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Abstracts of Papers Presented at The 108th Research Meeting of The Medical Research Centre of Bombay Hospital held on 14th July 2003, (Convenor Dr. HL Dhar)

1. Endoscopic Treatment of Paranasal Sinus Mucocoeles

Mukul Navnit, Nishit Shah

Mucocoeles or pyocoeles are seen most commonly in the frontal sinus and in the ethmoid sinuses and only rarely in the sphenoid and maxillary sinus. Due to the sinus expansion, the orbit will also get affected and there may be proptosis, and visual difficulties. External expansion will cause swelling over the sinus area and intracranial expansion could result in intracranial complications. CT scan or MRI is the investigation of choice. Clinical features include headache, nasal obstruction and swelling over the sinus.

Examination of the nose reveals congested mucosa, and often we can see the bulge of the mucocoele in the nose (especially with nasal endoscopy) and sometimes other pathology.

Today, the treatment of choice is definitely endoscopic marsupialisation of the mucocoele. Under endoscopic vision, the wall of the mucocoele is identified in the nose and a wide opening is made to drain the contents into the nose. The procedure may be done under local anaesthesia as an office procedure; it is safer and quicker as no excision is involved; there is minimal blood loss as the procedure is minimally invasive and there is no external scar; recurrence rates are low as the causative factors such as stenosis or polyposis are also dealt with during the surgery; and follow up is extremely easy and reliable with nasal endoscopy.

2. Endoscopic Treatment of Periosteal Abscess

Nitin Gupta, Nishit Shah

Traditionally orbital complications of sinusitis were managed by medical treatment and external incisions. With the advent and continued use of sinus endoscopes, we have now progressed to treating disease not just in the nose and sinuses but also in the adjacent areas. We can now follow disease originating in the ethmoid sinuses across the lamina papyracea and into the orbit. We preset one such case of a patient who complained of eye swelling and decrease vision. She had been treated with antibiotics for three days without any significant improvement. A CT scan was done which showed a sub-periosteal orbital abscess. An ophthalmic assessment was also done for proptosis and to record vision. A decision was made to take the patient urgently for surgery to prevent further visual loss. A 0° endoscope was introduced into the nose. There was significant congestion in the middle meatus. After adequate decongestion using xylocaine with adrenaline, an uncinectomy was done and the ethmoid opened. Thick pus drained out. Ethmoidectomy was completed and the lamina papyracea partly removed. The subperiosteal abscess with the same thick pus drained completely into the nasal cavity, orbital decompression was achieved by removing more of the lamina upto the orbital apex. A small pack was inserted in the ethmoidal sinus which was removed after 48 hours. IV antibiotics were continued for three days. The proptosis completely subsided and the vision returned to normal. The patient was discharged on oral antibiotics and had a further uneventful recovery. We present the operative technique used for this patient.

3. Endoscopic Dacryocystorhinostomy (DCR)

Nishit J Shah

Conventional dacryocystorhinostomy (DCR) usually involved extensive removal of bone at the lacrimal fossa and hence risks disruption of the lacrimal pump mechanism. The lacrimal sac can alternatively be approached with ease through the nose with the help of the nasal endoscope. This is a more physiological approach for naso-lacrimal blockage where the lacrimal sac is marsupialised into the nose.

In patients with apparent dacryocystitis, blockage of the nasolacrimal duct may be inferred by doing sac syringing. If the irrigation fluid flows out through the superior lacrimal punctum, it indicates that the canaliculi are patent, and the patient would benefit from an endoscopic DCR. However if there is a reflux of fluid through the lower punctum itself, it signifies a canalicular block, in which case a DCR is contraindicated. The diagnosis of chronic dacryocystitis can be confirmed with the help of a dacryocystogram wherein dye is seen in the sac with an obstructed naso-lacrimal duct through which the dye fails to flow.

The lacrimal bone and the frontal process of the maxilla form the anterior part of the lateral nasal wall. The mucosa of the lateral nasal wall anterior to the uncinate process is removed. The underlying bone is then exposed. With the help of a bone punch forceps, this bone is removed so that the sac can be visualized. Following exposure, the sac is then incised and the pus allowed to drain out. The opening in the sac is then widened. The patency can also be confirmed by injecting methylene blue dye through the lacrimal punctum and watching it trickle into the nose. A silicon stent may be kept in certain revision cases for a period of 4-6 weeks to prevent re-stenosis.

The endoscopic approach has various advantages. It is safe, quick, and far less traumatic. There is minimal blood loss and easily accepted by the patient, as there is no skin incision and therefore no cosmetic problem. The results are better than those of the conventional approach, as there is no disruption of the medial canthal structures and the pumping mechanism of the canaliculi. However, post-operative care is extremely important for the patient until healing occurs.

4. Chronic Inflammatory Lesions of Skull Base

NK Apte, Nitin Gupta

Fungal infections and granulomas of the paranasal sinuses in immunocompromised patients are well known. Depending on host resistance and organisms virulence the disease process may be limited or extensive. Invasive and fulminant fungal infection of nose and paranasal sinuses are known to involve skull base, orbit and even the brain. From paranasal sinuses disease spreads submucosally to cribriform plate, fovea ethmoidalis, laminapaparacea and sellar region. It may also extend to pharynx and clivus region.

Non invasive diseases can be treated by systemic antifungal and surgical clearance of disease. But fulminant and invasive fungus requires radical surgery followed by repeated cleaning alongwith systemic high dose antifungal therapy.
We are presenting few cases of chronic inflammatory lesions of skull base, there management and outcomes.

5. Speech and Dentition

NK Apte, Navnit Mukul

Teeth and nervous tissue both develop from epithelium. Teeth are developed from cells of neural crest and brain is from epithelium of neural tube. We know that eruption time of teeth and milestones of speech have definite timing and they occur in sequence. Purpose of presentation is to correlate the dentition periods - namely predentition, primary dentition, mixed dentition and permanent dentition with the musculature as well as the cognitive power of brain and the descent of larynx in neck.

6. Repositioning of Dislocated IOL Post Vitrectomy

Shreyas Laxman Palav, Karobi Lahiri Coutinho

Dislocation of IOL is a known complication of cataract surgery due to Pc rent, zonular dialysis or trauma post op.
This can be tackled by various modalities like leaving it alone and giving contact lens or surgically by IOL exchange, repositioning on capsular remnant, hooking it on or to iris or using scleral fixation suture, but all after doing a vitrectomy first.

Eighteen cases of dislocated IOL following ECCE, Phako Emulsification, SICS were selected. Following a vitrectomy the same dislocated IOL was repositioned as an AC/PC lens. Using 2 iridectomies superior and inferior for anchoring the haptics of the IOL and the pupil was then constricted over the optic.

This technique was cost effective to the patients and did not involve opening up of the limbus. Visual recovery of patients depended on presence of absence of cystoid macular oedema. Visual recovery was then studied.

7. Supra Choroidal Haemorrhage Management

Smita R Dixit, Karobi Lahiri Coutinho

Supra Choroidal Haemorrhage is a serious complication and it requires aggressive timely approach. Presenting 7 Pts of SCH due to trauma, surgery, post R/b, injection and following SRF drainage. Who were subjected to a release of Supra choroidal Haemorrhage within 15 days of occurrence with good results in 85.71% Pts. It is a good modality in an otherwise serious problem for which Evisceration was the answer earlier.

Abstracts of Papers Presented at The 109th Research Meeting of The Medical Research Centre of Bombay Hospital held on 11th August 2003, (Convenor Dr. HL Dhar)

1. Significance of the tumour marker serum Prostate-Specific Antigen (PSA) in monitoring post-therapy Prostate Cancer Patients

Soares Eric*, K Hema**, JN Kulkarni+, SR Kankonkar*

One of the most useful applications of tumour markers is diagnosis of tumour, specifically in supervising during the course of a disease; the second most useful application of a tumour marker is in monitoring for recurrence following the surgical removal of the tumour. A widely used tumour marker in detection and monitoring of prostate cancer is the serum marker Prostate-Specific Antigen (PSA). This tumour marker PSA plays an effective role in follow up of patients with prostate cancer. The success of any therapy now is judged by the absence of biochemical progression of PSA. The rise of PSA triggers therapy and the fall of PSA implies effective therapy.

The purpose of this work was to study the role of serum PSA levels in monitoring patients after treatment for prostate cancer.

Fifty age matched male controls having mean PSA levels of 1.38 ± 0.94 ng/ml (range 0.05-3.84 ng/ml), and 100 diagnosed patients with prostate cancer having mean age 67.9 yrs. With mean PSA levels of 51.68 ± 44.27 ng/ml (range 3.00-3.45 ng/ml) were studied. PSA was carried out on IMx system of Abbott laboratories with normal range of 0.00-4.00 ng/ml.
Of the 100 patients with prostate cancer, 15 underwent prostatectomy, 82 underwent orchidectomy, 1 patient underwent both the surgeries and 2 patients did not undergo any surgeries. These patients were followed up for a period of 12 months.

Thirteen patients reported for a regular 12 months follow up. All these patients had pre-operative serum PSA levels elevated. Of these, 10 patients had normal PSA levels at the end of 12 months with no evidence of the disease. Three of the patients developed recurrent disease with elevated levels of PSA. Of these three patients, 1 patient died after the last follow up. The sensitivity of PSA for 12 months was 78%.

From the present study, it has been observed that the serum prostate-specific antigen (PSA) is a powerful tool and plays a significant role as a tumour marker in monitoring patients after treatment for prostate cancer.

2. Meropenem Resistance : An Alarming Sign!!

Roopa Vishwanathan, MK Gupta

Meropenem is a carbapenem which is supposed to be stable to inactivation by human renal dehydropeptidase (DHP-1) and does not require concomitant administration of DHP-1 inhibitor such as Cilastatin. It has a broad spectrum of antibacterial activity in vitro, mainly against multidrug resistant Pseudomonas. This came as a relief to many intensivists managing Pseudomonas infection in the Intensive Care Units. The Drug was launched in March 2002. But by September 2002, resistance to the drug was achieved by the Pseudomonas strains. The data for the month of September showed that Pseudomonas aeruginosa strains showed more resistance to Meropenem than Pseudomonas Species. The per cent of Meropenem resistance in Pseudomonas was found to be 13.2%. If this is the state where do we look for the combat against multidrug resistant Pseudomonas? This again elucidates the need to use the antibiotics rationally and judiciously.

3. Evaluation of Quality of Latex Agglutination Kits for RA, CRP, ASO

Roopa Vishwanathan, KS Yadav, MK Gupta

Latex Agglutination is a passive agglutination test wherein latex particles sized 0.8 to 1 microns in diameter are used for coating the antigen. It is a rapid, simple test to detect antibodies in circulation. This method is used for the diagnosis of rhematoid arthritis (RA), poststreptococcal infection (ASO), for bacterial sepsis or any inflammation (CRP) and for cryptococcal infection. In the wake of discrepancy of results where clinical relevance were absent, it was decided to evaluate the Latex agglutination kits available in the market for RA, ASO and CRP Test. A scientific method of evaluation was resorted to wherein kits from 11 companies were tested with : - 1. Known calibrators for RA, ASO, CRP, 2. Controls of the Kits, 3. Unknown samples.

The Kits giving consistent results were Shortlisted.

In conclusion 1) The controls provided with the kits are not reliable for the Quality control of the kits as they are calibrated according to their requirements, 2. It is necessary to have known calibrators or Clinical sample for the quality assessment of kits, 3. There is every possibility for variations in the latex size whereby there are discrepant results. Hence continuous evaluation of the kits in use must be resorted to. A standby kit belonging to some other company must also be kept. Quality control programme is a must as a good laboratory practice and continuous quest for the Quality is necessary for the better management of health care system on the whole.

4. Salmonella Typhi in Breast Abscess

Roopa Vishwanathan, S Harikumar, MK Gupta

Salmonella typhi is known to cause enteric fever and gastroentiritis. It is also known to cause pyogenic infections. But it is rarely involved in breast abscess. We report such a rare case of Salmonella typhi induced breast abscess. The diagnosis would have been missed had the culture of the breast abscess not been sent. This emphasises the need for microbiological diagnosis for any breast abscess for the appropriate management of the patient.

5. Motivation Methods For Blood Donors

Ramesh Shah, Maya Parihar Malhotra

Most of the blood banks face problem of shortage of blood. Reason is demand of blood is more than supply of blood. In country like ours with population of approximately 100 crores, this should not have happened. More population does mean more number of sick people requiring blood. But still logically ratio of healthy persons is always more than sick people and hence healthy people who are able to donate blood is naturally very high. Then why this shortage of blood?

One reason is that Blood Bank is Urban phenomenon in our country. Naturally Urban population is having access to Blood Banks, awareness of blood banking and value of blood donation. Large rural population is thus not well informed, and not well aware of Blood Banks therefore they are not motivated for blood donation. So what can be done? They must be motivated to donate blood. How?

In existing, scenario, villagers have access to Radio, TV and News Papers. Communication facilities like telephones are also there. Though Primary Health Centers are managing certain medical emergencies, same can not be said about Blood Banks. So primarily Blood Bank facilities should be extended to villages, which will make them understand value of blood donation. Now the motivation for rural population.

Value and strength of media can not be ignored. Though TV, Radio and Press are very strong media, should it be utilized as primary media or not is one big question. Reason firstly we are not selling Soap or Shampoo. Ours is a social cause. Secondly we have to get maximum impact in terms of motivation with minimum cost and we know these are costly media.
Lastly it is a one way communication. Value of two way communication can not be ignored. Now we should give thought to alternative low cost media. But before selecting effective low cost media we must have base line survey done to know their awareness, myths and doubts. Once this is done, low cost media with two way communication can be given priority and high cost media like TV, Radio and Press can be used as support media depending on the budget for motivation. Thus selection of right media with proper media planning can give maximum impact with minimum cost.

Abstracts of Papers Presented at The 110th Research Meeting of the Medical Research Centre of Bombay Hospital held on 8th September 2003 (Convenor Dr. HL Dhar)

1. Filarial Lymphoedema of Legs Treated by Lymphonodo-venous Anastomosis, Venolysis, and Venous Stents

RF Ginwala, SR Tambwekar, MM Begani, K Khadalia, V Tambwekar, R Habbu

Filarial lymphoedema occurs following infestation by filarial worms due to the bite by a mosquito carrying microfilariae. The pathology mainly consists of fibrosis and blockage of the lymphatic pathways and the lymph nodes. Early disease is treated by conservative treatment modalities such as heat, compression and elevation, but later the bulkiness of the leg forces the patient to seek surgical relief.

MRI VENOGRAM in this case provided us with the information that he had a severe block in the common iliac vein at the level of its junction, with the venous flow traveling along a few bypass veins originating from below the site of the blockage to the opposite iliac veins.

The patient was followed up for a month, during which compression and elevation was continued, and there was further reduction in the oedema of the leg.

2. Jejunal Diverticulosis

H Mahantesh, N Agarwal, MM Begani

Small bowel diverticulosis are classified in to three i.e. Duodenal, jejunal and ileal. These diverticula are usually situated on the mesenteric border except Meckel’s diverticulum which is situated on antimesenteric of ileum. They occur at the penetration of blood vessels. They can be solitary or multiple. There are 3 patterns of diverticulum - pulsion, muscle coat defect and congenital.

Presenting symptoms - abdominal discomfort, megaloblastic anaemia, melaena. Complications - perforation, haemorrhage. We are presenting the rare case of jejunal diverticulosis.

3. Sciatic Hernia

C Padhane, A Agarwal, MM Begani

Sciatic hernia is an extremely a rare varity of hernia with only 35 reported cases from 17th century up to 1948 and from there after. Females are more affected than males. There are two types - greater sciatic and lesser sciatic. It is present in the form of (1) mass in gluteal area (2) Sciatic (3) Intestinal obstruction and (4) urinary disturbances. Treatment is surgery. We persent a similar case of 55 year old female who presented with history of anterior abdominal swelling and right gluteal swelling with right sciatic. She was diagnosed to have incisional hernia and right gluteal hernia and operated for both the entities.

Patient was operated for incisional and sciatic hernia. The contents of the sciatic hernia were reduced and a mesh was placed at the sciatic hernial site with peritoneum sutured over it. The incisional hernia was reduced. Now the patient is symptomatic with complete relief from right lower limb pain since last 2 years.

4. Initial of Biocontact Uncemented Total Hip Replacement A One to Four Year Follow-up Study

Kulkarni, JA Pachore, HR Jhunjhunwala, KT Dholakia

In this report, we present a prospective analysis of 87 cases (in 81 patients) of Bicontact uncemented total hip arthroplasty performed in a tertiary referral hospital in four years between 1998-2002. These patients were followed-up for a period of 1 to 4 years (average 18 months). The aetiology consisted mainly of secondary arthritis due to avascular necrosis (36), ankylosing spondylitis (17), post traumatic (11) and fracture dislocation of hip (9) among others. The average age of patients at the time of index arthroplasty was 43 years.

Clinical evaluation was done by Harris hip score ratings while radiological evaluation by the criteria of Engh et al post operatively at regular intervals. There was presence of spot welds along the acetabular cup in 62% of the patients and along the femoral stem in about 70% of the patients. Presence of a pedestal signs was seen in one patient in subsequent follow-ups. Three patients had Grade I and one patient had grade III heterotopic ossification according to classification of Brooker et al. Calcar atrophy was seen in 10% of the patients. There was no migration of the acetabular component. No subsidence of the femoral stem was seen during the follow up. Appearance of shake lines was not evident in any of the patients in subsequent follow-ups.

This study demonstrates the successful results of Bicontact uncemented prosthesis over a short period of 4 years. Nevertheless, more long-term results are needed to establish the merits of this prosthesis.

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