O bilateral cysts Right measuring 6.4 x 4.9 cm and left 5.1 x 4.0 cm suggestive of dermoid. Therapeutic laparoscopy was done with b/l dermoid excision with preservation of part of ovary in view of future pregnancy.

The specimen was removed in endobag through abdominal port and thorough suction irrigation done to avoid chemical peritonitis. Patient sent on 2nd post-operative day. Post-op period was uneventful.

3. Case of Secondary Abdominal Pregnancy

Daksha Bhangui, Deepak Bhenki, Nitin Paidhungat, PB Paidhungat
Abdominal pregnancy is one of the rarest ectopic pregnancy with incidence of 0.03%. Secondary abdominal pregnancy is more common than primary. 37 year female with HIV positive status was admitted with history of amenorrhoea since two months, lower abdominal pain on and off with urinary test positive. Past regular menstrual cycle.

On examination : Severe pallor, vitals stable, PA : Tender palpable mass, 14 weeks size with FHS heard on doppler, PV : Uterus bulky with mass felt in POD. Tenderness present.

USG - uterus bulky with homogeneous myometrial echo pattern with single viable foetus, with normal cardiac activity, seen in pelvis posterior and separate from uterus.

Exploratory laparotomy with preoperative blood transfusion and left salpingo oophorectomy with tubal ligation of right tube was done. Intra op finding- haemoperitoneum with blood clots, foetus with cardiac activity lying in abdominal cavity. Left tube ruptured with placenta attached to ovary and posterior surface of broad ligament. Right tube and ovary normal.

Post op period uneventful. Prophylactic dose of Methotrexate 50 mg im was given.

4. Timely Intervention in a Case of Previous Spontaneous Uterine Rupture with 32 Weeks of Pregnancy Leading to Successfull Outcome

Ruta Deshpande, Prashant Nyati, Sadhana Desai, Prema Kania
Spontaneous rupture at 32 weeks of pregnancy is a very rare phenomenon. Our patient had a spontaneous uterine rupture at 32 weeks in previous pregnancy. With good antenatal care and perfect timely intervention in this conception at 32 weeks of pregnancy in form of caesarean section gave a successful outcome. A viable foetus of 1570 grams was delivered; which with excellent neonatal care went home in good health.

5. Population Screening for Genetic Disorders - Jalna Camp Experience

BN Apte, SG Gogate
Genetic disorders play a very important role in morbidity and mortality in clinical medicine. Unfortunately genetics in medicine has not received the attention and the importance it deserves. There is no screening activity for genetic disorders, particularly in rural areas. Our camp held at Jalna was a small attempt to fill these lacunae. The camp was sponsored and organized by the ECO-LIFE Genetic Diagnostics and Research Center of Mumbai. The local logistic support was provided by the Jalna chapter of Red Swastik Society and the Rotary Inner Wheel Club. The population of the Jalna district was covered. Population awareness was generated by fliers and banners giving details about the camp. Prior enrollment was done. Detailed proforma for each patient was prepared.

The response was overwhelming, much beyond our expectation! We had to restrict the number of patient to be seen in a day to maintain high level of evaluation and consulting.

One hundred and twenty patients were evaluated of which 34 cases had problems not directly related to the genetic aetiology and were, therefore, not included in the screening and evaluation. They were guided to the appropriate medical speciality.

Eighty six cases were screened and evaluated for genetic disorders. Of these, 60 were in the paediatric age group, 16 adults and 10 pregnant women. It was unfortunate to see more than 25% of the cases, who had reached adulthood before approaching the medical facility for diagnosis and consulting.

The genetic disease profile was as follows:

  1. Inborn errors of metabolism (IEM)     44
  2. Chromosomal aberration                    10
  3. Unknown aetiology / Multifactorial      19
  4. Antenatal cases                                     10
  5. Congenital heart disease                      3

This was our first attempt to initiate the process of genetic awareness about the genetic diseases. The experience was indeed very encouraging. We hope to have many more small camps in future.

Abstracts of Papers Presented at the 122nd Research Meeting of The Medical Research Centre of Bombay Hospital (Convenor Dr. HL Dhar)

1. Extra-cellular Matrix Molecule Tenascin-C - Expression in Gliomas

PS Gaitonde, RS Dastur, JJ Nadkarni
Astrocytic gliomas constitute approximately 40% of all glial tumours. Depending on the degree of cellularity, vascularity and invasiveness, these are classified as Grade I to Grade IV astrocytomas. One of the factors affecting the tumourogenecity of gliomas is extracellular matrix glycoproteins. Tenascin-C which is specific for brain parenchyma, is one of these glycoproteins involved in cell-adhesion, cell migration and neovascularization. Immunohistochemical expression of Tenascin-C, on different grades of astrocytomas revealed a correlation between the intensity of expression of Tenascin-C and angiogenesis in astrocytic gliomas.

2. Microsurgical Internal Decompression of Lumbar Spinal Stenosis

Nootan Kumar Sharma, Keki E Turel, Joy Varghese, Shashank Joshi
Two hundred consecutive cases of lumbar canal stenosis operated by microsurgical internal decompression (MIDSS) by us were evaluated over 8 years (1991-1998).

The commonest symptoms were backache (85%) root pain (76%) and neurogenic claudication (72%). Other symptoms were paraesthesiae (30%) and cauda equina syndrome (4%).

These patients underwent microsurgical decompression of the central and/or lateral canal at single or multiple levels depending upon clinical and imaging findings. In addition to stenosis (68%), 32 cases also had significant disc protrusions.

The usual findings are: 1) hypertrophic facet joints, 2) extremely reduced interlaminar space by telescoping of the superior edge of the inferior laminar under the interior edge of the preceding one, 3) reduced interpedicular distance (or “kissing” joints), 4) hypertrophic ligamentum flavum, 5) engorged paraspinal veins, 6) disc protrusion.

3. Microsurgery of AVMs in Eloquent Areas of Brain


Joy Verghese, Keki E Turel, Nootan Kumar Sharma, Shashank Joshi
Cranial AVMs have always challenged the skill and patience of a microneurosurgeon, more so when the AVM is situated in an eloquent area. In recent years, introduction and refinement of endovascular techniques and gamma knife radiosurgery have changed the surgical indication of AVMs significantly. More and more eloquent area AVMs are subjected to these so called minimally invasive treatment modalities. Endovascular embolisation, at its best is only an adjuvant treatment modality, and results of radiosurgery are still debatable. In such a scenario, direct microsurgical removal (with or without prior embolisation) offers the only hope of complete cure. These AVMs account for 4-5% of the cranial AVMs.

In conclusion, microsurgical excision of eloquent area AVMs in experienced hands offers a hope of permanent one stage ‘cure’ with minimal or no morbidity.

4. A Case of Motor Neuron Disease associated with Hashimoto’s Thyroiditis

Ashish Bagdi, NE Bharucha
Hashimoto’s thyroiditis (HT) an autoimmune disorder occurs in all age groups. It is more common in middle age and is much more common in females than males. Amongst the neurological manifestation of HT, encephalopathy was first described by Brain et al in 1966, myelopathy by Tsutomu Azuma et al in 2000, ALS by Appel SH.

We present a case of motor system disease (ALS) associated with HT. A 53 year old housewife was admitted to Bombay Hospital. She had history of stiffness in her right great toe for 2 years. Subsequently, other toe, knee and thigh were affected and had occasional falls. Stiffness was gradually increasing. EMG revealed long standing widespread asymmetric motor axon degeneration affecting the muscles of lower limbs and right upper limb. Site of lesion most likely at the anterior horn cell level. She was treated with Epitril and Baclofen, methylprednisolone (5 days). There was marked improvement in stiffness and could walk with support of two persons Her reflexes were +++ and plantars were increased consistent with a combination of LMN and UMN involvement.

5. Cerebral Hemorrhage in Polycythaemia

Haresh Bharote, SV Khadilkar
We present a middle aged male presented with acute of aphasia without limb deficit. The neuro-imaging showed cerebral haemorrhage and haematology confirmed polycythaemia. We present this case for the rarily and relevant literature is reviewed.
Polycythaemia is used to describe an increased red cell, count packed cell volume or haemoglobin level. It is typically disorder of middle aged and elderly patients. Disorders starts insidiously, patient may present with an acute dramatic complication such as cerebrovascular accident or major thrombotic episode.

Absolute polycythaemia are divided into primary polycythaemia (polycythaemia vera) which is a myeloproliferative disorder characterised by increased red cell mass and normal arterial oxygen saturation.

Secondary polycythaemia may occur in association with cerebral haemangioblastoma, hepatoma, hypernephroma, uterine fibroid, benign renal cyst, carbon monoxide exposure and administration of androgen.

The majority of intracranial events are thrombotic in origin occurring due to thrombocytosis, platelet disorder and hyperviscosity. The larger cerebral arteries being most frequently involved, cerebral haemorrhage also occurs and is fatal in 3% of patients. Neurological presentation can be headache, dizziness, vertigo, tinnitus, visual disturbance, carotid and vertebrobasilar TIAs, chorea and fluctuating cognitive component.

6. Complications of Acute Stroke - A Prospective Study of 100 Patients

Sangamesh Bhagavati, BS Singhal
We studied 10 patients admitted with a history of acute stroke to our hospital over a period of one year. We included 60th cerebral infarction as well as primary intra cerebral haemorrhage. We followed up these patients in the hospital till the time of discharge or death for the development of any medical and/or neurological complications particularly medical complications were common after acute stroke (52%). Complications were highest in the intracerebral haemorrhage group (95%) followed by in the posterior circulation infarct group (57%) and partial anterior circulation infarct group (47%) respectively. Constipation (36%) and urinary retention (33%) were the common complications observed in our study followed by urinary tract infection (14)% and chest infection (9%) respectively. Frequency of neurological complications was low. Patients with a low GCS score had an increased frequency of complications. Four male patients died in the hospital and all had a GCS score of less than seven. Out of these four patients, three had an intracerebral bleed four, the remaining one had a big left MCA territory infarct with haemorrhagic transformation. The duration of stay in the hospital for the complicated stroke group (10.354 ± 4.3831 days) was significantly higher as compared to the uncomplicated stroke group (6.375 ± 1.96 days).

ANTIBIOTIC USE AND RESISTANCE IN EUROPE

‘Out study indicates a tendency to use new antibiotics, which fail to offer substantial improvements over other available drugs’

Antibiotic resistance is a major public-health problem, and inappropriate use is thought to be the reason. Herman Goossens and colleagues did a multinational study to assess outpatient use of antibiotics and association with resistance. They noted a shift from use of narrow-spectrum antibiotics to the newer broad-spectrum drugs. The researchers also recorded a correlation between resistance and use of antibiotics; seasonal fluctuations were also seen, with high winter peaks. In a Comment paper, John Turnidge and Keryn Christiansen say that although the method used to correlate antimicrobial use with resistance was crude, a more advanced method - incorporating influences such as proportion of individuals exposed, effects of different drug classes, and differences between bacterial species - could help us to design and measure the success of intervention strategies.

BMJ, 2004; 548, 579.

WHEN SNORING IS A PROBLEM

`Simple snoring is not a cardiovascular risk factor'

Obstructive sleep apnoea-hypopnoea affects a small proportion of the population, but is associated with high rates of morbidity and mortality mostly due to cardiovascular disease. Jose Marin and colleagues did an observational study to elucidate the long-term cardiovascular outcomes in men with the disease, with or without treatment with continuous positive airway pressure. The investigators report that incidence of cardiovascular events in untreated patients with severe obstructive apnoea-hypopnoea is significantly higher than in healthy individuals. Treatment with continuous positive airway pressure significantly reduces the cardio-vascular risk associated with this disease.

The Lancet, 2004; 1046.