Medi Magazine kauvery A quarterly magazine from VOLUME - 21 | ISSUE - 03 | JULY 2017 - 21 | ISSUE 03 JULY VOLUME

Anesthesia and A Rare Organism Challenges Causing Septic Arthritis of Hip Joint

Awareness on Vocal Hygiene Diabetic Retinopathy -An Overview Stricture Urethra

Inauguration of Chennai, Anna Nagar Branch Acute Myocardial Infarction in Infancy and Renal Update Childhood - A reality 2017 - CME

Annual Day 2017 Papillary Carcinoma of Thyroid Pattimandram

To download this magazine This magazine is free circulation for hospitals and doctors only, Not for sale. Design and logo of kauvery hospital are property of scan this QR Code Kauvery Hospital, To get this magazine copy mail us at: [email protected] with QR scanner APP If you want to know any other details contact us on Editorial Address in your smartphone KAUVERY CAPSULE | JANUARY 2017

CAPSULE MAGAZINE

Capsule Magazine is published by Kauvery Hospital

Copyright 2016 © Kauvery Hospital

PATRONS Dr. S. Chandrakumar Dr. S. Manivannan

ADVISORY BOARD Dr. D. Senguttuvan 00 Acute Myocardial Dr. Aravindan Selvaraj Dr. T. Senthil Kumar Infarction in Infancy & Childhood - A reality EDITOR Dr. S. Senthil Kumar Dr. Prashanth Sha, MBBS., MS., DNB., Consultant Cardiologist EDITORIAL TEAM Dr. Lakshmi Prashant, MBBS., MD(AIIMS)., Dr. S. Velmurugan Consultant Paediatrician Dr. S. Aravinda Kumar 01 Kauvery Hospital, Chennai From Dr. Iyyappan Ponnuswamy 00 the Editor’s Desk Acute Myocardial Infarction in Infancy &

TECHNICAL TEAM Dr. S. Senthil Kumar, Ms., DNB., (Uro) Childhood - A reality Dr. Ve. Senthil Vel Murugan HOD & Senior consultant Urologist & Dr. A. Subramanian Andrologist Dr. Prashanth Sha, MBBS., MS., DNB., Transplant Surgeon Consultant Cardiologist Laparoscopic surgeon Dr. Lakshmi Prashant, MBBS., MD(AIIMS)., ADMIN TEAM Kauvery Kidney Centre, Tennur, Trichy Consultant Paediatrician Mr. S. Sathishkumar Kauvery Hospital, Chennai Mrs. JPJ. Bindhu

CO-ORDINATORS Mrs. G. Percy Dr. K. Senthil Kumar, MBBS., DA., Dr. Arunkumar C Anesthesiologist Kauvery Hospital, Trichy

DESIGN & LAYOUT Mr. Vahid Ali N. Anesthesia and Challenges

Dr. K. Senthil Kumar, MBBS., DA., Anesthesiologist 00 Kauvery Hospital, Trichy Anesthesia and Challenges EDITORIAL OFFICE Kauvery Hospital VI Floor, Administrative Office, #6, Royal Road, Cantonment, Tiruchirappalli-620001. Call us at (431) 40 77 777 00 E: [email protected] W: www. kauveryhospital.com 00 From the Editor’s Desk

Dr. S. Senthil Kumar, Ms., DNB., (Uro) HOD & Senior consultant Urologist & Andrologist Transplant Surgeon Laparoscopic surgeon Kauvery Kidney Centre, Tennur, Trichy 00 Acute Myocardial Infarction in Infancy & Childhood - A reality

Dr. Prashanth Sha, MBBS., MS., DNB., 00 Consultant Cardiologist Acute Myocardial Dr. Lakshmi Prashant, MBBS., MD(AIIMS)., Infarction in Infancy & Consultant Paediatrician Childhood - A reality Kauvery Hospital, Chennai

Dr. Prashanth Sha, MBBS., MS., DNB., Consultant Cardiologist Dr. Lakshmi Prashant, MBBS., MD(AIIMS)., Consultant Paediatrician Kauvery Hospital, Chennai

Dr. K. Senthil Kumar, MBBS., DA., Anesthesiologist Kauvery Hospital, Trichy

Anesthesia and Challenges Dr. K. Senthil Kumar, MBBS., DA., Anesthesiologist Kauvery Hospital, Trichy

00 Anesthesia and Challenges 00 Editor’s desk

From the Editor’s Desk Dear Readers,

elcome to the 20th edition of capsule. It gives me immense happiness to connect with you through this capsule magazine. 2017 has been very eventful which consists of Annual Day of our hospital, and series of event to commemorate the Kidney W Day, observed on March 9th. 18th annual day of Kauvery hospital, was celebrated on 5th of March. It’s a day to rejoice, celebrate and bring the joy of togetherness within the Kauvery Family.

Kauvery hospital to commemorate Kidney day themed on “Obesity and Kidney Disease”, organized a series of events like water bottle campaigns, one week urology camp at Thennur Kauvery Hospital, for the public from 6th to 10th March 2017.

A Talk Show (Pattimandram) was conducted on 9th March by renowned orator of international repute, Mr.Suki Sivam,” to enhance the health awareness among the public. More than 750 people participated in the splendid event. A Urology CME titled “Renal Update -2017”, focusing on obesity and renal disease was conducted on 19th of March at Trichy. More than 150 practicing doctors were extensively benefitted out of the program.

Creating awareness and enhancing the health consciousness among public will help sustain the health and leap towards better living conditions. Together lets work towards for the betterment of humanity.

Dr. S. Senthil Kumar, Ms., DNB., (Uro) HOD & Senior consultant Urologist and Andrologist Transplant Surgeon Laparoscopic surgeon Kauvery Kidney Centre, Tennur, Trichy

01 • CAPSULE MAGAZINE • APRIL 2017 ACUTE MYOCARDIAL INFARCTION IN INFANCY AND CHILDHOOD - A REALITY

“Bombay blood group -A rare entity” Dr. Senguttuvan MBBS, DCH. Dr. Suresh Chelliah DCH, MD Dr. Senthil kumar MD, DM. Dr. Sivagurunathan DCH, MD. DR. Vignesh MBBS, MD Dr. Naresh Kumar N MBBS DCH DNB(PG) Dr. Pradeep MBBS DNB(PG)

The discovery of the ABO Case Report: was normal. His investigations revealed A three year old boy was referred to microcytic hypochromic anemia with blood group, over 100 our department for further other cell lines in normal limits. His years ago by Karl management of severe anaphylaxis reticulocyte count was on the higher reaction, which occurred immediately range. He had hyperbilirubinemia with Landsteiner has reduced after commencing blood transfusion. high urine bilirubin. His renal functions mortality secondary to Appropriate group(O positive) packed was normal. In view of acute hemolysis, red cell transfusion was commenced coomb’s test was done which revealed blood transfusion elsewhere in view of low haemoglobin negative DCT and significantly positive significantly. It is well (6.4 gm/dl), which was found on ICT. Hence minor & rare blood group evaluation for high grade intermittent disorder was considered and blood known that people with fever for 3 days with no localising signs. grouping with typing (forward and blood group A has Packed red cell transfusion was reverse) was repeated here, which antigen of type 'A' terminated immediately and he was revealed a rare blood group – referred here after adequate “Bombay blood group”. [Fig (1)] antibody of type 'B' in his management of anaphylaxis. /her blood. People with He was conservatively managed. In There was history of gradually view of increasing trend of AB have both antigen A progressing jaundice and dark yellow haemoglobin and iron deficiency and B in their blood and coloured urine since after blood anemia, blood transfusion was transfusion. There was no other deferred. His repeat liver enzymes no antibodies. localising symptoms. There was no gradually improved. He was started on significant past history. On examination, oral iron supplements and was he was icteric and febrile. His vitals discharged. He was doing well on his were normal. His systemic examination follow up.

APRIL 2017 • CAPSULE MAGAZINE • 02 ACUTE MYOCARDIAL INFARCTION IN INFANCY AND CHILDHOOD - A REALITY

Discussion: During cell grouping or routine Conclusion: The Bombay Blood Group is the rarest grouping, Bombay blood group would Bombay blood group individuals can of the rare in blood groups, which was be categorized as O group because receive blood only from individual with first reported in Bombay, India. The they wouldn't show any reaction to Bombay Phenotype. As Bomaby blood Bombay phenotype is characterized by anti-A and anti-B antibodies just like a group is usually misinterpretated as ‘O’ the absence of A, B, and H antigens on normal O group. When a cross group, kindly re-check serum typing its red cells and the serum of these matching is done, then it would show with reverse grouping along with individuals have anti-A and anti-B . But then it would show cross- reactivity or Anti-H lectin for all ‘O’ blood group the serum that agglutinates red cells of incompatibility. Therefore reverse patients requiring blood transfusion to ‘O’ group individuals through a wide grouping or serum grouping has to be avoid dreadful complications due to thermal range may be due to presence performed to detect the Bombay blood incompatibility. of strongly reactive anti-H antibodies . group . The concern with Bombay There is a registry for Bombay blood It was identified that the h allele is a blood group is that the individuals group maintained by result of mutation of the H gene (FUTI) having this group can only receive www.bombaybloodgroup.com. It is that would express the H antigen on either autologous blood donation or easy to get donors through this the red blood cell of ABO blood blood from an individual of Bombay registry. Also, kindly advice Bombay groups. Bombay phenotype is phenotype. blood group people to get registered homozygous (hh) for the 725G in this website. mutation in the FUT1 coding region.

Fig (1):Blood grouping report of our patient. Cell grouping (Forward grouping) and serum grouping (Reverse grouping)

03 • CAPSULE MAGAZINE • APRIL 2017 ANESTHESIA AND CHALLENGES

Once again she started bleeding and the haemoglobin level falls to 6 mg Uterine Artery and went for shock and hypotension.Intial resuscitation done and she was referred to our hospital for Embolization (UAE) further management. She was rescuciated with blood and blood Dr. MMMMMMMMMMMMMMn MBBS, DCH. products and bleeding was under control. She was explained about hysterectomy if further episodes A 26 years old female P1 L1 occurs. She wants to retained uterus A3 referred from peripheral hospital on and to conceive later as she is having only one live child. Uterine artery 22.01.17 for PPH after preterm normal embolisation was explained to her and delivery of twins . Patient was relatives as an alternative and effective method to overcome this problem. diagnosed to have placenta acreta antenataly. Placenta retained in toto She was taken up for UAE and embolisation usuing gelfoam done on and medical management given for bilateral uterine arteries and post placental evacuation but patient procedure complete cessation of bleeding PV occurred. Patient had mild developed PPH. Conservatively patient fever next day as expected and managed and send home. covered with adequate antibiotics . Patient become symptomless on third day and discharged.

APRIL 2017 • CAPSULE MAGAZINE • 04 ANESTHESIA AND CHALLENGES

Patient was followed up and she Procedure: Postprocedural complication like pain , expelled the placenta in bits after one After routine preprocedural workup fever , abnormal bleeding etc, may month and check scan done which and specific investigations like USG / occurs which usually settles with shows complete expulsion of placenta MRI, patient taken to cathlab . Under antibiotic coverages and analgesia. and patient is doing well. local anesthesia any one of the femoral Long term complication like infertility artery is punctured and 6F sheath is also a rare complication . Some Uterine artery embolisation (UAE) is an introduced using seldenger technique. patients may still need surgical interventional radiological technique to Using a specialized catheter named management for controlling bleed in occlude e the arterial supply to the Roberts Uterine Catheter (RUC) which case of PPH. uterus. facilitates access to both uterine arteries with tapering of size 5F at the Overall outcome is excellent in all the Indication: proximal end to 4F at the distal end. As indications like avoiding surgery in 1.Fibroids. a routine selective angiography done PPH., resumption of 2.PPH. and which will shows findings like menstruation,Reduction in volume of 3.Adenomyosis. hypertrophied arteries , fibroid about 75% within six months 4.Pelvic vascular pathologies. pseudoaneurysm , AVM , direct and successful pregnancy after UAE in a)Primary. extravasation etc. After engaging in PPH. b)Secondary to any appropriate place embolisation will be procedure / surgery. started. Embolising materials routinely To conclude UAE will be consider as a used are gelfoarm for temporary and primary option in patientss with PPH polyvinyl alcobal 300-350 mics (PVA) who wants to concise later and for Contraindications: for permanent embolisation. Once large fibroids in case of infertility. embolisation is over check angiogram No definite contraindication. done for confirmation of complete cessations of vascular abnormality.

Quiz Question Chest X-ray of 45 year old female admitted for dyspnea on exertion and on & off hemoptysis. What is the diagnosis?

Send your answers to [email protected] or WhatsApp to +91 96887 25479

Previous Issue’s Question & Answer Question: 1. What is this investigation? 2. What is the diagnostics? 3. What is the best time to treat this condition? 4. What are all the complications of this condition? Answer

Winner Dr.

05 • CAPSULE MAGAZINE • APRIL 2017 DIABETIC RETINOPATHY - AN OVERVIEW

Glossopharyngeal Neuralgia - A Rare Facial Pain Syndrome Dr.S.Balamurugan, MS,MCh(Neuro),FNS

A 67 years old, He was on medications for five years of glossopharyngeal nerve may induce and the intensity and frequency of this vagal response as cardiac dysrhythmia, Mr.Rajendran, came to pain episodes were increasing day by bradycardia, hypotension. Cerebral Kauvery with complaints day and the last five months he was hypoxia, Slowing of EEG activity, taking liquids only due to the fear of Syncope and Convulsions can occur in of severe electric shock like this pain. extreme cases. pain in the angle of left This condition, Glossopharyngeal Treatment options are medical therapy jaw, inner side of mouth, Neuralgia is usually caused by the with Carbamazepine, Gabapentin or Left side of the tongue and compression of the 9th cranial nerve by Surgical therapy like Percutaneous an adjacent artery near the brainstem. Rhizotomy or Microvascular throat. He was having this Rarely a tumour, an elongated styloid Decompression (MVD). Complications problem for the past five process or an infection in the region of of MVD are Dysphagia, Voice years and was diagnosed this nerve may cause this symptom impairment, Dyspnoea, Cardiac arrhythmias and Stroke due to Vascular as Glossopharyngeal The pain occurs in episodes and may injury. Neuralgia. be severe. Painful attacks may occur spontaneously but are more often In our patient the reason for his painful associated with a specific stimulus such episode was PICA( Posterior inferior as chewing, speaking, coughing, cerebellar artery) compressing the 9th swallowing, yawning or laughing. The cranial nerve near brainstem on the left attacks can occur frequently side.It has been diagnosed by MR throughout the day or once every Angiogram and we advised surgery for couple of weeks and they can also him. We did Retromastoid suboccipital disturb sleep. This pain is many a times craniectomy and Microvascular confused with Trigeminal Neuralgia and decompression , separated the PICA mistreated. from the 9th cranial nerve. Intense irritability and hyper-stimulation

APRIL 2017 • CAPSULE MAGAZINE • 06 DIABETIC RETINOPATHY - AN OVERVIEW

The patient became absolutely pain free on the first postop day and started taking liquids and solid diet also from that day itself without any discomfort. He got relieved of those painful episodes and has been discharged on the fourth day without any morbidity

The most common groin swelling is inguinal hernia. The other causes are undescended testis, enlarged lymph nodes, lipoma and encysted hydrocele of the cord. Rarer causes are inguinal endometriosis in women, lymphangioma Inguinal dermoid and neuroblastoma. A dermoid cyst of Dr. Devaji Rao the spermatic cord is a very rare condition, and this should be considered in the differential diagnosis especially in children, when it is nontender and not reducible. We present here a case of inguinal dermoid in an adult male.

07 • CAPSULE MAGAZINE • APRIL 2017 DIABETIC RETINOPATHY - AN OVERVIEW

Case report Discussion epithelium-lined connective tissue, A 40 year old male presented with a Though the most common diagnosis of including skin appendages, and swelling with mild pain in the left a groin swelling is an inguinal hernia, containing keratin, sebum, and hair. inguinal region for many months. On other causes of include femoral Histologically the wall of a dermoid cyst examination, it was a nontender hernias, undescended testis, enlarged consists of all components of the skin, irreducible swelling in the inguinal lymph nodes, lipoma, femoral artery including hair follicles, hair, sweat and region with normal testes bilaterally. A aneurysm, saphena varix and sebaceous glands. clinical diagnosis of incarcerated varicocele. Rarer causes include Dermoid cysts of the spermatic cord inguinal hernia was made and dermoid, inguinal endometriosis in are not painful, though they have been operated. During surgery, it was found women and thrombophlebitis of the known to mimic an incarcerated to be an encapsulated swelling long saphenous vein and inguinal hernia. It is also reported to adherent to the cord structures and lymphangiomas and neuroblastoma occur in conjunction with an ipsilateral contained pultaceous material, with A dermoid cyst of the spermatic cord is paratesticular epidermoid cyst. hair in the capsule. It was excised an unusual cause of groin swelling, with Dermoid cysts are always benign without any difficulty. The only a few cases reported to date. lesions. No case of malignant histopathology showed thin-walled Dermoid is a name given to cysts lined transformation has been reported. In cystic structures containing inspissated by squamous epithelium occurring in symptomatic cases, surgical excision keratin, lined by mature keratinising various parts of the body. Dermoid remains the only treatment option. squamous epithelium. The wall cysts in and beneath the skin occur In conclusion, dermoid cysts of the contained skin appendage structures mostly on the face, neck or scalp. spermatic cord should be considered with both eccrine glands and Dermoid cysts can also be intracranial, as part of the differential diagnosis of sebaceous glands. There was no intraspinal or perispinal. inguinal masses especially in children, evidence for dysplasia or malignancy in Intra-abdominal dermoid cysts can also when it is a long-standing, nontender, the lining of the cyst. The surrounding occur on the ovary or omentum. and irreducible inguinal mass. fatty connective tissue contained no By definition, dermoid is a tumor residual or atrophic testicular tissue. consisting of displaced ectodermal The histological appearances structures along the lines of embryonic correlated with a dermoid cyst. fusion, the wall being formed of

Excised specimen (A) Gross (B) Cut specimen Operative photograph

APRIL 2017 • CAPSULE MAGAZINE • 08 ADOLESCENT IDIOPATHIC SCOLIOSIS

Intra Operative Neuro Monitoring - “The Gaurdians Of The Brain” Dr. ------

26 year old lady The Fourth Ventricle is a complex space IONM: In 1848 Du Bois Raymond presented to our casualty with nuclei in the centre, which is elicited the first neuronal Action in a moribund state, helpful in mastication ans swallowing. Potential. In 1935 first use of Intra Op The floor is made up of Trigeminal, EEG and in 1978 first use of BAEP are drowsy, arousable, obeying Facial, Vestibular, Vagal, Hypoglossal already documented. Since then newer minimal commands, with nuclei apart from the Gracile techniques with modern technology &Cuneatus Tubercles and other vital has brought monitoring into the daiy papilledema for only eight structures. OT use itself. Now it is used in various hours. The only significant forms such as MEP, SSEP, BAEP, SSEP for This is where Neural Integrity Vascualr procedures to pick up ealry history she had was early Monitoring (NIM-ECLIPSE) comes in as hypoxia, localisation of morning headaches while the guardian of brain functioning. SnsoriMotorCortex, VEP, EEG etc has retching when she was Initially under anaesthesia the patient really opened a plethora of options for was postionedand electrodes for neuronal integrity monitoring. brushing her teeth for monitoring the Trigeminal, Facial, These gaurdians make the surgeon’s almost three months. Glossophayngeal, Accessory and job easier and less stressful and more Hypoglossal nerves. The Sub Occipital precise and help in more aggressive Craniotomy was done and the dura surgical clearance and inprove the opened. The patient was brought to a patient’s quality of life by preventing lighter anaesthesia plane and new morbidities and mortality. Scans showed an obstructive fourth “TeloVelarApproach” commenced. ventricular floor lesion causing The fleshy, vascular ependymoma was obstructive hydrocephalous. She was visualised and under IONM (Intra Op taken up for emergency Endoscopic Neuro Monitoring) near total excision Third Ventriculostomy following which was done except for a very miniscule she became fully normal with no part very firmly adherent to the floor. deficits – including any Cranial Nerve Throughout the surgery all the cranial deficits. nerves were intact with no loss of any potential. Post operative the patient So now she needed treatment of her recovered uneventfully with not even a main problem – the IV Ventricle lesion minimal cranial nerve palsy and was with no deficits discharged on the IV post op day.

09 • CAPSULE MAGAZINE • APRIL 2017 ADOLESCENT IDIOPATHIC SCOLIOSIS

Rotational Until recently calcified and totally occluded Atherectemy coronary arteries were conventionally treated Calcified and totally occluded coronary with bypass surgery as calcification prevent arteries can be safely balloon and stent expansion. treated using angioplasty

Dr. Amal. A. Louis

Conventional angioplasty In conclusion, with advanced techniques using plain techniques and technology PCI is now balloon angioplasty and possible for patients with three vessel stenting in heavily disease, calcified disease and in calcified vessels is chronic total occlusions. Kauvery associated with poor Hospitals , Chennai now has the longterm outcome due to technology and expertise to perform restenosis resulting from such complex coronary interventions stent underexpansion and very successfully with goo long term neointimal proliferation. outcomes. Drug eluting stents have effectively eliminated neo intimal proliferation and instent restenosis but an underexpanded drug eluting stent results in stent thrombosis and early restenosis. After explaining the various risks and Rotational atherectemy (rotablation) benefits from bypass surgery vs PCI , using a diamond tipped drilling device he opted to undergo PCI and was not helps in debulking and clearing keen on any surgery. Successful PCI calcified plaques, thereby facilitating was done to the RCA chronic total adequate stent expansion with occlusion using rotational atherectemy improved long term outcome post to the occluded portion as no balloon percutaneous coronary intervention would expand in that portion due to (PCI). heavy calcium. After rotablation Mr SN is a 58 yr old gentleman who stenting was done with two drug presented to Kauvery Hospitals, eluting stents to the RCA and one drug Chennai with exertional chest pain. His eluting stent in LAD and LCx. Without TMT was positive and his coronary rotablation RCA angioplasty would not angiogram showed severe triple vessel have been possible and patient would disease with a totally occluded right have required bypass operation. coronary artery (RCA) and severe Overall excellent result was obtained stenoses in the left anterior descending and Mr SN is now back at work and (LAD) and left circumflex (LCx) arteries. free of angina. Rotablation technique - diamond tipped burr during ablation inside a calcified plaque

APRIL 2017 • CAPSULE MAGAZINE • 10 STRICTURE URETHRA

LAD - Pre treatment LAD post treatment LCx post treatment LCx pre treatment

RCA post treatment Rotablation burr in the RCA Totally occluded RCA

Soft tissue sarcomas are rare tumors of mesenchymal origin with more than 50 histological types contributing to only 1-2% of all solid Soft Tissue tumors.They can occur at any site of the bodywith Sarcoma 45% occurring in extremities, 38% intrabdominally, 10% truncal and 5% in head and neck. The rarity of Dr.Anis B the tumor,heterogenecity in the anatomical site of occurrence and histopathological features along with the aggressive biological nature of the disease makes it one of the most difficult malignancies to manage.

11 • CAPSULE MAGAZINE • APRIL 2017 A RARE ORGANISM CAUSING SEPTIC ARTHRITIS OF HIP JOINT

CASE REPORT: gross margin of 2-3 cms three The biopsy should be carefully planned A 48 years old gentleman with post dimensionally all around the tumor with incision oriented along the long paralytic polio in left lower limb came along with periosteum of femur and axis of the extremity, and a minimal with swelling in right thigh for 6 lateral intermuscular septum for deeper amount of skin flap should be raised months withoccasional pain, No margin were removed enbloc and superficial to the incision. Meticulous difficulty in hip or knee movements, marker clips applied at the margins for hemostasis is essential to prevent the walks with crutches because of left leg radiation field. Sartorius muscle Trans dissemination of tumor cells. In patients residual paralysis, No metastatic positioned to cover the femur and with histological subtypes that are symptoms. wound closed primarily. sensitive to chemotheraphy like synovial sarcoma neoadjuvant chemo- On examination there was a large Final histopathology was suggestive of theraphy can be considered in tumor of size 15 *12 cms involving 11*8*6.5 cms malignant fibrous borderline resectable or Unresectable right anterior compartment of thigh, histiocytoma, grade III, all resection tumors.Surgery remains the primary- extending superiorly up to 5 cms from margins were free . modality of treatment but has evolved anterior superior iliac spine and Staged as pT2bN0M0 – Stage III now through the years from the era of inferiorly up to 6 cms from knee joint, receiving adjuvant External beam amputation to compartmental posterior compartment and medial radiation therapy and then planned for resection and now limb sparing surgery compartments were free, skin over the further chemotheraphy in view of high being the standard of care. Most tumor stretched but not infiltrated, No grade extremity tumor based on SMAC patients receive multimodality distal neurovascular deficit, Hip and metanalysis. treatment where wide local excision is knee movements were of full range,No performed to remove tumor with 2 inguinal lymphadenopathy. MRI right DISSCUSSION: cms gross margin and adjuvant lower limb showed Mixed intense soft Anterior thigh soft tissue sarcoma radiation therapy given to treat tissue tumor of size 12*10 cms corresponds to 30% of all soft tissue microscopic tumor cells and further confined to anterior compartment sarcomas and malignant fibrous chemotheraphy given for all high involving vastus lateralis, rectus femoris histiocytoma being the commonest grade extremity tumors more than 5 and part of vastus medialis . Abutting extremity sarcoma.Most often these cms to treat the micro metastasis and the periosteum in proximal femur but patients are asymptomatic for a long thereby decrease systemic failure and bone cortex was free, tumor was period before these tumors attain a improve overall survival. extending almost the entire vastus considerable size to produce symp- lateralis both distally and proximally, toms like pain and often they are Limb sparing surgery is possible in femoral vessels were free, knee joint misdiagnosed as a hematoma or some more than 90% of patients unless there and hip joints were free and no satellite benign swelling adding to the delay in is gross cortical bone involvement or lesions and no inguinal nodes. No lung diagnosis. In general any soft tissue major neurovascular involvement or metastasis in CT chest and Core biopsy mass that is symptomatic or enlarging, multi compartmental involvement or was suggestive of malignant fibrous any new mass that persists >4 weeks, inappropriate biopsy site which could histiocytoma, grade III after IHC or any soft tissue mass that is >5 cm in not be included in the surgical incision. studies. diameter should be evaluated further Hence the importance of proper with a imaging and core needle biopsy. planning of the pre op biopsy site and He was planned for wide local excision MRI is the imaging of choice for ideally the biopsy to be done by the with primary closure. Elliptical incision extremity sarcomas and CT for treating surgeon after imaging the local made enclosing the core needle biopsy retroperitoneal sarcomas. MRI gives part.Regional node dissection done scar and part of the stretched skin over information on the origin of tumor; only when the nodes are enlarged and the tumor vertically along the anterior extend of the tumor, underlying bone proven to be metastatic by cytological thigh. Skin flaps raised superficial to involvement, neurovascular involve- study. And when the nodes are positive deep fascia , Femoral triangle opened ment, adjacent joint involvement and it has a very poor prognosis. and femoral vessels and nerve for any satellite lesions. Metastatic dissected along the full course up to workup includes CT chest to rule out CONCLUSION: adductor canal, Profunda femoris lung metastasis. Core needle biopsy to Although soft tissue sarcomas are vessels identified ligated and divided, be done along the line of surgical biologically aggrresive tumors with a Femoral nerve branches supplying the incision and gives information on grade poor survival rate , when identified vastus muscles divided and Sartorius and the histological subtype which are early with proper pre-operative work muscle which was uninvolved by tumor the most important prognostic factors up and thorough planning from the was dissected along with its blood for survival. If the core biopsy is biopsy site to the extent of surgery supply and preserved, the entire tumor inconclusive then excisional or ,method of reconstruction and with a cuff of normal muscle which incisional biopsy is required. For a small rehabilitation strategies most often included the vastus lateralis, rectus mass between 3 to 5 cm an excisional limb sparing surgery can be done femoris, vastus intermedialis and part biopsy is appropriate if not then successfully with good functional of vastus medialis removed giving a incisional biopsy has to be performed. outcome. Along with multi-disciplinary

APRIL 2017 • CAPSULE MAGAZINE • 12 A RARE ORGANISM CAUSING SEPTIC ARTHRITIS OF HIP JOINT management including radiation therapy, chemotheraphyand strict follow up protocols especially in tertiary cancer care centres good survival outcomes can be attained most often.

MRI T2 coronal view showing the tumor involving almost the entire anterior compartment.

Femoral artery and vein dissected free along the entire course and profunda femoris vessels pointed.

MRI T2 Axial view showing the bulk of tumor involving vastus lateralis, rectus femoris and part of vastus medialis and abutting the periosteum but sparing Sartorius and femoral vessels.

After removal of tumor with periosteum and lateral inter muscular septum.

Sartorius muscle Trans positioned to cover Final specimen along with overlying skin the femoral vessels and bone.

13 • CAPSULE MAGAZINE • APRIL 2017 PAPILLARY CARCINOMA OF THYROID

Squash cytology was first introduced in 1930. The soft nature of CNS tissue is best suited for squash cytology, which in fact Squash cytology is a hindrance for frozen section. as intraoperative Moreover, ice crystal artifacts may make morphological diagnostic interpretation of frozen sectioned procedure. tissue difficult. Squash cytology Dr.Shantha Ravisankar MD; DCP can help neurosurgeon to deal Chief of Laboratory Services, Kauvery Hospital with an unexpected lesion than Dr. Ravindra Mohan MS(Ophthal) Consultant Ophthalmologist, Kauvery Hospital that determined on clinical and imaging grounds. Role of squash cytology has increased with the advent of stereotactic biopsy which provide very tiny tissue.

Case Study: 60yrs old female patient presented with right proptosis and orbital mass for 15yrs, with a blind eye. History of previous surgery 6years back in the same Smears (Fig.1)were cellular showing eye for which the biopsy sheets and whorls of oval to polygonal report was unavailable. cells with abundant eosinophilic Patient now came with cytoplasm. Few cells also showed recurrence of tumor to pseudonuclear inclusions and were Kauvery Hospital, Alwarpet, traversed by thick capillaries in a Chennai. haemorrhagic background. Which were MRI showed large right features suggestive of a Meningothelial intra-conal tumor filling the Meningioma. right orbit, optic nerve, inseparable, lobulated in The above intraoperative diagnosis was appearance. With these made within 15minutes. The histopa- features , a clinic-radiologi- thology by routine paraffin embedded cal diagnosis of a Vascular section also confirmed the diagnosis of tumor was considered. Meningothelial Meningioma.

Squash Cytology: Squash smears were made from fresh tissue, fixed in isopropyl alcohol and stained with Haematoxylin and eosin stain.

APRIL 2017 • CAPSULE MAGAZINE • 14 PAPILLARY CARCINOMA OF THYROID

Conclusion: Intra-operative squash cytology is a rapid and an inexpensive technique which can help the neurosurgeon with intra-operative decision making Fig.1 depending on the nature of the tumor. A. Whorls of meningothelial cells B.Pseudonuclear inclusions(arrow) In this case a intra-operative diagnosis on squash cytology has saved the patient the morbidity of a more extensive surgery and also precludes the need for any adjuvant radiotherapy of chemotherapy.

Fig.2 Histopathology showing meningothelial cells in whorls and lobules.

A new round the clock pharmacy has started functioning at the Trichy Airport complex to aid the passengers, staff and the pulic on 02-06-2017(Friday). The pharmacy is to function along with the prevailing dispensary at the airport terminal.

Dr.S.Manivannan, Joint Managing Director,Kauvery Hospital and The Director of Trichy Airport,K.Gunasekaran inaugurated the pharmacy outlet.

The kauvery Hospital Pharmacy is located in front of the terminals near the ticket counters of all the major airlines.

15 • CAPSULE MAGAZINE • APRIL 2017 AWARENESS ON VOCAL HYGIENE

You may even know if your cholesterol is diabetes, stroke and cardiovascular high or if your blood sugar is on the low conditions. By knowing your numbers, side. But do you know exactly what those you can compare them to healthy national levels are and what they mean to your numbers. This will help identify your health? personal risk factors for potential serious The Know Your Numbers campaign, which and chronic health conditions. encourages people to learn their numbers Many people do not understand the full Know related to cholesterol, blood pressure, meaning of their numbers that reflect blood sugar, weight and body mass index one’s current state of health, but knowl- (BMI), was designed to raise awareness, edge is power. “By understanding these Your increase detection of cardiovascular numbers and comparing them with disease and diabetes and encourage national normal numbers, one has the people to make healthier lifestyle choices. power to begin making healthy lifestyle choices, such as exercising and eating a Numbers “It’s important for people to know their healthy diet,” numbers since they comprise a key snapshot of personal health,” This campaign was done at Kauvery So how exactly do these numbers come in Heartcity, where many of the patients handy? were benefited. and the awareness about These health metrics are important the Numbers have been spread all along. because they’re risk factors for developing

APRIL 2017 • CAPSULE MAGAZINE • 16 AWARENESS ON VOCAL HYGIENE | QUIZ

HEALTHY Rava Idly

Directions: Instructions ( 1 cup =255 ml) Ingredients • firstly take a 4 tsp of oil • add in mustard seeds, cumin seeds, urad dal, channa dal, curry leaves and hing. allow to splutter. 1 cup bombay rava / sooji / semolina • then add ginger, chilli and saute till raw smell goes away. 1 cup curd, sour • also add grated carrot, turmeric and saute for 2 minutes. 10 whole cashews • now add rava and roast for 3 minutes. allow it to cool down. • once completely cooled and add curd and mix well. 1 carrot, gratted • add 1 - 1½ cup of water little by little (as required). form idli batter ½ tsp baking soda / eno fruit salt consistency. 1 tsp mustard seeds • add salt to taste and mix well. keep aside for some time. (approx. 20 ½ tsp urad dal min). • now add baking soda / eno fruit salt and mix till it turn frothy. 1 tsp cumin seeds / jeera • after adding baking soda do not let it sit for more time. grease the ½ tsp channa dhal plates with oil and place cashew in the mould. 4 tsp oil • pour the batter into the idli moulds. ½ tsp turmeric powder • and steam it for 10 mins • allow it to rest for 5 mins then unmould. serve hot with any chutney 10 curry leaves of your choice. pinch hing / asafoetida salt to taste water, as required

17 • CAPSULE MAGAZINE • APRIL 2017 RENAL UPDATE 2017

NEW DOCTORS ANY EVENTS

19 • CAPSULE MAGAZINE • APRIL 2017 PATTIMANDRAM

ANY EVENTS

APRIL 2017 • CAPSULE MAGAZINE • 20 TRICHY | CHENNAI | KARAIKUDI | HOSUR

No.1, K.C. Road, Tennur, Trichy-17. Ph: +91-431-40 22 555 W:www.kauveryhospital.com E:[email protected]