Medi Magazine kauvery A quarterly magazine from VOLUME - 20 | ISSUE 02 APRIL 2017 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 , Anna Nagar Branch Acute Myocardial Infarction in Infancy and Renal Update Childhood - A reality 2017 - CME

Annual Day Papillary Carcinoma 2017 of Thyroid Pattimandram

To download this magazine This magazine is free circulation for and doctors only, Not for sale. Design and logo of kauvery 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 01 From the Editor’s Desk PATRONS Dr. S. Chandrakumar Dr. S. Manivannan 02 Acute Myocardial ADVISORY BOARD Dr. D. Senguttuvan Infarction in Infancy & Dr. Aravindan Selvaraj Dr. S. Senthil Kumar, Ms., DNB., (Uro) Childhood - A reality Dr. T. Senthil Kumar HOD & Senior consultant Urologist & Andrologist Dr. Prashanth Sha, MBBS., MS., DNB., EDITOR Transplant Surgeon Consultant Cardiologist Dr. Lakshmi Prashant, MBBS., MD(AIIMS)., Dr. S. Senthil Kumar Laparoscopic surgeon Kauvery Kidney Centre, Tennur, Trichy Consultant Paediatrician Kauvery Hospital, Chennai EDITORIAL TEAM Dr. S. Velmurugan Dr. S. Aravinda Kumar Dr. Iyyappan Ponnuswamy

TECHNICAL TEAM Dr. Ve. Senthil Vel Murugan Dr. A. Subramanian

ADMIN TEAM Mr. S. Sathishkumar Mrs. JPJ. Bindhu

CO-ORDINATORS 04 Mrs. G. Percy Anesthesia and Dr. Arunkumar C Challenges Dr. K. Senthil Kumar, MBBS., DA., DESIGN & LAYOUT Anesthesiologist Mr. Vahid Ali N. Kauvery Hospital, Trichy 06 Diabetic Retinopathy -An Overview Dr. B.S. Anil Chandra, MS (Oph) Sr. Consultant Ophthalmic Surgeon, Kauvery Hospital, Chennai

EDITORIAL OFFICE Kauvery Hospital VI Floor, Administrative Office, #6, Royal Road, Cantonment, -620001. Call us at (431) 40 77 777 E: [email protected] W: www. kauveryhospital.com 11 Stricture Urethra Dr. S. Senthil Kumar, Ms., DNB., (Uro) HOD & Senior consultant Urologist & 09 Andrologist, Transplant Surgeon, Laparoscopic surgeon Adolescent Dr. N. Karthickeyan, M.S., MRCS(Edinburgh)., DNB., M.Ch () Idiopathic Scoliosis Consultant Urologist Dr. Vignesh Pushparaj, MBBS., D Ortho., FIPM., Kauvery Kidney Centre, Tennur, Trichy AO-FISS(Asia pacific)., FISS(Netherlands) M.S(General Surgery)., M.Ch(Plastic & Reconstructive Surgery) Spine & Orthopaedics Surgeon

Dr. Balamurali MBBS, MRCS (Edin), FRCS (Surgical ), MD (UK) Neurologist & Neurosurgeon Kauvery Hospital, Chennai 12 A Rare Organism Causing Septic Arthritis of Hip Joint Dr. Chockalingam, MBBS., D.Ortho., FRCS(Surgery)., FRCS(Trauma & Ortho)., Sr. consultant, Department of orthopedics. 14 Papillary Carcinoma Dr. Midhun Madhavan P.C, MBBS., DNB., of Thyroid PG() 16 Kauvery hospital, Trichy Dr. Anish, MS., MRCH., MCh., Consultant Surgical Oncologist Awareness on Vocal Hygiene Kauvery hospital, Tennur, Trichy Dr. Sundhari, MBBS., DNB(ENT)., MNAMS. Consultant-ENT Head and Neck Surgery Kauvery Hospital, Chennai 18 Renal Update 21 2017 - CME 5S-Kaizen Award 19 22 Pattimandram Healthy Chocolate Banana Pancake 20 Inauguration of Chennai, Anna Nagar Branch 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

Acute Myocardial Infarction in Infancy and Childhood - A reality

Dr. Prashanth Sha, MBBS., MS., DNB., Consultant Cardiologist

Dr. Lakshmi Prashant, MBBS., MD(AIIMS)., Consultant Paediatrician Kauvery Hospital, Chennai

Infants and children can also suffer pulmonary artery instead of the aorta. An acute what we call in common parlance, a In such cases the left main coronary Myocardial Infarction (MI) “heart attack” and present with carries deoxygenated blood is largely considered symptoms of myocardial ischemia (lack (oxygen-poor blood) under low of oxygen supply) and heart failure just pressure to the heart muscle. This leads a clinical event that affects as adults do. A six month old to myocardial ischemia. A the elderly and is distressed, malnourished baby girl was phenomenon known as “coronary presented to us with the steal” further damages the heart in attributed to coronary aforementioned features (poor feeding, babies with ALCAPA. Low blood artery disease. rapid breathing, and sweating, pale pressure in the pulmonary artery skin). Her status was mistaken for causes the blood from the abnormal common paediatric conditions such as left coronary artery to flow towards the reflux, colic and bronchiolitis. Our pulmonary artery instead of the heart. evaluation revealed cardiomegaly, rapid pulse, abnormal heart rhythm When and how does ALCAPA and ECG changes suggestive of a MI. present? The baby’s clinical condition was ALCAPA is present prenatally because pathognomonic of ALCAPA – of the favourable fetal physiology that anomalous origin of the left coronary includes (1) equivalent pressures in the artery from the pulmonary artery. She main pulmonary artery and aorta underwent prompt surgical correction secondary to a patent ductus for the same. arteriosus, and (2) relatively similar oxygen concentrations due to parallel What is ALCAPA? circulations. Shortly after birth, as the ALCAPA is a rare, serious congenital circulation becomes one in series, cardiac anomaly, where the left main pulmonary artery pressure and coronary artery originates from the resistance decrease, as does oxygen

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

content of pulmonary blood flow. This changes). Confirmation of the anomaly echocardiography is used to assess for results in myocardial ischemia. may be obtained by means of 2D improvement in left ventricular function echocardiography or cardiac and mitral regurgitation. Outpatient The symptoms usually present by 2 catheterization with angiography. therapy with diuretics and afterload months of age and include the reduction is often used after discharge. following: What is the treatment of ALCAPA? • Crying or sweating during Treatment of ALCAPA involves surgical What is the outcome and prognosis? feeding reimplantation and direct transfer of If such babies do not have surgery, • Pale skin the left coronary to the aortic root. The they most likely do not survive their • Poor feeding procedure is an open heart surgery first year. With timely intervention, they • Rapid breathing performed on cardiopulmonary can expect a normal life and • Poor weight gain by-pass. Mechanical ventilation and functionalities. With the right diagnosis, On examination they have features of inotropic support are typically required pre-surgical stabilization and congestive heart failure, mitral in the post-operative period in view of team-oriented post-operative regurgitation, diminished peripheral left ventricular dysfunction. Afterload paediatric care, ALCAPA has shown to pulses and classical ECG changes (deep reduction therapy is used to manage have an excellent outcome. q waves, peaked t waves, ST segment postoperative hypertension. Serial

Dr. S.Aravindakumar, Dr. A.Veni, Neurologist of Cardiologist of Kauvery Kauvery Hospital Heartcity, Trichy has been Cantonment was selected specialized in Clinical as the “Women and Achiever”, amongst five Interventional Cardiology. women of Trichy for their He has been conferred notable service and with internationally success in their own field acclaimed fellowship by a prominent satellite namely, FACC (The Fellow television channel. She of the American College was interviewed and was of Cardiology) and FESC aired on Women’s Day, to (Fellowship of the instill the spirit of European Society of Cardiology) recently. Womanhood. She was a state player in chess and a gold medalist in DM Neurology. FACC is one of the most distinguished designations and the ultimate recognition of professional According to her, women are the repository of energy. achievement based on outstanding credentials, The self confidence and the determination to achieve, achievements and community contributions to charges them to face even the strongest battle with cardiovascular medicine. stride. When asked about her secret of success, she told that Yoga and Meditation are the main cause to FESC has been conferred to Dr. S.Aravindakumar, curb the stress, and emphasizes women to accentuate recognizing his notable years of experience and their skills and constantly enhance it to make them distinguished service in clinical, educational, feel more confident. investigational, organizational or professional aspects of Cardiology

03 • CAPSULE MAGAZINE • APRIL 2017 ANESTHESIA AND CHALLENGES

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

This Neonate is a preterm by birth and 17 days old, for posterior urethral valve Do you want to be AWAKE during fulguration. Brain surgery? Considering the risk of The patient was also apnea of prematurity, asked to move his limbs. retinopathy of Anesthesia was provided prematurity and other to the regional block list of complications for (Scalp block) along with general anaesthesia, wonder drugs like we had provided Dexmeditomidine, subarachnoid block Midazolam, Fentanyl, according to the Propofol in order to Different Physiology guidelines. Neonate Yes, it is possible. A patient underwent make the patient Right from the Neonates till was comfortable “Awake Craniotomy,” for glioma comfortable, bring down Geriatric patients, throughout the involving motor cortex. The patient was the anxiety to zero, and Anesthesiologists face procedure, both kept ‘Awake’ because monitoring was of course to achieve our various challenges every clinically and needed to locate the extent of tumor primary goal of being day. Each individual vary haemodynamically. involvement during surgery. PAIN FREE.. physiologically, anatomically and pathologically, and hence anesthetic techniques Breaking the ‘TRIANGLE’ are also modified We know anesthesia includes a TRIANGLE of accordingly. To start with, we unconsciousness, involving analgesia, know the physiology of a skeletal and muscle relaxation. In some neonate is entirely different surgeries like scoliosis, from adults, right from their lipomyelomeningocele, spinal cord oxygen binding capacity of tumors….etc, we are forced to break our haemoglobin till maturation TRIANGLE by excluding muscle relaxation in and functioning of organ order to provide neurophysiological systems. monitoring intraoperatively. We achieve complete anesthesia favorable for surgeons with opioids, Inhalational anesthetics and sedative anesthetic agents appropriately.

APRIL 2017 • CAPSULE MAGAZINE • 04 ANESTHESIA AND CHALLENGES

Airway Challenges We come across huge through “Awake fiber-optic number of challenging intubation”, along with airways in our center very airway block and often. Thanks to Dr. Gustav premedication. The entire Killian, a German procedure was done with laryngologist and founder the extreme cooperation of the bronchoscopy, who of the patient, which was has initiated the first era of thoroughly painless. bronchoscopy in the year 1876. This later got Another patient was revolutionized in 1967as admitted with huge fiber-optic bronchoscope. retropharyngeal abscess extending till thoracic Everything can become cavity, nearly possible with fiber-optic compromising the airway. bronchoscope. A patient Even securing in was admitted with nil pathological airway unlike mouth opening as seen in previous case has now this picture, later was able made possible with to secure endotracheal tube fiber-optic bronchoscopy.

Neuraxial Challenges: We pacify kids in Different Way An obese patient with BMI of Not only perioperatively, we face 42 presented with perianal variety of challenges beyond abscess for incision and OT’s. For example, Imagine a drainage. Considering situation of a Central venous airway and ventilation Catheterisation for crying chubby difficulties, basal alveolar infant with low platelets, on top atelectasis on ventilation and of it, there was no peripheral IV parasympathetic response cannula (all peripheral veins, during procedure, we gone). Ultrasound guidance and proceeded with our way of pacifying child with Subarachnoid block with sedative, through internal jugular 25G (9cm in length) Quincke vein just before insertion of needle. Our routine spinal guidewire or intramuscular needle was able to reach anesthetic agent in sedative subarachnoid space only doses for kids with normal with further dimpling of skin coagulation profile is a choice. after full insertion of 9cm This picture is central venous needle. catherisation of a 22 days old neonate

A patient with RTA and In this case of burns chest injury with rib fracture contracture, where both as seen in the picture was entry points were blocked able to breathe hassle-free. pathologically. Together with He was also able to cough surgeons team work, to some extent and clear contracture at mouth was out secretions without any Scary Ending!! released with tumescent pain. As a step ahead, he Even fibreoptic infiltration to make way for also underwent surgery for bronchoscopy guided our Endotracheal intubation. closure of wound without intubation requires open general anesthesia, which is nares or mouth opening of made possible with Throacic atleast 1 finger breath to Epidural catheter used for pass the Faecal Occult Analgesia and Anaesthesia. Blood (FOB) and endotracheal tube.

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

Diabetic Retinopathy -An Overview Dr. B.S. Anil Chandra, MS (Oph) Sr. Consultant Ophthalmic Surgeon, Kauvery Hospital, Chennai

Diabetes mellitus Technological advances have improved and increased deposition of the diagnostic accuracy of screening extracellular matrix components (DM) is a major cause of methods and access of the diabetic contribute to the development of avoidable blindness patients to the specialist care. In the abnormal retinal hemodynamics. in both developing and last three decades, the treatment In diffuse type of Diabetic Macular strategies have been revised to include, Edema (DME), breakdown of the inner developed countries. besides laser photocoagulation, early blood-retinal barrier results in Patients with Diabetic surgical interventions and accumulation of extracellular fluid. pharmacotherapies. Increased retinal leukostasis has been Retinopathy (DR) are reported and it causes capillary occlusions and dropout, nonperfusion, 25 times more likely What is Diabetic Retinopathy? endothelial cell damage and vascular Diabetes causes weakening of the to become blind than leakage due to its less deformable blood vessels in the body. The tiny, nature. non-diabetics. delicate retinal blood vessels are particularly susceptible. This weakening Currently, there has been a great of retinal blood vessels, accompanied interest in vasoproliferative factors, by structural changes in the retina, is which induce neovascularization. It has called as diabetic retinopathy. been shown that retinal ischemia stimulates a pathologic Pathophysiology: neovascularization mediated by The final metabolic pathway causing angiogenic factors, such as Vascular DR is unknown. There are several Endothelial Growth Factor (VEGF), theories. Electrolytic imbalance caused which results in proliferative Diabetic by the high aldose reductase levels retinopathy (PDR). VEGFs are released leads to cell death, especially retinal by retinal pigment epithelium, pericytes pericytes, which cause microaneurysm and endothelial cells of the retina. formation. Apart from this, thickening of the capillary basement membrane

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

Types of diabetic retinopathy Angiography (FFA) and Optical There are two main categories of Coherence Tomography (OCT). The diabetic retinopathy: current treatment recommendation for • Non Proliferative Diabetic treating DME is intravitreal injections Retinopathy (when the blood vessels either Anti VEGF or intravitreal steroids leak and then close) followed by laser if necessary

• Proliferative Diabetic Retinopathy (when new blood vessels grow or proliferate) Proliferative Diabetic Retinopathy

Proliferative Diabetic Retinopathy (PDR) Progression to Proliferative Retinopathy is common in longstanding diabetes. Besides having non-proliferative Diabetic macular edema retinopathy, there may be vessels growing on the retina, and the complications that stem from that condition. Proliferative diabetic retinopathy, a stage that is associated with severe vision loss, is characterized by the development of abnormal blood vessels on the optic disc, retina, iris and angle structures. Retinal ischemia resulting from progressive retinal capillary closure stimulates the release of angiogenic factors, such as vascular endothelial growth factor and placental Diabetic macular edema growth factor. Such molecular mediators play an important role in Non proliferative diabetic promoting neovascularization and retinopathy (NPDR) fibrous tissue proliferation. The new NPDR is also called background blood vessels that form are fragile and retinopathy as the retina may contain bleed easily when subject to vitreous capillary leakage, capillary closure, or a traction, resulting in vitreous, pre retinal Optical coherence tomogram combination of the two. Non and retinal hemorrhages. When the proliferative diabetic retinopathy is the fibrovascular proliferation regresses it Risk factors for diabetes (and earlier stage of DR, and it is leaves behind a fibrous tissue that is therefore diabetic retinopathy) characterized by microaneurysms, attached to both the retina and the include: retinal capillary non-perfusion and posterior hyaloid. Such fibrous tissues • Obesity (more than 20% dot-blot or flame-shaped retinal allow traction to be transmitted to the heavier than your ideal body hemorrhages. If blood glucose levels retina during vitreous contraction, weight) remain uncontrolled, NPDR may resulting in Tractional Retinal • A family history of diabetes progress to severe NPDR, which is Detachment (TRD) and retinal break. • Hypertension (blood pressure defined as the presence of four of 140/90 or higher) quadrants of microaneurysms, two • Having a high density quadrants of venous beading or one Diabetic Macular Edema lipoprotein (HDL or "good quadrant of Intraretinal Microvascular Diabetic Macular Edema is the main cholesterol") reading of 35 Abnormalities (IRMA). Severe NPDR cause of vision loss in DR. DME can mg/dL or lower carries a 15 percent chance of develop at any stage of DR and is • Elevated triglyceride levels progressing to proliferative diabetic caused by an increase in the (250 mg/dL or higher) retinopathy within one year. permeability of the perifoveal capillaries • Having been diagnosed with leading to collection of fluid within the gestational diabetes during a layers of the retina. This can be pregnancy diagnosed by clinical examination and • Anemia evaluated by Fundus Fluorescein • Nephropathy

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

What are the symptoms of diabetic begins actually with tight glycemic Macular Oedema (DMO) and/or retinopathy? control along with control of all Proliferative Diabetic Retinopathy Diabetic retinopathy often has no early associated co morbid conditions like (PDR). DMO typically presents warning signs. There is no pain, and HTN, Nephropathy, Anemia and gradually, with blurred vision, central vision may remain unaffected until the Dyslipidemia. There is enough scientific distortion and difficulty reading. In disease becomes severe. If leaking evidence for us to convince the patient contrast, early PDR is often initially blood vessels cause swelling of the that unless his/her systemic risk factors asymptomatic and a high index of macula (called macular edema), central come under control the treatment of suspicion is required in patients with vision will become blurred, making it diabetic retinopathy will not give poorly controlled diabetes of significant hard to see clearly when driving or optimum results. The role of the duration. reading. Vision may get better or worse treating physician is so very important There is now extensive evidence for the during the day, depending on the in screening, detection and timely safety and superiority of intravitreal degree of edema. If leaking blood referral to an ophthalmologist for anti-vascular endothelial growth factor vessels cause bleeding in the eye, appropriate treatment of diabetic agents for the treatment of DMO and symptoms will vary based on how retinopathy. Instead of simply telling PDR, with the potential to improve much blood is involved. With relatively the patient to get an eye examination, vision in addition to stabilizing disease. limited bleeding, the visual disturbance the physician should make the referral, may appear as spots floating in your write a letter to the ophthalmologist, Key Points visual field. These spots may go away and expect a report in return. Strict Almost all people with diabetes after a few hours. If bleeding is more control of blood sugar levels reduces eventually develop some evidence of severe, vision may suddenly become the incidence of diabetic retinopathy by diabetic retinopathy. Regular screening severely clouded. This can occur about 35% for every 1% absolute is essential because diabetic overnight during sleep. It may take decrements in hemoglobin A1c. Still, retinopathy is common and has an months for the blood to clear from the more than 80% of diabetic patients effective treatment with laser eye, or it may not clear at all. eventually develop some degree of photocoagulation and Intravitreal retinopathy. injections. Most people with diabetes Eye evaluation in diabetic retinopathy eventually get some retinopathy. Early Diabetic retinopathy progresses rapidly The various options available to the detection through regular dilated-pupil without much warning. Hence periodic ophthalmologist today include: ophthalmoscopy or colour fundus eye examination is the only way to • Laser photocoagulation photography allows timely laser monitor the progression of disease and • Intravitreal injections of Anti treatment, which can prevent severe tackle vision threatening problems VEGF and steroids visual loss in over 90% of those at risk. before further damage occurs. • Surgical procedure called Despite this outstanding medical pars plana Vitrectomy benefit, only half our diabetic Recording patient’s history population is enrolled in a regular, The onset of diabetic retinopathy is Laser treatment and surgery can effective screening program. Tight related to the duration of diabetes. usually arrest the progression of control of blood glucose and Hence the ophthalmologist asks the retinopathy but usually cannot glycosylated haemoglobin levels over patient about the duration and family completely restore lost vision. If many years can greatly decrease the history of diabetes. Any history of eye primary care physicians wait until the risk of eye problems or their problems is also investigated. patient complains of blurred vision, it is progression to visual loss. usually too late—there is already Diagnosing diabetic retinopathy permanent retinal injury, and the lost Diagnostic tools such as a slit lamp vision almost never can be completely examination, ultra sound and restored. Hence the need for early procedures like Fluorescein detection of DR is such an important Angiography (FFA) and Optical concern for both the physician as well Coherence Tomography(OCT) are the treating ophthalmologist. used, in addition to an Unfortunately, only half of patients with Ophthalmoscope (Direct & Indirect) to diabetes undergo an appropriate assess whether a patient has diabetic examination every year. Only by retinopathy or other eye problem. teamwork between primary care physician and ophthalmologist can Management of Diabetic retinopathy blindness from diabetic retinopathy be Management of diabetic retinopathy reduced. depends on the stage and severity of Vision-threatening diabetic retinopathy the disease process. The management most commonly refers to Diabetic

APRIL 2017 • CAPSULE MAGAZINE • 08 ADOLESCENT IDIOPATHIC SCOLIOSIS

Adolescent Idiopathic Scoliosis Dr. Vignesh Pushparaj, MBBS., D Ortho., FIPM., AO-FISS(Asia pacific)., FISS(Netherlands) M.S(General Surgery)., M.Ch(Plastic & Reconstructive Surgery) Spine & Orthopaedics Surgeon

Dr. Balamurali, MBBS, MRCS (Edin), FRCS (Surgical Neurology), MD (UK) Neurologist & Neurosurgeon Kauvery Hospital, Chennai

Who develops scoliosis? Scoliosis can occur in any age groups, in more than 80 percent of scoliosis cases, a specific Scoliosis is a condition of cause is not known. Such cases are termed as idiopathic (undetermined cause), and they are abnormal side-to-side most commonly found in adolescent girls. spinal curves. On a spine Adolescent idiopathic scoliosis [Most common X-ray, the person type] is detected during the adolescent growth having scoliosis looks spurt (between the ages of 10 and 14 in girls and 12 and14 in boys, pre-pubertal and pubertal period). more like an “S” or ”C” Adolescent idiopathic scoliosis curve progression is than a straight line. accelerated during the time of puberty. Scoliosis does not Congenital, Early onset, Syndromic scoliosis occur in happen due to children below 10 years will have spinal cord carrying heavy items, anomalies and vertebral body abnormalities. Sometimes these are associated with cardiac and sports, poor posture, or renal abnormalities also. minor leg length Degenerative scoliosis occurs above 60 years abnormalities. of age due to degeneration over the spinal column.

09 • CAPSULE MAGAZINE • APRIL 2017 ADOLESCENT IDIOPATHIC SCOLIOSIS

How to identify Scoliosis? (Remember to expose the spine/ back fully up to the waist level during examination) Case Example: • If they stand in relaxed 12 year old girl found to have deformity position with their arms sides and we of back 1year ago. Deformity of the back can see a curvature in the spine with was picked up by her mother. Though the shoulder blade asymmetry (one shoulder blade more prominent than the other), waistline asymmetry and trunk shift (body that tilts to one side).

• If they bend forward at the waist, we can observe a rib prominence in the upper back and/or a flank or waist prominence in the lower back (Parents play a major role in identifying, mainly mothers)

What Investigations are needed? • X-ray of the entire spine from the neck to the pelvis (back and side views) is needed to confirm the scoliosis. • MRI Whole spine survey is to find out the associated spinal cord abnormalities. • (Sometimes CT scan may be needed to plan for surgery if curve was above 50 degree, we surgically corrected it. She is leading a complete needed)What are the treatment normal life after surgery. options? • Observation and bracing – We observe the scoliotic curves which are less than 25 to 30º and are still growing. And then we brace them to prevent further progression of the curve. • Scoliosis surgical correction is Where to Treat? often recommended for patients Scoliosis is a rare condition. Surgery for whose curves are greater than 45° and scoliosis is complex and it requires an still growing, or the curves which are expert team and equipments. continuing to progress greater than 45° Neuromonitoring is required to perform when growth stopped. these surgeries for safe correction. Kauvery hospital has got all the necessary expertise and equipments to perform these surgeries.

APRIL 2017 • CAPSULE MAGAZINE • 10 STRICTURE URETHRA

Stricture Urethra Dr. S. Senthil Kumar, Ms., DNB., (Uro) HOD & Senior consultant Urologist and Andrologist

Dr. N. Karthickeyan, M.S., MRCS(Edinburgh)., DNB., M.Ch (Urology) Consultant Urologist Kauvery Kidney Centre, Tennur, Trichy

Case summary: Discussion: Urethral strictures 40 year old male presented to us with Buccal mucosa has become the can result from complaints of inability to pass urine for preferred urethral substitute because of inflammatory, more than twenty four hours. He had availability, ease of harvest, surgical been suffering from the difficulty in handling characteristics, hairlessness, ischemic passing urine for the past two years. compatibility in wet environment, and or traumatic Clinically his bladder was distended graft survival. Buccal mucosal graft and attempted urethral catheterisation urethroplasty is the procedure of processes. had also failed. A diagnosis of stricture choice for long segment urethral urethra was made and trocar SPC was strictures because of technical ease of done to relieve bladder outlet performance, reliability and high obstruction. Ascending Urethrogram success rate in the experienced hands. (AUG) showed anterior urethral stricture with complete cut-off at the level of proximal bulbar urethra with minimal intravasation [Fig.1]. Patient was planned for Buccal Mucosal Graft (BMG) urethroplasty after three weeks urethral rest. These processes lead to scar tissue formation; scar tissue contracts and During surgery, nasal intubation was reduces the calibre of the urethral done to facilitate the harvesting of lumen, causing resistance to the buccal graft. Patient in lithotomy antegrade flow of urine. The most position, midline perineal incision was common presentation includes performed. Circumferential obstructive voiding symptoms, urinary mobilisation of bulbar urethra and retention, or urinary tract infections. pendulous urethra was done after Fig.1-AUG Showing complete cutoff Direct visual internal urethrotomy or invaginating the same through the at proximal bulbar urethra with urethroplasty is the recommended perineal wound. Dorsal urethrotomy intravasation treatment for stricture urethra based on was made at the level of mid bulbar location, length and completeness of urethra and extended on either side the stricture. until normal urethra. Buccal mucosa was harvested from both the cheeks and defatted to facilitate better uptake. BMG was then sutured to the urethral edges after fixing it dorsally with 4`0 vicryl [Fig.2].

Catheter was removed after 3 weeks and patient voided well without any residual urine. AUG was repeated after 1 month which showed good urethral Fig.2-Buccal mucosa fixed dorsally lumen. to tunica

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

A Rare Organism Causing Septic Arthritis of Hip Joint Dr. Chockalingam, MBBS., D.Ortho., FRCS(Surgery)., FRCS(Trauma & Ortho)., Sr. consultant, Department of orthopedics.

Dr. Midhun Madhavan P. C, MBBS., DNB., PG(Orthopedic surgery) Kauvery hospital, Trichy

The patient is not a known diabetic or His blood investigations showed Septic arthritis of hypertensive, no history of pulmonary anemia and elevated ESR and hip joint is caused by tuberculosis in the past, but an C-reactive proteins. Xray showed Inoculation or invasion of occasional alcoholic. Patient had a degenerative changes in the head of history of fever and jaundice five femur and evidence of core joint space by months back, for which he took decompression procedure. MRI was microorganisms leading treatment and was cured. suggestive of septic arthritis of right hip, with abscess collection in joint to arthritis. The patient consulted a local hospital space, head of femur and vastus for hip pain and arthroscopic synovial lateralis muscle, which was in biopsy and core decompression was communication with the exterior skin done from there. The surgical wound through a sinus tract. did not heal fully and had non It can be either direct inoculation, foul-smelling scanty discharge from the haematogenous spread or by wound site. Culture and sensitivity contiguous infection from nearby taken from a previous hospital showed tissue. The most common causes of growth of Morganella Morganii. septic arthritis of hip are Staphylococcus aureus, Streptococcus On arrival at our hospital, the patient pneumoniae and Streptococcus was febrile and tachycardic, with right Viridans. One rare cause of septic hip swelling and discharging sinus from arthritis is melioidosis which is caused one of the arthroscopic surgical portal by Burkholderia pseudomallei. In septic site. Local warmth and tenderness was arthritis of the hip, increased fluid there, and right thigh also was swollen pressure can lead to avascular necrosis and tender. There was minimal right of the head of femur, and septic knee effusion. Range of movements of arthritis of hip joint is a surgical right hip where grossly limited. Distal emergency. pulses, sensations, toe and ankle movements where normal. Case report A 30 year old gentleman came to the orthopedic department with complaints of intermittent fever and right hip pain for one and a half months duration. The fever was intermittent with spikes more in the night and occasional chills. Associated with the fever, he developed right hip pain which started initially was dull. The pain was on and off pain, progressing in intensity, present more during the night, aggravated by right hip movements, and relieved by rest and medication. Later on the pain was present even during rest and the daily activities of the patient were severely limited due to the pain.

APRIL 2017 • CAPSULE MAGAZINE • 12 A RARE ORGANISM CAUSING SEPTIC ARTHRITIS OF HIP JOINT

The patient was taken up for surgery On the 1st Post op day, the patient and open washout of right hip joint developed breathing difficulty, and intraoperatively, the patient was persistent tachycardia, tachypnoea and noted to have severe destruction of the drop in Oxygensaturation to 76%, and femoral head and articular cartilage he had Persistent fever spikes. Post-op and excision arthroplasty of the right investigations showed low Hb- 7.6, hip with antibiotic impregnated cement elevated Liver Function Tests & ALP. In bead (meropenem+ cefotaxime) view of SIRS and early ARDS, the application was done. Patient was put patient was intubated, ventilated, blood on intravenous antibiotics and and blood products transfused, analgesics and post operatively skin antibiotics escalated. Patient put on traction was applied. Synovial biopsy DVT prophylaxis. Pus culture and taken during the surgery showed sensitivity was taken during the surgery, non-specific synovitis and where it showed heavy growth of Histopathological examination of Burkholderia Pseudomallei. Antibiotics femoral head showed osteomyelitic where changed appropriately with changes. supportive care. With the above measures the patient improved, his The patient was taken up for surgery CRP decreased serially. Liver function Melioidosis and its orthopedic and open washout of right hip joint improved, and the patient was weaned manifestations and intraoperatively, the patient was from ventilator on POD6 and Melioidosis is caused by gram negative noted to have severe destruction of the extubated on POD7 and shifted to bacilli–Burkholderia femoral head and articular cartilage ward on POD8. The patient was taken pseudomallei/mallei, found in moist soil and excision arthroplasty of the right up for wound wash and removal of and water. It is endemic in Southeast hip with antibiotic impregnated cement antibiotic impregnated cement beads Asia and Australia. The usual mode of bead (meropenem+ cefotaxime) on the 16th post op day. The patient infection is either by inoculation, application was done. Patient was put continued to receive appropriate IV ingestion or inhalation. People with on intravenous antibiotics and antibiotics, analgesics and supportive diabetes, chronic alcoholics, immuno analgesics and post operatively skin care and his general condition suppressed individuals ….etc are found traction was applied. Synovial biopsy improved. Physiotherapy and to be affected more commonly. taken during the surgery showed mobilization was done, his surgical non-specific synovitis and wounds healed and was discharged Melioidosis has a broad spectrum of Histopathological examination of with advice to continue long term clinical manifestations and may present femoral head showed osteomyelitic antibiotics. changes. as pneumonia, fever, myalgia, or rare but well recognized orthopedic manifestations as septic arthritis. A study published in the Malaysian journal of orthopedics in 2009 showed that abscesses where the main cause of orthopedic referral in melioidosis cases accounting for up to 63.6% followed by septic arthritis and cellulitis. Melioidosis can also lead to severe septicemia and may prove to be life threatening.

Conclusion The patient was readmitted after six Melioidosis is a pyogenic months for right total hip replacement. infection caused by the gram negative Cementless total hip replacement was bacilli Burkholderia pseudomallei, with done for him. Now the patient is a wide variety of clinical manifestations comfortable, ambulant with a painless and high mortality. It may present as a hip. simple pneumonia, septic arthritis, or even severe sepsis, so the diagnosis should be made with a high index of clinical suspicion and prompt measures should be taken to ensure the patient’s wellbeing.

13 • CAPSULE MAGAZINE • APRIL 2017 PAPILLARY CARCINOMA OF THYROID

Papillary Carcinoma of Thyroid Dr. Anish, MS., MRCH., MCh., Consultant Surgical Oncologist Kauvery Cancer Centre, Tennur, Trichy

Case report Mrs. Durga Devi, a 27 yrs old lady with no major comorbids had come with swelling on both the sides of the neck. She noticed this around six months back, and found that it was gradually increasing in its size. On examination she was found to have bilateral large level 2 neck nodal mass around 4*3 cms in right side and 3*3 cms in left side, along with other small multiple level 4 and 5 nodes on both sides. A solitary nodule of size 2*2 cms was palpable in right lobe of thyroid with rest of the gland appearing normal. FNAC from the thyroid nodule and neck node was suggestive of papillary carcinoma of thyroid and her CT neck showed large bilateral neck nodal mass with other smaller nodes, IJV and carotids were free, no mediastinal nodes or lung metastasis seen.

Thyroid cancers are one of She underwent total thyroidectomy staging was pT1N1bMo (Stage 1), in preserving both sides recurrent view of her intermediate risk category, the commonest head and laryngeal and both parathyroid glands she was planned for thyroxine neck cancers, representing with central compartment neck withdrawal for 4 weeks and then for dissection (level 6) and bilateral radioiodine ablation therapy. around 5% of all cancers in modified radical neck dissection type III women and 2% in men. removing level 2, 3, 4 and 5 nodes Discussion Around 5-10 % of all after preserving spinal accessory nerve, Papillary carcinoma of thyroid is the internal jugular vein and commonest histological type thyroid nodules on sternocleidomastoid muscle on both representing 80-90% of thyroid evaluation are found to be the sides. Her postoperative period was cancers. They are slow growing tumors uneventful, without any hypocalcaemia which predominantly spread to lymph malignant. Incidence of or voice change. Her drains were nodes in the neck, initially to the central thyroid malignancy is removed on sixth day of the post-op compartment and then to the lateral and she was discharged after that. Her compartment. Surgical removal by total increasing steadily, because final histopathology showed unifocal thyroidectomy is the preferred method of more number of 1.5 *1.5 cm classical papillary in all patients diagnosed with papillary carcinoma of right lobe of thyroid carcinoma thyroid except in tumors less incidental nodules without any capsular invasion or than 1 cm with no high risk features detected by imaging and lymphovascular invasion. 7 out of the where it can be safely observed. further evaluation. 22 nodes removed were positive for Prophylactic central compartment neck malignancy. Her final pathological dissection is advised in T3/T4 tumors

APRIL 2017 • CAPSULE MAGAZINE • 14 PAPILLARY CARCINOMA OF THYROID

and all other patients’ central Conclusion compartment or lateral compartment Papillary carcinoma of thyroid is one of neck dissections are done only when those cancers with very good survival the nodes are involved by tumor.Post rate, even in the advanced stages. The operatively patients are risk stratified key to a successful treatment is based on the histopathology and aggressive surgical resection of the serum thyroglobulin levels into low risk, tumor, not leaving behind any residual intermediate and high risk groups. tumor or the thyroid tissue even at the Except for patients in low-risk groups, extent of resecting the trachea or the all other patients have to receive esophagus and the nodal tissues even radioiodine ablation after 4-6weeks of in locally advanced tumors to achieve thyroxine withdrawal period or receive the complete removal. With a good rTSH before ablation. Post ablation, the surgical resection along with post-op- patient has to receive suppressive dose erative radioiodine ablation therapy of thyroxine to maintain the TSH levels even in metastatic tumors especially in below 0.1u/ml and kept on follow up. patients below 55 years of age good overall survival can be achieved.

We extend a hearty welcome to our Kauvery family

Dr. B. Anish, MS., MRCH., MCh., Dr. P. Baskar Rao, MD., DM., Surgical Oncologist Medical and Radiation Oncologist Kauvery Cancer Centre, Tennur, Trichy Kauvery Cancer Centre, Tennur, Trichy

15 • CAPSULE MAGAZINE • APRIL 2017 AWARENESS ON VOCAL HYGIENE

Awareness on Vocal Hygiene Dr. Sundhari, MBBS., DNB(ENT)., MNAMS. Consultant-ENT Head and Neck Surgery Kauvery Hospital, Chennai

The impact of voice disorders in professions have a negative effect on the quality of life of those who suffer from voice problems negatively affects on job performance. There is lack of awareness of voice disorders as a work-related disease in most common professionals but voice disorders have been accepted as occupational disorders in some other countries and about and occupational safety for professional voice users are poor.

Many people use their voices for their work. Singers, teachers, doctors, lawyers, nurses, sales people, and public speakers (politicians) are among those who make great demands on their voices. Recent increase in attention for the speakers in media networking, news readers and sports anchors, radio DJs, puts them at risk for developing voice problems.

How do you know when your voice is not healthy? If you answer "yes" to any of the following questions, you may have a voice problem: • Has your voice become hoarse or raspy? • Have you lost your ability to hit some high notes when singing? • Does your voice suddenly sound deeper? • Does your throat often feel raw, achy, or strained? • Has it become an effort to talk? • Do you find yourself repeatedly clearing your throat?

Voice disorders can be caused by many different factors, like physical ailments and diseases. If any disorder in the larynx(voice box) it will shows the symptoms like hoarseness of voice, limitations in pitch and loudness, frequent throat clearance, shortness of breath or increased vocal effort may be a sign of any number of disorders of the larynx.

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

The hoarseness can be due to: contain alcohol or caffeine, which can Use your voice wisely: • Vocal misuse and overuse cause the body to lose water and make • Try not to overuse your voice. Avoid In the incorrect phonation of an the vocal folds and larynx dry. Alcohol speaking or singing when your voice is individual could have a breathy, also irritates the mucous membranes hoarse or tired. strained, husky, or hoarse voice, their that line the throat. resonation will be a hyper-nasality or • Absolute voice rest when you are sick. hypo-nasality. • Use a humidifier or steamer for Illness puts extra stress on your voice. • Singing or speaking with incorrect inhalation, especially in winter or in dry technique climates, dry cough and irritation. • Avoid using the extremes of your • Stress vocal range, such as screaming or • Emotions • Avoid or limit use of medications like whispering. Talking too loudly and too • Any inflammation due to: common cold and allergy medications. softly can both stress your voice. • Irritation, such as smoke If you have voice problems, ask your • Drying of the vocal cords doctor which medications would be • Practice good breathing techniques • Infection safest for you to use. when singing or talking. Support your • Acid reflux coming up from the voice with deep breaths from the chest, stomach and don't rely on your throat alone. • Allergies Maintain a healthy lifestyle and diet: Singers and speakers are often taught • Some medications • Don't smoke, it irritates the vocal exercises that improve this kind of • Structural changes in the vocal cords folds. Also, cancer of the vocal folds is breath control. such as: seen most often in individuals who • The early stages of nodules on the smoke. • Avoid cradling the phone when vocal cords talking. Cradling the phone between • A cyst • Avoid eating spicy, sour and fried the head and shoulder for extended • A polyp foods, avoid carbonated drinks. Spicy periods of time can cause muscle • A bleed into the vocal cord foods can cause stomach acid to move tension in the neck. • Nerve damage (very rare) associated into the throat or oesophagus, causing with stroke, post thyroidectomised heartburn or GERD. • Avoid talking in noisy places. Trying to surgery, post hospitalization in talk above noise causes strain on the Intensive medical care or any skull base • Include plenty of whole grains, fruits, voice. tumours and vegetables in your diet. These foods contain vitamins A, E, and C. Consider voice therapy. A speech-lan- Tips to prevent voice problems They also help keep the mucus guage pathologist who is experienced Stay hydrated: membranes that line the throat healthy. in treating voice problems can teach • Drink plenty of water. Six to eight you how to use your voice in a healthy glasses a day is recommended. • Get enough rest. Physical fatigue has way. a negative effect on voice. • Limit your intake of drinks that

Quiz 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?

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

Previous Issue’s Question & Answer Question: 16 year old male presented with history of dysphagia and chest discomfort. What is the investigation? What is the diagnosis? Answer Barium Swallow Study, Achalasia Cardia Winner Dr.S.Anandan, Nagapattinam

17 • CAPSULE MAGAZINE • APRIL 2017 RENAL UPDATE 2017

Renal Update 2017

Kauvery Kidney centre of Kauvery Hospital, Trichy to commemorate the World Kidney Day, observed on March 9th worldwide, has organized a Urology CME titled “Renal Update -2017”, focusing on obesity and renal disease on 19th of March at Sangam Hotel around 9.30 Am.

The theme for this year is Kidney Disease & Obesity. This CME has focused on obesity related renal disease with four exciting topics and a quiz. Dr.S.Kandaswamy, Consultant Nephrologist, and Dr.S.Senthil Kumar, Sr.Consultant Urologist, Dr.T.Rajarajan, Consultant Nephrologist were the prominent speakers of the CME.

Dr.Ve.Senthilvel Murugan, Sr.Consultant Radiologist of Kauvery hospital rendered the welcome address. Quiz was organized by Dr.Balaji, Consultant Nephrologist and Dr.N.Karthikeyan, Consultant Urologist. Around 150 delegates had participated in the workshop encompassing various Surgeons across . The Program paved a platform for the clinicians to develop skills and share their knowledge which would eventually benefit the patients Pattimandram Kauvery Kidney centre of Kauvery His scintillating performance had kept Hospital, Trichy to commemorate the the audience of 500, completely World Kidney Day, observed on March spellbound throughout the program. 9th worldwide, has organized a series He emphasized the need to adopt of events like water bottle campaigns, positivity in lifestyle and being cautions one week urology camp at Thennur at the same time to prevent enormous Kauvery Hospital, for the public from diseases. As human body is temple 6th to 10th March 2017. Radio Talk by where God resides, and the best Dr.N.Karthickeyan, Urologist, and service we can do to our body is to Dr.T.Rajarajan Nephrologist of Kauvery keep it hale and healthy. He also Hospital, on raising awareness on presented numerous facts and data kidneys was aired in the All India Radio. pertaining to myths involved in the Radio Jingles were aired on a leading organ transplant. Fm channel, emphasizing the importance of maintaining proper Along with the pattimandram, there kidney health. A Urology CME titled was an interactive session of the public “Renal Update -2017”, focusing on with the Doctors of Kauvery Hospital obesity and renal disease will also be on their qualms and doubts on various conducted on 19th of March at Trichy. topics pertaining to general health, organ donation, and life after surgeries. A Talk Show (Pattimandram) was Organ donors were specially honored conducted on 9th March 2017 at Devar in the occasion, for their humanity to Hall around 6.00 PM, by renowned help sustain a life. Organ donation is a orator of international repute, Mr.Suki gift from the medical science, which Sivam, on the topic “Who has the most ensures an organ recipient to lead a concern in their health? Men! Or normal walk of life. One human can Women!” He displayed a splendid treat save more than ten needy recipients. for the audience which was interactive, entertaining and also very educative.

19 • CAPSULE MAGAZINE • APRIL 2017 PATTIMANDRAM

Inauguration of Chennai, Anna Nagar Branch The Kauvery medical center at With friendly family-centric Anna Nagar was inaugurated doctors and staff, Kauvery on 15th of March 2017, by medical center aims to bring Ms.Suhasini Mani Rathnam. quality healthcare to During the inauguration, Anna-Nagar and more Ms.Suhasini Mani Rathnam localities in Chennai in the near spoke extensively about how future. With various specialties neighborhood clinics add value like General medicine, to healthcare, by being easily Diabetology, Geriatric accessible and how they help medicine, Cardiology, in identifying serious illnesses Orthopedics, , in patient groups who don't & Urology, immediately visit hospitals for , Mother & ailments. The out-patient unit Child Health, ENT, Plastic & of Kauvery medical center at Reconstructive Surgery, Anna-Nagar is a Kauvery Medical Centres in state-of-the-art facility Anna Nagar and locations designed to diagnose and treat across Chennai will be premier illnesses before they turn into clinics catering to multiple health crisis. The clinic boasts neighborhoods across the city. of facilities like a dedicated , Ultra-sound scan, Color Doppler, Echocardiogram, Digital X-Ray, Digital ECG, State-of-the-art laboratory and Health check up.

APRIL 2017 • CAPSULE MAGAZINE • 20 5S - KAIZEN AWARD

Kauvery Hospital is renowned for its environment, a process-driven excellent care and the commitment approach to healthcare and the towards swift healing, bringing reduction of costs through reduction of unmatched experience which are on wasteful expenses and processes are par with the global standards. The the prime reasons to bestow this award notable service towards humanity has upon Kauvery Hospital. been well received among the people of Trichy, which is the main attribute for Dr. S. Manivanan, Joint Managing its soaring success and elevated growth Director, Kauvery Hospital, expressed which extended in more than four cities his delight on the occasion, "It is widely and six units within the time span of 15 acknowledged that the 5S system years. boosts efficiency, reduces waste and improves quality of products and ABK-AOTS DOSOKAI, a registered services across all industries, and society to liaison between Japan and healthcare is no exception. Healthcare India across diverse spheres, has in India needs to adopt this system on conferred two awards for Kauvery a war footing so that hospitals both Kaizen Award hospital, on January 23rd at Chennai public and private will soon scale up to 5S for 5S Platinum Award, and another international standards. I am also award at Delhi on February 26 for proud to say that the 5S Platinum Quality Control. Platinum Medal and Award lifts Kauvery Hospital into a Certification for the Best Practices in select club of hospitals that have 5S, in Large and Medium Scale managed to acquire this status. This Industries is yet another feather in its award also establishes us as a cap, as Kauvery Hospital is the only world-class hospital that provides hospital to win this award this year, out quality and performance at par with of 50 companies from the global standards." manufacturing and service sector. Clean, safe and clutter-free HEALTHY CHOCOLATE BANANA PANCAKES

HEALTHY Chocolate Banana PANCAKES!

Ingredients Makes 18 servings, 32 calories per serving Although keep in mind, each pancake is pretty small (around 3 inches)

¾ cup of Flour ¾ cup of Skim/Non-fat Milk 2 Egg whites 2 Tbsp of Cocoa (I used Meijers hot cocoa mix which is 36 cals per tbsp!) 2 tbsp of baking powder 1 dash of Salt ½ medium Banana

Nutritional Information per 18 servings:

Calories : 570 Total Fat : 2.9 g Sat Fat : 1.8 g Cholesterol : 24mg Sodium : 469mg Total Carb : 110.6g Dietary Fiber : 4.6g Protein : 24.6g

Directions: 1. In a large bowl, mix the flour, egg whites, baking powder, milk, salt and cocoa until smooth 2. Slice the 1/2 a banana into small slices 3. Heat the griddle or frying pan on low heat. (If you decide to use oil, add those calories, I use cooking spray!) 4. Pour or scoop the batter onto the griddle or pan, use approximately a tablespoon of batter for each pancake. 5. Add banana slices onto the pancakes as they cook. 6. Brown on both sides and serve hot. Enjoy!

APRIL 2017 • CAPSULE MAGAZINE • 22 KMC INSTITUTE OF PARAMEDICAL SCIENCES (Affiliated to The Tamilnadu Dr. M.G.R. Medical University, Chennai)

ADMISSIONS OPEN FOR 2017-2018

Courses Offered • B.Sc (Nursing) • General Nursing (GNM), Tamilnadu Nursing Board • B.Sc Cardio Pulmonary Perfusion Care Technology • B.Sc Physician Assistant • B.Sc Accident & Emergency Care Technology • B.Sc Medical Laboratory Technology (MLT) • B.Sc & Imaging Technology • Diploma in Critical Care Technology • Diploma in Radiology & Imaging Technology

Contact: P: +91-431-2680190 M: +91-96888 33211

kauvery hospital In Association with

Bharathidasan University Offering One Year Certificate Courses

• Operation Theatre Technician • Respiratory Technician • Cardiac Technician • Emergency Care Technician • Radiological Assistant • Central Sterile Supply Department Technician • Dialysis Technology • Echo Technician • Anaesthesia Technician • Diabetic Technician

#1, K.C. Road, Tennur, Trichy - 17. Ph: 0431-40 22 555 | Cell: 94885-53763 | W: www.kauveryhospital.com ADMISSIONS OPEN FOR MASTERS IN EMERGENCY MEDICINE(MEM)

Eligibility: MBBS (with Indian Medical Council Number) 3 years Post Graduate Program in collaboration with Society for Emergency Medicine India (SEMI)

Course Highlights: • Training in Emergency medicine by experienced faculty • Supervised rotations in department such as Emergency, Critical care, Anesthesia and CCU • Excellent job opportunity in corporate hospitals • Course fees Rs.1,45,000 per year • Stipend Rs.25,000 per month • Three year course Facilities Available • Emergency department • ICU, Neuro ICU, Liver ICU, IMCU, PICU , CCU • Operation Theaters

Requirements: CV with originals for verification Walk in Interview: 20th April 2017 Contact Person: Mrs.Kirthikha – 9677580597 Time: 12.00 Noon Email id: [email protected]

Kauvery Hospital, No.6 , Royal Road, Cantonment, Trichy– 620 001. Trichy | Chennai | Karaikudi | Hosur kauvery cancer care centre Tennur, Trichy

Cancer doesn’t kill But Ignorance will...

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]