A Comparative Evaluation of the Anaesthetic Properties of Bupivacaine Hydrochloride and Ketamine Hydrochloride with Dextrose Given Intrathecally for Inguinal Hernia Repair - A Randomized Controlled Study in a Tertiary Centre in South Kerala

The above article has been withdrawn on authors’ request. Original CitationSebastian R, Kamalakshi RK, Parambath JM, et al. A comparative evaluation of the anaesthetic properties of upivacaine hydrochloride and ketamine hydrochloride with dextrose given intrathecally for inguinal hernia repair – a randomized controlled study in a tertiary centre in south Kerala. J Evid Based Med Healthc 2021;8(31):2830- 2834. DOI:10.18410/jebmh/2021/518

The Study of Serum Calcium to Magnesium Ratio in Patients with Acute Coronary Syndrome in a Tertiary Hospital, Hubli, Karnataka

BACKGROUND Cardiovascular diseases are one of the leading causes of morbidity and mortality worldwide. High Ca levels and low Mg levels are associated with increased cardiovascular risk in the general population.1 The balance between Ca and Mg seems to play an important role in homeostasis since Mg is considered as physiologic antagonist of Ca.2 Hence Ca/Mg ratio was considered to study its association with acute coronary syndrome (ACS). METHODS This is a case control study conducted in Karnataka Institute of Medical Sciences, Hubli over a period of 2 years, February 2019 to December 2020. 200 cases and 150 controls were included in the study. The biochemical measurements including complete blood count (CBC), cardiac biomarkers, liver function tests, renal function tests (RFT), serum electrolytes and lipid profile were measured using standard laboratory methods. Student ‘t’ test was used to compare the data. Optimum cut-offs for diagnosis of acute myocardial infarction was calculated using receiver operating characteristics (ROC) analysis. The association among markers was established by calculating Pearson’s correlation. RESULTS Serum Ca/Mg ratio was significantly higher (p value < 0.001) in ACS when compared to control groups. It was also found that Ca/Mg ratio was significantly lower (p value < 0.001) in non-ST elevation myocardial infarction (NSTEMI) when compared to STEMI group. Serum Mg was significantly lower (p value < 0.001) in ACS group when compared to control group. Significant correlation (p value < 0.05) was found between serum Ca/Mg ratio and cardiac markers (CKMB, Troponin-I). ROC analysis of Ca/Mg (4.19) ratios showed optimum cut-offs in diagnosis of AMI. CONCLUSIONS Serum Ca/Mg could be useful adjuvant marker in diagnosis of AMI. The ratio is higher in ST-segment elevation myocardial infarction when compared to non-STsegment myocardial infarction, which could be due to greater decrease in Mg levels when compared Ca in ACS. KEYWORDS ST Elevation Myocardial Infarction (STEMI), Non ST Elevation Myocardial Infarction (NSTEMI), Calcium (Ca), Magnesium (Mg), Acute Coronary Syndrome (ACS), Creatine Kinase-MB (CK-MB).

A Comparative Study of Endoscopic Coblation Adenoidectomy and Regular Curettage Adenoidectomy in a Tertiary Care Hospital in Kerala

BACKGROUND An ideal surgery to remove hypertrophied adenoid mass should be safe, with less bleeding and operation time along with post-operative improvement in the eustachian tubal ventilation and normal respiration. It should also have low morbidity and mortality. Among the various methods described for its removal, the two commonly used methods are conventional cold curettage method and coblation technique. The purpose of this study was to collate the safety and efficacy of endoscopic coblation adenoidectomy with the conventional curettage adenoidectomy. METHODS A prospective comparative study with fifty patients was studied who underwent adenoidectomy. Twenty five patients underwent endoscopy assisted coblation adenoidectomy and twenty five patients underwent regular adenoidectomy by curettage. RESULTS Patients who underwent coblation adenoidectomy showed better results during follow up in terms of completeness of removal. 80 % of children undergoing regular adenoidectomy by curettage method showed remnant adenoid tissue in the nasopharynx at the end of the procedure. But it was 6 % among the children undergoing endoscopic assisted coblation adenoidectomy. The mean duration of operation was higher for endoscopic assisted coblation adenoidectomy which was significant statistically. The mean blood loss was 30.36 ml in regular curettage adenoidectomy; 10.6 ml with endoscopic coblation adenoidectomy. The grading of pain was significantly lower in endoscopic assisted coblation adenoidectomy. There was no significant difference between two groups in terms of eustachian tube function after surgery. CONCLUSIONS Coblation adenoidectomy has significant advantages over conventional adenoidectomy in terms of completeness of removal, reduced blood loss, and lower post-operative pain grade. KEYWORDS Coblation, Adenoidectomy, Curettage, Haemorrhage and Complications

Assessing the Severity of Acute Pancreatitis with CT Severity Index and Other Conventional Methods in a Tertiary Care Hospital in Tamil Nadu, India – A Comparative Cross-Sectional Study

BACKGROUND Acute pancreatitis is not uncommon in surgical practice with variable clinical presentation. Because of its potential notable catastrophic complications, it is mandatory to assess the severity at the earliest. In recent times, the decision making in the management is quite difficult due to its complications and outcome. So, an objective assessment of severity based on clinical and laboratory scoring verses computed tomography (CT) severity is still debate, hence the need for study. The purpose of this study was to compare the efficiency of CT severity index verses APACHE II and Ranson criteria in predicting the severity of acute pancreatitis. METHODS A total number of 36 consecutive cases of acute pancreatitis who were admitted between January 2013 and December 2014 in Apollo Specialty Hospitals – Madurai were included in the study. Written informed consent was obtained from all study participants. RESULTS In our study, out of 36 patients, 30 (83.33 %) were males and 6 (16.66 %) were females. The sex distribution shows a clear male predominance. Most of the patients in the present study belonged to the middle age group. Alcohol was the most common cause accounting for 41.7 % of the cases followed by the billiary pathology. CT severity index was the superior tool for prediction of the prognosis and early complications. CONCLUSIONS When using contrast enhanced computed tomography, it was found that there was a significant correlation between the development of organ failure and severity of pancreatitis. The specificity, sensitivity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of Ranson and acute physiology and chronic health evaluation – II (APACHE II) at 48 hours of admission with acute pancreatitis does not correlate in determining the severity of acute pancreatitis. KEYWORDS Acute Pancreatitis, Severity Markers, CT Severity Index

Spectrum of Imaging Findings in Rhino-Orbito-Cerebral Mucormycosis (ROCM) in Post COVID Patients - A Pictorial Review with Clinico-Radiological Correlation

BACKGROUND Rhino-orbito-cerebral mucormycosis (ROCM) is a devastating fungal infection with very high rates of mortality. Many patients post corona virus disease (COVID) infection are increasingly being diagnosed with mucormycosis (black fungus). Imaging being central to the early diagnosis of the infection, the study aims to characterize the major radiological patterns of involvement of mucormycosis. Computed tomography (CT) & magnetic resonance imaging (MRI) findings of 10 patients who were subsequently conformed to have mucormycosis were analyzed and 7 major patterns of involvement were detected. Imaging plays a vital role in the early diagnosis of ROCM. Knowledge about the common patterns of spread helps in picking the subtle signs of infection. KEYWORDS Mucormycosis, Post COVID, Fungal Sinusitis, ROCM

A Prospective Observational Study to Compare the Effect of Adaptive Radiation Therapy in Head and Neck Cancer Patients Treated with Helical Tomotherapy – Bangalore, Karnataka

BACKGROUND Establishing the usefulness of adaptive radiotherapy in our setting with limited data might help to ensure better conformity and reduce treatment related morbidity. Hence we conducted this study to elicit the benefit of adaptive radiotherapy with helical tomotherapy. METHODS This is a prospective study conducted among 25 head and neck cancer patients undergoing radiotherapy with helical tomotherapy. All patients underwent initial radiation therapy treatment planning simulation positron emission tomography computed tomography (PET CT/ CT scan) [CT-1], followed by repeat PET CT/ CT scan at 4th - 5th week of radiotherapy [CT-2]. Planning for full intended dose [66 Gy - 70 Gy] was done on both the scans, keeping the radiation therapy planning parameters same. Changes in the volume of the clinical target volumes (CTV), changes in the volume and dose to spinal cord, bilateral parotids, and mandible were compared. A p - value of < 0.05 was considered for statistical significance. RESULTS A significant reduction in the volumes of tumour - CTV-1 [CT-1 v/s CT-2: 166.82 cc v/s. 150.63 cc] and of lymph nodal region - CTV-2 [CT-1 v/s CT-2: 260.29 cc v/s 228.00 cc], contra lateral parotid gland [CT-1 v/s CT-2: 33.00 cc v/s 18.72 cc] were observed (P < 0.05). The mean doses received by contra lateral parotid gland [CT-1 v/s. CT-2: 23.14 Gy v/s 21.26 Gy] were significantly lesser in the CT2 scans (P < 0.05). The mean maximum doses were also significantly lesser to the mandible and spinal cord i.e., CT-1 v/s. CT-2: 68.528 Gy v/s 67.39 Gy and 39.45 Gy v/s. 37.33 Gy respectively (P < 0.05). A significant reduction in standardised uptake value (SUV), values of the primary tumour and involved lymph nodes was observed between CT-1 and CT-2. CONCLUSIONS During 4th to 5th week of radiation therapy, significant reductions in the CTVs and in dose to OARs were noted. Thus, we recommend at least one re-simulation scan and re-planning during radiation therapy, irrespective of the type of technique of radiation therapy. KEYWORDS Adaptive Radiation Therapy, IMRT, Tomotherapy

Culture Sensitivity Patterns and Outcome of Liver Abscess in Children Admitted at a Tertiary Care Hospital in North India

BACKGROUND Liver abscess has been recognised since the time of Hippocrates. Liver abscess is defined as collection of purulent material in liver parenchyma. They are usually caused by bacterial and amoebic infections, and less commonly, by other protozoal and helminthic organisms. Amoebic liver abscess is the commonest extra intestinal site of invasive amoebiasis which mainly affects infants and young children. The incidence of pyogenic liver abscess is much higher among children in developing countries than those in developed countries. The purpose of this study was to evaluate culture sensitivity pattern (Blood & Pus) of liver abscess in children. METHODS This prospective observational study was conducted in the Department of Paediatrics, Chacha Nehru Bal Chikistalaya, Delhi from July 2016 –to August 2017. This study has got Institutional Ethics Committee approval (Regd No: IEC/MAMC/78, Dt: 26/07/2016). All children aged 1 month to 12 years admitted with liver abscess (included consecutively) were enrolled after considering inclusion and exclusion criteria. Written and informed consent was taken from parents/guardians of children. Their clinical characteristics, radiological features, laboratory data, clinical management, and outcomes were analysed. RESULTS In our study, out of 70 patients, 3.2 % patients showed growth in the blood culture. Organsims isolated were Methicillin resistant Staphylococcus aureus (MRSA) 1.4 % (1), Salmonella typhi 1.4 % (1), staphylococcus coagulase negative 1.4 % (1). Out of 70 patients of liver abscess enrolled in the study, 36 patients underwent aspiration of pus from the abscess. Out of 36 aspirated cases, gram positive cocci was identified in 1 (1.4 %) patient. In our study, no acid fast bacilli was identified and no fungal culture showed growth of organism. Out of 70 cases of liver abscess, 10 were found to be amoebic liver abscess. In our study, all the 70 patients were started on empirical antibiotics. Out of 70 patients, surgical intervention was done in 36 patients. In our study all the patients were started on empirical antibiotics according to hospital protocol. CONCLUSIONS Liver abscess should be considered in children presenting with fever and abdominal pain. Organisms recovered from liver abscesses vary greatly. Surgical drainage has been the traditional mode of treatment of pyogenic liver abscess, but this was replaced by IV broad-spectrum antibiotics and imaging-guided percutaneous drainage. KEYWORDS Paediatric Liver Abscess, Amoebic Liver Abscess, Pyogenic Liver Abscess, Culture-Sensitivity, Children

Comparison between Sniffing Position and 25 Degree Backup Position in View of Glottis During Direct Laryngoscopy and Intubation - A Study from Mangalore, Karnataka

BACKGROUND Endotracheal intubation for the purpose of providing anaesthesia was first described by William Mc Ewan. Jackson1 stressed the importance of anterior flexion of the lower cervical spine, in addition to obvious extension of the atlanto-occipital joint. Sniffing position has been commonly advocated as a standard head positioning for direct laryngoscopy which is achieved by flexion of the neck on chest and extension of the head at the atlanto-occipital joint. Present study was designed to evaluate the glottis view and ease of intubation achieved with direct laryngoscopy in the sniffing position with that of 25 degree backup position in a study group of 100 patients divided in 2 groups of 50 each. METHODS This study is a controlled comparative study. Controlled trial in 50 consecutive patients in each group [Group I and Group II] was conducted on patients who underwent elective surgery under general anaesthesia. Inclusion Criteria - General anaesthesia with endotracheal intubation, Aged 18 to 60 years, American society of Anaesthesiologists (ASA) grades I and II. Exclusion Criteria - Patients with body mass index more than 30 kg/m2. 1. Bucked teeth. 2. Restricted neck movement. 3. Inter-incisor gap less than 35 mm. 4. Thyro-mental distance less than 6 mm. 5. Patients with risk of regurgitation and aspiration. 6. Pharyngeal pathology. 7. Limitation of anterior and posterior movement of mandible 8. Pregnant patients Groups wereGroup I – Sniffing position Group II– 25 degree back up position RESULTS The glottis visualization was assessed by Cormack Lehane grading which revealed that glottis view was better in 25 degree backup position than sniffing position. CONCLUSIONS In our prospective randomized study in a series of 50 patients undergoing general anaesthesia in SIMS & RC, intubation difficulty scale (IDS) score was better in 25 degree backup position than sniffing position. It implies glottis view is better in 25 degree backup position than sniffing position. KEYWORDS Sniffing Position, 25 Degree Backup Position, Laryngoscopy

Platelet/Lymphocyte Ratio and Risk of In-Hospital Mortality in Patients with ST-Elevated Myocardial Infarction - A Prospective Observational Study from KIMS, Hubli, Karnataka

BACKGROUND Cardiovascular disease is a significant health problem in India with an estimate 3.7 million deaths each year. Mechanisms of myocardial ischemia include inflammation, endothelial dysfunction, platelet aggregation and coagulation. Acute coronary syndrome occurs due to rupture of atherosclerotic plaque. Platelets play a role in both development and rupture of the atherosclerotic plaque. Lymphocytes play a role in chronic inflammation of atherosclerosis. Lower lymphocyte count has increased mortality after acute myocardial infarction. METHODS The study was conducted in Department of General Medicine, Karnataka Institute of Medical Sciences, Hubli from February 2019 to December 2020. It is a prospective observational study. Patients aged ≥ 18 years with ST-elevated myocardial infarction (STEMI) were included in the study. Total 156 cases were selected based on inclusion and exclusion criteria. Cardiovascular events during the in-hospital period were noted. The study population was divided into tertiles based on the platelet-lymphocyte ratio (PLR) values. The low PLR group (n = 104) was defined as having values in the lower 2 tertiles (PLR ≤ 148.4) and the high PLR group (n = 52) was defined as having values in the highest tertile (PLR > 148.4). A ‘P’ value < 0.05 was considered statistically significant. RESULTS Out of 156 patients, 103 (66 %) were males and 53 (34 %) cases were female. Mean age group was 59 ± 10 years. Percentage of patients who underwent thrombolysis was higher in high PLR group (65.38 % vs. 48.07 %, P = 0.041). Death rate was higher in high PLR group (28.84 % vs. 8.65 %, P = 0.001). PLR > 148.4 was found to be an independent predictor of in-hospital cardiovascular mortality in multivariate analyses (hazard ratio: 13.222 (2.113-21.749) P = 0.006 with 95 % confidence interval). Receiver operating curve (ROC) analyses, a PLR value of 148.4 for in-hospital mortality rate had sensitivity of 62.5 % and a specificity of 72 % (area under the curve = 0.627, 95% confidence interval 0.485 – 0.769). CONCLUSIONS In our study, higher PLR had significant association with in-hospital mortality in patients with STEMI. KEYWORDS ST Elevation Myocardial Infarction (STEMI), Platelet/Lymphocyte Ratio (PLR), Ischemic Heart Disease (IHD)

Clinical Profile and Outcome in Patients with Snake Bite in a Tertiary Care Centre in Kerala

BACKGROUND The clinical profile and outcome of snake bite varies from place to place and depends on a number of factors including the type of snake bite, place of snake bite, time of bite, season, and duration of presentation after bite. The clinical profile, factors affecting the outcome and the outcome have not been previously well studied. METHODS This is a cross-sectional observational study conducted for a duration of six months from January 2021 to June 2021. Subjects meeting inclusion criteria were enrolled in the study group after obtaining written consent. Patients were evaluated based on the standard pro-forma with detailed history and clinical examination. All relevant investigations to assess systemic envenomation, treatment and outcome were documented in all the patients. RESULTS In the study, 204 (68 %) were male patients and 96 (32 %) were female patients. 108 (36 %) were admitted with venomous snake bite and 192 (64 %) were with non-poisonous snake bite. 52 patients had snake bite on the upper extremities, 234 had snake bite on the lower extremities, 8 patients had snake bite on the trunk whereas 6 patients had bite on other areas of the body. 202 patients had swelling at the bite site, 222 had pain at the site of bite, 86 patients had oozing of blood and 6 patients had vague somatic symptoms. 132 patients had local oedema, 148 had local tenderness, 66 patients had skin necrosis and 16 patients developed blisters at the site of bite. 124 patients had systemic manifestations of which 24 patients had vomiting, 12 patients developed abdominal pain, 10 patients developed anuria/oliguria, 14 patients developed hypotension, 12 patients developed bleeding manifestations, 10 patients developed neurological symptoms and 2 snakebite patients had syncope. Complications and mortality in poisonous snake bite due to renal failure was observed in 38 patients with a mortality of 1 patient, 10 patients developed intravascular haemolysis, 8 patients developed unexplained hypotension, 18 patients developed secondary infection, 4 patients developed intra-cerebral bleeding and 15 patients developed neurotoxity with a mortality of 2 patients. CONCLUSIONS Snake bite is a common problem encountered in tertiary care centres and the most common encountered type of snakebite was haemotoxic bite. Pain at the bite site was the commonest symptom and tenderness at bite site was the commonest sign in patients with snake bite. Mortality in venomous bite was 3.7%. Prolonged bite to needle time, development of renal failure, leukocytosis, neurotoxicity and severe degree of coagulopathy were factors associated with adverse outcome. KEYWORDS Clinical Profile, Outcome, Snake Bite, Tertiary Care Centre