Role of ultrasonography in evaluation of right iliac fossa mass compared to CT scan

Background: With the demonstration of origin and nature of RIF mass by high-resolution ultrasound and multidetector CT scan, the patients presenting with clinically palpable mass in RIF need not to undergo time consuming, uncomfortable and unpalatable barium study. The objective is to evaluate the diagnostic precision of CT and ultrasonography in the diagnosis of right iliac fossa masses and to assess the effectiveness of USG in diagnosing various right iliac fossa masses in comparison with CT scan in terms of sensitivity, specificity, and predictive accuracy. Methods: The study was conducted on 35 patients presenting with right iliac fossa mass who were stable enough to undergo USG followed by CT scan. The time gap between these studies had kept to minimum to make the studies comparable. USG and CT scan was performed by 2 expert radiologists, who had been blinded of each other findings. Results: More than 50% cases were related to appendicular pathology. Ultrasound abdomen had a sensitivity and specificity of 88.9% and 94.11% in diagnosis of appendicular mass, 71.42% and 96.42% in diagnosis of appendicular abscess, 66.7% and 96.6% in diagnosis of ileo-caecal tuberculosis, 50% and 100% in diagnosis of carcinoma caecum respectively as compared to CT scan. Conclusions: USG is the most easily available bed side investigation and excellent screening test for RIF mass. However, CECT whole abdomen remains the gold standard investigation for etiological diagnosis of RIF mass.

An unusual coalition of medullary nephrocalcinosis with a novel genotypic variant of Alport syndrome type-1

Alport’s syndrome is a type of inherited disorder of the basement membrane characterized by a spectrum of phenotypes ranging from progressive renal injury to varied extrarenal manifestations comprising auditory and ocular abnormalities. Here in, we present a 3-year-old child born out of nonconsanguineous marriage who presented with fever, intermittent microscopic haematuria, and recurrent gross haematuria, proteinuria with normal auditory brainstem response and ocular slit lamp examination findings. Renal biopsy yielded normal light microscopy and immunofluorescence study whereas minimal changes in the glomerular basement membrane (GBM) collagen were detected on electron microscopy, suggesting possibilities of Alport’s syndrome. Ultrasonographic renal imaging yielded the presence of bilateral medullary nephrocalcinosis. Angiotensin converting enzyme inhibitors along with angiotensin receptor blockers were used to curb the disease progression. A final clinical exome sequencing corroborated the phenotype with a diagnosis of Alport’s syndrome type-1 linked to a novel pathogenic variant c.1892dup (p.Gly632ArgfsTer2) showing hemizygous single base pair insertion/duplication in COL4A5 gene. To the best of our knowledge, this unusual association of Alport’s syndrome with medullary nephrocalcinosis has not been reported worldwide in any previous medical literature making this report a primi one.

Wolff-Parkinson-White syndrome: the supreme master of camouflage

Wolff-Parkinson-White (WPW) syndrome is a condition in which there is an aberrant conduction pathway between the atria and ventricles, resulting in tachycardia. Most of the patients remain asymptomatic throughout their lives; however, approximately half of the patients with WPW syndrome experience symptoms secondary to tachyarrhythmias, like paroxysmal supraventricular tachycardia, atrial fibrillation, atrial flutter, and, rarely, ventricular fibrillation and sudden death. Patients with WPW syndrome may present with a multitude of symptoms such as unexplained anxiety, palpitations, fatigue, light-headedness or dizziness, loss of consciousness, and shortness of breath and rarely with ischemic chest pain. We report a case of a 38-year-old male presented with various vague symptoms like feelings of constipations and anxiety accompanied by psychosocial stressors, lack of sleep with episodes of palpitations which was attributed to underlying anxiety and depressive disorder and stated on various antidepressive medication, but without any relief of symptoms. He was later diagnosed with WPW syndrome. Keeping cardiac dysrhythmia within the differentials would help in early diagnosis and appropriate treatment.

Burden of undiagnosed and uncontrolled hypertension and its associated factors among rural populations in South Andaman Islands, India

Background: Elevated BP is an important risk factor of cardiovascular diseases; undiagnosed and uncontrolled hypertension is a dangerous situation where target organ damage can occur leading morbidity and mortality in apparently healthy individuals. Therefore, with an aim to study the burden of undiagnosed and uncontrolled hypertension, this study with a cross sectional study design is undertaken in rural areas of South Andaman Islands. Methods: A community based cross sectional study. A total of 405 participants (Men: 175, Women: 230) were involved, mean age 48.36�.16 years (Men: 50.69�.01 years, Women: 46.58�.26 years). Results: 30.4% of the participants reported that they are known hypertensives, and out of them only 63.41% were on regular treatment. 17.8% of the participants were first time diagnosed with hypertension during this study. Overall, 48.1% of participants are having hypertension (known hypertensives眓ewly diagnosed hypertensives), and only 63.20% of them know their status on hypertension. A large proportion are in Pre-hypertension status (52.04%). Conclusions: Almost half of the population are having burden of hypertension, and nearly 1/3rd of them do not know that they have hypertension; and among those who know the status, only 2/3rd of them are on regular treatment; and a large proportion of population is in pre-hypertension. We need to undertake rigorous efforts to unmask, diagnose and treat hypertension in the community.

Report-based antibiotic sensitivity pattern of community-acquired urinary tract infection in rural Bengal

Background: Urinary tract infection (UTI), a common bacterial infection managed in general practice, is the second most common cause for antibiotic use in primary care setting. Antibiotic prescription is mostly empirical in UTI and it is imperative to choose one highly sensitive drug against the common pathogens. Aims and Objectives: In this study, it has been tried to find out the magnitude of community-acquired UTI in a rural population of West Bengal, its causative agents, and the sensitivity pattern of urinary isolates to reduce the development of antibiotic resistance. Materials and Methods: This is an observational, cross-sectional study over 1 year in a rural tertiary care hospital in West Bengal. Culture and sensitivity reports generated from diagnosed UTI patients from the different OPDs of the hospital were analyzed. Results: Out of 603 reports analyzed, culture-positive reports were 463. Escherichia coli was identified to be the most predominant (61.7%) followed by Staphylococcus aureus (17.3%). The sensitivity report of the empirically given antibiotics shows that among the oral antibiotics, nitrofurantoin was the most sensitive one (92%) followed by ciprofloxacin (83.1%) and ofloxacin (66%). Among the injectables, amikacin (84.5%) and ceftazidime (81.8%) were the antibiotics having the highest sensitivity. Conclusion: The sensitivity among the uropathogens to the commonly used antibiotics shows higher resistance rate toward norfloxacin, cephalexin, cotrimoxazole, ampicillin, amoxicillin, co-amoxiclav, and cefuroxime. Oral antibiotics such as nitrofurantoin and ciprofloxacin and parenteral antibiotic amikacin have found to be of higher sensitivity among all organisms identified clubbed together.

Reflective writing as a learning tool for Phase II MBBS students in India

Background: Reflection is essential in training physicians mainly because it helps them to participate in collaborative teams, respond in unique and compassionate manner to clinical cases and situations and behave professionally and with empathy. Aims and Objectives: The objective of this study was to observe the reflective writing ability of the Phase II MBBS students of the institute after a structured training and to obtain student feedback about the experience. Materials and Methods: This was a prospective, observational study conducted at the Department of Pharmacology, of a Medical college. A total of 102 students were included in an interactive lecture on reflection writing. Over 3 weeks they were shown three different videos (two of them doctor patient/family member interactions and one a teacher student interaction). The students were asked to reflect about what they saw in the videos. Their reflection was under three heads - “what happened, what was your reaction, and what can be done next.” Their reflection was analyzed using a scoring system (score 1 no refection to score 6 with in depth reflection) by a single observer. Their feedback was obtained using a 5-point Likert scale. Results: Average scores of the students in the three reflection exercises were 2.85 ± 0.78, 2.98 ± 0.84, and 3.36 ± 0.57, respectively, showing improvement in reflection skills. Feedback from the students showed that most liked the experience and recommended for their peers. Conclusions: We concluded that 2nd year MBBS students, when taught the structure of a reflective exercise may be able to reflect better on their day to day experiences.

High-grade mixed neuroendocrine non-neuroendocrine neoplasm of the gastroesophageal junction: A rare case report and review of literature

Mixed neuroendocrine non-neuroendocrine neoplasm (MiNeN) is a recently described entity of the esophagus in the latest (fifth) edition of WHO Classification of Digestive System Tumors. It is often a difficult pathological diagnosis, especially in small preoperative biopsies. We herein report a case of high-grade MiNeN of gastroesophageal junction diagnosed as a squamous cell carcinoma in preoperative biopsy and subsequently as a high-grade MiNeN in esophagogastrectomy specimen comprising areas of mucoepidermoid carcinoma and large-cell neuroendocrine carcinoma (NEC). This report accentuates the importance of deeper multisite preoperative biopsies as the management is completely different in a MiNeN from esophageal squamous cell carcinoma.

Clinico-radiological profile and outcome of patients undergoing intercostal tube drainage in a tertiary care hospital in West Bengal, India

Introduction: Evacuation of empyema which was first performed centuries ago, marked the beginning of thoracic drainage. The subsequent acquisition of a greater knowledge of the anatomy, physiology, and pathology of the pleural space directed the design of thoracic catheters and drainage systems and the development of the methods by which they are used. Thoracic drainage systems are designed to remove air and liquids from the pleural space or mediastinum, which collect there as a result of injury, disease, or surgical procedures. Method: A total of 100 patients who underwent intercostal tube drainage due to various etiologies are followed up for 3 months in the study Results: In this study it was observed that pneumothorax (67%) as the most common indication for chest drain insertion followed by hydro-pneumothorax. During this period 100 patients of different pathologies related to chest underwent chest intubations. Amongst them 88(88%) were male and 12(12%) were female. Subcutaneous emphysema was found to be the most common complication followed by ICD tube blockage. Among the study population 95% patients were successfully treated & unsuccessful outcome was only 5%. Conclusion: Chest tube insertion is a common procedure usually done for the purpose of draining accumulated air or fluid in the pleural cavity. Small-bore chest tubes (≤14F) are generally recommended as the first-line therapy for spontaneous pneumothorax in non-ventilated patients and pleural effusions in general. Large-bore chest drains may be useful for very large air leaks, as well as post-ineffective trial with small-bore drains.

A clinicopathological study of pleural effusion with special reference to malignant aetiology in a tertiary care hospital in West Bengal

Background: Pleural effusion has varied aetiological factors. It constitutes one of the major causes of morbidity in India as well in other parts of world. Because of the various aetiologies that can cause pleural effusion, itoften present a diagnostic problem, even after extensive investigations. Objective: In this study, authors aimed to identify the common aetiologies causing pleural effusion and their clinical profile in a tertiary care hospital. Materials and Methods: A hospital based cross-sectional study is conducted over a period of one year in tertiary care hospital in West Bengal. 150 patients of pleural effusion above 10 yrs of age were studied. Clinico-pathological, radiological, hematological and biochemical parameters were documented. Results: The most common cause pleural effusion in this study was tuberculosis (64.67%), followed by malignancy (14.67%), parapneumonic effusion (7.33%), cardiac failure (5.33%) and other minor causes. It was commonly seen in male (70%). The occurrence of tubercular pleural effusion was maximum in the age group 31-40 years. Right-sided effusions were more common. Pleural fluid cytology and adenosine deaminase played a pivotal role in the diagnosis of tubercular pleural effusion. Conclusion: The present study highlights tuberculosis as the common causative factor for pleural effusion, labels lung carcinoma as the most common cause of malignant pleural effusion, and defines the clinico-pathological, biochemical and imaging characteristics of different aetiologies of pleural effusion.

Assessment of efficacy of Anti-IgE (Omalizumab) therapy in patients with severe allergic asthma in a tertiary care hospital of Eastern India

Introduction: Immunoglobulin E dependent mechanisms play an important role in the development of airway inflammation in allergic asthma. Atopic patients with severe asthma frequently have poorly controlled disease. Many have poor asthma control despite intensive treatment. Severe allergic asthma patients frequently treated with oral corticosteroids and therefore may develop serious side-effects. Anti-IgE antibody had been used in severe persistent allergic asthma in Western countries. However, its long-term efficacy in patients in India has not been reported. Objective: To assess the efficacy of anti IgE therapy in patients with severe allergic asthma. Method: 30 (16 male and 14 female) patients, with mean age of 49 having severe persistent allergic asthma, with recurrent exacerbations and on oral/IV steroids, received Omalizumab 150mg/300mg/450 mg for 1 year. Total dose of oral Steroids, use of rescue medications, changes in lung function (FEV1) were recorded at the baseline, 16 weeks & at end of the treatment (52 weeks) and then analyzed. Results: Significant reduction observed in total oral steroid use at 16 week & at 52 weeks. -10.5mg (p<0.003) & 22.5mg respectively. Use of rescue medications decreased by -7.90 puffs(p- <0.001) at 16 weeks and by -13.67 puffs (13.67 (p -<0.001) at 52 weeks. Improvements in lung Function (FEV1) observed with a tune of 700 ml. from Baseline after 52 weeks therapy. Conclusion: Use of anti-IgE antibody for 1 year is well tolerated and led to an overall significant improvement in patients with severe persistent allergic asthma.

Impact of hepatitis B immunization among the Nicobarese tribe - antibody titres & seroprotection five years after vaccination.

Background & objectives: A total of 237 Nicobarese subjects who had received hepatitis B vaccination as part of mass vaccination project during 2000-2001 were screened for anti-HBsAg titres by quantitative ELISA five years after vaccination. Methods: Anti-HBsAg antibody was estimated using quantitative ELISA. Proportion of the subjects with protective levels of antibody and geometric mean antibody titres were calculated. Results: Among the 237 study subjects, 213 had received three doses of vaccine, 17 had received two doses and seven had received one dose. The geometric mean titres of anti-HBs antibodies were 201.7, 31.9 and 23.1 mIU/ml among those who received three, two and one dose of vaccine, respectively. Among those who received three doses of vaccination, 85.9 per cent had anti-HBs antibody levels of 10 mIU/ml or more, indicating seroprotection. The difference in the seroprotection rates among those who received three doses of vaccination (85.9%) and those who received less than three doses (58.3%) was significant. Seroprotection rates one month after the first, second and third dose of vaccination were 49.1, 86.9 and 96.7 per cent, respectively. It then declined to 89 per cent by the end of the second year and to 85.5 per cent by the end of the third year, but there was no decline thereafter. Interpretation & conclusions: Seroprotection rate reached at the maximum one month after the third dose of HBV vaccine. Although about 15 per cent of the vaccinated persons lost seroprotection by the end of the third year, no further loss in seroprotection was observed between the third year and the fifth year.

Clinical Outcome and Echocardiographic Evaluation of Inferior Myocardial Infarction with Right Ventricular Involvement.

Background : Acute right ventricular myocardial infarction complicates inferior wall myocardial infarction with an incidence of 14-84%. ECG is the cornerstone in initial diagnosis as it is cost effective and done easily. Echocardiographic analysis of the right ventricular involvement can shed light on the severity of the disease. Hence we aimed to study right ventricular infarction in acute inferior wall myocardial infarction using right precordial lead as well as echocardiography. Methods: Present study is based on the analysis of 100 patients admitted to Coronary care unit of the National Institute of Cardiovascular Diseases & Hospital during July 2010 to June 2011, with acute inferior wall myocardial infarction. 12 lead ECG with thorough physical examination was done along with right precordial mapping. ST ³ 1mm in V4R was initial diagnostic of right ventricular involvement followed by echocardiographic assessment of RV and LV within 24 hours. Results: A total of 50 patients showed right ventricular involvement with V4R being the sensitive lead. Echocardiography showed mean RVEF of patients with 29.5 % ± 9.5 in comparison of 44.9%±12.2 without right ventricular involvement. Right ventricular involvement presented with bradycardia (40%) and hypotension, 80% Kussmaul’s sign, 14% with complete heart block. Mortality in right ventricular involvement was 6 times higher than without right ventricular involvement (12 %). Conclusion: Clinical signs and symptomatology are not fully diagnostic of RVI in inferior wall acute MI. ECG can diagnose (using right precordial mapping) this condition very early. Echocardiography help to assess the right ventricular function high-risk groups for aggressive management like primary PCI. Early diagnosis will help in careful monitoring and management of such cases.

Echocardiographic Evaluation of Left Ventricular Diastolic Function after Percutaneous Coronary Intervention in Patients with Coronary Artery Disease.

Background: Although percutaneous coronary intervention (PCI) is an excellent therapy for coronary artery disease, there is a paucity of information on the efficacy of PCI in improving diastolic function, especially in Bangladesh. Because of the high prevalence of left ventricular diastolic dysfunction in coronary artery disease patients and its probable progression to heart failure, an evaluation of the role of PCI in improving diastolic function is required. Objective of the study was to evaluate the impact of percutaneous coronary intervention on left ventricular diastolic dysfunction by Doppler echocardiography in patients with coronary artery disease. Methods: One hundred patients scheduled for elective PCI were enrolled in this study whose left ventricular systolic ejection fraction was normal or only mildly abnormal. Before PCI and 48 hours after PCI, echocardiography was done to evaluate the indices of LV diastolic function in these patients.

Expressional Evaluation of Androgen Receptor in Transitional Cell Carcinoma of Urinary Bladder Patients.

The study was undertaken to evaluate the possible role of Androgen Receptor (AR) in relation to tumor grade, age, sex and urinary bladder cancer risk. Expression of AR detected by immunohistochemistry in 125 Transitional Cell Carcinoma and 100 control cases. Expression of AR was noticed in 28.8% cases. AR increased with increasing tumor grade. Expression of AR was seen to be significantly higher in male in the age group ≥ 50 years (p < 0.05). AR expression was found to be associated significantly with the tumor grades, age and sex suggesting that AR may be used as prognostic markers in the treatment of urinary bladder carcinomas.

Evaluation of 100 cases of ascites.

This has been a descriptive cross sectional study on 100 consecutive adult cases of ascites. They were studied regarding the incidence of underlying causes, variable clinical presentations and the co-relation of investigations with clinical features during the period of September, 2006 to August, 2007 in Sher-e-Bangla Medical College Hospital, Barisal, Bangladesh. Diagnosis of ascites was based on history, clinical examination & USG examination. Among the 100 cases, male were 68 & female were 32, age range was 13-61years. Causes of ascites were cirrhosis of liver 68%, tubercular peritonitis 9%, hepatocellular carcinoma 8%, congestive cardiac failure 6%, malignancy 4%, nephrotic syndrome 3%, lymphoma 2% and others 4%. Cirrhosis of liver is the major cause of ascites in our study. Many of the patients with cirrhosis & hepatocellular carcinoma were positive for HBsAg & anti HCV implying that hepatitis B & C viruses play a positive role in this condition.

Needle sticks injury among nurses involved in patient care: a study in two medical college hospitals of West Bengal.

A hospital-based retrospective study on a sample of 228 nurses involved in patient care, in two medical college hospitals of West Bengal, showed that 61.4% of them sustained at least one Needle Stick Injury (NSI) in last 12 months. The risk of such injuries per 1000 nurses per year was found to be 3,280. Out of the most recent injuries among 140 nurses, 92.9% remained unreported to appropriate authorities; in 52.9% events hand gloves were worn by the nurses; only 5% of those nurses received hepatitis B vaccine, 2.1% hepatitis B immunoglobulin and none of them received post exposure prophylaxis for HIV.

A study on delivery and newborn care practices in a rural block of West Bengal.

A cross-sectional study was conducted in a rural block of the State of West Bengal to generate area specific data on the proportion of home deliveries and certain newborn care practices prevalent in that area. The study was done through house-to-house survey among 165 mothers who delivered in last six months. 83.6% deliveries were conducted at home and untrained persons attended 36.3% deliveries. Bath within 24 hours of delivery was given to 17.58% newborns. Birthweight was not recorded in 38.18%. High proportion of newborns, 78.5%, was given prelacteal feeding. The health system should urgently address the deficiencies in the delivery and newborn care practices in the study area.