Clinico- Epidemiological Profile of Acute Appendicitis in a Tertiary Care Hospital in North India

Introduction: Acute appendicitis is one of the most commonsurgical emergencies. Accurate diagnosis of acute appendicitisneeds careful history, and physical evaluation, as the diagnosisis primarily clinical.Material and methods: A cross sectional study was done in50 patients who underwent emergency appendicectomy foracute appendicitis in a medical college hospital in Shimla.The aim was to study the clinical profile of patients with acuteappendicitis and compare it with the existing literature.Results: Mean age of patients was 26.48 (± 12.28) years.Out of 50 patients, 29 (58%) were males and 21 (42%) werefemales, so male predominance was seen in the present study.Most common complaints were pain in the right iliac fossa(100%), nausea and vomiting (82%), anorexia (80%), andmigration of pain (70%). Tenderness in right iliac fossa waspresent in all patients in our study (100%), while reboundtenderness (70%), guarding (64%), rigidity (6%), Rovsingsign (36%), Psoas sign (46%), Obturator sign (22%), andDunphy sign (60%), respectively.Conclusions: Acute appendicitis is more common amongmales than females, and between 10- 30 yrs of age. Themost common presenting features were pain abdomen,anorexia, nausea, and vomiting. The most common signs weretenderness, rebound tenderness and guarding. The rate ofaccuracy of clinical examination was 86%.

Dorsal sacral dimensional anatomy-revisited.

Background: Determination apex of sacral hiatus (SH) is of paramount importance to Anaesthetists, Orthopaedicians, Obstetricians and Gynaecologists for caudal epidural block (CEB). Dorsal sacral dimensions were therefore taken to facilitate them for easy location of SH. Methods: Following parameters of each of the sixty human sacra were measured using vernier calipers at the level of spinous process of second sacral vertebra (S2). a) Distance between the two supero-lateral crests b) Distance between the right supero-lateral crest level to the apex of sacral hiatus (SH) c) Distance between the left supero-lateral crest to the apex of SH d) Distance from the spinous process of S2 to the apex of SH e) Distance from the spinous process of S2 to the base of SH The data obtained was analysed statistically. Results: Mean of the distance between the two supero-lateral crests was 51 ± 6.37 mm and 52.7 ± 5.30 mm in males and females respectively, mean of the distance between the right supero-lateral crest and the left supero-lateral crest to the apex of SH was 45.91 ± 6.94 mm in males 42.50 ± 11.23 mm in females and 44.74 ± 6.77 mm in males and 42.50 ± 10.97 mm in females respectively , vertical distance from spinous process of S2 to the apex of SH in males and females was 38.83 ± 9.33 mm and 32.4 ± 1.64 mm respectively. Vertical distance from spinous process of S2 to the base of sacral hiatus was 59.20 mm ± 10.81 mm in males and 52.80 ± 9.18 mm in females. Conclusion: From the data obtained it was concluded that an isosceles triangle was formed between the two supero-lateral crests at the level of spinous process of S2 and the apex of SH.

Foramen of Huschke in North Indians: an anatomical study.

Background: The deficiency in the antero-inferior wall of the bony part of external auditory canal (EAC) closes by 5 years of age but if it persists beyond that age it is called foramen of Huschke. Depending on the population studied, persistence of this foramen has been seen in 0-67% of adult crania. Review of literature revealed that no data was available in North Indian population; therefore the present study is being undertaken. Methods: Sixty North Indian adult human crania were examined and the presence of foramen of Huschke was noted. The side to which it belonged to, its shape and size were observed. Size of the foramen was measured using vernier caliper. Results: Out of sixty North Indian adult human crania seen, foramen of Huschke was present in 14 crania. It was observed unilaterally in 10 crania and bilaterally in 4. Although different shapes of the foramen like pin point, pin head, circular, irregular and U shape were observed but in majority of cases it was U shaped. Its size varied from pin point- 10 mm transversely and pin point to 9 mm longitudinally. Conclusion: This study revealed that about 23% of North Indian adult human crania have foramen of Huschke. Persistent foramen of Huschke in the adult life may be involved in different abnormalities of the EAC and may lead to otological complications. Therefore, ENT surgeons should be aware of persistent foramen of Huschke and keep it as one of the possible diagnoses while dealing with patients presenting with otological complications. Also the surgeons should be careful while performing endoscopy of Temporomandibular Joint (TMJ) so that accidental damage of TMJ can be prevented.

Frequency of abnormal branching pattern of axillary artery: a cadaveric study.

Many authors suggest that abnormal branching pattern of axillary artery is very common. This compelled us to explore the axillary region of 20 formalin fixed cadavers of either sex to note the frequency of unusual branching of axillary artery over a period of five years. Axillary artery branched normally as described in various textbooks of Anatomy in thirty nine (97.5%) out of forty axillae examined. Only in one axilla (2.5%), it was observed that the second part of axillary artery branched unusually whereas on the other side it branched normally. Knowledge of such abnormal presentation of the axillary artery in the era of reconstructive surgeries is of great help to the interventionist so as to avoid any vascular catastrophe resulting in some kind of mishap. Awareness of such unusual branching pattern of axillary artery is also of great importance to vascular surgeons and radiologists dealing with this region. Embryological origin and the clinical relevance of the abnormality encountered in the branching pattern of the axillary artery in the present study have been discussed in the paper.

Incomplete development of second sacral lamina: a case report.

Sacrum is made up of large fused 5 sacral vertebra forming posterior wall of pelvis. On routine examination of the bones present in the bone bank of our department we noticed a sacrum in which sacral canal was incompletely formed due to imperfect formation of second sacral laminae. Knowledge of such type of variation may be of importance to the clinicians in dealing with patients presenting with bladder and or bowel disturbances or presenting with some neurological deficit of the lower limb. Orthopaedic surgeons should also be aware of this anomaly while operating in the sacral region.

Anatomical variations and clinical relevance of dorsal sacral foramina in North Indians.

Lateral side of each intermediate crest has four dorsal sacral foramina for the passage of posterior division of the sacral nerves. Not only they serve as an important landmark in placement of spinal instrumentation but are also of great importance in transsacral block of sacral nerves for producing analgesia and anesthesia in pelvic surgeries. Therefore a study on the variation in number of dorsal sacral foramina was conducted in 60 adult dry North Indian sacra. Three dorsal sacral foramina were seen on the lateral side of each intermediate crest in four sacra (6.6%) and five in 6 sacra (10%) amongst all the sacra examined. Either a single pair, double pair or totally absent foramina were not observed in any of the sacra seen. This study revealed that there is variation in the number of dorsal sacral foramina. Anaesthetists should be aware of this disparity to be able to perform trans-sacral nerve block successfully. Radiologists must also know about this variation to interpret the radiographs of lumbosacral region. Neurologist and orthopedist should also be cognizant of this fact to diagnose patients presenting with bizarre clinical findings.

Epidemiological trends of RF/RHD in school children of Shimla in north India.

Background & objectives: There are no active surveillance studies reported from South East Asian Region to document the impact of change in socio-economic state on the prevalence of rheumatic fever/rheumatic heart disease (RF/RHD) in children. Therefore, we conducted a study to determine the epidemiological trends of RF/RHD in school children of Shimla city and adjoining suburbs in north India and its association with change in socio-economic status. Methods : Active surveillance studies were conducted in 2007-2008 in urban and rural areas of Shimla, and 15145 school children, aged 5-15 yr were included and identical screening methodology as used in earlier similar survey conducted in 1992-1993 was used. The study samples were selected from schools of Shimla city and adjoining rural areas by multistage stratified cluster sampling method in both survey studies. After a relevant history and clinical examination by trained doctor, echocardiographic evaluation of suspected cases was done. An updated Jones (1992) criterion was used to diagnose cases of acute rheumatic fever (ARF) and identical 2D-morphological and Doppler criteria were used to diagnose RHD in both the survey studies. The socio-economic and healthcare transitions of study area were assessed during the study interval period. Results: Time trends of prevalence of RF/RHD revealed about five-fold decline from 2.98/1000 (95% C.I. 2.24-3.72/1000) in 1992-1993 to 0.59/1000 (95% C.I. 0.22-0.96/1000) in 2007-2008. (P<0.0001). While the prevalence of ARF and RHD with recurrence of activity was 0.176/1000 and 0.53/1000, respectively in 1992-1993, no case of RF was recorded in 2007-2008 study. Prevalence of RF/RHD was about two- fold higher in rural school children than urban school children in both the survey studies (4.42/1000 vs. 2.12/1000) and (0.88/1000 vs. 0.41/1000), respectively. The indices of socio-economic development revealed substantial improvement during this interim period. Interpretation & conclusions: The prevalence of RF/RHD has declined by five-fold over last 15 yr and appears to be largely contributed by improvement in socio-economic status and healthcare delivery systems. However, the role of change in the rheumatogenic characteristics of the streptococcal stains in the study area over a period of time in decline of RF/RHD cannot be ruled out. Policy interventions to improve living standards, existing healthcare facilities and awareness can go a long way in reducing the morbidity and mortality burden of RF/RHD in developing countries.

Congenital malformation of fifth lumbar vertebra: A case report.

Fifth lumbar vertebra is an atypical vertebra as it has widely separated inferior articular processes and thick transverse processes projecting out from the body and pedicles of the vertebra. On routine examination of osteology specimens we found a fifth lumbar vertebra in two separate parts. One part consisted of body, pedicles, transverse and superior articular processes. The other part consisted of lamina, spinous and inferior articular processes. Knowledge of this variation may be of importance to the clinicians for diagnosis of certain neurological deficits in the lower limb and to orthopaedic surgeons and neurosurgeons during the surgical intervention of that area.

Absence of costal element of the foramen transversarium of atlas vertebrae.

Background: Since scanty literature is available on the absence of costal element forming foramen transversarium of atlas vertebra therefore this study was undertaken. Atlas vertebrae were examined to see the presence of foramen transversarium and their boundaries. Methods: Hundred foramina transversaria of 50 atlas vertebrae were examined grossly. Results: Foramen transversarium was seen to be present in all the transverse processes of the atlas vertebrae examined. Costal element was found to be missing in seven foramina tranversaria out of 100 foramina seen. It was found to be absent on the right side in three vertebrae and in two it was absent bilaterally. Conclusions: In case the costal element of the foramen transversarium is absent, the second part of vertebral artery passing through this foramen is liable to be damaged while operating at the level of atlanto-occipital joint the operating surgeon should be aware of such variations so as to avoid injury of second part of vertebral artery and subsequently preventing any kind of neurological involvement. Radiologists must also know about such variations so as to correctly interpret radiological image of the craniovertebral region.