Clinical and Scientific Research

Stray dog menace fuelling rabies in India: what can be done? RV Suresh Kumar, A Jagadeesh Babu Journal of Clinical and Scientific Research 2018 7(2):51-52

Critical flicker frequency: A useful tool in diagnosis of minimal hepatic encephalopathy Sukanya Bhrugumalla, Padmavathi R Choudeswari, Nayana Joshi, Ajit Kumar Journal of Clinical and Scientific Research 2018 7(2):53-57 Background: Minimal hepatic encephalopathy (MHE) is viewed as mild neuro-cognitive abnormalities in cirrhotics without overt encephalopathy. Diagnostic strategies for MHE include portosystemic encephalopathy (PSE) syndrome test, critical flicker frequency test (CFF), computerised tests like Inhibitory control test, Scan test etc. We compared critical flicker frequency test with standard PSE syndrome test. Methods: Fifty patients with cirrhotics of liver without overt encephalopathy were studied. PSE syndrome test was done with the standard charts. PSE score was calculated from the normal distribution tables. CFF was tested with manual CFF tool. Results: Their mean age (years) was 46 ± 12.8; there were 45 males. Of these 22, 21 and 7 patients belonged to Child's A, B and C categories. PSE score detected MHE in 40%, of which 35% were in Child's A and 65% in Child's B/C. CFF was normal (>39HZ) in 36% patients and abnormal (<39HZ) in 64% patients. Mean ammonia levels were significantly higher in abnormal CFF (70.87 ± 14.38) as compared normal CFF (32.21 ± 7.9) group (P < 0.001). The sensitivity of CFF for detecting MHE was 85%, specificity 52%, positive predictive value 56% and negative predictive value 85%. Thus, CFF appears to be a good test for excluding MHE. Conclusions: CFF test is highly sensitive (85%) with high negative predictive value (85%). It is a useful test to rule out MHE. The test is simple, quick and in-expensive and can be performed in the outpatient settings.

Effect of sevoflurane with morphine or fentanyl on haemodynamic response to laryngoscopy and tracheal intubation: a prospective, randomised, double-blind study S. R A. N Bhushanam Padala, Muralidhar Anakapalli, Hanumantha Rao Mangu, Madhusudan Mukkara, Aloka Samantaray Journal of Clinical and Scientific Research 2018 7(2):58-63 Background: Multimodal therapy can be used for obtundation of the haemodynamic response to laryngoscopy and tracheal intubation. The current study was undertaken to compare the haemodynamic response to laryngoscopy and tracheal intubation after administration of 0.2 mg/kg morphine or 2 μg/kg fentanyl with 2% end tidal sevoflurane during induction of anaesthesia. Methods: Sixty patients were randomised into two equal groups to receive either 2% end tidal sevoflurane + fentanyl 2 μg/kg (Group SF) or 2% end tidal sevoflurane + morphine 0.2 mg/kg (Group SM). General anaesthesia technique was standardised for both the groups. Haemodynamic parameters heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were recorded for 15 min. Results: The maximum increase in HR compared to baseline was statistically significant in Group SM (16.5%, P = 0.0002) which occurred at one min after tracheal intubation. The maximum increases in SBP, DBP and MAP compared to baseline occurred at one min after tracheal intubation in both the groups, Group SF (7.04%, 6.5% and 7.9% respectively) and Group SM (6.2%, 8.2% and 8.1% respectively) which was not statistically significant. The attenuation of haemodynamic response between the two groups was not statistically significant (for HR P = 0.1428, for SBP P = 0.8558, for DBP P = 0.1958 and for MAP P = 0.5303). Conclusions: With 2% end tidal sevoflurane during induction of anaesthesia, both 0.2 mg/kg morphine and 2 μg/kg fentanyl were equally effective in attenuating haemodynamic response to laryngoscopy and tracheal intubation. However morphine appeared to be less effective in attenuating the chronotropic response resulting in a greater increase in heart rate from baseline.

Relationship of clinical deterioration in leprosy patients while on multidrug therapy with their glucose-6-phosphate dehydrogenase levels Abhishek Sharma, D Ramachandra Reddy, Prathap Reddy, Bhumesh Tyagi, Shivanu Mathon, Suryash Jain Journal of Clinical and Scientific Research 2018 7(2):64-68 Background: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is known to cause haemolysis in patients with Hansen's disease receiving dapsone containing multidrug-therapy (MDT). However, sparse recent data are available on this topic from India. Methods: All patients aged over 10 years with Hansen's disease receiving MDT who presented with clinical deterioration to our tertiary care teaching hospital in Moradabad, Uttar Pradesh, India, were included in the study. G6PD levels were estimated in all of them. Once G6PD deficiency was confirmed dapsone was stopped and rescue therapy was initiated. Results: Between March 2015 and June 2016, 50 patients (mean age 34 ± 13.3 years) were included. G6PD deficiency was found in 14.3% patients. Peripheral blood smear showed Heinz bodies and bite cells in all of them. Mean pretreatment G6PD levels were 19.5 (range 17.5 – 25) units/g haemoglobin, mean serum bilirubin was 3.3 (range 1.6-9.2) mg/dL. Nineteen patients had lepra reactions (type 1 = 5 type 2 = 14). Ten patients required packed red blood cell transfusion. Conclusions: Our observations suggest that checking for G6PD levels before initiating dapsone containing MDT can be helpful in reducing the occurrence of haemolytic complications.

Ectopic parathyroid adenoma: single-centre experience from India CV Harinarayan, Honey Ashok, Adil Sadiq, GR Prashant, Divya Badanidiyur, Neha Gupta, Indira Rajani, NK Sunil Kumar, Shabnam Roohi, G Nandita Journal of Clinical and Scientific Research 2018 7(2):69-74 Background: The commonest cause of primary hyperparathyroidism (PHPT) is hyperfunctional parathyroid adenoma (PA) (94%), parathyroid hyperplasia (<6%) and rarely parathyroid carcinoma (<1%). Excision of PA is a definitive cure with a success rate of 95%. Less than 15% have one or more hyperfunctioning glands in an ectopic location. Methods: Between 2014 to 2017, seven of the 13 patients with PHPT, who had failed surgical and noninvasive localisation, were included in the study. Hybrid localisation technique positron emission tomography-Computed tomography (PET-CT) with tracer 11C-choline was used. Location of parathyroid adenoma was classified using Perrier classification, which uses, letters A-G to describe the exact location of the adenoma. A 50% drop in PTH levels as compared with pre-incision values was confirmed as a cure. Results: The biochemical and hormonal profile of the 7 (54%) patients with ectopic PA are (mean±SD) serum calcium (mg/dL), 25OH-D (ng/dL) and PTH (pg/mL) 11.36 ± 0.82; 22.82 ± 8.57; 205 ± 105 respectively. Three of the seven had renal stones. In all, seven patients of PA were localised using PET-CT using tracer 11C-choline. The profile of PA were two type-G (intrathyroidal), one type-C (posterior mediastinum), two type-F (superior mediastinum), one of type D (mid region of posterior surface of thyroid parenchyma at the junction of recurrent laryngeal nerve and the middle thyroid vein) and one type B. Conclusion: Ectopic PA is rare. In a biochemically and hormonally confirmed PHPT and in failed imaging localisation techniques/failed neck exploration one should look for ectopic PA. Newer hybrid techniques combined with newer tracer agents (PET-CT) will help in localization of PA. To the best of our knowledge this is the first report of series of ectopic PA from a single center from India.

Smoking and Anaesthesia: Implications during perioperative period Aloka Samantaray Journal of Clinical and Scientific Research 2018 7(2):75-79 There are considerable myths which surround not only about the different terminology used for smoking but also about their possible impact during the perioperative period. The health hazards posed by smokeless tobacco(electronic cigar) is lower compared to tobacco cigarette smoke whereas actually the levels of aldehydes aerosol generated from new-generation devices at high power levels (Electronic cigars) could approach or even exceed the levels found in cigarette smoke. Nicotine has analgesic properties and thus many believe that smoking tobacco or inhaling nicotine only (e.g., smokeless tobacco) may have a similar effect on pain perceptions in the perioperative period. Many others have opined and associated smoking as a protective factor against postoperative nausea and vomiting. However smoking whether active or passive is always a general health problem and when such patients come for surgery possess additional challenges to the anaesthesiologist. This review will give a brief account of who is a smoker and different terminology being described in literature to describe smoking who need to quit smoking before surgery and when how smoking adversely affects the physiology of body and based on the available literature formulate an anaesthetic plan in smokers.

Unusual presentation of Bochdalek hernia in an adult Karanam Gowrinath, Mohammed Ismail Nizami Journal of Clinical and Scientific Research 2018 7(2):80-82 Left-sided Bochdalek hernia (BH) containing bowel loops and kidney in an adult is very rare and difficult to suspect if the symptoms are mild and non-specific. BH may also cause diagnostic confusion if clinical examination and routine postero-anterior chest radiograph findings mimic lung disease like pleural effusion. We report the case of an adult patient with BH who presented with radiographic appearance mimicking pleural effusion caused by the configuration of omentum with bowel loops in the left hemithorax. A lateral chest radiograph or chest ultrasound may help to avoid misdiagnosis and avoid management errors.

Intermittent flow centrifugation technique used for large volume leucapheresis in a low-body weight paediatric patient Yalamanchili Swapna Journal of Clinical and Scientific Research 2018 7(2):83-85 Paediatric leucapheresis is a preferred mode of stem cell collection compared to bone marrow harvest. However, the inherent risks of this procedure like difficult venous access, citrate toxicity, large extracorporeal volume and haemodynamic instability are of considerable importance. Leucapheresis can be done by continuous flow centrifugation (CFC) or intermittent flow centrifugation (IFC) technology. Based on the total blood volume that is processed; it is standard or large volume leucapheresis. The use of IFC blood cell separator in paediatric low body weight child to perform large volume leucapheresis is discussed.

A 21-year-old man, with ichthyosis, parotid swelling acute kidney injury M Aruna, E Suguna, M Hari Krishna Reddy, CV Anil Kumar, B Sangeetha Lakshmi, V Sarat Chandra, N Praveen, Manthri Ranadheer, TC Kalawat, R Ram, Aruna Prayag, S Sadasivaiah, V Siva Kumar Journal of Clinical and Scientific Research 2018 7(2):86-93

Screening for thyroid disorders in medical undergraduate students Doppalapudi Nikhita, P. V L. N Srinivasa Rao, V Suresh Journal of Clinical and Scientific Research 2018 7(2):94-96 Background: Thyroid dysfunction can have a negative impact on cognitive functions in young girls in adolescent age group as well as affect their future development of infertility, reproductive dysfunction and poor pregnancy outcome. Methods: Cross-sectional study of burden of thyroid disorders in 70 medical undergraduate students of 17-19 years age group studying in Sri Venkateswara Institute of Medical Sciences, Sri Padmavathi Medical College for Women, Tirupati. Results: Among the 70 female subjects screened for thyroid disorders, a single subject was found to have subclinical hypothyroidism. The thyroid stimulating hormone (TSH) level of this subject was 8.1 mIU/L, which is considered to be mildly elevated from the normal range and the thyroxine levels were 89 ng/mL which is within the normal reference range. Her anti-TPO antibodies test results were negative. Conclusions: Identification of subclinical hypothyroidism in asymptomatic young girls in adolescent age group can help in initiating treatment early.