A Study on Morphometry and Related Surgical Importance of Naso Lacrimal Duct

Introduction: The Nasolacrimal duct is the terminal part of the nasolacrimal apparatus or tear apparatus. The anatomy of lateral nasal wall is Important for planning the surgeries on lacrimal duct through intranasal approach. Objective: The current study was designed to review the anatomy of nasolacrimal duct in relation to the lateral nasal wall. Material and method: Thirty sagittal sections (14 right and 16 left side) of head and neck of formalin fixed adult cadavers of known sex, gender, ethnicity present in department of anatomy GMCH, Chandigarh were studied. The following parameters were made using a digital calliper and rounded off to the nearest millimetres. 1.Length of nasolacrimal duct (NLD Length) 2. Nearest distance from the nasolacrimal duct to maxillary sinus ostium (NLD - MSO) 3. Nearest distance from the NLD to the anterior nasal spine. (NLD- ANS)4. Nearest distance of the intranasal orifice of the NLD to the nasal floor (NLD- NF) 5. Nearest distance of the intranasal orifice of the NLD to the nasal roof. (NSD- NR) 6. Nearest distance of the intranasal orifice of the NLD to the anterior attachment of the Inferior concha. (NSD- AIT). Observations: In our study the average length of the NLD was 19.8±1.57mm. The intranasal orifice of the NLD was observed to be located on an average of 24.5±2.6mm from the anterior nasal spine, ranging from 5.5-2. 9mm.The average distance from the nasal roof was found to be 32.2±1.67mm and 16.08±1.71mm from nasal floor. In addition, the average distance from the anterior attachment of inferior nasal concha was found to be 14.82±2.37mm. In our study the NLD was an average of 4.08±0.67mm anterior to MSO at the level of the anterior attachment of the MT. On Comparing right and left side The NLD Was found to be slightly longer 22.7 in comparison of 22.2 mm on left side. The distance of NLD From MSO was also found to be larger on left side. The distances of NLD-ANS, NLD NR, NLD -AIT and NLD- NF were also longer on left side. Conclusion: We found that most of the parameters were closer to a study done by Ertugel while the NLD-NF distance was more in our specimen. Running title: nasolacrimal duct: morphometry, surgical importance

Suspecting and diagnosing transthyretin amyloid cardiomyopathy (ATTR-CM) in India: An Indian expert consensus

Transthyretin cardiac amyloidosis (ATTR-CM) is a rare and under-recognized disorder characterized by the aggregation of transthyretin-derived insoluble amyloid fibrils in the myocardium. Heterogeneity of symptoms at presentation, makes its diagnosis often delayed. An expert panel gathered on a virtual platform across India to conduct a meeting for developing a guiding tool for ATTR-CM diagnosis. The panel recommended younger age (40 years) for suspecting ATTR-CM and thick-walled non-dilated hypokinetic ventricle was considered as one of the important red flags. Electrocardiogram (ECG) and echocardiography (ECHO) findings were recommended as primary tests to raise the suspicion while nuclear scintigraphy and hematological tests were recommended to confirm the diagnosis and rule out amyloid light-chain (AL) amyloidosis. Cardiac magnetic resonance (CMR) and biopsy were recommended in case of ambiguity in the presence of red flags. Considering the lack of expert guidelines in the Indian scenario, a standardized diagnostic algorithm was also proposed.

Pterion: Morphometry and Surgical Significance

Introduction: Pterion is a H-Shaped formation of sutures and cranio-metric point on the lateral side of skull. It is marked by the junction of frontal, parietal, greater wing of sphenoid & squamous temporal bone. Objective: The study is aimed to determine prevalence of types of pterions, presence of epipteric bone. We also tried to find pterion’s relationship with anterior branch of middle meningeal artery Materials and methods: Study was done in department of Anatomy, GMCH-32, Chandigarh on 40 adult dried skulls without calvaria, of unknown age, gender and race. The skulls with broken lateral wall were excluded. Skulls were examined for 1. A. prevalence of pterion shape B. Prevalence of bilaterality of similar shape of pterion. C. Prevalence of unilateral variation of pterion on two sides of skull. 2. Epipteric bone A. Presence of epipteric bone B. relation to the suture on both sides. 3. Distance of pterion center point to frontozygomatic suture and upper border of zygomatic arch. 4. relationship of pterion on external and internal surface of skull and on inner side its relationship with anterior branch of Middle meningeal artery. Observations: In the present study 3 types of pterions i.e., Sphenoparietal, stellate, frontotemporal were observed. Sphenoparietal was found to be present bilaterally 40% on both sides. Frontotemporal & stellate were 2.5%. Sphenoparietal type of pterion was 55% on right side & 67.5% on left side. frontotemporal type of pterion was 5% on right side & 2.5% on left side, stellate type was 7.5% on right side & 2.5% on left side. epipteric bone were present in pterion on right side in 32.5% & on left side 27.5%. Pterion was lying approximately 3.5 cm above the zygomatic arch and 2.83 cm behind the posterior margin of frontozygomatic suture. Conclusion: in our study the commonest type of pterion shape was Sphenoparietal. This type was most common to be present bilaterally. Epipteric bone was found in Sphenoparietal type both unilaterally & bilaterally. The anterior branch of MMA was closest and farthest in stellate type.

Obstetric outcome in twin pregnancies complicated with single intrauterine fetal demise

Background: It has been reported that single intrauterine fetal death in twin pregnancy occurs in 3.7-6.8% all twin pregnancies. The objective of this study was to evaluate the maternal and fetal demographic features and feto-maternal outcomes in twin pregnancies complicated with single intrauterine fetal demise and evaluation of available management guidelines.Methods: This retrospective study was conducted at obstetrics and gynecology department of SGRRIM and HS, Dehradun, Uttarakhand between January 2015 and December 2019. There was a total of 182 twin deliveries at study hospital during this period and 35 of these cases were complicated with single intrauterine fetal demise. Maternal age, parity, chorionicity of twin gestation, gestational age at single intrauterine fetal demise, gestational age at delivery, mode of delivery, birth weight, Apgar Score at birth, neonatal intensive care unit stay of newborn,  maternal fibrinogen levels during pregnancy and delivery time and associated obstetric complications were analyzed in these cases of single intrauterine fetal demise with twin gestation. All monochorionic twin pregnancies were included in the study Group A and dichorionic twin in Group B.Results: The mean age of 32 patients included in study was 29.7±4.6 years. Twenty (62.5%) of these patients were dichorionic and 12 (37.5%) of these were monochorionic twin gestation. Single intrauterine fetal demise occurred in first trimester in 8 (25%) patients, during the second trimester 20 (62.5%) and 4 (12.5%) patients had third trimester single intrauterine fetal demise. Preterm deliveries occurred in 18 (56.3%) of patients and 8 (44.4%) of patients were of monochorionic and 10 (55.6%) of dichorionic twin patients. Among thirty-two patients, 11 (34.4%) patients had caesarean delivery and 21 (65.6%) patient had vaginal birth. No maternal or fetal mortality noted and none of the patients had maternal coagulation disorder.Conclusions: This study indicates that in cases of twin pregnancies with single fetal intrauterine demise with individualized management plan at higher centre and close maternal and fetal surveillance live fetus can be saved without any maternal risk.

Brachial Plexus: Variations in Infraclavicular Part and their Significance

Introduction: Brachial plexus extends from the neck to the axilla and gives motor and sensory nerves to the upper limb. Thebrachial plexus has two parts supraclavicular and infraclavicular parts.Material and Methods: The present study was carried out on 15 adult human cadavers (15 specimens of the right and leftside of the upper limb) in the Department of Anatomy, Government Medical College and Hospital, Chandigarh. All the cadaverswere male.Observations: Of 30 cases, one specimen (3.34%) had variation in the arrangement of all cords (lateral, medial, and posterior)respective to the 3rd part of axillary artery, i.e., all three t cords lie lateral to 3rd part of axillary artery. In one case (3.34%), it wasobserved that lateral cord gave separate branch to coracobrachialis muscle. Musculocutaneous nerve passes straight downwardplaced between biceps brachii and brachialis. Musculocutaneous nerve continues as lateral cutaneous nerve of forearm. Inanother two cases (6.66%), there is communication between musculocutaneous and median nerve. Five cases (16.66%) hadvariations in the formation of median nerve. Here, median nerve was formed from three roots of two roots were originating fromlateral cord and one root from medial cord. In three cases (10%), there is higher origin of median nerve by joining of its tworoots. In one case (3.34%), there are two upper subscapularis nerves from the posterior cord. Other branches of this cord arelower subscapular, nerve to latissimus dorsi, radial, and axillary nerve which is normal in their positions.Discussion: Development of brachial plexus starts at 34th–35th day of intrauterine life and definitive adult pattern is visible by46th–48th day of intrauterine life. The growing axons are regulated by chemoattractants and chemorepulsants in a site-specificfashion. Changes in the signaling pattern between mesenchymal cells and neuronal growth cones can lead to variations.Conclusion: These variations are important for surgeons, neurosurgeons, and plastic surgeons in their respective field inknowing area of loss, loss of muscle power as well as in designing various surgeries.

Clinical profile and outcome of scar endometriosis in a tertiary care centre of Northern India

Background: Endometriosis is defined as the presence and proliferation of the endometrium outside the uterine cavity affecting an estimated 89 million women of reproductive age worldwide. Endometriosis occurs in 5% to 10% of all women, often resulting in debilitating pain and infertility, endometriosis at the scar site known as Scar endometriosis has also been described following obstetrical and gynecological surgery. Scar endometriosis has a much rarer incidence with an illusive presentation and is often misdiagnosed and definitive treatment gets delayed. Objectives of this study was to review the demographic profile, clinical presentation, treatment modalities and outcome in patients with scar endometriosis.Methods: The retrospective study of patients with scar endometriosis managed at DMCH during January 2014 to December 2018 was done.Results: Eight patients of scar endometrosis were diagnosed and operated in our institution over a period of five years. All patients (six with previous caesarean section scar site and two at episiotomy site) presented with tender nodules with pain which got exaggerated during menstruation.Conclusions: A high index of suspicion of scar endometriosis should be kept in patients presented with cyclical pain and tender mass getting exaggerated during menstruation.

Evaluation of simple International ovarian tumor analysis ultra sound rules in differentiating between benign and malignant ovarian tumors and their histopathological correlation

Background: IOTA (International ovarian tumor analysis) study is considered one of the largest studies on ultrasound diagnosis of ovarian pathology conducted in literature till date. It was started in 1999 and included nine European countries. It is a standardized technique for preoperative classification of ovarian pathology defined by IOTA group.Methods: A retrospective study was analyzed from a period of January 2016 to December 2017 (2-year period). The records of all the patients operated for benign and malignant ovarian pathology in the gynae department of hospital were retrieved from medical record sections. USG findings were redefined as per IOTA simple rules by sonologist and its histopathological correlation was done using kappa statistical method.Results: In the present study, out of 61 patients IOTA was applicable to 57 patients. The sensitivity where IOTA simple rules were applicable was 92.8% and the specificity was 93%. The accuracy turned out to be 92.9%. If inconclusive results were taken as malignant then sensitivity increased to 94% and specificity decreased to 87%. Good level of agreement was found between sonological and histopathological findings with Kappa statistics application (K = 0.59).Conclusions: The IOTA simple rules can be considered as an important diagnostic modality in differentiation of benign and malignant ovarian tumors, it has an added advantage of abolishing the subjectivity of routine ultrasound. However inconclusive results demand further expertise in the field and need to be taken care of before interpretation of ovarian pathologies.

Sensitivity and specificity of prenatal screening methods for detection of risk of fetal chromosomal abnormalities

Background: Babies born with chromosomal abnormalities pose a burden on the family as well as the society at large. Early detection and management of fetal chromosomal abnormalities has become an essential component of antenatal care. Hence pregnant women of all ages are offered screening methods for early detection of chromosomal abnormalities. We intended to study the sensitivity and specificity of prenatal screening methods for detection of risk of fetal chromosomal abnormalities.Methods: A three-year retrospective study was conducted from January 2015 to December 2017 in 258 singleton pregnant mothers attending antenatal clinic and delivering at DMCH. The patients were screened for chromosomal abnormalities in the first trimester by NB NT scan along with dual marker and level II anomaly screen scan along with quadruple test in the second trimester. Based on the test results the patients were classified into high risk and low risk pregnant mothers. All the patients with abnormal quadruple test were subjected to amniocentesis for karyotyping. The results of the first trimester and second trimester screening methods were statistically analyzed using chi square test, sensitivity and specificity of the prenatal screening methods was calculated.Results: The sensitivity and specificity of dual marker test for detection of chromosomal abnormality is 50% and 85.94% respectively and that of quadruple test sensitivity is 50%, specificity is 95.3%. The difference was highly significant in the favour of the quadruple marker with P-value of 0.0004.Conclusions: While counseling the patients regarding possibility of having abnormal fetus, obstetrician should keep in mind the false negatives and false positives of prenatal screening and diagnostic methods.

Comparison of Morphometry of Foramen Magnum and Posterior Cranial Fossa in Dry Human Skull

Bougie is an important adjunct in the anaesthesiologist armoury for a difficult airway1. Physical damage to bougie leading to airway trauma is rare but can be catastrophic. We report a case of an anticipated difficult extubation, where the bougie, used to extubate over the tube broke and migrated into the trachea indicating the need of a protocol for routine inspection of bougie which should be strictly adhered to

Elective versus emergency caesarean section: differences in maternal outcome

Background: Caesarean section is a life-saving surgical procedure when certain complications arise during pregnancy or labour. The use of CS worldwide has increased worldwide unprecedented levels although the gap between higher- and lower-resource settings remains. The present study evaluates the difference in maternal outcome in elective versus emergency caesarean sections in our institute.Methods: The study included first 65 cases of emergency caesarean section (group A) and during the study period, first 65 elective caesarean section (group B) if they fulfilled the inclusion criteria. Various intra operative and postoperative events were recorded which included intra operative complications, postpartum haemorrhage and transfusion indices.Results: The most common indication of caesarean section in group A was fetal distress (27.7%). In group B most caesarean sections were classified under 5 followed by class 6, the most common indication being previous caesarean section (27.6%). It was observed that pre-operative mean haemoglobin in group A was 10.6 g/dl and in group B was 11.2g/dl. A drop of 1.36 g/dl in group A and 1.10 g/dl in group B was observed in the post-op period. Cross match / transfusion ratio 1.5 in group A and  2 in group B, transfusion probability ratio was 60 % in group A and  66.7%  in group B and transfusion index was 1 in group A and  group B. There was significantly higher contraception acceptance in group B compared to group A.Conclusions: Elective caesarean section has more favourable maternal outcome as compared to emergency caesarean section as the former is done under controlled and planned circumstances.  However, there should be stringent audit to scrutinise indication of caesarean section, outcome of caesarean and blood transfusion practices.

Foramen Magnum: Morphometry, Possible Variation In The Shape And Its Clinical Implication

Introduction: Foramen magnum is midline opening in the occipital bone in the floor of posterior cranial fossa. Morphometryof cranium also helps in establishing the origin of various neurological and skeletal pathologies and also designing varioussurgical procedures and approaches.Methods: We conducted a study on 50 dry skull bones in the Department of Anatomy, Government Medical College and Hospital,Chandigarh. The foramen magnum was analyzed for its shape, anteroposterior (AP) diameter, width/transverse diameter (TD),area, perimeter, and FM index. All the measurements were taken with Vernier caliper and were statistically evaluated.Results: The common shape observed was hexagonal in 45% of cases. The mean of AP and TD was found to be 34.44 mmand 30.46 mm. AP diameter was more than TD. FM index and perimeter were found to be 98.91 mm and 88.44. However, areaof foramen magnum was observed to be 745.727 mm2.

A Case Report Of A Variant Head Of Gastrocnemius

The Gastrocnemius muscle is a fusiform, two-headed, two-joint muscle. The two heads of origin are lateral andmedial head taking origin from medial and lateral condyles of femur. In between the two heads tibial nervepasses. Its other end forms a common tendon with the soleus muscle; this tendon is known as the tendocalcaneusor Achilles tendon which get inserted to posterior surface of calcaneum. The case was reported during routinedissection for undergraduate M.B.B.S. students in Government Medical College and Hospital, Chandigarh. Thesubject was 70-year-old male cadaver of North Indian origin. The accessory head was observed during thedissection of popliteal fossa. The Gastrocnemius muscle was bulky. The inferolateral and inferomedial boundaryof the popliteal fossa were made by medial and lateral head of gastrocnemius. In addition to the normal medialand lateral head an accessory head of gastrocnemius was observed. The accessory head had bipennatearrangement of the muscle fibers. in the left lower limb were observed. All the heads were innervated by branchesfrom tibial nerve. It is possible that this variant muscle could have a compressive effect on the tibial nerve andpopliteal vessels, and the awareness of this may prevent its misinterpretation as a pathological structure byradiologists and surgeons

Study of Genetic Fidelity of Somatic Embryos - Derived Plants of Gentiana kurroo Royle from Western Himalayas - Plant of Great Medicinal Value.

Aim: To study the effect of plant growth regulators on direct and indirect somatic embryogenesis on Gentiana kurroo Royle – an endangered medicinal plant. Place and Duration of Study: Department of Biotechnology, Dr Y. S. Parmar University of Horticulture and Forestry, Nauni, Solan-173230, Himachal Pradesh, India, 2010-2013. Methodology: For induction of direct and indirect somatic embryogenesis petiole, leaf and petiole derived callus (after incubation in activated charcoal) were cultured on MS medium supplemented with a range of combinations of auxins (2,4-D, picloram, dicamba) and cytokinins (zeatin, kinetin). Results: Somatic embryos were observed from both direct and indirect method. The best performance was observed on MS basal medium supplemented 1.0mg/l dicamba. Development of somatic embryos was observed on MS basal+0.50mg/l GA3+1.0 mg/lKn and the maximum plantlets formation was achieved when somatic embryos (directly and indirectly induced) were shifted to half strength MS basal medium. Conclusion: In direct pathway somatic embryos were in contact with maternal tissue in a suspensor like structure. In indirect pathway, the explants first proliferated to give rise to callus before embryoids were induced. Somatic embryos have their own vascular tissues, and can develop new plantlets independently.

Formulation and evaluation of enteric coated tablet of Ilaprazole.

The present study was an attempt to formulate and evaluate enteric coated tablets for Ilaprazole to reduce the gastrointestinal tract side effects. Four formulations of core tablets were prepared and one who shows rapid disintegration (near around three minutes) was selected for enteric coating. Ilaprazole which have an irritant effect on the stomach can be coated with a substance that will only dissolve in the small intestine. Enteric coat was optimized using two different polymers such as HPMCP 50 and Eudragit L 100 in different concentrations. The prepared tablets were evaluated in terms of their pre-compression parameters, physical characteristics and in-vitro release study. 2.5% seal coating on core tablets was optimized and 9% enteric coating on seal coated tablets was performed using HPMC P 50 (60%), triethyl citrate (10%) and IPA:DCM (60:40) which gives the highest dissolution release profile and f2 value.

Formulation and evaluation of enteric coated tablet of Ilaprazole.

The present study was an attempt to formulate and evaluate enteric coated tablets for Ilaprazole to reduce the gastrointestinal tract side effects. Four formulations of core tablets were prepared and one who shows rapid disintegration (near around three minutes) was selected for enteric coating. Ilaprazole which have an irritant effect on the stomach can be coated with a substance that will only dissolve in the small intestine. Enteric coat was optimized using two different polymers such as HPMCP 50 and Eudragit L 100 in different concentrations. The prepared tablets were evaluated in terms of their pre-compression parameters, physical characteristics and in-vitro release study. 2.5% seal coating on core tablets was optimized and 9% enteric coating on seal coated tablets was performed using HPMC P 50 (60%), triethyl citrate (10%) and IPA:DCM (60:40) which gives the highest dissolution release profile and f2 value.

Detection & management of anaemia in pregnancy in an urban primary health care institution.

BACKGROUND & OBJECTIVE: In India, anaemia in pregnancy remains a major public health problem associated with increased risk of low birth weight deliveries. A study was carried out at an urban primary health institution in Delhi, to assess feasibility of screening all pregnant women attending antenatal clinic for anaemia, identifying those with moderate anaemia (haemoglobin between 5.0 - 7.9 g/dl), administering intramuscular (im) therapy to them in the out-patient department (OPD), and observing the impact on maternal haemoglobin (Hb) levels and birth weight of the infant. METHODS: In the antenatal clinic all pregnant women were screened for anaemia. Women with Hb between 5.0- 7.9 g/dl were counselled and those who were willing, were given six intramuscular injections each consisting of iron sorbitol citric acid complex containing 150 microg elemental iron, 1500 microg folic acid, 150 microg hydroxocobalamine acetate (vitamin B1)). They were followed up through pregnancy and till delivery. Birth weight of infants of women who received therapy were compared with birth weight of infants born in DCMC. RESULTS: Over 80 per cent of 3698 women who attended the antenatal clinic were anaemic; 745 (20.1%) had Hb between 5.0-7.9 g/dl. Of these, 419 women agreed to take im therapy as outpatients; 367 took all 6 injections. Metallic taste on the tongue, nausea, vomiting and pain at the injection site were the side effects reported. The mean Hb even 9 wk after completion of therapy was only 9.6 g/dl. Mean birth weight in 340 women who completed the treatment was 2.8 kg - significantly (P<0.001) higher than birth weight in women who had Hb <8.0 g/dl at the time of delivery, but lower than birth weight of infants born to non anaemic women. INTERPRETATION & CONCLUSION: In urban primary health care institutions, it is possible to screen pregnant women for anaemia, identify those with Hb between 5.0 and 7.9 g/dl and give them im therapy as outpatients. Use of a preparation with fewer and milder side effects, counselling and support of women who develop side effect may result in high compliance rates; 900 mg of elemental iron as iron sorbitol citric acid was insufficient to raise mean Hb beyond 9.6 g/dl. The dosage has to be increased to achieve optimal results in relation to maternal haemoglobin levels and birth weight.

Fluoroscopy guided instillation therapy in chyluria using combination of povidone iodine with contrast agent: is a single instillation sufficient?

PURPOSE: To evaluate the safety and efficacy of a single instillation in a combination of povidone iodine with contrast agent under fluoroscopy guidance for the treatment of chyluria. MATERIALS AND METHODS: From December 1999 to July 2006 a total of 40 patients with chyluria were treated by renal pelvic instillation therapy (RPIS). The sclerosing solution was prepared using povidone iodine with contrast agent diluted with sterile water in a ratio of 1:1:3. It was instilled on the side having chylous efflux using a bulb tip ureteric catheter. Unilateral instillation was done in 26 cases, 10 on the right side and 16 on left. Fourteen patients had bilateral chylous efflux and RPIS was performed on both sides in the same session. Fluoroscopy was used to evaluate the complete filling of the pelvic calyceal system. The sclerosing solution was kept in the system for 5 minutes and the ureteric catheter was then withdrawn. RESULTS: Immediate clearance was observed in 39 patients. Recurrence occurred in five patients. They were treated again using the same procedure with satisfactory results. The longest follow-up was five years and the shortest five months. CONCLUSION: RPIS of chyluria using a single instillation a combination of povidone iodine with contrast agent is safe and effective. Use of fluoroscopy helps to determine the exact amount of sclerosing solution required to completely fill the system and therefore overfilling is avoided. Moreover, the complications, which arise due to pyelointerstitial backflow, are prevented.