Coverage Of Multiple Maxillary Gingival Recessions Using Coronally Advanced Flap With Subepithelial Connective Tissue Graft: A Case Report

Background:This case report describes treatment of multiple gingival recession with subgingival connective tissue graft and coronally advanced flap technique in treatment of maxillary teeth. Material And Methods:Connective tissue grafting wasdone in relation to upper right second premolar, first premolar, canine, right central incisor, left central incisor and left lateral incisor (#15,#14,#13,#11,#21,#22). A split thickness flap was elevated without disturbing periosteum in this region. The area between canine and second premolar was selected to harvest the graft. The graft was placed on the recipient bed and suturing was done. Result:Predictable root surface coverage could be obtained with use of coronally advanced flap and subepithelial connective tissue graft. Conclusion:Subepithelial connective tissue graft along with coronally advanced flap still stand as a gold standard treatment for gingival recession coverage.

Surgical management in portal hypertension

Background: Portal hypertension commonly accompanies cirrhosis of liver and is a consequence of an increase in splanchnic blood flow secondary to vasodilatation and increased resistance to the passage of blood through the cirrhotic liver. Development of oesophageal varices (OV) is one of the major complications of portal hypertension. In present study we attempted to compare different surgical modalities in case of Portal Hypertension (PHT) by their indications, contraindications, complications and outcomes in a group of 50 patients. Aim and objectives: To study the indications, contraindications, complications and outcomes in different decompressive shunt procedure and devascularisation procedure, to discuss the advantages and disadvantages of different surgical procedures in case of portal hypertension, to discuss role of shunt surgery in modern era of liver transplantation. Materials and methods: During our work period from June 2008 to November 2010, all patient admitted in our institution were considered for study. Detailed history was elicited in each case. Various symptoms were noted and a detailed general, systemic and local examination was done in cases. Various operative surgery was done in the form of Distal Spleenorenal Shunt, Spleenectomy with Devascularisation, Side to Side Mesocaval Shunt, side to side lineorenal Shunt. All the patients were observed for post operative complications and managed accordingly. Regular follow up of patient was conducted till date. All the case was studied on the basis of following proforma. Results: All patients were advised surgery. Out of this only 1 (2.56%) mortality were found which was with the DSRS. All patients with Child’s Criteria B were selected for side to side portocaval Baria B, Parmar N, Kumar S, Parmar H. Surgical management in portal hypertension. IAIM, 2016; 3(9): 194-199. Page 195 shunt of which there was no mortality, in all patients with Child’s Criteria A in whom different surgical modalities were conducted have 3.12% mortality with DSRS and associated morbidity variceal bleeding, total rebleeding and shunt occlusion in both groups. Variceal bleeding was found in 2 cases of which 50% was with Grade A and 50% was with Grade B of Child’s Criteria. Total rebleeding was found in only 1 (3.12%) patient with Child’s Criteria Grade A. Shunt occlusion was found in only 1 (3.12%) patient with Child’s Criteria Grade A. Encephalopathy was found in 5 (12.82%) patients out of which 4 (57.14%) patients were with Child’s Criteria Grade B, and only 1 (3.12%) patient with Child’s Criteria Grade A. Conclusion: More studies are needed to established any conclusion as there are some shortcomings like; patients are lost in follow up, liver transplantation is yet in developmental stage and scarcity of grafts in government setup.

Comparative study of Laparoscopic Nissen fundoplication Vs Posterior fundoplication in Gastroesophageal reflux disease

Background: Gastroesophageal reflux Disease is a highly prevalent gastrointestinal (GI) disorder and is one of the most common GI illnesses encountered in clinical practice. Gastroesophageal reflux disease (GERD) is one of the most common conditions presenting to primary care physicians and gastroenterologists. It refers to the abnormal exposure of the oesophageal mucosa to refluxed gastric contents, including acid and pepsin, resulting in symptoms and/or tissue damage. Our aim was to compare the result of nissen and toupet procedures and to determine which procedure is better in terms of symptomatic improvement symptom recurrence and post-operative complications. Materials and methods: This was the both prospective and retrospective study included 29 patients with GERD who were operated upon by Laproscopic Nissen Fundoplication and Laproscopic Posterior Fundoplication. Demographic and clinical profiles of all patients were recorded. All patients were subjected to thorough clinical evaluation, upper GI endoscopy done in all patients, esophageal Manometry and 24 ph study done in selected patients. All preoperative data compared with the postoperative data. Results: In our series 68.9% of the patients were below 50 years. 31.03% was above 50 years. The average age of occurrence was being 41.4 years. In our series Sex distribution were 75.8% of Males and 24.1% of Females. Wound (port site) infection 5 (17.2%) was treated with antibiotics and drainage, chest infection (atelectasis) 7 (24%) treated with IV antibiotics, Pleural effusion 2 (6.8%) was treated with physiotherapy settled down 2-3 days, mild surgical emphysema 2 (6.8%) may be due to good hiatal dissection and proper esophagus mobilization, it settled down in 2 days, urinary tract Patel Y, Baria B, Gohil K, Parmar H. Comparative study of Laparoscopic Nissen fundoplication Vs Posterior fundoplication in Gastroesophageal reflux disease. IAIM, 2016; 3(9): 189-193. Page 190 infection 3 (10.3%) was treated with antibiotics, port site hematoma 3 (10.3%) was managed conservatively. Conclusion: Both Laparoscopic Nissen fundoplication and Laparoscopic posterior fundoplication provides excellent results for GERD in terms of postoperative morbidity and complications.

Analytical Study of Upper Gastrointestinal Endoscopy – 200 cases

Background: Esophagogastroduodenoscopy (EGD) is an important tool to visualize the upper part of the gastrointestinal tract up to the duodenum. It has the added advantage of being not only a diagnostic but also a therapeutic tool. It’s importance in follow up cases is also well documented. It has indeed become a cost effective and reliable tool to modern surgery. Materials and methods: Clinically symptomatic cases of upper GI tract were made to undergo Upper GI Endoscopy after an informed written consent. The study covered 200 patients who were then analysed for different parameters. Our study showed that majority of patients were in their 3rd decade with a male: female ratio of 2.03:1. Pain in abdomen was the main presenting complaint. Study showed that 62% of patients were smokers whereas 71% were non alcoholic. Gastritis was the prominent finding in 41 (20.5%) cases followed by Hiatus Hernia and Reflux Esophagitis in 19.5% and 13% respectively. The study was found to be normal in 28 cases (14%). This study was also able to detect rare findings like esophageal polyp and Mallory Weiss tear. Endoscopy was also done in post Gastojejunostomy patients to assess the stoma from within. Conclusion: Endoscopy has proved to be a valuable tool in diagnosing as well as therapeutically treating patients with various pathologies. Upper GI endoscopy correlated well with the sign and symptom presentations in majority of patients and proved superior to conventional radiological studies. Thus endoscopy is not only useful and superior to many radiological investigations, but also helpful in therapeutic interventions as well as in follow up cases.

Etiology, age and sex distribution, investigations and treatment of gallstone pancreatitis

Background: Acute pancreatitis occurs in only 3-7% of patients with gallstones. But gallstones were implicated in about 27% cases of acute pancreatitis reported in a decade prior to 1980. The relative risk of developing acute pancreatitis varies from country to country, and within a given country it is influenced by socio-economic, ethnic, and cultural factors. The present study evaluated the incidence of the disease, age-sex distribution, clinical manifestations methods, and management of gallstone pancreatitis. Aim and objectives: To diagnose a case of gallstone pancreatitis by various investigations like blood investigations, USG or by CT scan, age-sex distribution, to observe the varied clinical presentations of biliary pancreatitis with regards to symptoms and signs, to study the management protocol of gallstone pancreatitis. Material and methods: 50 cases of gallstone pancreatitis were studied during the period from May 2012 to July 2014, from all surgical units at our institute. Inclusion criteria: All patients admitted in surgical wards in a given particular unit who have diagnosed as having gallstone pancreatitis. Exclusion criteria: Patients having pancreatitis other than biliary cause. This study included all the age groups and both the sex. Results: In our study, most (34%) of male patients at the age group of 50-70 years, biliary pancreatitis was more predominant. Most (34%) of female patients at the age group of 40-60 years had biliary pancreatitis. In our study, most (92%) of the patient’s serum amylase was 3 fold above normal value,alkaline phosphatase was raised in 88% of patients, 68% of them had increased AST, and 22% of them had had elevated serum bilirubin levels. Normal value of serum amylase ranges from 40 to 140 Naik N, Patel G, Parmar H. Etiology, age and sex distribution, investigations and treatment of gallstone pancreatitis. IAIM, 2016; 3(1): 46-50. Page 47 U/L, Alkaline phosphatase from 45 to 115 U/L and AST from 8 to 48 U/L. In our study, out of 50 patients, 28 patients underwent laparoscopic cholecystectomy and 8 patients underwent open cholecystectomy during same admission. In 9 patients endoscopic retrograde cholangiopancreatography (ERCP) plus endoscopic sphincterotomy (ES) was done and remaining patients managed conservatively. Conclusion: Gallstone pancreatitis represents the most severe form of disease. The diagnosis is based in history and physical examination, an elevation of serum amylase 3 fold above the normal level, and ultrasound and CT scans. Endoscopic retrograde cholangiopancreatography is one of the tools in less certain cases of the absence of an agent that can abort progression of the disease; therapy should consist of adequate resuscitation, nutritional support, and careful monitoring to detect early complications.

A comparative study of inguinal hernia repair by Shouldice method vs other methods

"Background:Hernia is one of the most common surgical conditions encountered in day to day practice. It is a common problem, more in industrial workers who are doing strenuous work over a long period of time. Any method which reduces the recurrence rate as well as lowers the morbidity and post-operative complication rate, must however be considered superior. The common aim in treatment of hernia is to restore the anatomical integrity of the disrupted tissue, performing a strong repair and to prevent further recurrences. Material and methods:This review was based on the study of 80 selected cases of uncomplicated inguinal hernias treated in our institution by random sampling. All the patients were investigated pre-operative check-up in out-patient clinic forplanned surgery. All patients were admitted in our hospital and surgery done under anesthesia (spinal, general, local). All patients in our studyreceived pre-operative antibiotic. In operative technique, the difference lies in the repair of the posterior wall. In the present study comparison of inguinal hernia repair by Shouldice versus other three methods modified Bassini’s repair, pre-peritoneal mesh repair and Lichtenstein tension-free repair hadbeen studied with a regular follow up. The selection of the patients for type of anaesthesia was done on the basis of associated cardiac and respiratory diseases. Results:Out of 80 patients,Shouldice repair was done in 20 patients and other three method of repair was also done in 20 patients each. In present study, wound haematoma occurred in three patients, which may be attributed to the extensive dissection. Seven patients developed wound infection, treated by antibiotics and dressing. Three patients developed scrotal oedema, which was treated by scrotal support andanti-inflammatory agents. Two patients developed urinary retention, relieved by Gohel J, Naik N, Parmar H, Solanki B. A comparative study of inguinal hernia repair by Shouldice method vs other methods. IAIM,2016; 3(1):13-17.Page14 analgesics, hot water bag and ambulation. None of them required catheterization. In the present study we encountered two cases of recurrences (2.5%). Conclusion:In S houldice repair,double breasting ensures the strong repair. In this method of repair minimal tension on the suture line, so relaxing incision are not necessary. Deep inguinal ring is narrowed in the lateral aspect of the repair. Recurrence rate is remarkably low.But the repair is difficult to perform and extensive dissection required and it takes longer operative time"

Comparison of USG guided modified rectus sheath block with intraperitoneal instillation with Inj Bupivacaine for postoperative pain relief in diagnostic laparoscopy

Background: Laparoscopic surgery is associated with considerable postoperative pain, though it is less compared to open surgery. Post laparoscopic pain results from phrenic nerve irritation caused by residual gas, stretching of the intraabdominal cavity and peritoneal inflammation. The Modified Rectus Sheath Block (MRSB) is fairly easy and reliable procedure when performed using ultrasound guidance so it is compared with the intraperitoneal instillation method by using Inj. Bupivacaine for postoperative analgesia in diagnostic laparoscopy. Aim of the study was to assess and compare the effect of the USG guided modified rectus sheath block (MRSB) with the intraperitoneal instillation using Inj. Bupivacaine in diagnostic laparoscopy. Material and methods: It was prospective randomized study. The Patients were randomly allocated in two groups. Group A were given USG guided rectus sheath block and Group B was given Patel V, Mehta K, Patel K, Parmar H. Comparison of USG guided modified rectus sheath block with intraperitoneal instillation with Inj. Bupivacaine for postoperative pain relief in diagnostic laparoscopy. IAIM, 2016; 3(1): 85-89. Page 86 intraperitoneal 25 mg Bupivacaine. Patients with obesity, local anesthetic agent allergy and emergency surgeries were excluded. Pain was assessed 1, 6, 10 and 24 hours postoperatively by visual analogue pain score. Results: Postoperative pain was assessed by visual analogue pain score (VAS) at every hour for 24 hours postoperatively. The VAS was significantly lower in Group A at 6 and 10 hours postoperatively. After 6 hours the median pain score was 3 in group A while it was 7 in group B. After 8 hourrs the median pain score was 2 in group A compared with 5 in group B and after 10 hours the median score were 2 and 5 in group A, group B respectively (p<.001 and <0.004 respectively). No significant difference noted in pain score at 1 hour and 24 hour post laparoscopy among the two groups. Conclusion: USG guided modified rectus sheath block (MRSB) provides prolonged post operative analgesia than intraperitoneal instillation in diagnostic laparoscopy.

Correlation of anatomical variations of Paranasal sinuses and Chronic Rhinosinusitis

Background: The anatomy of the nose and paranasal sinuses is complex, and many anatomical variations have been thoroughly studied. There is impact of these variations on the occurrence and severity of sinusitis. Computed Tomography (CT) scan is the modality of choice for evaluation of variable anatomical variations and different forms of sinusitis. Materials and methods: The aim of this research was to study the relation between recurrent sinusitis and anatomical variations of the osteomeatal complex and nasal structures by CT. A cross section prospective observation study was performed. We collected data of 120 patients subjected to CT of the paranasal sinuses. Result: Anatomical variations found by CT, nasal septal deviation represented the most common variation (75%), followed by concha bullosa and uncinate hypertrophy. Conclusion: There was a statistically significant correlation between nasal septal deviation, uncinate process anomalies and some patterns of sinusitis with the p value = <0.05.Computed tomography of the paranasal sinus has improved the visualization of paranasal sinus anatomy and variations and has allowed greater accuracy in evaluating paranasal sinus disease.

Comparative study in newer techniques for management of diabetic foot

Background: Diabetic foot is the commonest complication of Diabetes Mellitus. It is not totally curable or preventable but with positive approach mortality and morbidity due to diabetic foot can be reduced. Aim and objectives: To find out which type of treatment modality is better in terms of costeffectiveness and number of dressings in patients of diabetic foot, to salvage the limb in diabetic patient with help of various modalities of treatment available to our hospitals, to prevent the recurrence of such lesion by careful follow up, by educating the patient about foot care and prescribing pressure distributing footwear, and rehabilitation of patient once the ulcer has healed. Materials and methods: A total of 60 patients having diabetic foot were included. Clinical assessment was done of all patients after admitting them. History and clinical findings were written as per preformed proforma. All patients were sent to foot wear specialist. All this patients initially underwent debridement or removal of necrotic patch, according to the presenting feature. Depending on the condition of the ulcer (size or slough) they were dressed with newer techniques. Newer techniques used were Vac (Vacuum assisted closure) and Non-Vac (Hydrocolloid, Hydrogel, collagen, Platelet derived growth factor). Results: Majority of diabetic patients were having neuropathic and traumatic type of lesions. 30 patients were dressed with V ac (Vacuum assisted closure) and remaining 30 patients were dressed with Non-V ac. In which 5 patients were dressed with Hydrocolloid, 3 patients were dressed with Hydrogel, 12 patients were dressed with collagen and 10 patients were dressed with platelet derived growth factor. Comparison between V ac and Non-V ac types of dressing in terms of number of dressings, duration of stay, cost effectiveness is done by applying Z-Test. It was significant. Desai A, Panchal A, Parmar H. Comparative study in newer techniques for management of diabetic foot. IAIM, 2016; 3(8): 79-82. Page 80 Conclusion: Newer techniques for dressing- VAC or NON-VAC decreases the morbidity of the patient and also better in terms of cost-effectiveness and duration of stay as compared to conventional dressings.

Acute pancreatitis: Causes, pathophysiology, different modalities of management.

Background: This study was intended to throw light upon the topic of acute pancreatitis, its incidence, etiology, pathogenesis as well as its management. Aim and objectives: To review and study the patients who presented with acute pancreatitis, to find out the incidence of acute pancreatitis and study the various etiological factors, to study the various modalities of treatment of acute pancreatitis, both conservative as well as operative, to study the incidence and management of complications of acute pancreatitis, factors influencing incidence as well as its outcome. Materials and methods: This was a prospective study of management of 50 cases of acute pancreatitis, admitted in surgical department. All admitted patients underwent work up for the diagnosis and cause of Acute Pancreatitis. The severity grading was done according to the Ranson’s criteria. All patients were monitored with serial examinations and investigations. Patients with mild pancreatitis were treated conservatively at first and surgical intervention was done only in cases of gallstone pancreatitis with diagnosed GB or CBD calculi. Surgical intervention was in form of cholecystectomy or ERCP. Patients with severe pancreatitis were treated conservatively at first. Outcome was monitored in terms of discharge from hospital or mortality. Each patient was evaluated as per the predesigned proforma of the study, a copy of which is attached. Follow up of a minimum of six months was kept and patients with recurrent attacks were monitored and treated either conservatively or surgically as indicated. Results: The highest incidence of acute pancreatitis was found in the age group of 41 to 60 years followed by the age group of 21 to 40 years. Acute pancreatitis was found more commonly in males. Desai A, Panchal H, Parmar H. Acute pancreatitis: Causes, pathophysiology, different modalities of management. IAIM, 2016; 3(4): 66-71. Page 67 (41 out of 50 that is 82%) compared to females (9 out of 50 that is 18%). Alcohol was found to be the most common cause of acute pancreatitis (44%) , followed closely by Gallstones (36%), While in 10% of patients no cause could be found (idiopathic group). Overall conservative management is favorable over surgical management in terms of mortality in about 70% of cases. Mortality was not found in the mild pancreatitis group and all 34 patients were discharged. However, 6 out of 16 patients with severe pancreatitis expired (37.5%). Conclusion: Conservative management is more favourable in both mild and severe type of acute pancreatitis.

A clinical study of surgical management of benign ureteric stricture.

Background: Although incidence of ureteric stricture, in general population, is not known, proper evaluation of and treatment is essential to preserve the renal function and rule out malignancy. Strictures of the upper urinary tract are either congenital or acquired. With the exception of primary UPJ obstruction, most ureteral strictures are acquired and usually are iatrogenic. Before the development of endourological instruments and techniques, ureteral strictures were managed by open repair. The management of uretric stricture has changed dramatically over the last decade in conjunction with new developments in endourology. Material and methods: This bi-directional study was performed on 30 patients, diagnosed as a benign ureteric stricture by various modalities of diagnosis, which underwent open or laparoscopy surgical procedures. Data, with respect to patient’s demographic information, etiology, mode of presentation, stricture location and length, diagnostic modalities, operative procedures and their follow-up were recorded, analyzed and plotted on master chart. Various surgical treatment modalities are used according to length and location of strictures like: Upper and midreteric stricture: Ureteroureterostomy 2-3 cm, Uretero calycostomy/ pyeloureterostomy for long upper ureteric stricture, 4-5 cm with intra renal or scarred pelvis, Buccal mucosal graft ureteroplasty. Lower ureter: Ureteroneocystostomy 4-5 cm, Psoas hitch 6-10 cm, Boari flap 12-15 cm, Ileal ureter replacement for long segment defect > 10-15 cm, in every patient, we keep closed drainage system. Usually, drain was removed after 72 hours. We were keeping double j stent in every patient, which were removed after 1 month. Follow up the patient after 21 days of double j stent removal and thereafter 6 monthly for 2 years, then every yearly for 5 years Results: Among 30 patients, main causes are genitourinary TB 8 (26.66%), Iatrogenic 8 (26.66%). 46% strictures involve, lower ureter with length >3-5 cm, which correlates with characteristics of tuberculosis, involving multiple sites and long segment of ureter, 54% stricture involving upper ureter are < 3-5 cm which correlates with iatrogenic and impacted ureteric calculus related strictures. Among 30 patients, with 33 renal units 2 patient’s surgery failed, among which one required nephrectomy, and another required redo surgery, one patient who lost follow up was also considered as a failure. Conclusion: In era of endourology and minimal invasive surgery, open reconstructive surgery has its own place.

Low dose bupivacaine and bupivacaine with fentanyl for spinal anesthesia for transurethral resection of prostate.

Background: Spinal anesthesia is most frequently used for transurethral prostatectomy (TURP), because it permits early recognition of transurethral resection of prostate (TURP) syndrome and bladder perforation. In this study, we compared the effects of low dose bupivacaine (5 mg) with fentanyl (25μg) and conventional dose of bupivacaine (7.5 mg) in elderly patients undergoing TURP. This comparative study was conducted to evaluate the efficacy of addition of fentanyl 25 μg intra thecally to bupivacaine 5 mg and bupivacaine 7.5 mg alone for transurethral prostatectomy. Material and methods: The patients were randomly allocated into 2 groups, each having 30 patients. Group-A: Inj. Bupivacaine 5 mg (0.5%) (1ml) + Inj. Fentanyl 25 μg (0.5 ml). Group-B: Inj.Bupivacaine 7.5 mg (0.5%) (1.5 ml). A standard subarachnoid block was performed in L2-L3 / L3-L4 Space in sitting / lateral position with 22G/23G BD spinal edle (Quinky type, 3.5 inch long) under all aseptic and antiseptic precautions after local infiltration of skin and subcutaneous tissue with 2 cc 2 % lignocaine. Drugs were injected after checking of free flow of CSF and according to group selected. All the observations were recorded and all the results were analyzed statistically. Results: The mean time of onset sensory blockade was significantly shorter in group A than group B. Group A took less time to reach the peak sensory level (3.57 min) as compared to group B (5.8 min). Onset of motor blockade was delayed in group B as compared to group-A, and differences were statistically significant. Changes in pulse rate of all groups are statically not significant and comparable. The incidence of hypotension and shivering was significantly higher in group B as compared to group A. Conclusion: It was observed that intra thecal bupivacaine 5 mg combined with fentanyl 25 μg provided adequate anesthesia for TURP in elderly patients and is associated with lower incidence of hypotension and shivering than a conventional dose of bupivacaine. The addition of fentanyl improves the quality of block, increases duration of sensory block and makes the blockade hemodynamically more stable than conventional dose of bupivacaine.

Spectrums of opportunistic infections in HIV-infected patients at tertiary care hospital.

Background: Literature on the spectrum of opportunistic disease in human immunodeficiency virus (HIV)-infected patients from developing countries is sparse. HIV-related opportunistic infections (OIs) continued to cause morbidity and mortality in HIV-infected individuals. Objectives: The objective for this study was to elucidate the prevalence and spectrums of OIs in HIV- infected patients in the Gandhinagar Civil Hospital. Material and methods: The evaluation of the prevalence and spectrums of OIs was conducted by using the clinical data of 834 HIV-infected patients in the Gandhinagar Civil hospital from November 2012 to December 2013 those who were attended physician OPD for OIs. Results: The prevalence and spectrums of OIs varied contingent on sex, age, CD4 levels and treatment with ART. We found that tuberculosis was most common OI with prevalence being 20.50%, followed by Pneumocystis pneumonia (PCP) (5.16%) mycobacterium avium complex(MAC) (1.80%), candidiasis (1.56%), cytomegalovirus (CMV) infection (0.24%), progressive multifocal leukoencephalopathy (PML) (0.12%). Males (31.85%) were more prone to get OIs than females (27.85%). Pulmonary OI infections were the most prevalent morbidity and mortality in patients in the AIDS stage including pulmonary tuberculosis (7.43%) and PCP (5.16%). Fungal OIs were one of most prevalent morbidity in patients in the AIDS stage, including oral candidiasis (1.79). EPTB (13.07%) was more common than PTB (7.43%). OI in AIDS is more common in 41 to 60 years (32.93%) of age group. OI was more common in patients with CD4 count from 51-100 (86.96%) followed by 101 to 150 (69.05%). OI was more common in patients who were not on ART (72.33%) than those on ART (27.67%). Conclusion: The prevalence and spectrums of OIs, was discussed in this study. It would help to increase the awareness for physicians to make a diagnosis and empirical treatment sooner and plan good management strategies, especially in resource limited regions.

Pulmonary function test in mitral valve disease.

Background: In Rheumatic heart disease, mitral valve is most commonly affected. Approximately 25% of all patients with rheumatic heart disease have pure mitral stenosis. 10% of all rheumatic heart disease patients have pure mitral regurgitation and 40% have combined mitral stenosis and mitral regurgitation. This study is the correlation between clinical status and common pulmonary functions in patient with mitral valvular disease and improvement in pulmonary functions after surgery in mitral valvular heart diseases. Aim and objectives: To study the pulmonary function test (PFT) in patients with mitral valvular heart diseases, to study PFT in patients with mitral valvular heart diseases with various age groups, to study clinical features and investigatory profile of mitral valvular heart diseases with various age groups, to study clinical features and investigatory profile of mitral valvular heart disease patients, to study study PFT in various stages of mitral stenosis and mitral regurgitation, to compare the pulmonary function test results before and after treatment of mitral stenosis (MS) and mitral regurgitation (MR). Material and methods: This present study was carried out of total fifty patients of mitral valve disease to determine the changes in Spirometric pulmonary function. Out of this, forty patients were of mitral stenosis and ten patients were of mitral regurgitation. These patients were selected from indoor as well as outdoor cases of Civil Hospital, Ahmedabad and U. N. Mehta Cardiology Institute, Ahmedabad. The diagnosis was made by clinical features , X-ray , electrocardiography and echocardiography studies and all patients, selected for study, were underwent operative procedure. Results: Mean age of cases in this study was 30.46 years. So that present study showed that younger age groups were more affected in rheumatic mitral stenosis and regurgitation. Present study showed that mean value of FEV1/FVC% was 84.69 % in NYHA class II, 88.49% in NYHA class III and 81.51% in NYHA class. Present study showed that mean value of FEV1/FVC% of all classes were 86.06% preoperatively and after operation 89.94%. Present study showed that mean value of FEF 25- 75% was 2.47 liter/sec preoperatively and after operation 2.81 liter/sec. Conclusion: In all cases of mitral valve disease, pulmonary function tests abnormality predominantly reveals restrictive pattern of lungs.

Clinical profile and outcome of acute pancreatitis and necrotizing pancreatitis.

Background: Acute pancreatitis includes a wide spectrum of disease, from mild self limiting symptoms to a fulminant process with multiple organ failure and high mortality. Around 20% of the patients of acute pancreatitis develop acute severe pancreatitis in the form of extensive pancreatic or peripancreatic fat tissue necrosis with associated peripancreatic collection. These patients run a protracted clinical course with high morbidity and mortality. Material and methods: Clinically, radiologically and by blood investigated, diagnosed 40 patients ofacute pancreatitis were prospectively evaluated for the clinical outcome with respect to presence or absence of pancreatic necrosis and severity in terms of CTSI. Results: 24 patients had acute pancreatitis without necrosis (Group A) whereas 16 patients had necrosis including >30% of gland (Group B). The rate of organ dysfunction and mortality (0% versus 25%) rate of was significantly higher in the group B. Multi organ failure (MOF) was present in 4.17% of group A and 20.84% of group B patients. 80% patients were managed conservatively, who all survived and 20% patients underwent surgical intervention of whom 50% survived. Conclusion: CECT is the modality of choice to diagnose acute pancreatitis, presence or absence of necrosis, to stage the severity of pancreatic necrosis, depict severity of inflammatory processes and local complications. Patients with pancreatic necrosis with transient end organ dysfunction can be treated conservatively with favorable outcome. The need for intervention should be individualized and based on the clinical condition of patient.

Role of RNTCP in the management of MDR-TB.

Background: MDR-TB is defined as resistance to isoniazid and rifampicin with or without resistance to other drugs. India is one of the countries with largest burden of MDR TB in the world. Second line Anti-tuberculous therapy is now available for patients with MDR-TB under the RNTCP Category IV. but there are many challenges for MDR-TB control in india. This study was done to analyses the RNTCP data for MDR-TB maintained at a TU, in the city of Ahmedabad, Gujarat, and to compare it with the data available in literature. This study also aimed to identify challenges faced while treating MDR-TB and to address the same. Material and methods: We had restropectively analyzed 353 patients referred to the TU from the respective Direct Microscopy Center (DMC) with suspicion of MDR-TB during a period of January 2014 to December 2014. Results: Of the 353 suspected MDR_TB patients referred to the TU, 48 patients (13.597%) were diagnosed to have MDR-TB. Of these 48 patients, 46 patients had pulmonary TB (95.833%) and 2 patients had extra-pulmonary MDR-TB (4.166%). Of the 48 patients, 08 (16.67%) patients were transferred to their respective TU and 40 patients (83.33%) were enrolled for Cat IV from our TU. Of the 40 patients enrolled at our TU, 30 patients (75%) were continuing Category IV at the end of 2014 (25 were on intensive phase and 05 were on continuation phase), 03 patients (7.5%) died during treatment, 01 patient (2.5%) defaulted treatment, 05 patients (12.5%) refused treatment and 01 patient had XDR-TB (2.5%). Of the 40 patients, 05 patients (12.5%) had ofloxacin resistance. NO patient had intolerance to any oral or injectable ATT. None of the diagnosed MDR-TB patients had HIV co-infection Conclusion: Drug resistance in tuberculosis is a “man-made problem”. Anti-TB chemotherapy must be given optimally by (i) ensuring adequate absorption of drugs, (ii) timely diagnosis and management of drug toxicities and (iii) treatment adherence. To ensure that all patients get adequate treatment and to have a close follow-up of defaulters and patients who refuse treatment; we need to strengthen our existing management information system and also incorporate private sectors into our system.

Gelastic syncope: An unusual condition.

Gelastic syncope or laughter-induced syncope is a rare disease often misdiagnosed as narcolepsy or cataplexy. We report a 54-year-old man with syncopal episodes. Each episode started after laughter, leading to light-headedness with blurring of vision and loss of consciousness for a few seconds. The episodes resolved spontaneously. The treatment of gelastic syncope is the same as that for neurally mediated syncope.

Magnetic resonance arthrography in recurrent anterior shoulder instability as compared to arthroscopy: a prospective comparative study.

AIM: To evaluate the accuracy of magnetic resonance (MR) arthrographic imaging in the diagnosis of glenoid labral and ligament tears in recurrent shoulder instability. SETTINGS AND DESIGN: Prospective, comparative study at a tertiary care centre. MATERIAL AND METHODS: Patients with three or more episodes of anterior shoulder dislocation were enrolled in the study. They were subjected to magnetic resonance arthrography (MRA) for delineation of abnormalities. The findings obtained at MRA were compared with those found at arthroscopy and surgical exploration. RESULTS: MRA detected glenoid tears in all 22 patients with 20 (90%) patients having antero-inferior tears, 3 (14%) patients had superior labral involvement and 2 (10%) patients had posterior labral abnormality. On arthroscopy, antero-inferior, superior and posterior labral tear were found in 21 (95%), 5 (22%) and 7 (32%) patients respectively. MRA showed a sensitivity of 95%, and a specificity of 100% for the detection of the antero-inferior labral tears. The sensitivity of MRA for the detection of superior, middle and inferior glenohumeral ligament tear was 83%, 80% and 86% with a specificity of 100%, 71% and 93% respectively. MRA was 100% sensitive for the detection of rotator cuff injuries and detection of bony lesions like Hill-Sach's and bony Bankart's lesion. CONCLUSIONS: MRA is a sensitive and specific modality for evaluation of anterior shoulder instability.

Isolated symmetrical mediastinal lipomatosis.

Symmetrical mediatinal lipomatosis is a rare benign condition characterized by deposition of a large amount of mature adipose tissue within the mediastinum. Usually secondary to exogenous obesity, administration of steroids and Cushing's disease, it is more common in middle-aged males and is associated with alcohol abuse. Various other associations have been reported. CT and MRI can decisively diagnose this benign condition, which also helps in deciding treatment options. We present a case of a young female with a bizarre appearance on chest radiographs. Isolated, bilaterally symmetrical mediastinal lipomatosis was diagnosed on CT and MRI. The patient was thin and did not consume alcohol or steroids. Cushing's disease and other known associations were excluded.