Abstract Book

JIC 2020 January 3-5, 2020

Abstract Book

Annual Scientific GMERS th Medical College, Symposium Sola, 16 Ahmedabad 25th Year of Academics 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020

LOCAL ORGANIZING COMMITTEE

Conference Chairman : Dr. Keyur Parikh CIMS Hospital, Ahmedabad Conference Patron : Dr. Nitin Vora GMERS, Sola, Ahmedabad Chairman, Scientific Committee : Dr. Milan Chag CIMS Hospital, Ahmedabad Organizing Secretary : Dr. Satya Gupta CIMS Hospital, Ahmedabad : Dr. Tejas V. Patel CIMS Hospital, Ahmedabad

Conference Advisor : Dr. R.M. Jitea GMERS, Sola, Ahmedabad Dr. Ajesh Desai GMERS, Sola, Ahmedabad Dr. H.R. Jadav GMERS, Sola, Ahmedabad

ASSOCIATION OF PHYSICIANS OF AHMEDABAD Dr. Ashvin Gadhavi President (APA) Dr. Anil Kulshrestha Hon Secretary (APA)

Conference Directors & Co-ordinators

Dr. Hemang Baxi Dr. Hiren Dholakia Dr. Pranav Modi Dr. Jayesh V. Patel Dr. Jignesh Shah Dr. Sneha Baxi Dr. Manish Gandhi Dr. Ajay Naik Dr. Mayur Patil Dr. Pranav Shah Dr. Sagar Betai Dr. T.K.B. Ganpathy Dr. Dhaval Naik Dr. Ashka Prajapati Dr. Manisha Shah Dr. Darshan Bhansali Dr. Sneha Gohil Dr. Parth Parekh Dr. Hardik R. Shah Dr. Nitesh Shah Dr. Niren Bhavsar Dr. Parth Goyal Dr. Maulik Parmar Dr. Divyesh Sadadiwala Dr. Deepa Shah Dr. Devang Bhavsar Dr. Kishor Gupta Dr. Gunvant Patel Dr. Vineet Sankhla Dr. Kirtan Shah Dr. Maulik Bhensdadia Dr. Krunal H. Patel Dr. Chandni Patel Dr. Praveen Sarda Dr. Rupesh Shah Dr. Parloop Bhatt Dr. Rajiv Harshe Dr. Vivek Patel Dr. Urmil Shah Dr. Nimish Sharma Dr. Reena Sharma Dr. Keyur Buch Dr. Abhinav Jain Dr. Prashant Patel Dr. Dhiren Shah Dr. Chintan Sheth Dr. Amit Chandan Dr. Rahul Jaiswal Dr. Mayank Patel Dr. Shaunak Shah Dr. Kashyap Sheth Dr. Anish Chandarana Dr. Pranav Joshi Dr. Rushi Patel Dr. Bhagyesh Shah Dr. Rachit Sheth Dr. Parvin Chandarana Dr. Vikramjit Kanwar Dr. Purna Patel Dr. Hemal Shah Dr. Samip Sheth Dr. Amit Chitaliya Dr. Vipul Kapoor Dr. Devang Patel Dr. Umakant Shah Dr. Puja Srivastava Dr. Rashmi Chovatia Dr. Anand Khakhar Dr. Tarang Patel Dr. Jeegar Shah Dr. Mahavir Tadaiya Dr. Dipak Desai Dr. Vatsal Kothari Dr. Ashok Patel Dr. Chirag Shah Dr. Vipul Thakkar Dr. Pradip Dabhi Dr. Surabhi Madan Dr. Natoo Patel Dr. Bhavini Shah Dr. Bhavesh Thakkar Dr. Parindra Desai Dr. Reedham Mehta Dr. Satish Patel Dr. Rechal Shah Dr. Deepa Trivedi Dr. Chirag Desai Dr. Uma Mehta Dr. Amit Patel Dr. Shalin Shah Ms. Reena Trivedi Dr. Prapti Patel Desai Dr. Ankita Midha Dr. Malhar Patel Dr. Chintan Shah Dr. Deven Zaveri

GMERS Organization Team

Dr. Jignasa Bhalodia Dr. H.R. Jadav Dr. Kiran Rami Dr. Falguni Shah Dr. Neena Bhalodiya Dr. Rajesh Mehta Dr. Krina Patel Dr. Bhavesh Jesalpura Dr. Parul Bhatt Dr. Prakash Mehta Dr. Nehal Patel Dr. Deepika Singhal Dr. Pranav Chakravarty Dr. Nehal Naik Dr. Ila Patel Dr. Nidhi Sood Dr. Ajesh Desai Dr. Jigesh Shah Dr. Sunil Patni Dr. Mukesh Vora

Jointly Organized by Care Institute Medical Society for Research and GMERS Medical College , Education (CIMSRE) & GMERS Medical College, Sola, Sola, Ahmedabad and in association with Ahmedabad Association of Physicians of Ahmedabad.

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FROM THE DESK OF ORGANIZING COMMITTEE

We proudly announce JIC 2020 (January 3-5, 2020) in Ahmedabad, India.

First of all, we would like to thank you for your immense support and active participation in JIC every year.

With each passing year, JIC is strongly identified as a great scientific learning experience.

We do our utmost to deliver interactive, case-based sessions for you to become active participants in the program.

Panel Discussions and Question-Answer at the end of each session go on to create a collaborative and interactive experience for delegates.

This year we have introduced for the first time 'An All Women Clinician Session' to recognise, appreciate and acknowledge the growing role of women in the medical field.

On January 3-4 we have a 'Town Hall Meeting Session' which makes for great interaction and open forum for your questions to be answered.

JIC 2020 has an exhaustive and comprehensive Scientific Agenda with an eminent list of speakers from all over the globe.

We look forward to meeting you at JIC 2020.

Dr. Keyur Parikh Dr. Milan Chag Dr. Satya Gupta Dr. Tejas V. Patel Conference Chairman Chairman, Scientific Committee Conference Secretary Conference Secretary

See you at JIC 2020 Ahmedabad, India

PANDIT DINDAYAL UPADHYAY AUDITORIUM Rajapth Club Road, Ahmedabad

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INTERNATIONAL FACULTY

Dr. Claire D. Brindis Dr. Ralph Brindis Dr. Ramesh Daggubati Dr. Bhavin Dalal Dr. Ashit Jain Dr. Samir Kapadia Dr. Neil Mehta

Dr. Roosha Parikh Dr. Apurva Patel

CANADA GERMANY

Prof. Dr. Carsten Tschöpe HUNGARY

USA

Dr. Peter Lin Dr. Geza Fontos

NATIONAL FACULTY

Dr. Amit Gupte Mumbai Dr. Keyur Panchal Mumbai Dr. Parag Shah Ahmedabad

Dr. Uday Jadhav Mumbai Dr. Sanjeev Phatak Ahmedabad Dr. Manoj Vithlani Ahmedabad

Dr. Ashish Nabar Mumbai Dr. P. Piraman Chennai Dr. Preyas Vaidya Mumbai

Dr. Sandeep Nayar Delhi Dr. Banshi Saboo Ahmedabad

Dr. Mayur Patel Ahmedabad Dr. Rajesh Sainani Mumbai

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Introduction to 25 years of Academics /Lipid Guidelines: 2020 - We Should all Adapt Dr. Keyur Parikh Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Figure 1: The 2019 ESC/EAS Guidelines New Lipid Goals:

Greater Benefit from Ezetimibe added to statin in High-Risk patients: TIMI Risk Score for secondary prevention (TRS 20 P) applied to IMPROVE-IT to identify high-risk patients and data suggest the benefit of adding EZETIMIBE is much more in high risk group patients. In order to be aligned with these new findings, the ESC/EAS Guidelines have proposed new LDL-C goals, as well as a revised CV risk stratification, which are especially relevant to high- and very-high-risk patients. Table 1: Intensifying Lipid-Lowering Treatment to Reach LDL-C Goals:

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In the 2019 ESC/EAS Guidelines, patients classified as being at very high risk are those with documented ASCVD; patients with diabetes with target organ damage; patients with familial hypercholesterolaemia with ASCVD or another major risk factor, and patients with severe chronic kidney disease. The 2019 ESC/EAS guidelines recommend both a ≥50% LDL-C reduction from baseline and an absolute LDL-C treatment goal of <1.4 mmol/L (<55 mg/dL) for very high-risk patients. For patients at high risk, a ≥50% LDL-C reduction and an LDL-C goal of <1.8 mmol/L (<70 mg/dL) are recommended. A high-intensity statin should be prescribed up to the highest tolerated dose to achieve specified goals. DL-C levels tend to decrease during the first days of ACS and therefore a lipid profile should be obtained as soon as possible after admission for ACS. Patients do not have to be fasting as this has little impact on LDL-C levels. Lipid-lowering treatment should be initiated as early as possible to increase patient adherence after discharge. Lipid levels should be re-evaluated 4–6 weeks after ACS to determine whether treatment goals have been achieved and to check for any safety issues; the therapeutic regimen can then be adapted accordingly. Possible reasons for failure to meet LDL-C goals are as below: Lack of adherence, drug intolerance, patient characteristics, lack of lifestyle changes, failure to titrate/switch to more potent dose/statin, underuse of additional lipid-lowering therapies and inadequate follow-up. Importance of adherence to lipid lowering agent with high intensity lipid lowering drugs have been found to be associated with better CV outcomes. Decreased likelihood of reaching LDL-C goal: female, stable angina, obese, sedentary lifestyle, current smokers. Increased likelihood of reaching LDL-C goal: patients with T2D or CKD (and high CV risk). Conclusion: Statins remain the mainstay in reducing CV risk. The addition of ezetimibe provides further LDL-C lowering. Very low LDL-C levels can lead to regression of atherosclerosis. New lipid guidelines endorse lower LDL-C goals, particularly for patients with very high-risk ASCVD. According to 2019 ESC/EAS guidelines only about one-quarter of very high-risk patients need an additional LDL-C lowering with ezetimibe and/or PCSK9 inhibitor.

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History of Angioplasty and the Way Ahead into 2020 - 40 years of Innovation Dr. Keyur Parikh Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Introduction: To answer the question of how balloon angioplasty was invented, it is necessary to know how the idea of using a balloon to dilate a coronary artery was successfully tested, and how this intuition opened up a new era in the treatment of coronary artery disease. Andreas Grüntzig’s dream was to treat vascular disease percutaneously with a catheter in conscious and alert patients. The genius of Andreas Grüntzig allowed improvements to Charles Dotter’s tools in an effort to perform balloon dilatation of coronary arteries.

Andreas Gruntzig Home-made Catheter Stents Images

Ÿ The first course, held in August 7-10, 1978, was attended by 28 cardiologists. Andreas Grüntzig’s experience at that time involved 25 patients.The potential of this new method was coming to light, bringing hope for a simple treatment for coronary artery disease. Ÿ The second course, held in April 1979, was attended by 90 participants. At that time, 264 coronary angioplasties had been carried out worldwide with a 60% primary success rate, 2% in-hospital mortality rate and 10% emergency surgery rate. Ÿ The third course, held in January 1980, was attended by 171 participants. Ÿ In February 1981, the first course in Atlanta, USA was held in the auditorium of the magnificent Woodruff Center. Robert Woodruff, owner of Coca-Cola and a leading philanthropist, had given a $105 million grant to the Emory University School of Medicine in 1979

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1985-86 September, 5th USA Attendees=200 TCT 2019, First ever complex angioplasty course in USA’S FOREMOST ANGIOPLASTY COURSE HAD OVER the world was in September 1986 which 10,000 ATTENDEES THIS YEAR Dr. Keyur Parikh had attended

MECHANICAL TREATMENTS: The concept of using Directional Atherectomy (Devices for Vascular Intervention, Redwood City, CA, USA) in coronary arteries was introduced by John Simpson in 1985. It was the first alternative interventional technique after balloon angioplasty. The Rotablator (Rotational Atherectomy system, Heart Technology, acquired by Boston Scientific), was developed by David Auth and was used in coronary arteries for the first time by Jean Louis Fourrier in Lille, on January 6, 1988. The Cutting Balloon (Flextome Cutting Balloon, InterVentional Technologies, San Diego, CA, USA, acquired by Boston Scientific), invented by Peter Barath was used for the first time in 1993.

Conclusion: Interventions-2020 has come a long way. Coronary artery stents, Bioresorbable scaffolds, Drug- coated balloons, Calcified Coronary Lesions - Rotablator and OA, Directional atherectomy, Laser, therapy, Distal protection and thrombectomy, Bifurcation lesions, Ostial lesions, Left main coronary artery disease. Complex Coronary-Interventions. Peripheral Interventions. Congenital Heart Disease Interventions. Valvular Interventions and Other Interventions like, Left atrial appendage occlusion, Alcohol septal ablation for hypertrophic obstructive cardiomyopathy, Percutaneous closure of paravalvular, leaks, Alternative techniques to alcohol septal ablation for hypertrophic obstructive cardiomyopathy Renal Nerve Ablation in Hypertension myocardial stem cell delivery, Cell-based regenerative therapy, Pulmonary embolism and pulmonary hypertension, Balloon pulmonary angioplasty and Endovascular treatment of acute ischemic stroke and the list goes on.

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Stabilizing Potential Organ Donor (Brain Dead) for Meaningful Organ Donation Dr. Chintan Sheth Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

Every day, the demand for organs is increasing at a faster rate than that at which organs are becoming available for transplants. With this increasing demand, the responsibility with regard to caring for potential organ donors is also rising. Appropriate medical management of a potential organ donor is a very important issue, requiring a multidisciplinary team approach for successful organ transplantation. For graft survival after donation, all available organs in the donor need to be maintained at their normal physiological condition until the time of organ retrieval. Brain death is associated with numerous pathophysiolocal changes that requires prompt anticipation and management. Brain death patient requires aggressive intensive care as circulatory death is common within 48 hours post brain death. In upcoming lecture, I will discuss pathophysiological changes associated with brain death and its management.

Case-Based: RAAS Inhibition in Kidney Disease: Balancing Risk vs Benefit Dr. Anish Chandarana Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

Should we continue or STOP Angiotensin Converting Enzyme Inhibitors/Angiotensin Receptor Blockers in Advanced Kidney Disease?” has been a very commonly asked question as well as a conflicting clinical situation in day to day practice. Chronic kidney disease (CKD) is a serious health problem associated with a high prevalence of cardiovascular disease and reduced quantity and quality of life. Angiotensin converting enzyme inhibitors (ACEI) and angiotensin II receptor antagonists (ARB) are commonly used in patients with early CKD, but their value in advanced CKD (estimated GFR (eGFR) ≤ 30 ml/min/1.73 m 2 ) is unknown. There are no studies assessing the benefits of ACEI/ARB therapy in cardiovascular risk reduction in advanced non-dialysis CKD. There remains a debate about the omission of ACEI/ARB in patients with advanced CKD. Also, sizable population of chronic heart failure (CHF) and post myocardial infarction-LV systolic dysfunction (PMILVD) patients, who need these drugs for their overall risk reduction, do suffer from CKD. Unfortunately, in all randomized, controlled trials done with ACEI/ARB in patients with CHF/PMILVD have excluded patients with advanced CKD. Thus, use of ACEI/ARB for whatever indication in patients with advanced CKD remains to be proven. Most important question is- does the potential gain in eGFR with ACEI/ARB cessation outweigh the potential adverse cardiovascular outcomes? This case presentation will help physicians’ clinical decision making in such situations.

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Case-Based: Approach to Endocrine Hypertension Dr. Vivek Patel Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID : [email protected]

Endocrine causes of hypertension include primary aldosteronism, pheochromocytoma, Cushing’s syndrome, hyperparathyroidism and hypo- and hyperthyroidism. They comprise of the 5% – 10% of the causes of secondary hypertension. Primary hyperaldosteronism, the most common of the endocrine cause of hypertension often presents with resistant or difficult to control hypertension sometimes associated with hypokalaemia. Pheochromocytoma, the great mimicker of many conditions, is associated with high morbidity and mortality if left untreated. It is important to detect these conditions as many of them have specific treatment and frequently curable. A complete history, physical examination along with a high index of suspicion with focused biochemical and radiological evaluation is required to diagnose and effectively treat these conditions. A multidisciplinary approach involving primary care physician, endocrinologists and surgeons is recommended in optimal management of these conditions.

Management of Non Alcoholic Fatty Liver Disease Dr. Bhavesh Thakkar Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

Fatty liver disease is excessive accumulation of fat of >5% within the liver associated with insulin resistance and exclusion of secondary causes & alcoholic liver disease. NAFLD is the most common liver disorder in Western countries, affecting 17–46% of adults parallels the prevalence of metabolic syndrome (MetS) and its components, which also increase the risk of more advanced disease NAFLD is also present in 7% of normal-weight (lean) individuals. In India: In the general population, prevalence of NAFLD varies from 9% to 35%. NAFLD ranges from the more benign condition of nonalcoholic fatty liver (NAFL) to nonalcoholic steatohepatitis (NASH), which is at the more severe end of the spectrum. In NAFL, hepatic steatosis is present without evidence of inflammation, whereas in NASH, hepatic steatosis is associated with lobular inflammation and apoptosis that can lead to fibrosis and cirrhosis. Fibroscan is accurate tool for non-invasive quantification of hepatic fibrosis.

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Management of Nonalcoholic Fatty liver disease: Ÿ Abstinence of alcohol. Ÿ Immunization for Hepatitis A and Hepatitis B Ÿ Modification of cardiovascular risk factors like Hypertension and dyslipidemia Ÿ Weight reduction upto 7 to 10 % Ÿ Pharmacotherapy Ÿ Strict control of diabetes mellitus

COPD and CAD are Two Sides of One Coin! Dr. Bhavin Dalal Oakland University William Beaumont School of Medicine and Beaumont Health, Royal Oak, Michigan, USA Corresponding Email ID: [email protected]

Most of the patients with COPD are smokers or exposed to smoke which is one of the most important risk factors for CAD also. So, CAD and COPD are great buddies! Importantly there are clinical consequences for each disease. Signs and symptoms of both diseases overlap with each other frequently. So, at given time it Is difficult to decide which disease is acting up. These facts are very important as there are several misconceptions in management. For e.g. B blockers are contraindicated in patients with COPD. According to newer studies and evidences B blockers in patients with COPD doesn’t affect lung function. In fact, patients who required B blockers for the purpose of CAD or CHF, mortality was lower in patients who were on B blockers compared to patients who were not on B blocker.

Case-Based: Roll of Cardiac MRI in Heart Failure: Current Roll and Case Discussion Dr. Deepa Shah Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

Noninvasive imaging plays a central role in the diagnosis of heart failure, assessment of prognosis, and monitoring of therapy. Cardiovascular magnetic resonance (CMR) offers a comprehensive assessment of heart failure patients and is now the gold standard imaging technique to assess myocardial anatomy, regional and global function and viability. Furthermore, it allows assessment of perfusion and acute tissue injury (edema and necrosis), whereas in nonischemic heart failure, fibrosis, infiltration, and iron overload can be detected.

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The information derived from CMR often reveals the underlying etiology of heart failure, and its high measurement accuracy makes it an ideal technique for monitoring disease progression and the effects of treatment. Evidence on the prognostic value of CMR-derived parameters in heart failure is rapidly emerging. Cardiovascular magnetic resonance (CMR) is a rapidly evolving technology that is increasingly being used for the noninvasive imaging of the expanding HF population. In this lecture discussion is about: 1) measurement of LV function by CMR 2) Differentiation between coronary and non coronary cardiomyopathy in patients with HF and 3) what the expanding role of CMR is for prognostic evaluation in the HF population. Today, a plethora of non-invasive imaging tools are available to clinicians to assess coronary heart disease( CHD). These include nuclear medicine, echo ultrasound, CT, and MRI ; each used with its pros and cons to complement and correlate findings based on guidelines and investigations. Magnetic resonance imaging (MRI) offers new standards of excellence in the diagnosis and management of cardiac care. This minimally invasive procedure, does not involve radiation to deliver unparalleled image quality. Principally cardiac MRI protocols can be divided into three groups: (1)Anatomic / Morphologic,(2) Function / Motion and (3)Myocardial Viability / Perfusion. Cardiac magnetic resonance (CMR) provides a unique perspective on myocardial tissue characteristics, which is important for diagnosis and management of patients with CHD and is recognized as a "gold standard" for myocardial viability. This test provides an accurate assessment for evaluation of myocardial viability, ventricular and valvular functions; causes of heart failure and arrhythmias , cardiac masses, visualization of congenital abnormalities, characterization of the aorta and pulmonary veins. This presentation focuses on the usefulness of cardiac magnetic resonance (CMR) imaging and its comparison with contemporary imaging modality for varied useful indications to the clinicians. In times to come it would not be an exaggeration to write Cardiac MRI- “One stop shop” in diagnostic cardiology.

Case-Based: Role of MRI in Cardiomyopathies & Myocarditis: Mandatory MRI in Today's Era Dr. Roosha Parikh Houston Methodist DeBakey Heart & Vascular Center, Houston, USA Corresponding E-mail id: [email protected]

Imaging in Cardiomyopathy: Cardiomyopathy Class I defines a 2-dimensional echocardiogram with Doppler should be performed during initial evaluation of patients presenting with heart failure to assess ventricular function, size, wall thickness, wall motion, and valve function. Class IIa - Radionuclide ventriculography or magnetic resonance imaging can be useful to assess LVEF and volume when echocardiography is inadequate.

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Case Discussions: HPI: 44 year old man with chest pain with history of tobacco abuse and positive family history for premature CAD and during hospital course ECG suggested nonspecific ST-T abnormalities, Peak CK 1050, MB 105, Trop 30, treated with IV heparin and 2B/3A inhibitors. Subject’s coronary angiography showed normal coronaries.

Figure 4: Different Healing stages of Myocarditis: Figure5: Idiopathic dilated CMP:

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Figure 6: Clinical Magnetic Resonance Imaging:

Role of CMR in Cardiomyopathy: LV Function: HFrEF vs. HFpEF. CAD status: Ischemic vs. Nonischemic and Myocardial Fibrosis via CMR LGE aids in: Diagnosis as well as Prognosis. Conclusion: In today’s era MRI stands as a mandatory diagnostic tool in Cardiomyopathies and Myocarditis

Case-Based: What is New in Infectious Diseases? Dr. Surabhi Madan Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

Keeping ourselves updated in our respective fields is the need of the hour. We will be discussing about what has happened in the last one year in the field of infectious diseases, citing some cases and examples. It would include all the important trials and studies which have changed our practice.

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Best Practices Update: Integration of Liver Elastography in Clinical Practice - A Case Based Discussion Dr. Abhinav Jain Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

Chronic liver diseases (CLD) are very common. Both the prognosis and the management of CLD patients are closely linked to the level of liver fibrosis. A liver biopsy is the reference procedure for liver fibrosis evaluation, but it is invasive and therefore is not utilized routinely. liver stiffness measurement (LSM) by elastography is a non-invasive alternative to liver biopsy. By fibroscan in patients with CLD, we can estimate the baseline fibrosis and monitor for progression or regression via serial measurements. The fibroscan results may also guide the decisions regarding management. The advantages of fibroscan are its non-invasive nature, short procedure time (5 minutes), reproducibility and safety.

In this lecture, we shall discuss the position of fibroscan in routine practice as well as its interpretation.

Immunotherapy: New Tool to Fight Cancer Dr. Chirag Desai Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

Human body is comprised of trillions of cells forming several organs that function harmoniously to sustain the life. Critical to the function is apoptosis of the ageing cells and replacement of these cells by active duplication of normal cells. Apoptosis as well as duplication is occurring simultaneously in billions of cells daily and is a tightly controlled activity. The cells have tightly controlled system to check the need of duplication and the process of cell division. If cell prepares to go out of control in the division, it is picked by internal system and is forced to undergo apoptosis. If this check mechanism is evaded by a dividing cell, it has a potential to become a cancerous cell. Daily, thousands of dividing cells in our body have potential to transform to cancer cells. Our immunity has the capacity to identify and kill the cells that have transformed to malignant cells by evading the internal check mechanisms. The cancer cells are the best examples of “survival of fittest” rule of evolution. They find ways to evade the immunity as well and hence they survive and grow and then subsequently metastasize.

Let us understand how body’s immunity identify and eliminate transformed malignant cells. The cancer cells

14 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 are often expressing “neo”antigens. These antigens are identified by dendritic cells and are presented to T lymphocytes in lymph nodes. These T cells are primed and activated to fight against the tumor cells expressing the neoantigens. The pool of these activated T lymphocytes expands, enters blood circulation, reach the tumor sites, infiltrate the tumor microenvironment, identify the tumor cell and mounts attack on the tumor cells.

If this happens, then why the cancers still often go unabated and kill scores of the people? The activation of T cells, their expansion, infiltration and immune attack of tumor cells again is tightly regulated function. The purpose of this tight regulation is to ensure that the immunity is not unnecessarily activated and to protect the normal organs and tissues from immune attack. The understanding of stimulatory and inhibitory signals has improved in recent years and has resulted in better exploitation of body’s immunity to fight cancer.

We have been using immunotherapy to treat cancers for several years with varying success. The examples are:

1. Interferon in chronic myeloid leukemia, renal cell carcinoma and malignant melanoma 2. Interleukin 2 in renal cell carcinoma and malignant melanoma 3. BCG vaccine in urinary bladder carcinoma

Because of poorly understood and nonspecific mechanism of action, these drugs have not been able to make huge impact on the outcome of these cancers. The toxicity of these drugs also prohibit widespread use of these drugs. In recent years, with better understanding of mechanisms of inhibition of immunity to fight cancer, we have been able to counter some of these mechanisms and that has resulted in success in outcome of treatment. These mechanisms together are called “Checkpoints”. We have identified 3 checkpoints and have targeted them to treat cancers. These are: 1. Cytotoxic T Lymphocyte Antigen 4 (CTLA 4) – the drugs inhibiting this checkpoint are – ipilimumab and tremelimumab 2. Programmed Death 1 (PD1) – the drugs targeting this checkpoint are nivolumab and pembrolizumab 3. Programmed Death Ligand 1 (PD-L1) – the examples of drugs targeting this checkpoint are – atezolizumab, durvalumab and avelumab

These drugs are already available in market and are resulting in significant improvement in outcome of some of metastatic cancers. Some of the deadly cancers are successfully treated by these checkpoint inhibitors. Metastatic malignant melanoma is an aggressive cancer with median survival of about 1 year. Practically no patient survival beyond 2-3 years. With the use of ipilimumab, approximately 20% of patients are surviving beyond 10 years. This is one of the examples of success of immunotherapy. Various checkpoint inhibitors as listed above are useful in lung cancer, head and neck cancer, breast cancer, liver cancer, kidney cancer, urinary bladder cancer, melanoma and a few other cancers. In the presentation, I will show a few other examples of success of incorporating immunotherapy in management of cancers. Immunotherapy has emerged as a useful tool in fight against cancer and a lot of research is occurring in this direction.

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Case-Based: Evaluating the Science of Cardiogenic Shock: Redefining the Sequence of Care Dr. Satya Gupta Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

Cardiogenic shock most commonly results from myocardial infarction and is associated with mortality rates ranging from 40% to 50%. Pump failure (rapid development of severe left ventricular dysfunction) is the most common and important cause of developing early cardiogenic shock in patient with myocardial infarction. Mechanical complications viz; papillary muscle dysfunction or rupture leading to severe mitral valve regurgitation, ventricular septal rupture, pseudo or true cardiac aneurysms are not very uncommon. Sudden free wall cardiac rupture rarely occurs but seldom diagnosed due to rapid fatality. Early revascularization improves mortality. Mechanical complications of myocardial infarction require surgical intervention. Medical, devices and mechanical therapies may improve hemodynamics transiently. Massive pulmonary embolism may also result in cardiogenic shock. Prevention of fatal RV failure requires treatment that will result in rapid restoration of flow through the occluded pulmonary arteries. Rarely massive pericardial effusion or tamponade can be seen in early or late stage of infarction and that can lead to cardiogenic shock. Early anticipation of complications of myocardial infarction that can lead cardiogenic shock and management related to specific cause is the key to improve survival in these patients.

Case-Based: Lipid Updates: Implication for Clinical Care Dr. Vipul Kapoor Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Intensity of LDL-lowering therapy should be based on (A) risk, irrespective of cause(s) of the risk (e.g., primary or secondary prevention, diabetes, or chronic kidney disease); and (B) baseline LDL cholesterol (which determines how much reduction in risk can be achieved). Lower is better: lowering LDL-C with statins, ezetimibe, or PCSK9-inhibitors safe and effective to <1.4 mmol/L (55 mg/dL).

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Case-Based: Prevention is Better - Even for Critically ill Dr. Vipul Thakkar Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

As we have experienced while caring for different illnesses, infections and injuries, the old saying “Prevention is better than cure” proves its worth. This is equally applicable in settings of critical care medicine. Common preventive measures in ICU cares are standards of care like, Deep Vein Thrombosis prophylaxis, stress ulcer prophylaxis, pressure sore prophylaxis. Again, while providing critical care in ICU, different nosocomial infection prevention bundles like, VAP, CA-UTI, CRBSI prevention bundles of care are equally important. Our focus at JIC 2020 would be prevention of 1) Acute kidney injury in ICU 2) Aspiration Pneumonia 3) avoidable cardiac arrest in hospital. For any preventive plan to be effective, following are the necessities: 1) Identifying who are “at risk” 2) Well educated and trained team which can assess and implement preventive measures when at risk patient shows signs of early deteriorations(Early Warning Score or calling criteria)

Case-Based: Transcatheter Aortic Valve Implantation in All Aortic Stenosis Patients? Dr. Geza Fontos National Cardiovascular Center, Budapest, Hungary Corresponding Email Id: [email protected]

Background: A decade ago TAVI was criticized to be an expensive treatment of very old patients with limited life expectancy. Nowadays TAVI is becoming the leading treatment modality for management of symptomatic severe aortic valve stenosis thanks to new transcatheter valve platforms, increasing operators’ experience and a series of landmark clinical trials. More than 700,000 TAVI devices have been implanted worldwide to date and the annual volume is likely to reach at 300,000 cases by 2025. Transcatheter aortic valve implantation has been accepted as one of primary options for treatment of symptomatic severe aortic stenosis.

Discussion: Current debates focus on the expansion of TAVI as the standard of care for the treatment of patients with AS in intermediate to low surgical risk patients. Outcomes after transcatheter aortic valve replacement were superior or at least as good as those following surgical aortic valve replacement among patients with severe aortic stenosis at low surgical risk, according to results of the Partner3 and EVOLUT Low- Risk trials. At 30 days, TAVI was statistically superior to surgery for the secondary combined endpoint of all- cause mortality or disabling stroke. Patients receiving TAVI had significantly better quality of life and hemodynamics. One of the issues against TAVI is the increased rates of PVL that were consistently observed after TAVI compared to SAVR. With the current generation of TAVI devices the post procedural PVL rate has

17 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 dropped significantly. With the Evolut Pro THV the majority of patients (89.1%) had no or trace regurgitation. Since the indication for TAVI is moving toward a healthier and younger patient population, new PPMs may become more of an issue. Although the PPM rate of TAVI is still higher than SAVR the amount of mechanical trauma to the conduction system and periprocedural patient management offers the potential for optimization. By optimizing TAVI procedure the ability to achieve low PPM rates is close to reality. Based on the cost-effectiveness studies the significantly higher procedural costs of TAVI are compensated for by shorter hospitalization and substantially lower costs during follow-up. Regional and national differences in reimbursement and device costs impede generalization of these results. The most important unresolved issue of long-term valve durability is probably the key challenge in expanding TAVI to low risk and younger age patients. To eliminate durability concerns after TAVI, very solid durability data available for surgical bioprostheses over the course of more than a decade will need to be matched. Conclusions: Although TAVI has been predominantly used for patients at high risk or with old age who were not considered optimal candidates for surgical aortic valve replacement, its indication is now expanding towards intermediate to low risk patients and younger age. Today, the last frontier for TAVI in becoming the gold standard therapy of AS patients is the lack of long-term durability data. Until we got it SAVR remains the standard therapy for patients <75 years of age with low surgical risk.

Case-Based: Osteoporosis- Frequently Undiagnosed and Undertreated Problem Dr. Vivek Patel Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID : [email protected]

Osteoporosis is a progressive skeletal disorder characterized by reduced bone mass and deterioration of bone microarchitecture. Fragility fractures, the consequence of osteoporosis, are responsible for excess mortality, morbidity, chronic pain, admission to hospitals and economic costs. Osteoporosis is ever increasing as life expectancy continues to increase across the world. In 2013, it was estimated that 50 million people in India are either osteoporotic (T score < −2.5) or have low bone mass (T score between −1.0 and −2.5). Despite this large prevalence, the awareness of osteoporosis is low in India with surveys indicating that only 10% – 15% is aware of the disease. Preventive measures should be started at an early age and should include smoking cessation and weight-bearing exercises. Early diagnosis can be made by regular BMD screening, even before the first fragility fracture. Pharmacologic prevention methods include calcium supplementation and anti-resorptive therapy. For patients with established osteoporosis, medical intervention can halt its progression. Currently available therapies include bisphosphonates, denosumab, teriparatide and calcitonin.

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Case-Based: AF and Stroke - LAA Closure: Still Underutilized! Dr. Geza Fontos National Cardiovascular Center, Budapest, Hungary Corresponding Email ID: [email protected]

Background: In non-valvular atrial fibrillation patients, the stroke prevention efficacy of oral anticoagulant therapy has clearly been demonstrated. However, there are substantial number of patients who are not candidates for long-term oral anticoagulant therapy despite being at high risk for thromboembolic events, therefore the interest in alternative treatment strategies are in focus these days. The most common place within the heart for thrombus formation in patients with non-valvular atrial fibrillation is the left atrial appendage. Transcatheter LAA closure is an emerging alternative to long-term oral anticoagulation. Discussion: Long-term follow-up of randomized clinical trials demonstrate that LAA closure provides significant reductions in hemorrhagic stroke, cardiovascular death and all-cause mortality compared with continued warfarin therapy. Major bleeding is also reduced compared with continued warfarin therapy once the post- implant pharmacologic regimen is completed. Unfortunately the randomized trials that have been performed so far did not compare LAA occlusion with NOACs which are easier to use and generally safer than warfarin. The ongoing/upcoming trials of novel devices use noninferiority versus the Watchman device, future randomized controlled trials that are sufficiently powered to compare the efficacy of transcatheter LAA occlusion with long-term OACs/NOACs are unlikely to be performed. Theoretically patient selection should rely on the assessment of the following factors: the patient’s stroke risk without OAC, the bleeding risk on indefinite anticoagulation therapy and the procedural risk of device closure. Evidently, patients should not have other indication for long-term OAC (mechanical heart valve, recurrent DVT). Mitral stenosis is associated with left atrial thrombus formation not involving the LAA; these patients would probably not benefit from LAA closure either. Conclusions: At present LAA closure procedure may be an acceptable alternative in selected high-risk patients with non-valvular atrial fibrillation who are not or suboptimal candidates for oral anticoagulant therapy. The most important messages of the latest “EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion – an update” (Aug 2019) are the following: Ÿ According to current guidelines, patients who are eligible for long-term OAC and who also require prevention of stroke and embolism should receive OAC, preferably NOAC therapy. Ÿ LAA occlusion is preferred in AF patients with CHA2DS2-VASc score ≥2 (3 in females) who have absolute contraindications for long-term OAC may be considered for LAAO if a minimum period (2-4 weeks) of a

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single antiaggregant can be given. Ÿ In patients with an elevated bleeding risk during long-term oral anticoagulation (e.g., post intracranial bleeding) an individual risk-benefit assessment needs to be carried out between oral anticoagulation and LAA occlusion.

Case-Based: Up-titration of Medications in HF: Start Low but Aim High and Stay High Dr. Keyur Parikh Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Introduction: In heart failure with reduced ejection fraction (HFrEF) the following medications can reduce morbidity and mortality when titrated to maximum tolerated dose: Angiotensin-converting-enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) or angiotensin receptor-neprilysin inhibitor (ARNI), HF guideline recommended beta-blockers and Mineralocorticoid receptor antagonists (MRA). Figure 1: The ESC Guidelines for HF Management: Considerations for Advanced HF Treatments

Monitoring recommendations: Ÿ Check blood pressure (BP) (including postural drop) and heart rate (HR) each visit and clinically review the patient prior to each dose adjustment. Ÿ ACE inhibitors/ARB/ARNI/MRA check: serum K+, creatinine, eGFR, and urea 1 week after commencing or titrating dose. Ÿ MRA: ensure that baseline serum potassium (K+) is less than 5mmol/L and eGFR is greater than 30mL/min; check serum K+, creatinine, eGFR, and urea monthly for 6 months, then 6 monthly once dose is stable.

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Ÿ Diuretic dose change beyond 3 days requires medical, blood chemistry, and fluid status review Diuretic use in HFrEF: Diuretics are used to relieve symptoms and signs of congestion. Goal is to use the lower dose of a diuretic when possible. Higher doses of diuretics may lead to renal impairment. The goal is to achieve and maintain euvolemia at the lowest dose, while providing system relief. Gaps between what is achievable in clinical trials and the “real world”: Patients who are part of clinical trials are usually- Younger, Healthier, more willing to do something to modify their disease than patients in the real world. Clinicians must at least attempt to uptitrate therapies. Why are Drugs not Uptitrated in HFrEF? If dizziness or lowered BP is being experienced, the patient may ask for the drug dose to be reduced. Patients don’t usually request that the drug dose be increased. If symptoms have improved, the patient may not expect a dose increase. Legitimate reasons for not uptitrating drug doses: BP and risk of Hypertension; especially in beta blockade, Renal Impairment, Heart Rate Less Legitimate reasons for the Gap, not uptitrating drug doses in HFrEF: At least the drug was started, patient does not feel the need to increase the dose and physician does not feel the need to increase the dose. Conclusion: We can do better with drug uptitration. Recommended therapies for HFrEF should be prescribed, but we must remember to strive for maximum target doses that are tolerated.

Case-Based: Update on the Treatment and Duration of Dual Antiplatelet Therapy in Patients with CAD - Dr. Ralph Brindis Department of Medicine & the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco Corresponding Email ID: [email protected]

Introduction: Dual antiplatelet therapy (DAPT) with aspirin (ASA) and a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) is a standard therapeutic regimen to prevent stent thrombosis after percutaneous coronary intervention (PCI) with drug-eluting stents (DESs). The duration of DAPT has significant risk/benefit consequences and implications on quality improvement and patient safety. Since the last American College of Cardiology (ACC) and American Heart Association (AHA) PCI DAPT Guidelines were published in 2016,1 there has been an explosion of data regarding strategies to shorten the duration of DAPT. Review of Published ACC/AHA 2016 DAPT Duration Guidelines in DES patients1 Stable Ischemic Heart Disease (SIHD): Six months followed by monotherapy with ASA. Patients with a high

21 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 bleeding risk (HBR) may be shortened to three months. Acute Coronary Syndromes (ACS): ACS without ST-segment elevation (NSTE-ACS) or ST-elevation myocardial infarction (STEMI): 12 months followed by monotherapy with ASA. Patients with an HBR may be shortened to six months. Patients Requiring Noncardiac Surgery: Interruption of DAPT before three months after a DES is harmful. It may be considered between three to six months if the risk of delaying surgery outweighs the risk of stent thrombosis. Interruption or discontinuation of DAPT six months after a DES is appropriate, regardless of original clinical presentation. If at all possible, low-dose ASA should be continued if the P2Y12 agent is interrupted or discontinued. Risk Scores: DAPT Score: > 2, favorable benefit/risk ratio for prolonged DAPT; < 2, unfavorable benefit/risk ratio for prolonged DAPT PRECISE-DAPT Score: <25, non-HBR; > 25 HBR Most Recent Studies on DAPT Duration: RCTs are ongoing and should be peer-review published within the ongoing year. The following are selected snapshots of the most recent impactful peer-reviewed publications: PRECISE-DAPT Study2 A meta-analysis of 14,963 patients from eight randomized trials where the PRECISE-DAPT score was applied in complex versus noncomplex and long-DAPT versus short-DAPT DES patients. Long-term DAPT in non-HBR patients (< 25 score) reduced ischemic events in both complex and noncomplex PCI. Short-term-DAPT in both groups reduced bleeding and ischemia risk only in the HBR (> 25 score) patients. SENIOR Study3 A multicenter trial of 12,604 patients > 75 years old were randomized to PCI with a bare-metal stent (BMS) or a platinum-chromium bioabsorbable polymer everolimus-eluting stent (PtCr-BP-EES) with one month of DAPT for SIHD and six months of DAPT for ACS. A strategy of PtCr-BP-EES and a short duration of DAPT were better than a BMS and a similar duration of DAPT with respect to the occurrence of all-cause mortality, myocardial infarction, stroke, and ischemia-driven target lesion revascularization.

STOPDAPT-2 Trial4 A multicenter Japanese trial of 3,045 patients who underwent PCI with implantation of a cobalt-chromium durable polymer (CoCr-DP-EES) were randomized to one month of DAPT followed by clopidogrel monotherapy or 12 months of DAPT with ASA and clopidogrel. The one-month strategy compared with the 12-month strategy resulted in a significantly lower rate of a composite of cardiovascular and bleeding events, meeting criteria for both noninferiority and superiority.

SMART-CHOICE Trial5

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A multicenter Korean open-label trial of 2,993 patients who underwent PCI with a variety of durable polymer (DP) or bioabsorbable polymer (BP) DESs were randomized to receive ASA and a P2Y12 inhibitor for three months followed by P2Y12 inhibitor monotherapy alone or DAPT for 12 months. The three-month DAPT strategy followed by monotherapy with a P2Y12 inhibitor was noninferior to rates of major adverse events compared to the 12-month DAPT strategy.

TWILIGHT Trial6 A multicenter international trial of 9,006 HBR patients who underwent PCI with a variety of DESs were followed by three months of DAPT with ASA and ticagrelor. If at three months there were no bleeding or ischemic events, they were continued on ticagrelor and double-blind randomized to either ASA or a placebo. At one year, ticagrelor monotherapy was associated with a lower incidence of clinically relevant bleeding compared to ticagrelor plus ASA with no higher risk of death, myocardial infarction, or stroke.

Summary: Ÿ Patient risk for stent thrombosis versus the increased bleeding risk and the duration of DAPT will vary with patient clinical characteristics, acute versus stable presentation, complexity of coronary anatomy, type of DES, and bleeding/thrombotic scores. Ÿ Ongoing data for a shorter duration of DAPT and a switch to monotherapy at three months—and even one month after implantation of a newer-generation, thinner strut DP DES and BP DES—are intriguing and may very well justify a change in clinical practice. Ÿ There is emerging data that a P2Y12 agent may be a better choice than ASA for antiplatelet monotherapy after DAPT in a DES. If so, the type of P2Y12—clopidogrel, ticagrelor, or prasugrel not well studied in any head-to-head trials. Ÿ From a medical-legal standpoint, the strategy for duration of DAPT after a DES should still follow the current 2016 ACC/AHA guidelines. Ÿ In certain select risk/benefit cases, it may be appropriate to further shorten DAPT. If so, the rationale should be well documented in the medical record and pertinent references cited. Ÿ The next Focused Update on Duration of DAPT after Coronary Stent Implantation should give more succinct guidance as to a safe and effective strategy based on more recent data.

References: Ÿ Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease. J Am Coll Cardiol 2016;68(10):1082-1115. Ÿ Costa F, van Klaveren D, Feres F, et al. Dual Antiplatelet Therapy Duration Based on Ischemic and Bleeding Risks After Coronary Stenting. J Am Coll Cardiol 2019;73(7):741–54.

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Ÿ Varenne O, Cook S, Sideris G, et al. Drug-eluting stents in elderly patients with coronary artery disease (SENIOR): a randomised single-blind trial. The Lancet 2018;391(10115):41–50. Ÿ Watanabe H, Domei T, Morimoto T, et al. Effect of 1-Month Dual Antiplatelet Therapy Followed by Clopidogrel vs 12-Month Dual Antiplatelet Therapy on Cardiovascular and Bleeding Events in Patients Receiving PCI; The STOPDAPT-2 Randomized Clinical Trial. JAMA. 2019;321(24):2414-2427. Ÿ Hahn J-Y, Song YB, Oh J-H, et al. Effect of P2Y12 Inhibitor Monotherapy vs Dual Antiplatelet Therapy on Cardiovascular Events in Patients Undergoing Percutaneous Coronary Intervention: The SMART-CHOICE Randomized Clinical Trial. JAMA. 2019;321(24):2428-2437. Ÿ Mehran R, Baber U, Sharma SK, et al. Ticagrelor with or without Aspirin in High-Risk Patients after PCI. [published online ahead of print September 26, 2019]. N Engl J Med. doi: 10.1056/NEJMoa1908419

Case-Based: Pharmacologic Management of PAH Dr. Bhavin Dalal Oakland University William Beaumont School of Medicine and Beaumont Health, Royal Oak, Michigan, USA Corresponding Email ID: [email protected]

Pulmonary Arterial Hypertension is a rare disorder. Physicians and patients both need to understand difference between Pulmonary Hypertension and Pulmonary Arterial Hypertension. Traditionally patients with Idiopathic PAH (Group I PAH) has poor prognosis and patients used to die within 3 years from onset of symptoms or diagnosis. Fortunately, there are 16 different medications approved for treatment of pulmonary hypertension. These medications are costly and hazardous. Judicious use and understanding about medication are necessary. During this session we will discuss few cases for treatment of PH and PAH.

Case-Based: Statin Intolerance Dr. Anish Chandarana Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

HMG CoA Reductase Inhibitors, popularly known as Statin group of drugs have a very high-quality data for reducing cardiovascular risk in primary and secondary prevention settings in various clinical situations. Though, statins do have some side effects, on the whole, cardiovascular benefit-adverse effect risk ratio in the patient population it is recommended is highly favorable. What is statin intolerance? Is it a real or perceived phenomenon? What are the causes? Is this a “curable” phenomenon? Are all statins same or do the differences

24 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 among them exist? How to deal with this situation? Is “alternate day statin” a justifiable and effective approach? What are other medicinal options? All these, and many more practical questions going through mind of a physician will be dealt with in this case-based narration.

A Case of Hypertriglyceridemia- Current Approach Dr. Ralph Brindis Department of Medicine and the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco Corresponding Email ID: [email protected]

A residual High Triglyceride level predicts ASCVD risk despite achieving LDL-C at Goal on Statin Monotherapy. Data from PROVE-IT-TIMI 22 found that despite achieving LDL-C <70 mg/dL with a high-dose statin, patients with TG ≥150 mg/dL have a 41% higher risk of coronary events. Classification of Fasting TG Levels (mg/dL): Optimal <100, Normal <150, Borderline high 150-100, High 200- 499, Very high >500. The prevalence of Hypertriglyceridemia defined as Triglycerides >150 mg/dL is 32% of patients on statins representing 12 million patients while 57 million of all US patients (either statin treated or statin untreated) have elevated TGs. Importantly ASCVD 10-yr Risk by ACC/AHA criteria, varies strongly by fasting TG levels. Risk of >7.5%/10 years occurs 77% of the time if TG>500mg/dL while 47% of the time if TG 200-499. There are at least three possible mechanisms to explain elevated ASCVD risk due to elevated TGs: Ÿ Elevated TG leads to smaller, denser LDL particles taken up by vascular wall macrophages. Ÿ Triglyceride-rich lipoproteins may promote artery wall inflammation Ÿ Concurrent Non-lipid Factors that may drive CVD Risk including effects on coagulation factors, impairment of fibrinolysis, proinflammatory factors, and endothelial dysfunction. Important secondary causes of elevated TG include: Caloric imbalance, increased carbohydrate intake, adiposity, diabetes, hyperthyroidism, nephrotic syndrome, recreational drugs (alcohol, heavy marijuana use), and certain medications. Lifestyle and diet can have major beneficial effects on Hypertriglyceridemia with a 20% – 50% reduction in TG may be obtainable with lifestyle interventions that include weight loss, exercise and dietary changes including increasing intake of fruits, vegetables while maintaining low/non-fat dairy, decreased total carbohydrates and added sugars and decreases in total fat intake (if fasting TG >800) along with increasing dietary fiber intake. Medications to lower TGs demonstrating improved clinical outcomes until recently have been disappointing. Niacin recently was removed as a potential TG lowering treatment based on two negative studies when added to statin therapy. Somewhat surprisingly, Niacin RCTs (AIM-HIGH and HPS2-THRIVE) despite lowering TGs by 26-29% found no difference in the key clinical endpoints versus controls. Fenofibrates with adverse side effects such as elevated liver enzymes, myalgias, increased creatinine and nausea have also been downgraded for

25 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 recommended use to lower TGs. Until recently, Omega 3 Fatty Acids and fish oil supplements assessed in multiple studies have not shown clinical benefit in terms of decreasing CAD events, stroke or coronary revascularization and therefore also not recommended as treatment. Recently however the REDUCE-IT (Reduction of CV Events with Icosapent Ethyl – Intervention Trial) demonstrated significant benefits. Patient inclusion criteria included ≥45 years of age with established CHD or at high risk for CHD (diabetes + ≥1 risk factor) and Atherogenic dyslipidemia = All patients required to be on stable statin therapy for at least 4 weeks with LDL-C >40 mg/dL and ≤100 mg/dL prior to randomization into the study and Fasting TGs of 135499 mg/dL. Patients were randomized between pure Icosapent Ethyl 4 g/day + stable statin therapy versus statin and placebo. The study duration was 4-6 years with Primary Endpoint of Prevention of 1st major CV event (MACE); defined as: CV death, nonfatal MI, nonfatal stroke, coronary revascularization or unstable angina requiring hospitalization. Both a primary CAD prevention and a secondary CAD prevention cohort were studied. Icosapent Ethyl (EPA) achieved a highly significant decrease in the primary endpoint with a relative risk reduction of 24.8% after 5 years of randomization. The absolute risk reduction in primary end points was almost 5%. EPA was well tolerated with a slight increase in propensity in the development of Atrial Fibrillation. Sub-group analysis presented at AHA November 2019, REDUCE-IT USA demonstrated that for every 1,000 patients treated with EPA for 5 years led to a decrease of 27 CV deaths, 43 fatal or non-fatal MI’s, 88 coronary revascularizations, 26 hospitalizations for unstable angina and 34 total mortalities. Take Home Messages: Ÿ Take a Hx of diet (calories, fat, sugar, alcohol, body weight, weight changes) and physical activity (frequency, type, intensity) Ÿ Measure BMI, waist, TSH, fasting glucose, A1c, urinary protein Ÿ Recommend low-calorie, low-sugar, low-to-no alcohol, low-fat but high-fiber diet Ÿ Recommend patient-appropriate physical activity plan Ÿ Treat underlying diseases causing HTG (e.g., A1c, thyroid function) Ÿ Consider possible changes away from TG-raising medications

Approach to patients with elevated TGs on statin therapy in 2020: Ÿ R/O secondary causes of TG Ÿ Stress lifestyle and dietary interventions Ÿ Consider discussion of residual risk and EPA (eicosapentaenoic acid) Rx

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2019 ESC/EAS Guidelines for Themanagement of Dyslipidaemias: Lipid Modification to Reduce Cardiovascular Risk Dr. Satya Gupta Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

10 Points to remembers for physicians (1) Cholesterol and risk. Prospective studies, randomized trials, and Mendelian randomization studies have all shown that raised LDL-C is a cause of ASCVD. Throughout the range of LDL-C levels, ‘lower is better’ with no lower threshold, at least down to _1 mmol/L. Lowering LDL-C may yield worthwhile benefits in patients with average or below average LDL-C who are already receiving LDL-C-lowering treatment. The proportional reduction in ASCVD risk achieved by lowering LDL-C (e.g. with a statin, ezetimibe, or PCSK9-inhibitor) depends on the absolute reduction in LDL-C, with each 1 mmol/L reduction corresponding to a reduction of about one- fifth in ASCVD. (2) PCSK-9 inhibitors. Large trials have shown that PCSK9 inhibitors further reduce ASCVD risk when given on top of statin-based therapy and their use may need to be restricted to those at the highest risk for ASCVD. (3) Use of cardiac imaging for risk stratification. CAC score assessment with CT may be helpful in reaching decisions about treatment in people who are at moderate risk of ASCVD. Obtaining such a score may assist in discussions about treatment strategies in patients where the LDL-C goal is not achieved with lifestyle intervention alone and there is a question of whether to institute LDL-C-lowering treatment. Assessment of arterial (carotid or femoral) plaque burden on ultrasonography may also be informative in these circumstances. (4) Use of ApoB in risk stratification. ApoB may be a better measure of an individual’s exposure to atherosclerotic lipoproteins, and hence its use may be particularly helpful for risk assessment in people where measurement of LDL-C underestimates this burden, such as those with high TG, DM, obesity, or very low LDL-C. (5) Use of Lp(a) in risk stratification. A one-off measurement of Lp(a) may help to identify people with very high inherited Lp(a) levels who may have a substantial lifetime risk of ASCVD. It may also be helpful in further risk stratification of patients at high risk of ASCVD, in patients with a family history of premature CVD, and to determine treatment strategies in people whose estimated risk is on the border of risk categories. (6) Intensification of treatment goals. It is important to ensure that treatment of the highest-risk patients achieves the largest LDL-C reduction possible. These Guidelines aim to support this by setting both a minimum percentage LDL-C reduction (50%) and an absolute LDL-C treatment goal of <1.4 mmol/L (<55 mg/ dL) for very- high-risk patients, and <1.8 mmol/L (<70 mg/dL) for high-risk patients. It is recommended that FH patients with ASCVD or who have another major risk factor are treated as very-high-risk, and those with no prior ASCVD or other risk factors as high-risk.

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(7) Treatment of patients with recent ACS. New randomized trials support a strategy of intensification of LDL- C-lowering therapy in very-high-risk patients with ACS (MI or unstable angina). If the specified LDL-C treatment goal is not achieved after 4_6 weeks with the highest tolerated statin dose and ezetimibe, it is appropriate to add a PCSK9 inhibitor. (8) Safety of low LDL cholesterol concentrations. There are no known adverse effects of very low LDL-C concentrations [e.g. <1 mmol/L (40 mg/dL)]. (9) Management of statin ‘intolerance’. While statins rarely cause serious muscle damage (myopathy, or rhabdomyolysis in the most severe cases), there is much public concern that statins may commonly cause less serious muscle symptoms. Such statin ‘intolerance’ is frequently encountered by practitioners and may be difficult to manage. However, placebo-controlled randomized trials have shown very clearly that true statin intolerance is rare, and that it is generally possible to institute some form of statin therapy (e.g. by changing the statin or reducing the dose) in the overwhelming majority of patients at risk of ASCVD. (10) Statin treatment for older people. A meta-analysis of randomized trials has shown that the effects of statin therapy are determined by the absolute reduction in LDL-C as well as the baseline ASCVD risk, and are independent of all known risk factors, including age. Statin therapy in older people should therefore be considered according to the estimated level of risk and baseline LDL-C, albeit with due regard to an individual’s underlying health status and the risk of drug interactions. There is less certainty about the effects of statins in individuals aged >75 years, particularly in primary prevention. Statin therapy should be started at a low dose if there is significant renal impairment and/or the potential for drug interactions, and then titrated upwards to achieve LDL-C treatment goals. Reference : download from https://academic.oup.com/eurheartj/advance-article- abstract/doi/10.1093/eurheartj/ehz455/5556353.

Pulmonary Embolism Treatment Guidelines Dr. Vipul Kapoor Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Discussion Includes: • Hemodynamic instability and high-risk pulmonary embolism Risk-adapted diagnostic algorithms • New recommendations for diagnosis • Prognostic importance of right ventricular dysfunction • Integrated management algorithm • Indications for extended treatment after acute pulmonary embolism • Cancer-associated pulmonary embolism • Diagnosis and management of pulmonary embolism in pregnancy • Long-term follow-up and search for late sequelae

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Merging the Art and Science of Managing OH and nOH in Clinical Practice : What are they ? Dr. Keyur Parikh Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Orthostatic hypotension (OH) is a sustained fall in blood pressure on standing that can cause symptoms of organ hypoperfusion. OH is associated with increased morbidity and mortality and leads to a significant number of hospital admissions, particularly in the elderly (233 per 100,000 patients >75 years of age in the United States). OH can result from volume depletion, blood loss, large varicose veins, medications, or because of defective activation of sympathetic nerves and reduced norepinephrine release on standing (i.e., neurogenic OH). The prevalence of neurogenic orthostatic hypotension (nOH) increases with age and is associated with autonomic failure in neurodegenerative diseases (e.g., Parkinson's disease). Symptoms can interfere with daily activities that require standing or walking and can increase risk of falls and related morbidity. It frequently affects older people and patients who have neurodegenerative disease, diabetes, or hypertension. Unfortunately, OH is often unrecognized or misdiagnosed and may be an overlooked factor associated with increased cardiovascular morbidity and all-cause mortality. Its management includes both pharmacological and nonpharmacological measures that are not always satisfactory and may lead to complications Evaluation of orthostatic hypo tension: Early morning measurement of blood pressure and heart rate in Supine for 5 minutes and Standing for 1 and 3 minutes. Common Comorbidities includes H y p e r t e n s i o n , Heart Failure, Diabetes mellitus, Peripheral neuropathy, Parkinson’s disease, Random eye movement-behavior disorders. Common drugs that cause orthostatic hypo tension are diuretics, alpha-adrenoceptor blockers for prostatic hypertrophy, antihypertensive drugs, and calcium channel blockers. Management of Orthostatic Hypotension Based on the Pathophysiology

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CNS = central nervous system; CV = cardiovascular Neurogenic orthostatic hypotension (nOH) is a condition in which the autonomic system, which controls the automatic functions of the body, loses the ability to properly regulate blood pressure as one moves from sitting or lying down to standing, or when one changes positions quickly. Treatment algorithm for nOH:

Patients in 5 categories at Higher risk for OH or nOH:

Assessing nOH treatment Success: Measurement of Symptomatic Improvements: Critically important for patients to be educated on symptoms of nOH, Patients should keep a diary of their nOH symptoms. Additional clinical assessments and treatments should be driven by nOH symptom frequency and severity. Ongoing BP Monitoring: A period of at-home BP monitoring should be implemented with new, additional, or other changes in treatments. BP diary should be evaluated 2 weeks after therapeutic changes. If BPs has been stable, BP monitoring frequency can be reduced but reinstituted if symptoms worsen or if treatments change. Every patient visit should include nOH symptom review and orthostatic BP measurements.

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Choosing Wisely - How Clinicians Can Prepare for the Future? Dr. Ralph Brindis Department of Medicine & the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco Corresponding Email ID: [email protected]

Inherent in the doctor–patient relationship is the desire for physicians to use available knowledge and judgment to provide the best possible care to their patients. In return, physicians hope to earn the trust and respect of their patients and community. Physicians have the historical opportunity of autonomy in their practice and with that comes the responsibility and privilege of self-regulation. Unfortunately, as health care costs continue to spiral upward, concerns about the overuse and misuse of costly procedures have been amplified. In response, the communities at large, and specifically payers, have implemented volume- and cost- control mechanisms. One approach is to require “pre-authorization” for services—an activity generally felt by physicians and their office staff to be onerous, expensive to operationalize, intrusive on the physician–patient relationship, and lacking educational feedback to improve quality of care. Another questionable mechanism is to arbitrarily decrease payments for services. Paradoxically, this has potential to increase the volume of services, or even worse, result in underuse of services, which may be essential for improved outcomes in a particular patient. Amid this turmoil, many have asked, “Is there not a better way?”

In response to these growing concerns and to develop a culture in which we, as professionals, are better stewards of the privilege of self-regulation, the American College of Cardiology in collaboration with many other professional organizations developed appropriate use criteria (AUC) for cardiovascular imaging modalities and recently coronary revascularization. The methodology for this process has been well described (1,2,3). Some in the cardiovascular community are concerned that the AUC process, public reporting, and inappropriate ratings could prevent patients from receiving cutting-edge therapies based on the latest studies. It is also critically important to understand and not distort the meaning of inappropriate rating categories. It is never expected that any physician or facility would have a zero rate of inappropriate procedures. There may be unique clinical and patient-specific reasons that justify a procedure rated in this category. However, when the frequency of these ratings becomes higher than the norm, we should have the courage to ask why and consider additional documentation to justify the procedure. Although this sounds onerous, is it not better for us to impose these controls on ourselves than what is done currently by payers to control costs and procedures? Many clinicians acknowledge that inappropriate procedures are occurring, but no one will admit that they have personally done one. Therein is the perfect description of the situation we now face. Our profession has the

31 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 privilege of self-regulation, and this is our struggle. Failure to accept this responsibility will only accelerate regulation by those whose motives may be different and who are not at the bedside with the patient. Is there not a better way? How can benchmarking based on AUC be rationally implemented and improved without impeding doctor–patient relationships and innovation? The AUC must remain current with the evidence. Differences between practice patterns and the AUC must be identified. The American College of Cardiology’s CathPCI (Catheterization/Percutaneous Coronary Intervention) Registry was designed to collect the necessary information to benchmark participants based on the coronary revascularization AUC. Data repositories like the National Cardiovascular Data Registry highlight areas for which differences between real-life practice and the AUC may require modifications in clinical practice, the AUC, or both. Moreover, such comparisons will identify when new research is needed to clarify the benefits and risks for a specific patient population. Benchmarking of facility- and potentially physician- specific patient selection through the National Cardiovascular Data Registry can guide better understanding of practice patterns and patient mix. Evaluation of such data can highlight not only potential areas of overuse but also underuse. Such evaluations are the best way to dispel misconceptions and misinformation such as the assertion by a US physician television personality that more than 50% of all PCIs in the U.S. are unnecessary, when based on prior studies of guidelines adherence, only 8% do not match current recommendations. Used for their intended purpose, the AUC can improve patient care and intelligently prevent misuse of procedures while reducing costs. Finally, and potentially most importantly, involvement from the cardiovascular community in benchmarking will undoubtedly refine their understanding about the benefits and risk of procedures and in turn impact acceptance of the current AUC and help craft future updates of the AUC. To have meaningful traction with our colleagues, payers, and most importantly our patients, we must continue to provide a transparent and impartial evaluation of our practices based on the best current knowledge. The mirror of AUC helps us reflect on the value of care we provide to patients. With this continued work, we hope to keep the privilege of self-regulation and most importantly the trust of our community and patients. If cardiovascular specialists do not attempt to define and measure appropriateness, we may lose the last opportunity for thoughtful and meaningful self-regulation. We can indeed, utilizing tools such as Appropriate Use Criteria along with measuring and benchmarking our performance the opportunity to “choose wisely” when delivering cardiovascular healthcare to our patients.

References: Ÿ Hendel RC, Patel MR, Allen JM, Min JK, Shaw LJ, Wolk MJ, Douglas PS, Kramer CM, Stainback RF, Bailey SR, Doherty JU, Brindis RG. Appropriate Use of Cardiovascular Technology: 2013 ACCF Appropriate Use Criteria Methodology Update. J Am Coll Cardiol 2013;61:1305–17.

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Ÿ Hendel RC, Lindsay BD, Allen JM, Brindis RG, Patel MR, White L, Winchester DE, Wolk MJ. ACC Appropriate Use Criteria Methodology: 2018 update. J Am Coll Cardiol 2018;71:935–48. Ÿ Patel MR, Calhoon JH, Dehmer GJ, et al. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 appropriate use criteria for coronary revascularization in patients with stable ischemic heart disease: a report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2017;69:2212–41.

Point of Care Ultrasound- Replacing the Stethoscope? Dr. Neil Mehta Cleveland Clinic Lerner College of Medicine at Case Western Reserve University Corresponding Email ID: [email protected]

Ultrasound guidance has been shown to reduce complications and improve effectiveness of various procedures like thoracentesis and central venous line access. At the same time, the ultrasound devices are becoming increasingly portable. The emergency medicine community has taken the lead and adopted the POCUS as a standard in the clinical evaluation of the emergency patient. We will review the common applications of POCUS in clinical practice.

Best Management of Severe Aortic Stenosis - Current Evidence and Guidelines Dr. Geza Fontos National Cardiovascular Center, Budapest, Hungary Corresponding Email ID: [email protected]

Background: Transcatheter aortic valve implantation has revolutionized the treatment of symptomatic severe aortic valve stenosis. Advances in patient selection and pre-procedural planning, new transcatheter valve platforms, procedure streamlining and growing operator experience have improved procedural safety and valve performance. Within the last decade, transcatheter aortic valve implantation has emerged as a valuable alternative to surgical aortic valve replacement in an increasingly wide spectrum of patients with severe symptomatic aortic stenosis. Discussion: The safety and efficacy of TAVI was initially established in patients at high surgical risk in the PARTNER 1A and US Core Valve high-risk trials demonstrating comparable clinical outcomes compared to SAVR. A role for TAVI in patients at intermediate risk for surgery has been subsequently investigated in the

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PARTNER 2A and SURTAVI trials, showing non-inferiority of TAVI in this patient population. Newly available evidences from randomized controlled trials comparing TAVI with SAVR among low-risk patients (PARTNER3 and Evolut Low-Risk trials) with severe symptomatic aortic stenosis proved that TAVI even had an early safety benefit over surgical aortic valve replacement and was associated with faster discharge, recovery and fewer re- hospitalizations. In patients with symptomatic severe AS TAVI has now been explored across the entire spectrum of operative risk, from inoperable to low-risk populations, in properly designed RCTs, although data on the long-term durability of these valves are lacking. Conclusions: As a summary of the “2017 ESC/EACTS Guidelines for the management of valvular heart disease” and the “2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease” we can draw the following important conclusions: Ÿ Aortic valve interventions should only be performed in centres with both departments of cardiology and cardiac surgery on site and with structured collaboration between the two, including a Heart Team (IC) Ÿ The choice for intervention must be based on careful individual evaluation of technical suitability and weighing of risks and benefits of each modality (IC) Ÿ TAVI is recommended in patients who are not suitable for SAVR as assessed by the Heart Team (IB) Ÿ In patients who are at increased surgical risk, the decision between SAVR and TAVI should be made by the Heart Team according to the individual patient characteristics, with TAVI being favoured in elderly patients suitable for transfemoral access (IB) Ÿ TAVR is a reasonable alternative to surgical AVR for symptomatic patients with severe AS and an intermediate surgical risk, depending on patient-specific procedural risks, values, and preferences (IIA) Ÿ SAVR is recommended in patients at low surgical risk (IB)

Trials of 2019 Part - I - Which Changed My Clinical Practice Dr Milan Chag Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

(1) DAPA-HF: Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction (J.J.V. McMurray et al. NEJM Sept 19, 2019) Background: In patients with type 2 diabetes, inhibitors of sodium–glucose cotransporter 2 (SGLT2) reduce the risk of a first hospitalization for heart failure, possibly through glucose independent mechanisms. More data are needed regarding the effects of SGLT2 inhibitors in patients with established heart failure and a reduced ejection fraction, regardless of the presence or absence of type 2 diabetes. Methods: In this phase 3, placebo-controlled trial, we randomly assigned 4744 patients with New York Heart Association class II, III, or IV heart failure and an ejection fraction of 40% or less to receive either dapagliflozin

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(at a dose of 10 mg once daily) or placebo, in addition to recommended therapy. The primary outcome was a composite of worsening heart failure (hospitalization or an urgent visit resulting in intravenous therapy for heart failure) or cardiovascular death. Results: Over a median of 18.2 months, the primary outcome occurred in 386 of 2373 patients (16.3%) in the dapagliflozin group and in 502 of 2371 patients (21.2%) in the placebo group (hazard ratio, 0.74; 95% confidence interval [CI], 0.65 to 0.85; P<0.001). A first worsening heart failure event occurred in 237 patients (10.0%) in the dapagliflozin group and in 326 patients (13.7%) in the placebo group (hazard ratio, 0.70; 95% CI, 0.59 to 0.83). Death from cardiovascular causes occurred in 227 patients (9.6%) in the dapagliflozin group and in 273 patients (11.5%) in the placebo group (hazard ratio, 0.82; 95% CI, 0.69 to 0.98); 276 patients (11.6%) and 329 patients (13.9%), respectively, died from any cause (hazard ratio, 0.83; 95% CI, 0.71 to 0.97). Findings in patients with diabetes were similar to those in patients without diabetes. The frequency of adverse events related to volume depletion, renal dysfunction, and hypoglycemia did not differ between treatment groups. Conclusions: Among patients with heart failure and a reduced ejection fraction, the risk of worsening heart failure or death from cardiovascular causes was lower among those who received dapagliflozin than among those who received placebo, regardless of the presence or absence of diabetes.

(2) Paragon HF: Angiotensin–Neprilysin Inhibition in Heart Failure with Preserved Ejection Fraction ( S D Solomon et al. NEJM Sept 1, 2019) Background: The angiotensin receptor–neprilysin inhibitor sacubitril–valsartan led to a reduced risk of hospitalization for heart failure or death from cardiovascular causes among patients with heart failure and reduced ejection fraction. The effect of angiotensin receptor– neprilysin inhibition in patients with heart failure with preserved ejection fraction is unclear. Methods: We randomly assigned 4822 patients with New York Heart Association (NYHA) class II to IV heart failure, ejection fraction of 45% or higher, elevated level of natriuretic peptides, and structural heart disease to receive sacubitril–valsartan (target dose, 97 mg of sacubitril with 103 mg of valsartan twice daily) or valsartan (target dose, 160 mg twice daily). The primary outcome was a composite of total hospitalizations for heart failure and death from cardiovascular causes. Primary outcome components, secondary outcomes (including NYHA class change, worsening renal function, and change in Kansas City Cardiomyopathy Questionnaire [KCCQ] clinical summary score [scale, 0 to 100, with higher scores indicating fewer symptoms and physical limitations]), and safety were also assessed. Results: There were 894 primary events in 526 patients in the sacubitril–valsartan group and 1009 primary events in 557 patients in the valsartan group (rate ratio, 0.87; 95% confidence interval [CI], 0.75 to 1.01; P = 0.06). The incidence of death from cardiovascular causes was 8.5% in the sacubitril–valsartan group and 8.9% in the valsartan group (hazard ratio, 0.95; 95% CI, 0.79 to 1.16); there were 690 and 797 total hospitalizations

35 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 for heart failure, respectively (rate ratio, 0.85; 95% CI, 0.72 to 1.00). NYHA class improved in 15.0% of the patients in the sacubitril–valsartan group and in 12.6% of those in the valsartan group (odds ratio, 1.45; 95% CI, 1.13 to 1.86); renal function worsened in 1.4% and 2.7%, respectively (hazard ratio, 0.50; 95% CI, 0.33 to 0.77). The mean change in the KCCQ clinical summary score at 8 months was 1.0 point (95% CI, 0.0 to 2.1) higher in the sacubitril–valsartan group. Patients in the sacubitril–valsartan group had a higher incidence of hypotension and angioedema and a lower incidence of hyperkalemia. Among 12 prespecified subgroups, there was suggestion of heterogeneity with possible benefit with sacubitril–valsartan in patients with lower ejection fraction and in women. Conclusions: Sacubitril–valsartan did not result in a significantly lower rate of total hospitalizations for heart failure and death from cardiovascular causes among patients with heart failure and an ejection fraction of 45% or higher.

(3) Credance: Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy (V. Perkovic Et Al. NEJM April 14, 2019) Background: Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long- term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. Methods: In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to <90 ml per minute per 1.73 m2 of bodysurface area and albuminuria (ratio of albumin [mg] to creatinine [g], >300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of <15 ml per minute per 1.73 m2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. Results: The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P = 0.00001). The relative risk of the renal-specific composite of end- stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P<0.001), and the relative risk of endstage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P = 0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P = 0.01) and

36 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P<0.001). There were no significant differences in rates of amputation or fracture.

Conclusions: In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years.

(4) Recovery: Early Surgery or Conservative Care for Asymptomatic Aortic Stenosis (Duk Hyun Kang Et Al. NEJM Nov 16, 2019) Background: The timing and indications for surgical intervention in asymptomatic patients with severe aortic stenosis remain controversial. Methods: In a multicenter trial, we randomly assigned 145 asymptomatic patients with very severe aortic stenosis (defined as an aortic-valve area of ≤0.75 cm2 with either an aortic jet velocity of ≥4.5 m per second or a mean transaortic gradient of ≥ 50 mm Hg) to early surgery or to conservative care according to the recommendations of current guidelines. The primary end point was a composite of death during or within 30 days after surgery (often called operative mortality) or death from cardiovascular causes during the entire follow-up period. The major secondary end point was death from any cause during follow-up. Results: In the early-surgery group, 69 of 73 patients (95%) underwent surgery within 2 months after randomization, and there was no operative mortality. In an intention-to-treat analysis, a primary endpoint event occurred in 1 patient in the early-surgery group (1%) and in 11 of 72 patients in the conservative- care group (15%) (hazard ratio, 0.09; 95% confidence interval [CI], 0.01 to 0.67; P = 0.003). Death from any cause occurred in 5 patients in the early-surgery group (7%) and in 15 patients in the conservative- care group (21%) (hazard ratio, 0.33; 95% CI, 0.12 to 0.90). In the conservative- care group, the cumulative incidence of sudden death was 4% at 4 years and 14% at 8 years. Conclusions: Among asymptomatic patients with very severe aortic stenosis, the incidence of the composite of operative mortality or death from cardiovascular causes during the follow-up period was significantly lower among those who underwent early aortic valve replacement surgery than among those who received conservative care.

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Case-Based: A Patient with Acute Chest Pain in ER - What to Do ? Dr. Satya Gupta Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

Chest pain or discomfort fearing of heart attack or myocardial ischemia is one of the most common reasons for emergency department (ED) presentation. Almost 20 % of patients with ED visit turn out to be of cardiac origin and rest all are non-cardiac. Chest pain is one of the few disease processes in which patients may initially appear to be well but in fact have an underlying life-threatening condition. Inadvertent discharge of patients with acute coronary syndrome (ACS) has been associated with a short-term mortality as well as major risk of liability. Identifying patients with chest pain who are at risk of adverse events is important not only to ED physicians but also to all physicians who evaluate such patients. Myocardial infarction can be missed for a number of reasons. To name a few are; not able to pick up proper relevant history by ED physician, failure to narrate proper symptoms by patient or family members, relatively younger age of patient, physician inexperience, atypical presentations, and , misinterpretation of findings on electrocardiography (ECG) are more common. It is very important to correlate proper history, clinical examination, ECG, relevant blood investigations, chest x ray and echocardiography (if done) for final conclusion of diagnosis. If there is strong suspicion of ischemic heart disease, patient should be counselled and directed for revascularization strategy at a proper time. Other non-cardiac differential diagnosis of acute chest pain (may be either life threatening or benign) must be ruled out before discharging patient from ED. The other causes may include; reflux esophagitis; and costochondritis, pulmonary (e.g., pneumonia, pulmonary embolism), gastrointestinal (e.g., gastroesophageal reflux disease [GERD]), and psychological (e.g., anxiety, panic disorder) etiologies, and acute aortic dissection.

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Case-Based: Non-invasive Evaluation for CAD Dr. Vipul Kapoor Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Several noninvasive tests are available for the assessment of CAD, and all are aimed at helping the risk stratification process. The mainstays are Echocardiography, which uses ultrasound technology to produce images, and Nuclear Cardiac Imaging, which uses radiation to produce images. Echocardiography provides information regarding function and hemodynamic parameters, whereas the strength of nuclear cardiac imaging is in its ability to demonstrate function, perfusion, and metabolic phenotypic features of myocardial performance. Not so new are cardiac MRI and cardiac CT

Case-based: Stroke Patient in Aortic-stenosis- What to do? Dr. Keyur Parikh Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Transcatheter aortic valve implantation (TAVI) is the principal therapeutic option in patients with severe aortic stenosis considered inoperable or at high risk for open-heart surgery. Thus has progressively increased the rates of its use with this indication. Increasing evidence point towards the effectiveness of TAVI in patients considered at intermediate or even at low surgical risk. Stroke is an unpredictable complication during and after TAVI with potential devastating outcomes. Clinically silent lesions are detected by MRI in the majority of the TAVI patients and may be associated with cognitive impairment. Case: A 64 year old female with hypertension and recent cerebrovascular event with thickened, calcified severe aortic stenosis-Sevier’s I Bicuspid AVA 0.4 cm2; totally occluded right internal carotid artery (ICA) and occluded right subclavian artery with excellent left to right collaterals from patent but small left ICA with a Society of Thoracic Surgeons Score: 4.071% but still high risk in view of a CVA few months earlier was treated . Case Strategy: Based on pre-procedure investigations, she underwent TAVI using 20 mm MyVal THV through transfemoral approach. However, the patient had history of stroke and her right internal carotid artery was totally occluded and heavily calcific Bicuspid valve. Patient was at increased risk of developing post-operative stroke. Use of cerebral embolic protection device was considered. Emboshield NAV6 embolic protection system (Abbott) 5-7mm was not suitable for 8+ mm Left Common Carotid Artery and was large for 3.0 mm for left Internal Carotid Artery.

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CT Brain and Angiography: Relatively well-defined hypodense areas were noted involving left frontal lobe , left fronto-parietal lobe and right high posterior frontal cortical region suggesting area of old infarct / gliosis. Proximal short segment of right CCA was opacified and showed tapering narrowing. No flow with complete occlusion of long distal segment of right CCA. Severely reduced flow was noted in V4 segment of right vertebral artery. Figure 1: CT Angiography Images

Finally, the decision was made to get an on-table carotid angiogram post-TAVR to assess the risk of stroke and be prepared to manage in case that happened. Figure 2: Different Types of Cerebral Embolic Protection Devices

Figure 3: Sources of Embolization with TAVR Figure 4: Post-Procedural Towne’s View

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Conclusion: TAVI performed very well without any complications in stroke patients; on table Carotid-cerebral angiogram post-TAVI could play an important role in assessing neuro-ischemic events in patients who are at increased risk of developing post-operative stroke. Always consider embolic protection in high risk TAVI cases and should consider using available alternatives. Have a pre-procedure Cerebral Angiogram-CT angio or MRI angio or cathangio pre procedure. In high risk cases recommend to do Uni-bilateral Cerebral Angiogram post procedure. For stroke prevention filter is advisable but in selective high risk cases. TAVI can be done especially in conscious sedation without cerebral protection but it is very important to end the case with cerebral angiography to evaluate Circle of Willis. The incidence of stroke after TAVI exceeds that of any other interventional procedure. The cause of the stroke is likely not clot, but atherosclerotic debris and not likely lyse- able or retrievable. Patients are under anesthesia when the stroke occurs. May be hours before they regain consciousness and can be assessed for stroke which reduces the time available for stroke intervention. TAVI patients can receive IV thrombolysis but fresh access sites could bleed. Broad acceptance of embolic protection devices in TAVI awaits more randomized trial data. Available information and common sense dictate that some form of embolic protection will become standard treatment in TAVI.

Case-Based: Acute Pulmonary Embolism: When to? How? Dr. Bhavin Dalal Oakland University William Beaumont School of Medicine and Beaumont Health, Royal Oak, Michigan, USA Corresponding Email ID: [email protected]

Acute pulmonary embolism (PE) occurs commonly (39-115 cases per 100,000 Population) and cause almost 300,000 death annually in US. Case fatality rates vary widely, but approximately 10% of all patients with acute pulmonary embolism die within 3 months. Even though it is common clinical condition, clinicians experience dilemma in making decision due to rapidly growing body of evidences. Not only that, even different guideline statements differ in their recommendations because the evidence is interpreted differently. For e.g. Rescue thrombolysis for intermediate risk PE had grade IIC recommendation in ACCP 2016 guidelines vs. Grade I recommendation in 2019 ESC/ERS guidelines. For high risk pulmonary embolism. For high risk pulmonary embolism thrombolysis or catheter directed thrombectomy is the way to success. For Intermediate risk PE (sub-massive PE) thrombolysis is controversial and debatable. During this session we will discuss role of thrombolysis in Intermediate risk PE.

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Living in Time of Uncertainty: Advancing Women’s Health in India Dr. Claire Brindis Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco Corresponding Email ID: [email protected]

Background: Women commonly experience Coronary Risk Factors (CRF), increasing markedly with age, although occurring far later in life as compared to men (10-20 years later). Two-thirds of women have at least 1 risk factor, including hypertension, diabetes, and sedentary lifestyle. Methods: Irrespective of age of onset, type of manifestation, or risk factor burden, women have more symptoms, more disability, more often chest pain without obstructive coronary disease, heart failure, and higher mortality after acute MI. Although they are significantly at risk, a specific focus on women’s cardiac health and treatment has been traditionally overlooked, including being excluded or poorly represented in the original clinical trials of interventions that have been shown to be clinically effective with men. Another challenge is to recognize modifiable (smoking and exposure to secondary smoke) and non-modifiable factors (age, gender) to better tailor services to patients, particularly women. Results: There is a significant adverse gender gap in CHD-MI mortality. Women, particularly younger women, face a more adverse CHD prognosis. Even when there is adjustment for disease severity, comorbidity and treatment does not fully account for the gap. This reflects that women have been marginalized – not included in basic studies and provided with poorer treatment at diagnoses, treatment, and follow-up. For example, they are less likely to treated with statins. There are key points of intervention in a woman’s life that would significantly improve the cardiac health of women and this requires a more comprehensive, team-focused response, including earlier identification of women at risk of poor cardiac outcomes, including experiencing a challenging pregnancy and delivering a low birthweight baby (pregnancy as mother nature’s “stress test”). Conclusions: While women face a wide variety of risks for CVD, adopting an socio-ecological and system perspective can help: Identify critical points of earlier intervention; Promote better nutrition, physical activity, and less exposure to smoking; Identify those at risk earlier in their lives and provide equitable and tailored care during and post visits.

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Case-Based: Bugs-Bugs Everywhere- Should I Treat All of Them? Dr. Surabhi Madan Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

Misuse and overuse of antibiotics has been one of the biggest risk factors responsible for the growing drug-resistance. It is high time that along with being thorough with our knowledge regarding the indications of antibiotics, we also know exactly when not to administer antibiotics! With the help of some cases, we discuss in this presentation when can we avoid or deescalate antibiotics.

Rheumatoid Arthritis: What’s New in 2020? Dr. Puja Srivastava Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

Rheumatoid Arthritis (RA) is chronic disabling disease like diabetes and hypertension, which requires regular treatment to prevent joint deformities and other disease related systemic complications. Clinicians and scientists are doing lot of research to improve the disease control and quality of life of patients suffering from RA. With the turn of decade in 2020, it is worthwhile to discuss the recent advances in management of RA. In last few years, few new disease modifying anti-rheumatic drugs (DMARDs) like Iguratimod, biologics and small molecules like Tofacitinib and Baricitinib have been to the treatment armamentarium of RA. It will be worthwhile to discuss during JIC CON 2020 about the impact of these new molecules on the management of RA. Apart from introduction of new drugs, there has been significant change in concepts of management of RA. One such important concept is “Treat-to-target”. It has shifted the focus away from traditional metrics of joint damage, towards the individual needs of patients. According to this concept, DMARDs should be started soon after diagnosis; and disease activity should be monitored regularly. Biologics and small molecules should be introduced where diseases is persistently active despite conventional DMARDs. Finally, disease activity should be measured at regular intervals using well defined outcome measures, and remission or low disease activity should be the preferred treatment target.

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Mindfulness in Medicine Dr. Neil Mehta Cleveland Clinic Lerner College of Medicine at Case Western Reserve University Corresponding Email ID: [email protected]

Meditation is a very old technique described in Buddhism and Hinduism. Over the last few decades, there has been increasing recognition of the types of meditation and their impact on mental and physical health. With the advent of functional MRI, it has become possible to research the outcomes of meditation and mindfulness. We will review the evidence for use of these techniques in daily life and for common health conditions.

All Shadows on CXR are not TB…. When to Think of ILD! Dr. Bhavin Dalal Oakland University William Beaumont School of Medicine and Beaumont Health, Royal Oak, Michigan, USA Corresponding Email ID: [email protected]

Chest x-ray (CXR) is one of the most common modalities of investigation for primary care physicians and for specialists. Tuberculosis is highly prevalent in India and most commonly diagnoses with help of CXR with classic signs and symptoms of cough, weight loss, anorexia, low grade fever and night sweats. There are so many other pulmonary and cardiac disorders which can create similar findings on CXR and mimic tuberculosis. High index of suspicion from history and physical examination is required to consider alternative diagnosis especially interstitial lung disease (ILDs). ILDs are inherently complex disorders and differentiation from CXRs is nearly impossible but there are several characteristics CXRs findings which are important for thinking ILDs as differential diagnosis. During this session we will discuss some of the CXR findings which can be good clue towards the diagnosis of ILDs.

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Case-Based: Evaluation and Management of ACS Dr. Ralph Brindis Department of Medicine and the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco Corresponding Email ID: [email protected]

The approach to patients presenting with the possibility of an acute coronary syndrome (ACS) focuses initially on the contingent probabilities of the likelihood of obstructive CAD causing the patient’s symptoms versus the risk of a bad outcome. Does this patient have symptoms due to acute ischemia from obstructive CAD based on findings on examination, symptoms, biomarkers (Troponins typically) and Risk scores (e.g., TIMI or GRACE)? The risk of bad outcome is dominated by acute findings: older age, hemodynamic abnormalities critical, ECG, and levels of biomarkers. Defining what is the likelihood of death, MI, heart failure will drive decision making in the context of the patient’s underlying health and co-morbid conditions along with patient and family preferences. Based on these factors, the clinician will decide on either an early invasive or an ischemia guided strategy for evaluation and treatment. Immediate invasive strategy recommended (within 2 h): Refractory angina, Signs or symptoms of HF or new or worsening mitral regurgitation, Hemodynamic instability, Recurrent angina or ischemia at rest or with low- level activities despite intensive medical therapy or Sustained VT or VF. Early invasive (within 24 h): GRACE risk score >140, Temporal change in Tn, New or presumably new ST depression Delayed invasive (within 25-72 h) None of the above but diabetes mellitus, Renal insufficiency (GFR <60 mL/min/1.73 m2), Reduced LV systolic function (EF <0.40), Early postinfarction angina, PCI within 6 months, Prior CABG, GRACE risk score 109–140 or TIMI score >2. Ischemia-guided strategy (non-invasive risk stratification): Low-risk score (e.g., TIMI [0 or 1], GRACE [<109]), Low-risk Tn-negative female patients, Patient or clinician preference in the absence of high-risk features Non-invasive risk stratification suggesting high risk (>3% annual mortality rate): Ÿ Severe resting LV dysfunction (LVEF <35%) Ÿ High-risk treadmill score (score ≤11) Ÿ Severe exercise LV dysfunction (exercise LVEF <35%) Ÿ Stress-induced large perfusion defect (particularly if anterior) Ÿ Stress-induced multiple perfusion defects of moderate size Ÿ Large, fixed perfusion defect with LV dilation or increased lung uptake (thallium-201) Ÿ Stress-induced moderate perfusion defect with LV dilation or increased lung uptake (thallium-201) Ÿ Echocardiographic wall-motion abnormality (involving >2 segments) developing at low dose of

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dobutamine (≤10 mcg per kg per min) or at a low heart rate (<120 beats per min) Ÿ Stress echocardiographic evidence of extensive ischemia Non- invasive risk stratification suggesting Intermediate risk (1% to 3% annual mortality rate) Ÿ Mild/moderate resting LV dysfunction (LVEF = 0.35 to 0.49) Ÿ Intermediate-risk treadmill score (-11 to 5) Ÿ Stress-induced moderate perfusion defect without LV dilation or increased lung intake (thallium-201) Ÿ Limited stress echocardiographic ischemia with a wall-motion abnormality only at higher doses of dobutamine involving ≤ 2 segments Non-invasive risk stratification suggesting Low risk (<1% annual mortality rate) Ÿ Low-risk treadmill score (score ≥5) Ÿ Normal or small myocardial perfusion defect at rest or with stress Ÿ Normal stress echocardiographic wall motion or no change of limited resting wall-motion abnormalities during stress. Concomitant medical management with a documented ACS presentation centers around oral beta blockers if without contraindication, high intensity statins, ACE or ARB inhibitors if ejection fraction < 40%, Aldosterone blockade if LV Ejection fraction <40% without contraindications and the administration of a P2Y12 inhibitor typically clopidogrel or ticagrelor. Anticoagulation options include enoxaparin, bivalirudin, fondaparinux or UFH- unfractionated heparin. Revascularization strategy will be dependent on catheterization findings along with patient co-morbidities and preferences but included PCI or CABG versus medical therapy. Post ACS care should focus on cardiac rehabilitation and secondary risk factor reduction. Length of dual antiplatelet therapy (DAPT) therapy after PCI with an ACS presentation in general is for one year although patients at high risk of bleeding can be considered for a more abbreviated length of therapy- typically 6 months.

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High Sensitive Troponin: 1 hr Algorithm as per ESC Guidelines Dr. Urmil Shah Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

BACKGROUND: Troponin/ High sensitivity (Hs) Troponin is marker of myocardial injury. Raise and fall of troponin level is suggestive of acute myocardial injury. Myocardial injury can occur without ischemia in conditions like myocarditis and acute heart failure, which also can elevate Troponin/ High sensitivity (Hs) and has its own prognostic importance. when it is with myocardial ischemia it is called as infarction - when it is associated with plaque rupture is known as type I myocardial infarction and when it is associated with demand supply imbalance as it occurs in severe hypertension or sustained tachyarrhythmia - type II myocardial infarction. (Figure 1)

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As one can understand that abnormal troponin/Hs troponin does not necessarily indicate myocardial infarction (MI). One always has to keep in mind the non-MI causes also. Below table shows causes of elevation of troponin/Hs Troponin. Causes of Elevated Troponin Levels (Table 1):

According to 4th universal definition acute myocardial infarction, the diagnosis of acute MI entails a combination of criteria that includes the detection of an increase and/or decrease of a cardiac biomarker, preferably high-sensitivity cardiac troponin, with at least one value above the 99th percentile of the upper reference limit and at least one of the evidence of ischemia – New ECG changes / imaging evidence of new loss of viable myocardium or regional wall motion abnormality. Increase or decrease of troponin/Hs troponin is going to differentiate acute condition from other causes of chronic troponin elevation like structural heat disease and CKD. Hs Troponin assay can detect troponin much earlier in the blood compare to conventional troponin after the onset of myocardial infarction (Figure 2). Serial change in troponin level especially Hs sensitive troponin is used for early ruling out and ruling in of acute MI in ER.

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Time for ruing in/ rule out can be reduced to 3 hours or to 1 hour with the help of Hs troponin assays, compare to with use of conventional troponin. Recently ESC guideline approved both 0 to 3 hour as well as 0 to 1 hour algorithm using Hs sensitive troponin that is T0/t1-h Algorithm (Figure 3) and T0/t3-h Algorithm (Figure 4) to reduce the time to diagnose MI. Figure 3 : ‘Rule-In’ And ‘Rule-Out’ Algorithms:

For ‘rapid rule-out’, two alternative approaches to the 0 h/3 h algorithms: (Figure 4)

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Advantages of Hs Troponin Figure 5 compare to Conventional Troponin: As Hs troponin is very précises it has very high diagnostic accuracy and is very accurate for ruling out MI. As it reduces time to repeat testing & reduces time to diagnosis it will unable more early ED discharge and d e c r e a s e e m e r g e n c y department length of stay (Figure 5). As the time to diagnosed MI with help of Hs troponin is reduced one can start the treatment much early Figure 6 compare to conventional troponin assays which in turn reduced the morbidity and mortality (Figure 6).

ER algorithm using Hs troponin for patient presenting with chest pain: When there is Chest pain with ST elevation/fresh LBBB no need to get troponin levels for diagnosis one should start treatment immediately. Patient without ST elevation and very high level of Hs troponin (More than 100 ng/l) should undergo angiography considering higher risk of acute MI. Patients with very low level of Hs troponin can be considered for early discharge. If patient with Hs troponin level > 99 percentile and not very high is associated with significant concentration change then it is suggestive of acute myocardial injury and if associated with myocardial ischemia then diagnosis is of MI is confirmed (Figure 7). Figure 7

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CONCLUSION: Chest pain evaluation in emergency room is very tricky as we cannot keep all patients with chest pain admitted in ICU and we cannot miss the diagnosis of acute myocardial infarction. Understanding about troponin and HS troponin as well as using 0 to 1 hours and 0 to 3 hours algorithm is very helpful in early ER discharge with surety and very early diagnosis of acute myocardial infarction as well as starting treatment of MI very fast.

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Case-Based: Aspirin for Primary Prevention- Is There any Role Left in 2020? Dr. Neil Mehta Cleveland Clinic Lerner College of Medicine at Case Western Reserve University Corresponding Email ID:[email protected]

Based on the results of studies like the Physicians’ Health Study conducted before the age of the statins, aspirin has often been recommended for primary prevention of coronary artery disease and strokes. This is particularly true of patients at higher risk of cardiovascular events like those with diabetes. The benefits of aspirin in patients with known cardiovascular disease are unquestioned. But aspirin can increase the risk of GI ulcers and bleeding both GI and elsewhere. In addition, since the widespread use of statins, there has been significant decrease in risk of cardiovascular events. Does it still make sense to use aspirin for primary prevention? How do you balance the risk and benefit of aspirin and how do you identify the patients who are candidates for aspirin? We will review recent evidence including the ascend, arrive and aspree trial data and discuss how to apply these to practice.

How Would I Treat Ischaemic Stroke in First 24 Hours? Dr Keyur Panchal Interventional Neurologist, Mumbai Corresponding Email ID: [email protected]

Background: Stroke is a leading cause of mortality and disability worldwide. Acute stroke management in the ED is complex decision requiring a team-based approach, particularly as the therapeutic window for ischemic strokes has been extended to 24 hours from symptom onset. Recent concepts of revascularization of ischeamic tissue either by pharmacological(thrombolytic agents) or Endovascular mechanical thrombectomy (MT) for the treatment of acute stroke due to large vessel occlusion has evolved significantly with the publication of multiple positive trials. Both are now a recommended treatment for acute ischemic stroke. This made decision making in Acute stroke, a complex decision making exercise for physicians. As physicians are often first medical contact for such patients, having thorough knowledge of available option and treatment protocols is critical. Discussion: Intravenous thrombolytic therapy(IVT) in the first 3 hours after stroke onset was first demonstrated to be beneficial in National Institute of Neurological Disorders and Stroke (NINDS) tissue plasminogen activator (tPA) trials . In this patients treated with tPA within 3 hours of onset had a substantially better chance of functional independence with minimal or no disability 3 months after treatment. Four other phase 3 IV tPA trials, ECASS 1, ECASS 2, ATLANTIS A, and ATLANTIS B supported it. The European Cooperative

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Acute Stroke Study 3 (ECASS 3) trial was performed to confirm or disconfirm the findings from initial trials suggesting benefit of IV tPA therapy in the 3- to 4.5-hour window , further expanding therapeutic window upto 4.5 hours. NOR-TEST and EXTEND-IA TNK advocate use of another agent TENECTASE which is cheaper and used as a bolus. However poor outcome after IVT in patient with stroke due to large vessel occlusion(LVO) leads to discovery of mechanical device that can remove clot from cerebral arteries. After 2015 4 trials gave positive result in ischaemic stroke with LVO upto 6 hours. In 2018 DAWN and DIFFUSE extended therapeutic window upto 24 hours in selected patients. Conclusions: Ÿ Acute stroke treatment is rapidly changing field in medicine. Physician need to be aware of current and ever changing treatment options and recommended guidelines. Ÿ IV thrombolysis must be offered whenever indicated. Ÿ Mechanical thrombectomy is now a class 1 indication in stroke due to large vessel occlusion

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Case-Based: ACS in a Patient of AF on OAC - What to do? Dr. Ralph Brindis Department of Medicinea and the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco Corresponding Email ID: [email protected]

It is estimated that about 20% to 40% of patients with Atrial Fibrillation (AF) also present with coronary artery disease (CAD), a sizeable proportion of whom requires revascularization using percutaneous coronary intervention (PCI) and stent implantation. Such patients need dual antiplatelet therapy (DAPT) to prevent the risk of stent thrombosis and additional thrombotic ischemic events. Overall, about 5% to 10% of patients referred to coronary angiography with or without PCI present with AF or other indications for chronic Oral Anticoagulation (OAC). The optimal antithrombotic treatment regimen for patients with AF undergoing PCI is a clinical conundrum. The combination of OAC and DAPT, a regimen also known as triple antithrombotic therapy (TAT), is theoretically required to decrease both the risk of thromboembolism due to AF and the risk of thrombotic events due to coronary stents in patients with underlying CAD. However, TAT markedly increases the risk of major and fatal bleeding. Randomized controlled trials are now available that compare TAT with alternative antithrombotic therapy regimens, such as double antithrombotic therapy (DAT), which combines OAC with single antiplatelet therapy (SAPT). 1. When it comes to stroke prevention for AF, OAC outperforms SAPT (aspirin) or DAPT (aspirin plus clopidogrel). The ACTIVE (Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events) W trial, comparing OAC with DAPT, was stopped early because of a clear evidence of superiority: OAC with a vitamin K antagonist (VKA) resulted in 31% fewer vascular events at 1 year. This has been also been confirmed with Direct Oral Anticoagulants (DOACs). OAC is recommended for all male AF patients with a CHA2DS2-VASc score of >2 and for all female AF patients with a CHA2DS2-VASc score of >3. 2. When it comes to stent thrombosis prevention for patients undergoing PCI, the benefit of DAPT over OAC is unequivocal. DAPT is the present standard of care after PCI both in the elective setting, with aspirin and clopidogrel, and in the course of an acute coronary syndrome (ACS), with aspirin and, preferably, ticagrelor or prasugrel. 3. Default DAPT durations in these settings are 6 (stable CAD) and 12 months (ACS) but these durations are flexible depending on the individual risk of ischemia and bleeding. Multiple investigations in PCI patients are ongoing to define whether in the era of newer generation drug-eluting stents (DES) and more potent P2Y12 inhibitors than clopidogrel (e.g., ticagrelor, prasugrel), SAPT is equally, if not more, protective as DAPT. 4. Multiple studies have demonstrated that TAT (anticoagulant plus DAPT) confers a 1.5- to 2-fold increase in major bleeding in these patients and a resultant increase in mortality. In clinical practice, this has led to wide

54 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 variations in antithrombotic agents utilized, dosage, and duration. The WOEST trial for example, examined the use of dual therapy (warfarin plus clopidogrel) versus warfarin-based triple therapy (dual therapy plus aspirin). As expected, bleeding rates were markedly lower in the dual-therapy arm (19.4% vs. 44.4%; p < 0.0001). 5. In the RE-DUAL PCI trial, 2,725 patients with AF and undergoing PCI were randomly assigned to receive 1 of 3 treatments: dual therapy with dabigatran (110 mg twice daily) plus either clopidogrel or ticagrelor, dual therapy with dabigatran (150 mg twice daily) plus either clopidogrel or ticagrelor, or triple therapy with warfarin plus aspirin (≤100 mg daily) and either clopidogrel or ticagrelor. In the warfarin-based triple-therapy group, aspirin was discontinued after 1 month in patients who had a bare-metal stent implanted and after 3 months in patients who had a drug-eluting stent implanted. The primary endpoint was the occurrence of major or nonmajor clinically relevant bleeding, not atherothrombosis prevention (e.g., ischemic events). This endpoint was statistically lower in both the 150-mg and 110-mg dual-therapy group than in the warfarin-based triple-therapy arm. Importantly, when both dabigatran groups were combined, the ischemic endpoint (a composite of death, myocardial infarction, stroke, systemic embolism, or unplanned revascularization) was noninferior to the warfarin-based triple-therapy group. 6. The recent randomized AUGUSTUS utilizing a 2 × 2 factorial design, standard-dose apixaban with or without aspirin was compared with warfarin with or without low-dose aspirin, on a background of concomitant P2Y12 inhibitor therapy for 6 months in patients with AF and recent acute coronary syndrome or PCI. They found that use of dual therapy with apixaban and a P2Y12inhibitor resulted in the lowest bleeding rates without sacrificing increased thrombotic risk.

Many questions remain unanswered, including the use of non–warfarin-based triple therapy, the safest combinations of DOACs and P2Y12 agents, and duration of therapy for each component of triple (or even dual) therapy. Perhaps the way forward will be to better define individual thrombotic risks and tailor the antiplatelet and anticoagulant risk accordingly, with patient preferences incorporated. For the foreseeable future, the practitioner and patient will continue to face uncertainty and will be balancing opposing risks on a case by case basis in their daily practice. In the absence of definitive trials, we will continue to rely on well-informed clinicians, their judgment, and shared decision making; post-PCI care will continue to require the irreplaceable art of clinical experience and informed patient input.

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Current Recommendations:

Reference: Capodanno et al. Management of Antithrombotic Therapy in Atrial Fibrillation Patients Undergoing PCI. JACC State-of-the-Art Review. J Am Coll Cardiol 2019;74:83–99.

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NOACs in Neurology- Current Indications(Approved and Off Label) and Antiplatelets in Stroke-Single or Dual for How Long? Dr Keyur Panchal Interventional Neurologist, Mumbai Corresponding Email ID: [email protected] Background: Stroke is a leading cause of mortality and disability worldwide. Initial manifestations of acute cerebral ischemia (Stroke/TIA) are often followed by recurrent vascular events, including recurrent stroke, which could be major in term of disability. To reduce this burden, antiplatelet therapy is a key component of the management of noncardioembolic ischemic stroke and TIA. However this benefit comes with possible risk of increased haemorhagic events. This signify the need for precise and personalized antiplatelet treatment for each patient.This presentation will focus on the evidence for antiplatelets: aspirin, aspirin-dipyridamole, clopidogrel, and Ticagrelor and how to compile this evidence into clinical practice to determine optimum antiplatelets combination and duration. Discussion: For acute treatment of nonembolic TIA or ischemic stroke, 2 trials have convincingly demonstrated reductions in recurrent ischemic strokes with the combination of aspirin and clopidogrel (versus aspirin monotherapy), lasting 21 or 90 days. For long-term prevention of recurrent vascular events in patients with a history of ischemic stroke or TIA, several options are available. These include aspirin, aspirin-dipyridamole, and clopidogrel. DAPT combining clopidogrel and Aspirin has not convincingly demonstrated prevention of recurrent events in long-term prevention trials, whereas major Hemorrhage is significantly increased (MATCH, SPS3, CHARISMA).Ticagrelor was compared directly with aspirin in the SOCRATES trial, which showed a strong trend toward lower stroke rates in patients assigned to ticagrelor in the acute setting. This difference was magnified in the subgroup of patients with atherosclerotic stroke. The ongoing THALES trial should better define the role of ticagrelor in acute cerebrovascular disease. The combination of aspirin and ticagrelor is being compared with aspirin alone. Apart from this possible haemmorhagic risk has to be taken into account. Several data based calculators available online for risk/benefit estimation.

Conclusions: People with high risk transient ischaemic attack or minor ischaemic stroke are at an increased risk of recurrent stroke and death l Aspirin and clopidogrel decrease this risk, even more so when used in combination l Strong recommendation for dual antiplatelet therapy (DAPT) with clopidogrel and aspirin to be started within 24 hours in patients who have had a high risk transient ischaemic attack or minor stroke l Strong recommendation for DAPT to be continued for 10-21 days, at which point patients should continue with single antiplatelet therapy l DAPT is not to be used for major stroke because of the increased risk of intracranial bleeding in these patients

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What Every Physician Should Know ? / Case-Based: LMCA Disease: A Heart Team Approach: CABG or PCI? Dr. Keyur Parikh Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Percutaneous coronary intervention (PCI) for significant left main coronary artery (LMCA) stenosis is increasingly being viewed as a viable alternative to coronary artery bypass grafting (CABG). CABG is the treatment option for LMCA lesions that has the highest evidence level in guideline recommendations. PCI for significant LMCA stenosis is increasingly being viewed as a viable alternative to CABG. In recent era, optical coherence tomography (OCT) imaging, with its high spatial resolution, has emerged as a useful tool for planning PCI and optimizing stent deployment, particularly in patients with complex lesions. Nevertheless, the reports of OCT-guided PCI in LMCA are very limited. Here, we present a case of frequency- domain OCT-guided stenting in patients with complex LMCA lesions, performed at our institute. Optical Coherence Tomography (OCT) visualize the coronary artery from inside to better accuracy, accurate positioning, placement expansion, post expansion evaluation as well as plaque characteristics has improved intervention in areas like Left Main Coronary Artery. Case: A 79 years old, female patient with history of Hypertension since last 2 years and Type-II Diabetes Mellitus. Present complaints of dyspnea on exertion since 2-3 days with chest pain, Coronary Artery Disease and Unstable Angina. Significant findings on examination were left main coronary artery with triple vessel disease. Her vitals were: BP-148/89 mmHg, HR– 82 bpm. Echo findings: LVEF: 55% with hypokinesia of infero-posterior wall, hypokinesia of apical septum apex. Detailed Angiography Report: • LMCA : Distal shows 80% lesion • LAD : Osteum shows 70-80% lesion • LCX : Osteum shows 70% lesion • RCA : Mid RCA shows 80% lesion Patient was advised for early CABG but during Pre-CABG workup, she was diagnosed with Laryngeal Deformity. So she was planned for high risk multi-vessel PCI.

Pre PCI (OCT Image):

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Post PCI (OCT Image):

Conclusion:OCT-IVUS guided PCI could be a good alternative to CABG in selected patients with LMCA stenosis. Post-procedure OCT-IVUS study is useful for the evaluation of stent expansion and strut apposition to vessel wall immediately after stent deployment.

Case-Based: Pulmonary Hypertension: Newer Drugs: Update Dr. Bhavin Dalal Oakland University William Beaumont School of Medicine and Beaumont Health, Royal Oak, Michigan, USA Corresponding Email ID: [email protected]

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A Primer on Heart Failure Therapies and Why They Are So Critical Dr. Keyur Parikh Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

The main terminology used to describe heart Failure (HF) is historically based on measurement of the left ventricular ejection fraction (LVEF). HF affects a wide range of patients, from those with normal LVEF (typically considered as ≥50 %; HF with preserved EF [HFpEF]) to those with reduced LVEF (typically considered as <40 %; HF with reduced EF [HFrEF]). Patients with an LVEF in the range of 40–49 % represent a ‘grey area’, which is now deﬁned as HF with mid-range EF (HFmrEF). It is remarkable that the new classification includes natriuretic peptides as key factors for the definition of HFmrEF and HFpEF Fig.1: Heart Failure Challenges:

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Fig. 2 proposes algorithm to aid in decision making for the treatment of HF:

Consensus recommendation: - Sacubitril/valsartan is recommended as a replacement for ACE-I/ARBs to reduce the risk of HF hospitalization and death in ambulatory patients with HFrEF who remain symptomatic despite optimal medical treatment with an ACE-I, a beta-blocker and a MRA. - Initiation of sacubitril/valsartan rather than an ACE-I or an ARB may be considered for patients hospitalised with new-onset HF or decompensated CHF to reduce the short-term risk of adverse events and to simplify management (by avoiding the need to titrate ACE-I first and then switch to sacubitril/valsartan). Because these patients are already at high risk of events, there is no need to check plasma concentrations of natriuretic peptides prior to initiating sacubitril/valsartan. Specific new recommendations have been made based on the evidence from major trials published since 2016, including SGLT2 inhibitors in type 2 diabetes mellitus; MitraClip for functional mitral regurgitation; atrial fibrillation ablation in HF; tafamidis in cardiac transthyretin amyloidosis; rivaroxaban in HF; ICD’s in non- ischaemic HF; and telemedicine for HF. In addition, new trial evidence from smaller trials and updated meta- analyses has given us the chance to provide refined recommendations in selected other areas. HFA-ESC criteria for defining Advanced HF: Ÿ Severe and persistent symptoms of advanced HF (NYHA III or IV) Ÿ Severe cardiac dysfunction* Ÿ Episodes of pulmonary or systemic congestion requiring high dose IV diuretics; episodes of low output requiring inotropes or vasoactive drugs or malignant arrhythmias causing > 1 unplanned visit or hospitalization in the last 12 months Ÿ Severe impairment of exercise capacity* Ÿ Additional criteria related to extra-cardiac organ dysfunction due to HF or type 2 pulmonary hypertension may be present

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Ÿ Criteria for NYHA III or IV and exercise capacity impairment may be combined* Ÿ Management of the advanced heart failure patient can be complex. Therapies include cardiac transplantation and mechanical circulatory support, as well inotropic agents for the short-term. Ÿ In patients requiring a pacemaker as a result of having heart block, implantation of a CRT device is also recommended (class I, level of evidence A). In particular, implantable cardioverter-defibrillators (ICDs) are indicated under the following circumstances: Ÿ Primary prevention in patients with HF and reduced systolic function (LVEF <35 %) despite optimal medical treatment (class I recommendation) Ÿ Level of evidence A in patients with ischaemic cardiomyopathy Ÿ Level of evidence B in patients with non-ischaemic dilated cardiomyopathy Ÿ Secondary prevention in patients with <1 year estimated survival (class I, level of evidence A recommendation) Conclusion:According to Advanced HF study, the primary care MD refers to cardiology as heart failure is complex for any generalist to ensure optimal HF care, it is important to refer often and early refer if: NYHA III-IV, Hypotension, Worsening renal function, Anemia, Repeat hospitalization and Poor tolerance of HF medications. Also optimize medications, Consider devices and catheter-based interventions, Consider transplantation and Consider palliative care.

NODAT (New Onset Diabetes after Transplantation): Clinical Insights Dr. Vivek Patel Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID : [email protected]

New onset diabetes mellitus after transplantation (NODAT) is a serious and common complication following solid organ transplantation. NODAT has been reported to occur in 2% to 53% of all solid organ transplants. NODAT developed partly due to immunosuppressive medications such as calcineurin inhibitors, corticosteroids, or mammalian target of rapamycin inhibitors. Solid organ transplant recipients who develop NODAT are at increased risk of fatal and nonfatal cardiovascular events and other adverse outcomes including infection, reduced patient survival, graft rejection, and accelerated graft loss compared with those who do not develop diabetes. Identification of high-risk patients and implementation of measures to reduce the development of NODAT may improve long-term patient and graft outcome.

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Case-Based: Diabetes Management in Elderly: Updated on Endocrine Society Guideline Dr. Vivek Patel Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

Diabetes, particularly type 2, is becoming more prevalent in the general population, especially in individuals over the age of 65 years. The underlying pathophysiology of the disease in these patients is exacerbated by the direct effects of aging on metabolic regulation and progression of diabetes complications. The priorities and therapeutic strategies need to be cautiously individualized. Treatment decisions are influenced by age and life expectancy, comorbid conditions and severity of the vascular complications. Adherence to dietary therapy, physical activity, and medication regimens may be compromised by comorbid conditions and psychosocial limitations. Drug-induced hypoglycemia has been the main consideration and the most serious potential complication. Age-related changes in pharmacokinetics and the potential for adverse effects and drug interactions should also be considered when choosing appropriate pharmacological therapy. In general, a conservative and stepwise approach to the treatment of the elderly patient with type 2 diabetes is suggested. Strict glycemic control may not be achievable in all patients or even desirable in many elderly patients.

Chronic DVT and CTEPH: Management Update Dr. Satya Gupta Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

Venous thromboembolism (VTE) is a common disease that is associated with significant risk of recurrence, chronic complications, and substantial mortality. The development of novel anticoagulants has revolutionized the treatment of acute VTE, while strategies for prevention and treatment of chronic complications still under evaluation. Impaired thrombus resolution is the common denominator behind VTE complications, which are post-thrombotic syndrome (PTS) and chronic thromboembolic pulmonary hypertension (CTEPH). PTS and CTEPH are associated with substantial morbidity and high healthcare expenses. While PTS occurs in up to 50% of patients after symptomatic deep vein thrombosis, only a small and poorly defined number of patients are diagnosed with CTEPH after pulmonary embolism. Chronic pulmonary thromboembolic disease is an important cause of severe pulmonary hypertension, and as such is associated with significant morbidity and mortality. The prognosis of this condition reflects the degree of associated right ventricular dysfunction, with predictable mortality related to the severity of the underlying pulmonary hypertension Once considered a rare condition, chronic thromboembolic pulmonary hypertension (CTEPH) was recently documented to complicate 3.8% of acute pulmonary embolic events. CTEPH is the only cause of severe pulmonary hypertension which is potentially curable without the need to resort to lung transplantation. Pulmonary endarterectomy (PEA) is the surgical procedure which removes the obstructing thromboembolic material, resulting in significant improvements (and in many cases

63 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 normalization) in right ventricular haemodynamics and function. This procedure requires a high degree of anaesthetic and surgical skill, coupled with assiduous preoperative evaluation of potential patients. Surgery is generally considered only in patients with proximal chronic thromboembolic disease as assessed by radiological investigations. For those patients unsuitable for surgery, or with significant pulmonary hypertension post‐PEA, PAH specific drugs may be an effective therapeutic option. Chronic thromboembolic pulmonary hypertension (CTEPH): key points Ÿ CTEPH should be specifically considered in the diagnostic workup of all patients with pulmonary hypertension Ÿ Following an acute pulmonary embolism, patients at risk of developing CTEPH include those with any of the following: a major central thromboembolic event, significant haemodynamic disturbance on presentation, a documented thrombophilia, or persistent abnormalities of lung perfusion on follow up Ÿ If present to a significant degree, small vessel arteriopathy contributes substantially to the outcome of treatment for CTEPH Ÿ Ventilation/perfusion (V/Q) scanning is the screening investigation of choice for CTEPH Ÿ Patients with suspected CTEPH should be referred to a centre with significant experience in the assessment and treatment of this condition Ÿ In patients with operable CTEPH, pulmonary endarterectomy is the treatment of choice

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Case-Based: LDL - Hypothesis in back ! How to Achieve your Goals ? Dr. Urmil Shah Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

The main principles for LDL-Lowering therapy: There is a causal relationship between low-density lipoprotein cholesterol (LDL-C) and the development of atherosclerotic cardiovascular disease (ASCVD). Trials of LDL Lowering indicate relative risk reduction is proportional to the absolute reduction in LDL-C. Lower LDL-C is better. According to recent data SWEDEHEART study published in 2019 post MI patient with a high quartile of LDL-C decrease (70 mg/dl) from index event to follow up had a lower risk of mortality, compared to those with a lower quartile of LDL-C decrease. Using statin, ezetimibe, or Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors is safe and effective down to < 1 mmol/L (40mg/dl). According to new 2019 ESC/EAS Guidelines, intensity of LDL lowering should be based on risk, irrespective of the cause(s) (e.g., primary or secondary prevention, diabetes, or CKD). Table 1: Evidence for Efficacy of LDL-Lowering Therapies Lower than 1.4 mmol/L (55 mg/dl)

Above table shows that LDL reduction below 55 using combination of high intensity statin, Ezetimibe, PCSK9 inhibitor in various trials have shown significant outcome advantage.

Cardiovascular Outcomes according to data from ODYSSEY and FOURIER study using adding of PCSK9 inhibitor to maximally tolerated statin:

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Figure 1

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In order to be aligned with these new findings, the ESC/EAS Guidelines have proposed new LDL-C goals, as well as a revised CV risk stratification, which are especially relevant to high- and very-high-risk patients. Table 2 : Lower LDL-C goals for very high-risk patients and risk stratification that includes goal-focused treatment strategies helps define physician practice.

Table 3: Intensifying Lipid-Lowering Treatment to Reach LDL-C Goals:

The addition of a PCSK9 inhibitor is recommended in patients at very high risk who are not achieving treatment goals on a maximum tolerated dose of a statin and ezetimibe. Key Takeaways from the ESC/EAS guidelines for the management of dyslipidemias are as mentioned below: In the 2019 ESC/EAS Guidelines, patients classified as being at very high risk are those with documented ASCVD, patients with diabetes with target organ damage, patients with familial hypercholesterolaemia with ASCVD or another major risk factor, and patients with severe chronic kidney disease. The 2019 ESC/EAS guidelines recommend both a ≥50% LDL-C reduction from baseline and an absolute LDL-C treatment goal of <1.4 mmol/L (<55 mg/dL) for very high-risk patients. For patients at high risk, a ≥50% LDL-C reduction and an LDL-C goal of <1.8 mmol/L (<70 mg/dL) are recommended. A high-intensity statin should be prescribed up to the highest tolerated dose to achieve specified goals. LDL Management in Acute Coronary Syndrome: LDL-C levels tend to decrease during the first days of ACS and therefore a lipid profile should be obtained as soon as possible after admission for ACS. Patients do not have to

67 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 be fasting as this has little impact on LDL-C levels. Lipid-lowering treatment should be initiated as early as possible to increase patient adherence after discharge. Lipid levels should be re-evaluated 4–6 weeks after ACS to determine whether treatment goals have been achieved and add EZETIMIBE and PCSK9 inhibitor to reach LDL target as fast as possible How to reach to LDL goals: Many US adults are not reaching LDL goals despite effective statin treatment. Even on high-intensity statins, around 80% of established CVD patients do not achieve LDL-C < 70 mg/dl. Possible reasons for failure to meet LDL-C goals are Lack of adherence, drug intolerance, patient characteristics, lack of lifestyle changes, failure to titrate/switch to more potent dose/statin, underuse of additional lipid- lowering therapies and Inadequate follow-up. High intensity lipid lowering drugs with high level of adherence have been found to be associated with better CV outcomes (Figure 3). Tactics to increase medication adherence to lipid-lowering therapy: Simplify drug regimen, providing patient education and information, regular follow-up, electronic reminders, behavioral approaches (group sessions, rewards to increase motivation), decision support systems (computer- based information systems to aid decision-making), Administrative improvements (audit, documentation) and Pharmacy-led automated telephone intervention. We know that PCSK9 inhibitor is very costly treatment so one has to adopt cost effective strategy for his or her own country. In India Cost-effective indication are as follows:

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Case Based Approach to Stress Cardiomyopathy Takotsubo Syndrome Dr. Keyur Parikh Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Stress cardiomyopathy (Takotsubo syndrome) was first described in 1990 in Japan and has since been increasingly recognized around the world which is also known as Stress cardiomyopathy, Broken heart syndrome, or Apical ballooning syndrome and Happy Heart Syndrome is an important form of acute reversible myocardial injury. Stress cardiomyopathy is a clinical syndrome characterized by an Acute and transient (21 days) Left ventricular (LV) systolic (and diastolic) dysfunction related to an emotional or physical stressful event, most often identified in the preceding days (1 to 5 days). Stress cardiomyopathy occurs in approximately 1 to 2 percent of patients presenting with troponin-positive suspected acute coronary syndrome (ACS) or suspected ST-elevation myocardial infarction. Stress cardiomyopathy is suspected on the basis of the clinical syndrome, ECG abnormalities, Mild elevation of cardiac troponin, Significant elevation in serum natriuretic peptide levels (BNP or NT-proBNP), Noninvasive cardiovascular imaging. Figure 1: Diagnosis of Stress Cardiomyopathy:

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Figure 2: Acute Treatment of Patients with Stress Cardiomyopathy and Hemodynamic Compromise ECG Monitoring

In majority of the cases, the patient has experienced an emotional or physical stress that he/she may not share with the health care provider unless asked. Chest pain has typical characteristics of angina. Shortness of breath is usually the result of pulmonary edema;dizziness and syncope derived from hypotension and hypoperfusion; cardiac arrest due to ventricular arrhythmias. Figure 3: Central Illustration Pathophysiology of Stress Cardiomyopathy:

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Conclusion: Stress cardiomyopathy is an acute cardiac disorder with a transient left ventricular wall motion abnormality, and it must be promptly differentiated from ACS. Stress cardiomyopathy has an in-hospital mortality of up to 5%. Recurrences are common- 2% to 4% per year and up to 20% at 10 years. TTS is estimated to represent approximately 1-3 percent of all patients and 5-6 percent of female patients presenting with suspected STEMI.

Difficult Cases of Pulmonary HT Dr. Bhavin Dalal Oakland University William Beaumont School of Medicine and Beaumont Health, Royal Oak, Michigan, USA Corresponding Email ID: [email protected]

Pulmonary hypertension (PH) is very common although pulmonary arterial hypertension (PAH) is a rare disorder (1-5 cases in 1 million population). Commonest cause of PH (not PAH) is left sided heart failure. According to ACC/AHA definition to diagnose PAH we need to have Right heart catheterization and left sided pressures should be normal. (i.e. PCWP<15) During the session we will talk about difficult cases of PH and PAH, especially how to differentiate and how to diagnose if there is overlap between Left sided heart failure and right sided heart failure.

Case-Based: A Patient with Acute Breathlessness in ER Dr. Bhavin Dalal Oakland University William Beaumont School of Medicine and Beaumont Health, Royal Oak, Michigan, USA Corresponding Email ID: [email protected]

Shortness of breath or dyspnea is one of very commons symptoms for primary care doctors, specialists as well as ER physicians. Time is money in terms of correct diagnosis and management. Focused history and physical examinations are still valuable. So many times, investigations are misleading. Several unnecessary investigations can be prevented, and correct diagnosis can be achieved with simple algorithmic process. During this session we will discuss few cases of SOB in which a simple approach can achieve diagnosis easily.

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P-101 Severe Dengue Due to Secondary Hemophagocytic Lymphohistiocytosis: A Case Study Patel Tirthesh General Medicine, Smt. NHL Municipal Medical College, Ahmedabad. Corresponding Email ID: [email protected]

Introduction: Hemophagocytic lymphohistiocytosis (HLH), a potentially fatal condition that is often under recognised contributing to its high mortality and morbidity. Early recognition is crucial for any efforts at curative therapy. Although HLH is now being increasingly detected in clinical practice due to improved understanding on the part of physicians, pathologists and microbiologists; still much work remains to raise awareness, explore treatment options and improve outcome of this complex condition. We report a case of dengue associated HLH who had a successful outcome following timely diagnosis and appropriate intervention. Case Report: A 56-year-old male with fever for six days and vomiting and pain abdomen for a day. Significant findings on examination were fever of 38.3 °C, epigastric and right hypochondriac tenderness and dullness over lung bases. Routine laboratory parameters revealed haemoglobin 10.4gm/dl, Leukopenia with presence of reactive Lymphocytes (WBC count 2230 mm−3; reference value [RV]:4000–10000 mm−3) and low platelet count (55000 mm−3; RV: 150000–400000 mm−3). There were significant derangements of the biochemical parameters as well. Liver enzymes were elevated, AST 241 U/L (RV: 10–42 U/L) and ALT 239 U/L (RV: 10–40 U/L). Serum amylase and lipase levels were high 286 U/L; (RV: 25–125 U/L) and 364 U/L; (RV: 22–51 U/L) respectively. Serum ferritin level done at day 2 of admission was 75031 ng/ml (RV: 30–400 ng/ml). Serum procalcitonin level at admission was 2 ng/dl (RV: <0.5 ng/ml) which was indicative of bacterial sepsis. Serum triglyceride and plasma fibrinogen levels were within normal range. The platelet count dropped to 45,000 mm−3on day three of admission with coffee ground vomiting. The patient subsequently received two units of single donor platelet. Ultrasound imaging showed mild splenomegaly (measured length13 cm), minimal free fluid in abdomen and edematous pancreas and bilateral pleural effusion. Chest X-ray showed pneumonitic changes in both lung fields. Work up of locally common infectious causes were done including urine and blood cultures, Malaria smear and antigen detection, Dengue NS1 antigen detection. The Dengue NS1 antigen test was positive while all other tests were negative including cultures. A diagnosis of dengue fever complicated by pancreatitis and hepatitis with associated chest infection was made. Treatment: Despite supportive therapy he remained unwell with spikes of temperature, worsening abdominal pain and progressive bi-basal crepitations. Laboratory investigations showed persistent leukopenia, thrombocytopenia and rising aminotransferases. A bone marrow aspiration and trephine biopsy were done for further evaluation on day 4 of admission triggered by high ferritin and bicytopenia. Bone marrow study showed normocellular reactive marrow with evidence of macrophage activation and hemophagocytosis. A dengue serology on day 6 of fever was positive for IgM antibodies by capture ELISA (Index 5.71, RV: Index < 1.1) but negative for IgG antibodies establishing the diagnosis of primary dengue infection with secondary HLH. Following the diagnosis of HLH, the patient was given intravenous immunoglobulin (400 mg/kg/day for 5 days) starting on day 5 of hospitalisation in view of associated pancreatitis and chest infection. The patient continued

72 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 to be febrile (T max 38.3 °C) till day 8 of admission. He improved over the next few days, became afebrile and was discharged after 13 days in the hospital. At the time of discharge his blood counts and biochemical parameters had recovered to almost normal levels. Methods: Prospective and Observational Case Study. Discussion: HLH is a disease with major therapeutic and diagnostic difficulties. The diagnosis HLH was based on five criteria (fever, splenomegaly, bicytopenia, hypertriglyceridemia and/or hypofibrinogenemia, and hemophagocytosis). In 2004 three additional criteria were introduced by the Histiocyte Society; low or absent NK-cell-activity, hyperferritinemia, and high-soluble interleukin-2-receptor levels. Five of these eight criteria must be fulfilled for a diagnosis of HLH. The NK cell activity and soluble IL2 receptor quantitation tests are not done in routine clinical practice since they require sending samples out to specialized centers and hence usefulness of these tests in day to day practice is limited. This patient fulfilled five of the eight criteria — splenomegaly, bicytopenia (decr fever, splenomegaly, bicytopenia (decrease in platelets and leucocytes) hyperferritinemia and presence of haemophagocytes in the bone marrow and accordingly was diagnosed as a case of secondary HLH. HLH may be primary (familial) and secondary. In recent years there is an increased incidence of this disease probably because of better diagnostic abilities of clinicians. Secondary HLH develop due to over activation of immune system. Secondary HLH has been associated with a variety of viral, bacterial, fungal and parasitic infections as well as collagen vascular diseases and malignancies particularly T-cell lymphomas. The term reactive HLH has been suggested when HLH is associated with an identifiable infectious or non-infectious etiology to distinguish it from the familial form. Infection has been found to be associated with HLH in half of all reported cases. Phagocytosis of blood cells and their precursors is a hallmark of hemophagocytic syndromes. Hemophagocytosis is achieved mostly by monocytes and macrophages. Excessive activation of monocytes in HLH is due to stimulation by high levels of activating cytokines. It has been recognized that high levels of cytokines like interferon-γ, soluble interleukin-2 receptor, tumor necrosis factor (TNF-α), interleukin-1 and Interleukin-6 by T helper cells result in stimulation of macrophages leading to the cascade of events. About one third of secondary HLH are triggered by viral infections. Several viral infections have been reported to trigger HLH, EBV infection being the most notorious. EBV triggered HLH has been widely reported and studied. Other viruses which are known to trigger HLH include Herpesviridae, Poxviridae, Flaviviridae, Orthomyxoviridae, Paramyxoviridae and Retroviridae. The aim of management of infection associated HLH is to treat the underlying infection that triggered it. Most cases of HLH also need to be treated upfront with standard protocols. Regarding treatment of dengue associated HLH, review of the existing literature showed that few cases have recovered spontaneously with supportive treatment only. However, in majority of the cases pulse dosage of methylprednisolone or dexamethasone have been used to suppress the hyperinflammatory state. Intravenous immunoglobulin G has been used in few cases either alone or with dexamethasone or methylprednisolone. Raju et al. reported successful use of intravenous immunoglobulin G in nineteen children suffering from dengue related HLH. Srichaikul et al., Tan et al. and Wan et al. have reported treating three adult patients successfully with combination of intravenous immunoglobulin G and dexamethasone or methylprednisolone. In the present

73 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 case high dose steroids was not considered because of associated pancreatitis and concurrent sepsis as the patient had high procalcitonin at presentation and evidence of chest infection in X ray. Our patient of severe dengue with evidence of plasma leak had an uneventful recovery following prompt diagnosis of HLH (on day 7 of fever and 4 of hospitalization) and early institution of specific therapy. The treatment of dengue induced HLH by intravenous immunoglobulin G seems to be associated with a favourable outcome as this case report and similar other cases reported in the literature seem to suggest. Secondary HLH and severe sepsis, systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS) share clinical and laboratory inflammatory phenotypes and therefore it is important to distinguish these conditions as therapeutic options are radically different. Progressive pancytopenia along with presence of hemophagocytes in the bone marrow helped in establishing the diagnosis of HLH in this patient. This case report aims to generate awareness about dengue induced HLH and the importance of a high clinical suspicion for early detection thereby facilitating successful treatment. Dengue affects thousands of people worldwide every year and hence may be lifesaving to detect HLH in patients suffering from dengue. In dengue patients with persistent low counts and multi-organ dysfunction, the possibility of HLH should be kept in mind particularly in first episode dengue infections. The diagnosis is usually challenging, as it can be easily mistaken with other clinical situations, such as sepsis or other systemic inflammatory response syndromes (SIRS). Elevated ferritin levels > 10,000 μg/L has been demonstrated to be 90% sensitive and 96% specific for HLH and should be used as screening tool for early detection of HLH, triggering further investigations. This report adds to the limited adult cases of dengue-associated hemophagocytic syndrome described in the literature and stresses the need to work up patients with severe dengue for possibility of HLH. Keywords: Dengue, DSS, DHF, HLH, ELISA, SIRS, MODS. Refrences: 1. Henter J.I., Horne A., Aricó M., Egeler M., Filipovich A., Imashuku S. HLH-2004: diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer. 2007;48:124–131. 2. Henter J.I., Elinder G., Ost A. Diagnostic guidelines for hemophagocytic lymphohistiocytosis. the FHL study group of the histiocyte society. Semin Oncol. 1991;18(1):29–33. 3. Fishman D.N. Hemophagocytic syndromes and infection. Emerg Infect Dis. 2000;6:601–60 4. Harrison’s Principle of Internal Medicine.

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P-102 Regional Anaesthesia in High Risk Cardiopulmonary Involvement in Two Cases of Modified Radical Mastectomy Desai Dipak, Patel Tarang Care Institute of Medical Sciences Corresponding Email ID: [email protected]

Background: 71 yrs old lady was scheduled for modified radical mastectomy on account of advanced carcinoma of Lt breast , patient was known case of chemotherapy induced severe LV dysfunction with LBBB , she was been managed with T carvidelol , lanoxin , aldactone . Additionally She had history of SAH 10 yrs back but recovered and presently she is fully concious ,following verbal commands. Her 2D echo shows severe LV dysfunction with global hypokinesia with 20% LVEF with RVSP 35 mm of Hg with mild pericardial effusion. On evening prior to surgery her vitals sign were as follows : pulse – 62/min, BP 102/70, RR 20/min , Temp 38C . Her chest was clinically clear , other examination findings were normal. Her Hb : 11.1 gm% , ECG shows LBBB , X ray chest shows prominent BVM , other investigation include electrolytes, urea , creatinine , PT INR , viral markers were within normal limits. Based on comorbid condition she was assigned class III ASA. She was explained and consulted for thoracic epidural anaesthesia as general anaesthesia was considered a more risky alternative and consent for thoracic epidural was obtained. On morning of surgery her vitals were – Pulse : 68/min, BP : 106/72, ECG shows LBBB, RBS : 80 mg% , she took all cardiac medications with sips of water 3 hrs prior to surgery . Second case: A 62 year lady with known case of Interstitial Lung disease with radiological evidence and on steroid Nebulization , hypertensive on treatment of carvidelol and diuretics . She had received chemotherapy before surgery was planned and 2D echocardiography showed LVEF 35% with RVSP 35 mm of Hg Pulmonary function test preoperatively showed severe obstructive ventilatory defects with partial post bronchodilator reversibility and sever reduction in ventilatory response She was once consulted for pre operative assessment of anaesthesia for surgery and she was not given consent for epidural anaesthesia and surgery was not able to posted. After 15 days she again came and admitted for surgery, again she was councelled for epidural anaesthesia and prepared for anaesthesia with bronchodilator/steroid nebulization on previous day of surgery and also on day of surgery 1 hr prior to surgery also. Her chest was clinically clear and other examination findings were normal In operation theatre a multipara monitor with invasive arterial line monitoring was applied Baseline values were as follows: PR 102/min, BP 146/86, and Spo2 : 96% with nasal cannula with 2-3 L O2/min Pre operative X ray chest: In operation theatre a multiparameter monitor was applied to patient with addition to Arterial line for continuous caridiac output monitor ( flotrac ) applied to patient. Baseline values were as follows: PR 78/min, BP 122/80, Spo2 99% , CO 4L/min, SV 45ml/min, SVR : 960 dynes. In sitting position – midline thoracic epidural was performed at T4-5 interspinous space using size 18 ganze

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Touhy epidural needle and loss of resistance to saline technique used to locate epidural space , skin to epidural depth was 5 cm and another 5-6 cm of epidural catheter was inserted in cephaled direction and catheter was properly fixed with adhesive tap. After test dose of 2-3 ml of Xylocaine + Adrenaline followed by loading dose of 10 ml xylocaine+ Adrenaline (1:200000) was given in slowly increased doses over period of 5-10 min and epidural catheter was connected to continuous infusion 0f 0.25% bupivacaine @ 2-4 ml/hr. After 10 min later sensory block height was achieved T1-T10 level bilaterally and checked for surgery with pricking dermatomes. Surgery started , the breast tissues and tumor were excised en mass including axillary lymph nodes dissection removed. Oxygen was given via face mask at 4L/min throughout surgery which lasted for 120-150 min Sedation in form of 1-2 mg midazolam was used during surgery. Cardiac monitor with cardiac output were monitored during surgery and all parameters remained within normal range during surgery. Inj NS 500 ml given as continuous fluid during surgery , patient needs one bolus dose of inj ephidrin 15 mg during course of surgery. Post operatively patient was admitted to HDU for observation and pain management which consisted of 0.25% bupivacaine @ 2-3 ml/hr and IV Paracetamol 1gm every 12 hrly for 24-36 hrs as additional analgesia. Patient resumed oral feeding after 6-8 hrs of surgery postoperatively. Patient was discharged from HDU after 24 hrs to Room and from hospital on third day draine was removed and discharged from hospital on 4 th day of admission. Outcome and follow up: Both cases under epidural anaesthesia were remained hemodynamically stable without any adverse events during course of surgery and 24 hrs postoperative period. Both patients were admitted in HDU for 24 hrs observation and post operative epidural infusion for analgesia and for expert nurse care for hemodynamic monitoring. Both patients were shifted to general ward after 24 hours observation in HDU. Both pateints were early mobilized after shifting to ward and discharged early from hospitalization in comparison of patients who received general anaesthesia. Facial pain score of both patients remained less than 4 during hospitalization with good satisfaction. Discussion: Radical mastectomy with axillary clearance is traditionally performed under Genaral anaesthesia. This was the first case of mastectomy under solely thoracic epidural anaesthesia in our center followed by another case also. In a previous study it was documented the safety and superiority f thoracic epidural over general anaesthesia in 40 patients scheduled for mastectomy . In that study thoracic epidural was found to be superior to general anasthesia in terms of hemodynamic stability , reduced nausea and vomiting, lower analgesic consumption ,

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Hemodynamics during Surgery Axillary Dissection Under Mastectomy Incision Thoracic Epidural superior postoperative analgesia and shorter duration of hospitalization . Similar observations have been reported by other researchers also. The infrequent use of thoracic epidural anaesthesia for oncologic breast surgeries in our environment may be attributed to fear of potential complications of thoracic epidural which include spinal injuries, epidural hematoma and epidural abcess as well as postdural puncture headache. However with experience and expertise and due precautions these complications are extremely few in numbers. Moreover the benefits of thoracic epidural anaesthesia makes it a technique of choice in high risk cardiopulmonary morbid high risk patients In previous studies have identified history of hypertension as risk factor for cadiovascular complications during general anaesthesia. Hypertension has been reported to be more common intraoperatively in patients undergoing surgeries with general anaesthesia compared to thoracic epidural. During general anaesthesia wide fluctuations in blood pressure are usually occurred during larygoscopy and intubation , surgical stimulation and during extubation and recovery. These airway manipulations are usually avoided in thoracic epidural anaesthesia and hence our patients was hemodynamically stable throughout procedure inspite of cadiovascular and respirtatory co morbidity. In our patient inspite of low cardiac ouput we noticed one episode of hypotension after bolus dose of epidural injection but with due monitoring of cadiac ouput . Stroke volume and SVR we managed it with only one bolus dose of ephidrine and bolus dose of IV fluid. In other patient who refused by pulmonolgist to deliver general anaesthesia due to very high index of reactive airway , patient tolerated epidural anaesthesia during surgery and as well as during postoperative period with excellent analgesia with no episodes of bronchial spasm and managed throughout course of hospitalization and dischared early in comparison with patients who received general anaesthesia Etta and Edubio previously reported on thoracic epidural anaesthesia for lapartomy in an asthmatic patient. Their patient developed acute asthmatic attack postoperatively in general ward and this was attributed to inadequate analgesia. Our both patients were admitted for to HDU postoperatively for 24 hrs for continuous epidural infusion for analgesia. This enabled the patient to receive the full benefit of epidural analgesia since syringe pumps and nurses trained in epidural analgesia management were not available in general ward.

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Conclusion: Thoracic epidural anaesthesia and analgesia for radiacal mastectomy is feasible and it offers additional benefits in high risk patients particularly in cardiorespiratory co morbid patients with expertise anaesthesiologist and well equipped ICU observation. Epidural anaesthesia has some advantages when compared with general anaesthesia and can be considered an anaesthesia option in oncologic mastectomies with axillary dissection. Complementary sedation was necessary in 100% of patients who underwent epidural block and complementary sedation with infiltration of local anaesthetic in axilla in 15% of the patients in this group. The rate of hypertension was more frequent in group of patients who underwent general anaesthesia whil hypotension was more frequent in epidural group. Nausea(30%) and vomiting (45%) were more frequent in general anaesthesia group.

The quality of postoperative analgesia was better in epidural group which also presented lower consumption of analgesics , the length of hospitalization in this group was also lower.

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P-103 A Rare Case of Anti PL12 Antibody Positive Antisynthetase Syndrome Shah Ravi, Parikh Ami General Medicine , Smt. NHL Municipal Medical College, Ahmedabad. Corresponding Email ID: [email protected]

Under guidance of Dr. Ami P. Parikh, HOD, General medicine, Smt NHL municipal medical college. The inflammatory myopathies are a group of diseases, with no known cause, that involve chronic muscle inflammation accompanied by muscle weakness. They include Dermatomyositis, Polymyositis, Antisynthetase syndrome, Inclusion body myositis and Nectrozing Myopathy. Anti-synthetase syndrome is an autoimmune condition, characterized by antibodies directed against an aminoacycl transfer RNA synthetase along with clinical features that can include interstitial lung disease, myositis, Raynaud’s phenomenon, and arthritis. Of the antibodies for ASS, most common of these is anti-Jo-1. Others include PL-7 and PL-12. A 31 year old female presented with complaints of fever, proximal muscle weakness and Breathlessness. ESR(110 mm/hr) and CRP were high and CPK total was also positive(1096 U/l). HRCT was s/o NSIP. ANA was positive in cytoplasmic pattern and ANA profile by immunoblot had specific bands for PL-12 antibodies. On examination, patient had thickened, dry, cracked skin on sides of palms and fingers suggestive of mechanics hand. Patient also had complaints of pain with morning stiffness in small joints of hand. Patient was diagnosed as anti synthetase syndrome. Patient was treated with Inj methylprednisolone 1 gram IV for 3 days along with cyclophosphamide 500 mg IV. Patient's Breathlessness significantly improved during her hospital admission and was discharged on oral prednisone 1 mg/kg. Patient was advised second dose of IV cyclophosphamide 500 mg after 15 days.

P-104 Reversible Cardiomyopathy in Case of Aluminium Phosphide Ingestion. Kataria Yogesh , Shah Harshil , Trivedi Aarti Department of General Medicine, PDU Medical College, Rajkot, Gujarat (India) Corresponding Email ID: [email protected]

Introduction: Cardiac Dysfunction due to Functionally Abnormal Myocardium in absence of any other structural disease, due to Aluminium Phosphide Toxicity. Case Report: A 52 year Male Patient Aluminium Phosphide Ingestion 30min before presented with Emesis, Diaphoresis, Palpitation and Acute onset of Dyspnoea, without any significant Past and Personal history of Medical illness. Examination: Patient was Hemodynamically Unstable, having Tachycardia (PR-120/min), Hypotension (Systolic BP-60mmhg), Tachypnoea (RR-44/min), Spo2-70%on room air. On R/S Auscultation bilateral lower zone Crepitation present.

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Investigation & Management: ECG suggestive of Sinus Tachycardia, RBBB, ST-T changes in lead II, III, AVF with broad qrs. ABG shows Metabolic Acidosis. Serum Creatinine raised, Cardiac biomarker- CKMB raised with negative Troponin-I. Patient was manage in Intensive Care Unit with Invasive mode of ventilation with Correction of metabolic acidosis, Inotropic support given. On Stabilization, 2D Echo suggestive of Segmental wall motion abnormality, EF~35% with Systolic dysfunction, Coronary Angiography was Normal. On repeat 2D Echo, on 14th day suggestive of EF~55% with no regional wall motion abnormality. Conclusion: Aluminium Phosphide Poisoning, can cause Severe Cardiac Toxicity (Cardiomyopathy), which is reversible , provided patient receive Intensive Hemodynamic support during initial insult period.

P-105 A Case of Methemoglobinemia Due to Aniline Poisoning Patel Parth General Medicine, Smt. NHL Municipal Medical College, Ahmedabad. Corresponding Email ID: [email protected]

Methemoglobinemia occurs in the presence of an elevated circulating fraction of methemoglobin within the red blood cells. Normal hemoglobin contains the iron molecule in the divalent ferrous state,Fe(II). Methemoglobin results from the oxidation of Fe(II) to a trivalent ferric form, Fe(III). Methemoglobin cannot bind and carry oxygen, resulting in functional anemia and hypoxia. Methemoglobinemia can be hereditary or acquired. Hereditary methemoglobinemia commonly stems from a deficiency in either the erythrocyte or the membrane-associated NADH cytochrome b5 methemoglobin reductase enzyme. Acquired Methemoglobinemia is commonly caused by exposure to medical substances, such as benzocaine and dapsone, that oxidize hemoglobin to MetHb; exhaust fumes from internal combustion engines; herbicides and pesticides; and chemicals, such as nitrobenzene and aniline. Aniline is a prototypical aromatic amine in a pale yellow liquid form with an unpleasant odor of rotten fish. It is used in the production of dyes, rubber processing chemicals, and antioxidants. The most common occupational exposure to aniline includes inhalation, oral ingestion, and absorption through the skin. Here we report a case of 21-year-old male exposed to aniline via oral ingestion. He presented with chief complaints of Dyspnea and Cyanoderma. His chest X-ray was normal and initial blood methemoglobin concentration level of 18.8% but blood methemoglobin concentration level reached maximally 46.8% during hospitalization. He was treated with methylene blue due to relatively high blood methemoglobin level. Gradually after the treatment, his methemoglobin concentration level was normalized to 0.8% and simultaneously symptoms were resolved.

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P-106 Frosted Branch Angitis :A Case Report of a Rare Disease Pandher Shweta PDU Medical College, Rajkot, Gujarat Corresponding Email ID: [email protected]

Introduction: Frosted branch angitis is a rare presentation of retina atypically in some of the diseases. It is observed as Florid sheathing of retinal arterioles and venules, anterior uveitis and retinal oedema are common features in eye fundus examination. Frosted branch angitis describes the characteristic fundus picture usually bilateral and may represent a specific entity (primary) are common path way in response to multiple stimuli. Secondary Frosted branch angitis may be associated with infectious retinitis notable cytomegalo virus retinatie, other condition such as lymphoma and leukaemia etc. Primary (idiopathic) Frosted branch angitis is rare and typically affects children’s and young adult in whom presentation with bilateral visual loss (6/30 to PL) photopsia. There may be viral prodrome sometimes. The main treatment is with systemic steroid though some authorities’ believe prognosis which is usually good primary form is unaffected. Case Report: A 19 year old female patient admitted in department of medicine with history of fever (38.7’C) for 15 days, vomiting, head ache and altered behavior for 5 days with generalized weakness. She had no significant any past history of medical diseases. Family history was also non significant. On examination: patient had altered sensorium with neck rigidity present and bilateral planter reflex extension. On cerebrospinal fluid examination cells counts (100 dec 70% L, 30% N), protein (154.7), sugar (40), with nearly normal report. She was diagnosed as have TBM and stating CAT-I AKT under RNTCP guideline. She improved clinically on 8th day of treatment, she complained of blurring of vision. On fundus examination she found as have FBA which is atypically found in TBA. She was treated accordingly and discharged with further treatment given. VZV (IGM 0.48 nrgative), CMV (0.16 negative), HSV type- I (IgG 0.31, IgM 0.80 negative), HSV type-II (IgG 0.22, IgM 0.52 negative), HBsAg (negative), HIV (Negative), HAV (Negative), HEV (Negative), HCV (Negative) In our case Frosted branch angitis occur in young female who has tuberculous meningitis was treated with tablet acyclovir (800mg) 4 times a day for 14 days, tablet omnacortil (60mg, 40mg, 20mg, 10mg) in tappering doses. Conclusion: Patient diagnosed with tuberculous meningitis associated with frosted branch angitis which is very rare disease.

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P-107 Wilson’s Disease: Fatal when Overlooked, Curable when Diagnosed - Rare Case Report of Twin Wilson Brothers. Hirani Balkrushna M.D. General Medicine, Smt. N.H.L. Municipal Medical college, Ahmedabad. Corresponding Email ID: [email protected]

Background: Wilson’s disease is an inherited disorder characterized by the excessive accumulation of copper or abnormal copper metabolism. It occurs predominantly in the liver and brain. The genetic factor leading to Wilson’s disease is the mutation of copper transporting gene ATP7B.The main clinical symptoms in Wilson’s disease include neurological, psychiatric and hepatic. The primary treatment in Wilson’s disease is use of copper chelating agent such as D-penicillamine and trientine. Case Presentation: A 13-year-old male, C/O Jaundice and generalised oedema since last 4 year which is recorvered over a period of time, C/O imbalance while walking for 1 year and abnormal posturing of limbs and difficulty in speech 6 months. Pallor+ KF rings+, abnormal laughter+, waddling gait+, lordosis+. Serum ceruloplasimin=3mg/dl. MRI brain was done s/o bilateral Symmetrical hyper-intensities in putamen, head of caudate nuclei and ventrolateral thalamus. Transaminases, PT INR were raised, Bilirubin was high. USG abdomen done showed cirrhosis of liver with portal hypertension. UGIE was done grade 2 oesophageal varices was found, EVL was done. In family, Twin Brother also diagnosed with Wilson disease. Keywords: Wilson disease, Liver, Kayser-Fleischer ring, Copper, Autosomal Recessive.

P-108 A Rare Case of Myasthenia Gravis in HIV Patient Chaudhari Sagarbhai , Patel Dushyant, Vora Chitralekha B. J. Medical College , Civil Hospital, Ahmedabad , Gujarat Corresponding Email ID: [email protected]

HIV infection and myasthenia gravis are common disorders but their association is rare. Myasthenia gravis occurs in immune-competent HIV infected patient and occur as a part of immune restoration disease. A 42 year old male presented with features of difficulty in speech, proximal muscles weakness of both upper limb and lower limb of 1 week duration and dysphagia and episode of diplopia since few days and neurological examination revealed proximal muscle weakness grade 3/2 and easy fatigability on clinical feature testing single breath count and breath holding test, positive Neostigmine test, AchR antibody titre 1.03. Patient was started on treatment Tablet Neostigmine 60mg QID and Tablet Prednisolone 60mg daily to which patient showed excellent response and started improving within 1 week.

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P- 109 Presentation of an Unusual Patient with Lafora Disease: A Case Study Patel Adityakumar, Malhan Sundeep, Vyas Chintal, Garg Pankaj General Medicine,Smt. NHL Municipal Medical College, Ahmedabad. Corresponding Email ID: [email protected]

Background: Lafora disease is a rare, fatal, autosomal recessive progressive myoclonic epilepsy. The condition is characterized by recurrent seizures, myoclonus, dementia and ataxia. Some recent studies and case reports have reported variability of the clinical characteristics with respect to the age at onset and prognosis. It usually appears in late childhood or adolescence and is marked by a rapid decline. Diagnosis is made by skin biopsy, mostly in the axilla and looking for lafora bodies ( inclusion bodies) in the sweat gland cells. The genetic tests can also be done looking for mutation on the EPM2A gene or NHLRC1 gene. Unfortunately, there is no current treatment available to slow its progression. Case Report: A 17 year old male presented with disabling myoclonic jerks and GTCS type of semiology. Until the age of 15, the patient had ataxia clinically which was insidious in onset and gradually progressive. His myoclonic jerks were not controlled with Inj. Encorate 500mg BID and Inj. Levera 500mg BID. The patient was thoroughly investigated for all possible etiologies. CSF study, MRI Brain with contrast, serum copper and ceruloplasmin ( in view of Wilson’s disease) and ANA( autoimmune etiology) were done which came out to be normal. The patient’s skin biopsy ( from axilla) was done which came out to be positive for Lafora Disease. Later on, genetic analysis showed a mutation in the EPM2A gene. His myoclonus was treated by increasing the dosage of ongoing anti-epileptics plus adding new anti-epileptic drugs. His relatives were informed about the illness and its prognosis and he was discharged on hemodynamically stable condition. Method: Prospective and Observational Case Study. Keywords: Disabling myoclonus, epilepsy, ataxia, lafora disease. References: 1.Minassian BA. Progressive myoclonus epilepsy with polyglucosan bodies: Lafora disease. Adv Neurol 2002; 89: 199-210. 2. Ganesh S, Delgado-Escueta AV, Suzuki T, et al. Genotype phenotype 3. correlations for EPM2A mutations in Lafora’s progressive myoclonus epilepsy: exon 1 mutations associate with an early-onset cognitive deficit sub phenotype .HumMol Genet 2002; 11: 1263-71.

P-110 Guillain–Barré Syndrome with Unilateral Facial Nerve Palsy: Rare Phenomenon Panchal Tarang Internal medicine department, B. J. Medical College , Civil Hospital, Ahmedabad , Gujarat Corresponding Email ID: [email protected]

Gullian barre syndrome is characterized with rapidly evolving areflexic motor paralysis with or without sensory disturbance. Guillain-Barré syndrome (GBS) is an acute, frequently severe and fulminant

83 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 polyradiculoneuropathy that is autoimmune in nature. The usual pattern is an ascending paresis that may be first noticed as rubbery legs. Weakness typically evolves over hours to a few days and is frequently accompanied by tingling sensation in the extremities.The legs are usually more affected than the arms, and bilateral facial palsy is present in 50% of affected individuals. We describe a Guillain–Barré syndrome variant presenting with unilateral peripheral facial palsy.A 40-year-old female had progressive lower extremity weakness and numbness 2 days prior to onset of unilateral peripheral facial palsy. On presentation, diagnosis of Guillain–Barré syndrome was supported by areflexia and albuminocytologic dissociation.Normal MR study of Brain and whole spine magnetic resonance imaging scans showed posterolateral disc bulge.Treatment with intravenous immunoglobulin and intravenous steroids led to an uneventful clinical course with partial recovery within 1 week. In summary, Guillain–Barré syndrome should be considered as a possible cause of unilateral peripheral facial palsy. Early intervention with intravenous immunoglobulin may benefit these patients.

P-111 Poster Topic: Sanfilippo Syndrome Chauhan Hinali Department of Paediatrics, A.M.C MET Medical College, L.G.Hospital,Ahmedabad, Gujarat,India Corresponding E-Mail ID: [email protected]

Introduction: Sanfilippo syndrome is a rare autosomal recessive lysosomal storage disease.It is caused by deficiency in one of the enzymes needed to break down glycosaminoglycan(GAGs),heparan sulfate. Case report: 2 year old female child with 16.1kg weight presented with c/o regression of milestones since 4 years of age in all areas with progressive intellectual decline with speech delay,behavioral problems including hyper activity, temper tantrums, sleep disturbances followed by severe dementia. Diagnosis: Qualitative analysis of urine by one dimensional electrophoresis for GAGs shows raised level of chondroitin sulfate and heparan sulfate. Lysosomal enzyme study from leucocytes shows absence of heparan sulfamidase which confirms that this patient is affected with sanfilippo syndrome type-A. Management: Management is symptomatic and multidisciplinary. Primary prevention is by genetic counselling. Prognosis: Prognosis is poor. MPS IIIA is more common, more severe subtype. The median age of death for children affected with MPS IIIA is 15.4+/-4.1. Keywords: Sanfilippo syndrome, MPS IIIA, Lysosomal Enzyme Study from Leucocytes

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P-112 A Case of Tabes Dorsalis in a Young Immuno-Competent Individual Sheth Nirmit B. J. Medical College , Civil Hospital, Ahmedabad , Gujarat Corresponding Email ID: [email protected]

Neurosyphilis is caused by the bacterium Treponema pallidum subspecies pallidum (T. pallidum). The organism gains entry into the central nervous system (CNS) early (primary syphilis or chancre phase) in the course of infection. While most patients are able to mount an immune response that effectively clears CNS invasion without long-term complications, a minority go on to develop asymptomatic or symptomatic neurosyphilis. Neurosyphilis includes asymptomatic meningitis, symptomatic meningitis, meningovascular syphilis and parenchymatous syphilis (which includes general paresis and tabes dorsalis). Ocular and otologic syphilis can occur at any time but often accompany the acute meningitis of early neurosyphilis. The diagnosis of symptomatic neurosyphilis requires meeting clinical, serologic, and cerebrospinal fluid (CSF) criteria. Here is a case of 23 year old male who presented with Tabes Dorsalis and improved dramatically with Injectable Crystalline Penicillin.

P-113 Atypical Hemolytic Uremic Syndrome Sanghavi Keval, Patel Jagdish Department of General Medicine, B.J.Medical College,Civil Hospital,Ahmedabad, Gujarat Corresponding Email ID: [email protected]

Atypical Hemolytic Uremic Syndrome (aHUS) is defined by the triad of microangiopathic haemolytic anemia, thrombocytopenia and renal impairment. Atypical HUS is the result of congenital complement dysregulation. The affected patient have low C3 and normal C4 level, Factor H deficiency the most common defect linked to familial with aHUS. Mutations in the genes encoding complement regulatory protein H, membrane cofactor protein (MCP),factor I or thrombomodulin have been demonstrated and mutation in the genes of C3 convertase proteins,C3 and Factor B.In addition patients have anti factor H antibodies.The disease should have no association with shiga toxins and TTP should also be excluded. A 33 year old male patient came to emergency department with the chief complain of decreased urine output and multiple purpuric skin lesions since 2 days and recent history of diarrhoea 15 days back. On investigation S.Creatinine 7.28 , S.Urea 107.40 , HB : 9.96 ,TC 12,200 Platelet Count 78000 ,SGPT:29 ,D.Billirubin 0.8 ; I.Billirubin 1.9; T.Billirubin 2.7 . Special investigations Retic Count -0.6; S.LDH -735IU/L(Normal range <248IU/L) , ANA negative, C ANCA Negative , P ANCA negative , LA negative , CRP negative , RA negative , ASO negative , C3 level 0.63(normal level 0.9-1.83), C4 level 0.16(normal range 0.1-0.4), CPK Total 52. Patient’s 2D ECHO was normal and his Ultrasound abdomen pelvis showed raised cortical echogenecity in both kidneys with preserved cortico medullary differentiation. Confirmatory diagnosis was made by ANTI FACTOR H ANTIBODY LEVEL which was 76.1 AU/ml(normal range 0-20AU/ml).Patient was treated with plasmapheresis and hemodialysis & other supportive therapy.

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P-114 A Case of New Onset Seizures and Psychosis in a Young Female Diagnosed as CNS Lupus Vachhani Karan , Mankad B Department of Medicine, GCS Medical college, Hospital and Research Centre – Ahmedabad, Gujarat,India. Corresponding Email ID: [email protected]

SLE is an autoimmune disease in which organs and cells undergo damage initially mediated by tissue binding auto - antibodies and immune complexes. SLE affects most commonly the women of child bearing years; people of all genders, ages and ethnic groups are susceptible. SLE at its onset may involve one or several organ systems. We report a case of 23 years old young female who came to our OPD and admitted with chief complaints of easy fatigability, hair loss and recurrent oral ulcers, episodes of involuntary movements of all four limbs, visual hallucinations. From the clinical, laboratory and radiological findings the diagnosis of CNS Lupus was made. Patient was treated with Injection Cyclophosphamide, anti - epileptic Levetiracetam and improved dramatically.

P-115 A Case of Wilson's Disease presented with Fulminant Hepatic Failure: A Case Report Agrawal Sachinkumar, Bhansali Prashant Department of Medicine , AMC MET Medical College & LGhospital, Ahmedabad,Gujarat,India. Corresponding E.mail ID : [email protected]

Wilson's disease is a rare autosomal recessive disorder of copper metabolism,characterized by liver disease and neurological symptoms.It is caused by mutations in a gene encoding a copper-transporting P-type ATPase. In affected individuals there is a cumulation of excess copper in the liver, deficient ceruloplasm in synthesis and a marked reduction in biliary Copper excretion. Increased amounts of copper deposited in the tissues are responsible for the Hepatic and neurological changes, thegreenish-brown pigmented rings in the periphery of the cornea(Kayser–Fleischerrings) and lesions in the kidneys and other organs.Tissue damage Leads to cirrhosis of the liver, and bilateral Softening and degeneration of thebasal ganglia of the brain. A 16 yr old hindu unmarried male presented with complaints of yellowish discoloration of sclera and urine since 1week, lethargy and low grade fever since 1week. No complains of Itching over body, burningmicturition, breathlessness. P/H/O of jaundice present few years back No P/H/O of TB, Blood tranfusion/DM-2/HTN/IHD. Onexamination, icterus was present, pt was conscious and well oriented to time, place and Person and noneurological deficits oral teredsensorium was present. T-normal

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P-84/min BP-116/70mmHg SpO2-99%onair RS-B/LAirentrypresent,clear CVS-S1S2present P/A-Ascitespresent Eye examination: Kayser Fleisher's ring seen Lab.Investigations: K+ 4.4 CBC:Hb8.8 AsciticFluidrm:Totalcells:150 TC8830 Polymorphs:30% DC88/7/2/1 Lymphocytes:70% APC2.49lakhs Sugar:144mg% S.Bilir.12.3-direct:10.2 Protein:1.0g% Indirect:2.1 RBCs:10 SGPT158 ADA:1.75 ALP 183 ANAbyImmunofluroscence-negative S.Creat0.4 S.Ceruloplasmin-14.40(N-15to30) Na+ 135 24hrurinarycopper:74.16(N-<60)

P-116 A Case of Acute Renal Failure as Presentation of Multiple Myeloma Patel Tirth, Bhansali Prashant Dept. of General Medicine, LG hospital, AMC MET Medical College, Maninagar, Ahmedabad, Gujarat, India. Corresponding Email ID : [email protected]

Introduction: Multiple myeloma is a clonal B-cell malignancy characterized by the accumulation of terminally differentiated, antibody-producing plasma cells in the bone marrow. Genetic mutations within the myeloma cells and their interaction with various cytokines and growth factors contribute to the invasiveness of the disease and enhanced drug resistance. Patients are generally asymptomatic until very late stage of disease. However, once disease is present, localization in the bones is common. Case Presentation: History: A case of 65 year old male, married, non-alcoholic, normotensive, non-diabetic presented with the history of abdominal pain for 7 days, diffuse, dull aching in nature, not associated with food or bowel habits, not relieved by medications, associated with generalized

87 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 body ache, nausea. No H/O fever, vomiting, loose stool, constipation, burning micturition, yellowish discolouration of urine No P/H/O hypertension, diabetes mellitus, ischemic heart disease, COPD, tuberculosis, thyroid disorder, jaundice, blood transfusion. No F/H/O similar symptoms On Examination: Vitals- Temp - Normal, Pulse – 100/min, regular, BP – 110/70 mmHg, SpO2 – 98 % General Examination- Pallor present; No icterus, oedema, cyanosis, clubbing, lymphadenopathy Systemic Examination- CNS - Conscious, Oriented PA - Soft, non-tender, no hepatosplenomegaly. RS - B/L AE +, Clear. CVS - S1S2+. Lab Investigations- CBC Hb = 7.2 g/dl, RBC = 2.38 lakh, MCV = 92.9 WBC = 3100, DC = 55/40/1/4, APC = 83000 ESR = 135 mm RBS 93 LFT Bilirubin = 0.1, SGPT = 24, ALP = 93 RFT Urea = 79, Creatinine = 6.9 Na+ = 136, K+ = 3.2, Cl- = 112 Ca++ = 8.3, Uric acid = 11.9 PO4 = 8.51, iPTH = 19.20 Urine R&M Protein – Trace ECG – WNL/NSR CXR-PA – NAD Skull Radiograph – AP & Lateral View

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Multiple lytic lesions Protein Electrophoresis Total protein = 6.0 Albumin = 1.49, Globulin = 4.51, A/G ratio = 0.33 Alpha1 = 0.24, Alpha2 = 0.34, Beta1 = 3.47, Beta2 = 0.37, Gamma = 0.09 M Band = 3.31 g/dl S/O Monoclonal gammopathy Treatment: Symptomatic treatment 2 units of PCV given for correction of anaemia Patient referred to higher centre for further management of multiple myeloma

P-117 Right Ventricular Mass Presenting with Right Ventricular Outflow Tract Ventricular Tachycardia Patel Aksh, Verma Y. Geetanjali Medical College And Hospital,Department of General Medicine,Udaipur,India. Corresponding Email ID: [email protected]

Cardiac metastasis occurs,mostly in patients after sixth decade and is incident equally among both sexes. Studies report that renal cell carcinoma, adenocarcinoma of colon, melanoma, hepatocellular carcinoma and bronchogenic carcinoma are commonly metastasised in endocardium of heart. However, carcinoma of lung being metastasised into heart is rarely stated.Cardiac metastasis in endocardium of primary lung origin was observed.A 64-year-old male was admitted with history of recurrent episodes of palpitation, perspiration and chest pain since 2 months. He had no family history of QT prolongation, arrhythmia or sudden cardiac death.On admission, electrocardiogram was done which showed monomorphic ventricular tachycardia with LBBB and inferior axis was suggestive of right ventricular outflow tract ventricular tachycardia (RVOT-VT). Immediately synchronised DC shock was used to cardiovert to normal sinus rhythm. 2D Echocardiography which showed large echogenic mass on right ventricular wall extending up to RVOT. It was adherent to myocardium, sessile with rough borders suspicious of tumour or metastasis. Cardiac MRI showed neoplastic mass in right ventricle with a mass in left lower lobe of lung.biopsy was taken from right ventricle Histopathological report showed intermediate grade fibrosarcoma or malignant fibrohistiocytic tumour. Cardiac metastasis has various presentation however early diagnosis using propper modalities can be helpful.

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P-118 Comparison of Pleural Fluid Analysis with Semirigid Thoracoscopy Guided Pleural Biopsy in 25 Cases of Undiagnosed Exudative Pleural Effusion Jose Jince Baroda Medical College and SSG Hospital Corresponding Email ID: [email protected]

Pleural effusion evolves in the course of a variety of diseases and the correct diagnosis of underlying disease is essential for rational management. Primary diagnosis of pleural effusion involves pleural fluid analysis followed by closed needle biopsy. The yield of these is not usually as satisfactory as compared to that of thoracoscopic pleural biopsy Aim: To compare the diagnostic efficacy of pleural fluid analysis with thoracoscopic pleural biopsy in the diagnosis of undiagnosed pleural effusion Patients and Methods: 25 patients with undiagnosed exudative effusion(ADA<70IU/L, cytology inconclusive) had undergone thoracoscopic biopsy over a period of 7 months(January 2019 to July 2019) in tertiary care centre and pleural fluid analysis was compared keeping thoracoscopic biopsy as the gold standard. Results: Diagnostic yield of thoracoscopic biopsy was 92%, 8% remained undiagnosed. Out of 52% cases with malignancy (61.5% adenocarcinoma,7.7% mesothelioma, 7.7% metastasis from primary breast cancer, 7.7% small cell carcinoma, 7.7% squamous and 7.7% adenosquamous), large pleural nodules were seen in 92.3% and necrotic debris with pleural plaques in 7.7%. Fluid cytology was positive for glandular or dysplastic cells in 46.15% with the average mesothelial cells 17.3%,lymphocytes 51.84%. Out of 40% cases with tuberculous effusion, 20% had sagograin nodules, fibrous septa with necrotic material in 60% , bigger nodules in 20%. ADA average was 36% with 71.2% lymphocytes Conclusion: Thoracoscopy guided pleural biopsy remains the gold standard in undiagnosed pleural effusions.

P-119 Drug Use Pattern in Glaucoma and Assessment of Medication Adherence and QoL Using Glaucoma Specific Questionnaires Shah Shailja, Raval Reema, Malhotra Supriya Smt. NHL Municipal Medical College, Ahmedabad Corresponding Email ID: [email protected]

Background: Glaucoma, a chronic, progressive and most often asymptomatic disease, is the second leading cause of blindness worldwide. Patients with Glaucoma eventually become visually handicapped as it causes irreversible blindness and this hampers patients’ quality of life (QOL). Most eye drops contain preservatives to provide a level of antimicrobial activity. Adherence with glaucoma medications is a key component of a successful glaucoma treatment. The main goal of treatment in patients of glaucoma is to improve clinical outcomes thereby improving the patient’s QOL. Objectives: To study the drug use pattern in patients of Glaucoma, to evaluate the safety aspect with

90 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 preservative or preservative free drugs, to evaluate medication adherence using Glaucoma Treatment Compliance Assessment Tool (GTCAT) and to evaluate quality of life using the National Eye Institute Visual Function Questionnaire (NEIVFQ25). Methods: After approval from Institutional Review Board (IRB) and written consent from the patients, a total no. of 80 patients above 18 years of age and of either gender presenting to Outpatient department of Ophthalmology diagnosed with Glaucoma and on medical therapy for at least a month were included in our study during the period of 16 weeks. The data was recorded in a case record form containing patient's demographic details, diagnosis and the complete prescription. Assessment of medication adherence was done with the help of GTCAT included 47 statements and a 5-interval Likert-type scale response with anchoring definitions and 9 different domains. Quality of life assessment was done using the interviewer-administered format of the NEI-VFQ-25. Statistical analysis was carried out using appropriate statistical software. Results: A total of 80 patients were enrolled, out of them Glaucoma was found to be more prevalent in age group of 51 – 60 years (35%) and male:female ratio was 0.86:1. Patients with a history of past ocular surgery were 29 (36%). Total 21 patient (26%) had a family history of glaucoma. Total number of drugs prescribed were 146 (mean=1.68). Patients on single medication are 28 (35%), that is Prostaglandin analogues. Among them two third of patients were using Travoprost. Most common drug used was Prostaglandin analogues (66%) and among them 25 (31%) were using preservative free eye drops. Brimonidine and Timolol was the most common drug combination used. Average Intraocular pressure (IOP) of patients is 17.43 mm of Hg despite treatment. In our study GTCAT score revealed that 47 (58.75%) patients had 50% knowledge of facts related to glaucoma, the disease. In the NEI-VFQ-25 more than two third of the patients were worried about their eyesight and around 16 (20%) patients had difficulty in reading newspaper. Conclusions: Majority of patients belonged to 51 to 60 years. Positive family history is a major risk factor for development of Glaucoma. PG analogues commonly Travoprost were the most prescribed drug in monotherapy. Intraocular pressure was on the higher side despite treatment. The study plans to focus on the difference in the safety of preservative free and with preservative Prostaglandin analogues in future. Keywords: Drug use pattern, PG analogues, Travoprost, GTCAT, NEI-VFQ-25 References: 1. Robin A, Grover DS. Compliance and adherence in glaucoma management. Indian J Ophthalmol [serial online] 2011 [cited 2019 Jul 5];59, Suppl S1:93-6. Available from: http://www.ijo.in/text.asp?2011/59/7/93/73693 2. Mansberger SL, Sheppler CR, McClure TM, et al. Psychometrics of a new questionnaire to assess glaucoma adherence: the Glaucoma Treatment Compliance Assessment Tool (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2013; 111:1–16. 3. Quaranta L, Riva I, Gerardi C, Oddone F, Floriani I, Konstas AG. Quality of Life in Glaucoma: A Review of the Literature [published correction appears in Adv Ther. 2016 Jun;33(6):982]. Adv Ther. 2016;33(6):959–981. doi:10.1007/s12325-016-0333-6

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P-120 Anaesthetic Management of Right Sided Renal Cell Mass Having Dual Right Renal Arterial Supply Posted for Elective Exploratory Laparotomy and Excision of Mass Kakadiya Dhara , Solanki Nayna, Kheskani Divya Anaesthesia Department, G.C.S Medical College, Hospital and Research Center, Ahmedabad Corresponding Email ID: [email protected]

Aims: 1. To maintain hemodynamic stability 2. To prevent and treat peri-operative complications if any 3. To provide optimum analgesia Method: A 45 years old, hypertensive, female patient presented with burning micturition, right sided flank pain who underwent CECT of abdomen was diagnosed as having right renal cell carcinoma involving perirenal fat with dual renal arterial supply on right side. She was posted for exploratory laparotomy for excision of renal cell carcinoma mass. Intra operatively, during dissection of tumor, sudden tachycardia and hypertension occurred in spite of deeper plane of anaesthesia which was managed meticulously by using vasodilators. Patient was extubated and shifted to ICU for post-operative hemodynamic monitoring. Result: Intra operatively hypertensive crisis developed during manipulation of tumor that lasted for 1 hour and 30 minutes and was treated with intravenous beta blockers and α2 agonists. Patient was managed uneventfully and tumor mass was removed. Conclusion: The underlying right-side renal cell carcinoma manipulation led to intra-operative hypertensive crisis which was well managed without any complications. The meticulous and collaborative efforts of anaesthesiologist, general surgeon and paramedical staff led to optimal management of such patient intraoperatively and post-operatively.

P-121 Study of Clinical Profile of Poisoning Cases Admitted in Emergency Medicine Department of Tertiary Care Teaching Hospital Vala Jasvin , Gohil Jaldeepsinh, Gupta Sapna, Thakor Advait Emergency Medicine Department , Smt NHL Municipal Medical College,Ahmedabad. Corresponding Email ID: [email protected]

Objective: To assess the clinical profile and outcomes in the patients with poisoning admitted to the emergency wards of a tertiary care hospital. Methods: The prospective observational study was conducted for a period of 1 year in the emergency wards of a tertiary care hospital. The demographic data, hospital admission variables and outcomes were collected from various sources and documented. Cluster analysis was used to find the interaction between the sociodemographic and hospital admission variables in association with outcomes of poisoning.

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Results: A total of 160 patients were admitted with acute poisoning. The most common age group was 21-30 years of age males (51%) were dominant over females (49%). Incidents of poisoning were predominant in married (53%), abiding in urban region (66%) and The poisonings were intentional (66.25%) occurring through oral route (82.5%) at home (82%).. Majority of the victims recovered (75.62%) while (13.12% ) took DAMA discharge whilst 11% died. Conclusion: It is observed that there is an alarming increase in case of poisoning mainly for suicidal purposes. Increase in pubilc awareness about seriousness of problem through health education and effort to distress and develop a healthy outlook towards life should be undertaken. Keywords: Intentional Poisoning, Clinical Profile , Public Awareness

P-122 Microscopic Polyangitis Dhami Param, Parmar Sarita Department of General Medicine, B. J, Medical College,Civil Hospital,Ahmedabad, Gujarat Corresponding Email ID: [email protected]

Microscopic Polyangitis is a member of the family of ANCA associated vasculitis with annual incidence of 3.8 cases per 1 million population.It was first recognised in a subset of polyarteritis nodosa patients who presented with segmental glomerulonephritis.This systemic small-vessel vasculitis is the most common cause of the pulmonary renal syndrome, leading to renal failure and pulmonary haemorrhage, the two most clinically relavent features of microscopic polyangitis. On investigation Hb:6.47gm/dl,ESR 120mm per hour ,S.Urea 148.10mg/dl,S.creatinine 11.13mg/dl,PT 15.5sec INR 1.4 ,Urine plenty of fresh RBC/hpf.Positive P ANCA ,ANTI GBM ANTIBODY 62RU/ml.USG abdomen raised cortical echogenicity with preserved CMD.CXR Bilateral fluffy opacity in mid zone suggestive of pulmonary hemorrhage.Patient was treated with BIPAP mode of mechanical ventilation Hemodialysis and plasmapharesis was done on alternate day.steroid and immunosuppressant were given.After 10 days of treatment patient deteriorated and succumbed to death.

P-123 A Case of Para-Aniline Nitrate Gas Inhalation Management in Emergency Department Virani Devanshi , Sangani Shruti , Patel Chirag Department Of Emergency Medicine, B. J. Medical College, Civil Hospital, Ahmedabad. Corresponding Email ID: [email protected]

93 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 with difficulty in breathing and drowsiness after accidental inhalation of Para-aniline Nitrate Gas while working for a chemical company. Patient presented with complain of breathlessness at rest, drowsiness and had central cyanosis with normal temperature, pulse rate 122/min, blood pressure 116/78mmHg, respiratory rate 34/min and SpO2 56% on air. Patient was immediately started on supportive care of oxygen via non re-breathing mask at 15L/min, IV fluids and patient's blood sample was sent for arterial blood gas analysis which was suggestive of partially compensated respiratory alkalosis. Patient was then treated with methylene blue intravenous injection as 10mg diluted in 500ml normal saline. Patient started improving and became conscious with resolving central cyanosis and improving O2 saturation. After injecting two such vials in 12 hours duration, patient became fully conscious with normal temperature, pulse rate 84/min, blood pressure 114/72mmHg, respiratory rate 14/min and SpO2 96% on room air. Patient was discharged after continuous monitoring and supportive therapy for 36hours after getting stabilized. Conclusion: Patient presenting in ED after getting exposed to gases containing anilines can be treated with injection methylene blue and stabilized in ED. Methylene blue acts by reducing methaemoglobin to haemoglobin by combining with NADPH in presence of NADPH reductase.

P-124 Dyke Davidoff Mason Syndrome : A Case Report Patel Nishi, Dabhi Leena Department of medicine , AMCMET Medical College and LG Hospital, Ahmedabad, Gujarat, India. Corresponding Email ID: [email protected]

Dyke Davidoff Masson Syndrome is a rare clinical condition characterised by seizures, facial assymetry, contralateral spastic hemiparesis or hemiplagia and learning didficulties. Also known as cerebral hemi atrophy. A 35 year old female presented in OPD with complain of generalised tonic clonic seizures since age of 10 years. Patient took anti-epileptic drug treatment including phenytoin and phenobarbitone. However continued to have seizures on and off and presented in OPD with complain of intractable seizures. Patient had complain of weakness of right half of body for last 10 years , non progressive in nature. She revealed developmental delay of milestones during childhood. There was no history of similar illness in family. Patient was prescribed with sodium valproate and came for regular followup visits but still had intermittent episodes of seizures in between and therefore referred to neurosurgery.

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P-125 A Rare Case of Creutzfeldt-Jakob Disease Thakkar Deepkumar, Shah Neha Department of Medicine, GCS Medical College, Hospital and Research Centre- Ahmedabad Corresponding Email ID: [email protected]

Creutzfeldt-Jakob disease (CJD) is a rare, fatal neurodegenerative disease caused by an infectious protein called prion and is characterized by spongiform changes, neuronal loss, reactive astrocytic proliferation and accumulation of pathologic cellular protein. Clinical presentation of CJD is characterized by rapidly progressive dementia, visual impairment, extrapyramidal dysfunction, akinetic mutism and psychiatric symptoms. The diagnosis is based on clinical presentation, magnetic resonance imaging (MRI), electroencephalogram(EEG) and cerebrospinal fluid analysis. We report a case of 72 year old male with progressive dementia, myoclonic jerk and typical neurologic symptoms with MRI and EEG finding of CJD. This case highlights the need for a high index of suspicion to diagnose CJD.

P-126 SLE or Autoimmune Hepatitis? A Diagnostic Dilemma: A Rare Case Report of an Overlap Syndrome. Parmar Nachiketa , Vyas Chintal, Malhan Sundeep, Garg Pankaj General Medicine, Smt. NHL Municipal Medical College, Ahmedabad Corresponding Email ID: [email protected]

Background: Systemic Lupus Erythematosus (SLE) is a disease of unknown aetiology in which tissues and cells are damaged by pathogenic autoantibodies and immune complex, affecting multiple organs including the liver, kidney, and CNS. Autoimmune Hepatitis (AIH) is a chronic necro-inflammatory liver disease of unknown aetiology associated with circulating autoantibodies and high serum globin level. AIH has been considered to infrequently in SLE. Liver Dysfunction occurs frequently in patients with SLE, and patients with SLE and elevated liver enzymes present a complicated and difficult differential diagnosis. Lupus Hepatitis and AIH are two immunologic conditions involving liver which have similar immunologic mechanisms, clinical, laboratory and systemic presentations leading to difficulties in diagnosis. It’s critical to differentiate the two as Lupus Hepatitis is a benign condition, and AIH is associated with poor prognosis, higher rates of progression and the need for aggressive therapy. Case Report: A 22 year old female presented with jaundice, breathlessness, abdominal distention, pedal oedema and multiple joint pain for 30 days. She had past history of TB Lymphadenitis 6 years back for which she took AKT for 6 months, Neuromyleitis Optica 4 years ago and Hypothyroidism since 4 months. Patient was admitted and all routine investigations were done which were suggestive of normocytic, hypochromic anaemia, proteinuria, acute kidney injury, elevated liver enzymes and bilirubin. Usg was suggestive of altered liver echotexture and mild to moderate ascites. Patient was thoroughly investigated for possible aetiology. Viral markers including HBsAG, antibody to HEV, HAV, HCV, HIV were negative, there was no evidence of KF ring

95 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 on slit examination. Patient’s ANA was positive (3+, cytoplasmic pattern) and ANA profile was significantly positive for Ab to DsDNA, SSA/RO and Ribosomes PO. LKM1 antibody, AMA and ASMA were negative but serum IgG was significantly high. Patient was diagnosed as SLE according to ACR criteria and Liver biopsy was done to differentiate between Lupus Hepatitis and AIH which showed Interface Hepatitis with Cirrhosis of Liver suggesting AIH. Patient was started on Tab Prednisolone 40mg OD and Tab HCQ 300mg OD, later Tab Azathioprine 50mg was added due to worsening RFTs and persistent proteinuria and prednisolone tapered to stable dose of 10mg OD. Renal Biopsy was planned in follow up for Lupus Nephritis and patient was discharged in stable hemodynamic condition and with normalized liver enzymes and RFTs. Keywords: Systemic Lupus Erythematosus, Autoimmune Hepatitis, Lupus Hepatitis, Elevated liver enzymes.

P-127 A Case of Right Side Facial Palsy in a Young Female Diagnosed as Multi Drug Resistant Tuberculous Meningitis Patel Sachin, Vachhani Karan, Mankad B. Department of General Medicine, GCS Medical College, Hospital and Research Centre - Ahmedabad, Gujarat India. Corresponding Email ID: [email protected]

A 27 yr old female patient presented with c/o left side deviation of mouth with fever since 1 day. O/E patient conscious, oriented, left side deviation of mouth, right side weak ballooning of mouth, right side weak frowning present. No any other neurological deficit found. CT brain was normal. On basis of this finding patient diagnosed as right side facial palsy and T. acyclovir and T prednisolone was started. After 4 days Pt again visited with complain of nausea, headache, vertigo, fever since 3 -4 days. O/E Neck rigidity present subsequently MRI brain was done which was s/o granulomatous lesion in pons and cerebellum with diffuse leptomeningeal enhancement p/o koch’s etiology. CSF examination was done s/o Tuberculous Meningitis. Pt was put on AKT under RNTCP. Inj dexona, T. Levera, T. B long and other supportive treatment but patient was not improved. On csf CBNAAT report showed rifampicin resistant TB and after respiratory medicine dept opinion pt was put on oral regimen for MDR TB containing bedaquiline, Linezolid, cycloserin, clofazimine, levofloxacin. Pt was gradually improved on this regimen after which patient was discharged with advise to follow up weekly in opd.

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P-128 A Case of Takayasu’s Arteritis With Severe Left Ventricular Dysfunction And Stroke Makani Janki, Patel Khushali, Dutt Jayesh, Mod Jaydev General Medicine, Smt. NHL Municipal Medical College,Ahmedabad. Corresponding Email ID: [email protected]

Takayasu’s arteritis is chronic idiopathic and granulomatous vasculitis manifesting as panaortitis. Autoimmune cell mediated immunity is probably responsible for disease. The inflammation commences from adventitia and progresses to intima and leads to segmental stenosis, occlusion and dilatation and aneurysm. Most common part of aorta being aortic arch and its branches. It is more prevalent in young and adolescent females. The commonest mode of presentation being hypertension associated with congestive heart failure, cerebrovascular accident, myocardial infarction, aneurysmal rupture, renal failure. Here we are presenting a case of 12 year old female patient with total duration of illness 8 months. She presented with sudden onset of slurring of speech, deviation of mouth to right side weakness in bilateral upper limb and lower limb. She also developed abdominal pain. Ultrasound of abdomen s/o splenic infarct She had difficulty in breathing for which she further investigated. 2D echo suggestive of dilated cardiomyopathy with LVEF-15%,severe global Hypokinesia with left atrial appendage clot. Angiography of aorta suggestive of moderate to severe narrowing of thoracic and abdominal aorta. Introduction: Takayasu arteritis, aka pulseless disease, is a systemic inflammatory condition which leads to damage of the medium and large arteries and their branches. It occurs predominantly in young Asian women. It usually involves the aorta and its major branches, particularly the renal arteries, carotid arteries, and subclavian arteries, and leads to stenosis, occlusions, or aneurysmal degeneration of these large arteries. An abnormality in cell-mediated immunity seems to be its main pathogenesis, but its etiology is still largely unknown. Diagnosis is based on suspicion as well arteriographic findings. Treatment usually begins with medical management using corticosteroids; however, surgical management has become more common recently due to findings of an overall lack of disease regression and high rates of relapse with just medical management alone. Case Report: A 12 year old female patient with total duration of illness 8 months had c/o low grade fever, malaise, cough with expectoration around 7 months ago for which she was consulted to paediatrician and was treated with antibiotics without any significant improvement. In march, 2019 while travelling in train she developed sudden onset of slurring of speech, deviation of mouth to right side, bilateral upper limb and lower limb weakness which improved within few hours. She was admitted at during march, 2019 at some private hospital where she was diagnosed to have pneumonia and treated accordingly and discharged after 5 days. On 25th march,2019 she had abdominal pain after an hour of meal with vomiting without any c/o blood in stool,malena. On further investigations found to havedilated cardiomyopathy with LVEF-15%,dilated LV,global hypokinesia, moderate MR, large LAA clot, moderate PAH. And USG abdomen s/o ? infarct in spleen. She was started on Inj.LMWH which was overlapped with T.Acitrom 2 mg and was referred to higher center for further management.

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On 27th march,2019 she was admitted in U.N.Mehta institute where on angiogram of aorta was done s/o clots in LAA, mild luminal narrowing of right CCA, mild osteal stenosis in left vertebral artery, luminal irregularities in 2nd part of left SCA, moderate to severe narrowing of thoracic and abdominal aorta, mild stenosis in SMA, partial thrombus at LPA bifurcation and complete chronic thrombotic occlusion of left descending pulmonary artery and segmental –sub segmental branches of left lower lobe. Based on which she was diagnosed with takayasu’s arteritis and advised on Inj.methyl prednisolone 500 mg for 3 days with MMF 500 mg tab 1 BD. She had a single episode of transient monocular blindness in right eye which recovered in 4 hours and later on same day she had right hemiparesis and was founs to have acute infarct in left basal ganglia. She was discharged on MMF,diuretics,Dual antiplatelets, digoxin, warfarin, prednisolone. She came for follow up in SVP hospital where she had right carotid bruit with carotidynia and was advised Inj. Tocilizumab. On 15th july,2019 she had an episode of focal seizure involving right upperlimband admitted at SVP hospital. CT brain s/o gliotic area in left basal ganglia, anterior limb of internal capsule extending to centrum semiovale. And she was diagnosed as scar epilepsy and started on anticonvulsants as well.on examination left brachial and radial, in both lower limb are absent. She has no active complaints at present and responding well on tocilizumab, she was discharged on MMF, diuretics, Dual antiplatelets, digoxin, warfarin, prednisolone and ACE inhibitors. Discussion: Takayasu arteritis is a systemic disorder that affects multiple organs. The diagnosis of TA can be a challenge, especially in its initial phases: there is no diagnostic serologic test, and symptoms are generally constitutional, including malaise, fever, fatigue, and arthralgia. One common presentation is typical angina in a patient in whom one would not otherwise expect coronary artery disease. The finding of hypertension and arterial bruits in young adults necessitates the examination of pulses and blood pressures in different limbs in order to detect asymmetry. Elevated erythrocyte sedimentation rate is a common finding; however, caution is advised, because up to 50% of patients may have active TA disease and a normal sedimentation rate.The differential diagnosis can include certain congenital disorders that affect the tissue matrix (for example, Marfan and Ehler-Danlos syndromes); however, these disorders are not associated with stenotic lesions in large vessels, which is the common finding in TA. Although infectious causes of large-vessel aneurysm (mycobacterial, syphilitic, or fungal) should be considered, these are similarly not associated with stenotic arterial lesions. Certain autoimmune illnesses (such as systemic lupus, Cogan syndrome, and Behçet's disease) can be associated with large-vessel vasculitis; however, these more typically have other distinguishing factors and distinct age predilection (such as in Kawasaki disease, and giant-cell arteritis of the elderly). Sarcoidosis should also be included in the differential diagnosis of TA. The correct diagnosis usually depends upon the presence of other characteristic features (skin lesions, hilar adenopathy, or Bell's palsy). The diagnosis of TA is reached on the basis of clinical presentation and imaging results; histopathologic

98 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 confirmation can be obtained in patients who undergo vascular surgery. Cardiac complications related to TA are due more to poorly controlled hypertension from aorto-renal arterial disease than to disease of the aorto-ostia of the coronary arteries.Aortic regurgitation that is secondary to aortic root dilation can occur. Left ventricular dysfunction caused by myocarditis has been reported. The mainstay of therapy in TA is immunosuppression, primarily with steroids or methotrexate Clinically significant coronary artery disease has been treated with angioplasty, although CABG has usually been preferred. If possible, surgery should be delayed until the acute phase of the disease has passed. Takayasu arteritis is a chronic, progressive disease. Its degree of activity varies over time: the intensity of its inflammatory processes typically fluctuates between exacerbation and reduction or remission. Vascular involvement tends to be progressive. Vascular complications of the cardiac, renal, and central nervous systems are the chief causes of morbidity and death in TA, which is usually fatal when it remains untreated. Remission remains the goal of therapy. Identifying comorbid complications (such as hypertension) and initiating aggressive treatment may afford better chances of symptom-free survival. Poor outcome depends chiefly on the presence of such complications as hypertension, aortic regurgitation, and aneurysm, and on a rapidly progressive course. As is evidenced by our patient's presentation and the course of her TA, the care of patients who have the disease can be very complex. A fundamental understanding of the pathophysiology of TA is imperative in the choice of optimal care. Conclusion: TA, a large vessel vasculitis in children, remains a fascinating and difficult disease characterized by constitutional features, hypertension, heart failure, and pulse loss. The pathological features vary with the stage of the disease and include granulomatous inflammation, adventitial and medial fibrosis, vessel dilatation, and stenosis or occlusions of the involved arteries. The clinical course of the disease is variable, with the active and quiescent phases, and treatment strategies need individualized management. Consent: Written informed consent was obtained from the patient’s guardian/parent/next of kin for the publication of this report and any accompanying images.

P-129 A Case Report of Peri-partum Renal Cortical Necrosis Leading to End-Stage Renal Disease Patel Japan , Shah Maulin, Parikh Mital, Agarwal Anup, Vaishnav Bhalendu Shree Krishna Hospital, Karamasad, Anand, Gujarat, India Corresponding Email ID: [email protected]

A 23 year old women, G3P1A1L1, 34 weeks of amenorrhoea, diagnosed with intra uterine fetal death at an outside hospital presented to our emergency department for further management. On physical exam she was tachycardic, pulse rate-110/min, normotensive and not hypoxic. On further exam she had circumferential growth at cervix, and absent fetal heart sound. Emergent Lower segment caesarean section was done because of the presence of cervical growth. Intra-operative findings revealed a dead fetus with purulent fluid in the

99 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 uterine cavity. Cervical biopsy showed acute cervicitis. Post-operatively she was started on iv antibiotics and transferred to intensive care unit (ICU). In the ICU she was anuric for 2 days and her creatinine trended upwards from 0.92 to 8 mg/dl. She was initiated on haemodialysis. Her renal biopsy showed patchy cortical necrosis. She was seen on follow up- now producing urine but continues to be on intermittent haemodialysis. Learining Point: Renal cortical necrosis is a well-known complication of sepsis during pregnancy leading to end- stage renal disease and significant maternal morbidity. In this case it may have been easily prevented through proper ante-natal care and early initiation of antibiotics. In our efforts to reduce maternal mortality rate, the focus is mainly on improving labour room practices and institutional deliveries. Similar efforts should be made to improve the quality of ante-natal and post-natal care. These efforts will not only reduce maternal mortality but also maternal morbidity. Further studies should be done to understand the epidemiology, outcomes and management of renal cortical necrosis.

P-130 Polycythemia Vera: A Case Report of a Rare Disease Parikh Manas AMC MET Hospital , General Medicine Department , Maninagar , Ahmedabad Corresponding Email ID : [email protected]

Introduction: Polycythemia Vera is a clonal heamatopoetic stem cell disorder in which phenotypically normal RBC , granulocytes and platelets accumulate in absence of any other recognizable stimulus. Abstract: A 67 year old male Hindu non alcoholic, non tobacco chewer patient named Upendrabhai Narayanbhai Pithadiya residing at Ishanpur , Ahmedabad presented with complain of abdominal discomfort and feeling of abdominal distention and occasional dyspepsia since 3 months. There was no associated complains of fever, fatigue, rashes, bleeding, vomiting, purpura, etc. On general examination there was Grade 3 splenomegaly with spleen reaching up to the umbilicus with no associated ascites or hepatomegaly. On routine investigations HB : 17.7 g/dl with RBC Count : 8460000/ul showing increased RBC mass with predominant population of normocytic normochromic RBC’s with minimal anisocytosis. Reticulocyte count was 0.6% . Total WBC Count : 20720/ul showing predominantly neutrophilic leukocytosis with marked eosinophilia(13%) and 5% Band cells seen on peripheral smear. Platelet Count 4,81,000/ul with giant platelets. ESR was 15mm/hour. Calculated hematocrit was Hematocrit : 57.5%. Other biochemical Parameters were within normal range except Akaline Phosphatase was found to be elevated 1314 Iu/L and S.bilirubin 1.2mg%. S.LDH was 625.0 U/L [85-227]. S. Erythropoetin was 11.2[3.7-29.5]. JAK2 V617F mutation by PCR was found to be POSITIVE. Ultrasound Abdomen : Enlarged spleen of 18.3cm with splenic vein 7mm at hilum and 68x49 mm hypoechoic lesion in upper pole suggestive of splenic infarct. Solid organs appear to be normal with no ascites. Contrast Enhanced CT scan Abdomen : 19cm spleen reaching up to lumbar region and splenic abscess in upper pole of spleen and few non-specific inflammatory lesion in lower pole. A hypodense wedge shaped lesion on mid and lower pole possibility of SPLENIC INFARCT. Bone Marrow Biopsy shows Hyper cellular bone marrow aspirate with Granulocytic precursors and polymorphs consists 46% and are well preserved. Erythroid

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Precursor show mild hyperplasia with normoblastic maturation and constitute 40%. Megakaryocytes are increased in number. M:E Ratio is 1:2:1. Hypercellular Bone Marrow shows panmyelosis consistent with POLYCYTHEMIA VERA. Conclusion: Cases of Polycythemia Vera with JAK2 V617F positive has an association with bcr/abl negative myeloproliferative disorders. As treatment regular phlebotomy is being done to reduce the blood concentration in the body and prevent any ischeamic injury. Early detection and proper follow up can lead to early detection of myeloproliferative disorder leading to early treatment and prevention of further complications. P-131 Subacute Combined Degeneration of Spinal Cord: A Rare Neurological Manifestation of B12 Deficiency Malaviya Sangita, Parikh Jitendra Internal medicine department, B.J.medical college ,Civil Hospital, Ahmedabad, Gujarat Corresponding Email ID: [email protected]

SACD is degeneration of posterior coloumn and lateral coloumn of spinal cord which is mostly misdiagnosed as multiple sclerosis , chronic fatigue syndrome. SACD is treatable myelopathy presented with subacute paresthesia in hand and feets, loss of vibration and position sense, progressive spastic and ataxic weakness. A 14 year old female patient presented with complaint of tingling and numbness in upper and lower extremities with bilateral lower limb weakness and bladder and bowel incontinence since 12 days.Diagnosis was supported by low B12, macrocytic RBC’s, hypersegmented neutrophils and MRI spine with contrast suggestive of hyperintense signal T2W images in posterior coloumn.Patient was treated with Inj.Cyanocobalamine 1000 microgram once a week for 1month.patient improved after 1 month in follow up.

P-132 A Rare Case Presentation of Takayasu’s Arteritis Somani Rushabh AMCMET Medical Collage , LG Hospital Ahmedabad . Corresponding Email ID : [email protected]

Introduction: Takayasu’s arteritis is a form of large vessel granulomatous vasculitis with massive intimal fibrosis and vascular narrowing affecting most commonly young and middle aged women more. This disease is also known as “aortic arch syndrome” or “ pulseless disease” . Abstract: A 25 year old hindu female patient name Seema sharma resides at narol Ahmedabad presented with c/o chest pain , throbbing headache and palpitation since 1 to 2 year.There is no c/o fever ,breathlessness, Loss of conciousness , photophobia, phonophobia, dizziness .no significant family history or addiction history. on general examination pulse in left radial artery -80/ min and Pulse in right radial artery 80/min and fable. Force and tension in left radial artery is low as compare to right radial artery .BP: by auscultatory method in right radial artery -180/90 mmhg and in left radial artery -98/50 mmhg. In Left lower limb pulse is also fable .in auscultatory finding of CVS : load A2 , systolic murmur at aortic region grade ||/||| radiating to carotid artery

101 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 and Pan systolic murmur in peri umbilical area .ECG finding :suggestive of strain pattern . In laboratory finding HB: 8.6, WBC: 11083, PLATELATES: 5.3 lakh, HCT :26, ESR:113 CRP:4.5, HIV/RPR : non reactive ,ANA / ANCA : negative. CT ANGIO: suggestive of Generalized vessel wall thickening and calcification upto bifurcation of aorta.Rt. BCA ,Rt SCA , Rt,CCA appear dilated 32mm, 21mm ,18mm respectively Lt. CCA , Lt SCA ,Lt. vertebral artery luman narrowing 6.5 mm 5mm respectively .s/o large vessel vasculitis Conclusion: After starting steroids as prednisolone 1 mg per kg in tapering does patient respond well and side effect of steroids is minimal and well tolerated patient’s does of anti hypertensive medicine is also tapered early detaction and early treatment prevent long term side effect of high blood pressure and long term harmful effect of disease .

P-133 A Rare Case of Hereditary Spastic Paraplegia Datraniya Mohini , Upadhyay Kamlesh Department Of Medicine, B.J.Medical College, Civil Hospital,Ahmedabad Corresponding Email ID: [email protected]

Hereditary spastic paraplegia refers to a group of familial diseases that are characterised by progressive degenration of the corticospinal tracts. Clinically,they present with lower limb spasticity and weakness. Initially reffered as STRUMPELL LORRAIN DISEASE. HSP is rare with overall prevalence of approximately 1 to 10 per 100000. 18 years old male k/c/o mental retardation presented with difficulty in walking without support since last 7-8 years and difficulty in walking with support since last 1 month. Patient having family history of similar complains in younger sibling.After diagnosed with HSP, patient has been given supportive treatment and advised for regular physiotherapy. There is no disease-modifying treatment. Treatment is symptomatic and supportive. The goal of symptomatic treatment is to improve mobility,increase range of motion and relieve the discomfort associated with spasticity. The prognosis for individuals with HSP varies. Some individuals are very disabled and others have only mild disability. The majority of individuals with uncomplicated HSP have a normal life expectancy.

P-134 A Case of Lupus Nephritis Gamit Dileep, Upadhyay Kamlesh Department Of Medicine,B.J.Medical College,Civil Hospital,Ahmedabad Corresponding Email ID: [email protected]

Lupus nephritis is the result of a type iii hypersensitivity reaction. This occurs when immune complexes are formed. Anti double stranded DNA (anti-dsDNA),an autoantibody,binds to DNA,which forms an anti-dsDNA immune complex. These immune complexes deposit on the mesangium,subendothelial and subepithelial

102 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 space near the glomerular basement membrane of the kidney. This leads to an inflammatory response with the onset of lupus nephritis,in which the complement pathway is activated with a resultant influx of neutrophils and the release of proinflammatory cytokines. The activation of the complement pathway results in low C3 and C4,which indicates active LN. A 33 years old male patient k/c/o Rheumatoid arthritis since 3 years come with h/o weight loss and generelised weakness since last 3 months and bilateral pedal oedema,scrotal swelling,breathlessness on exertion since last 3 days. After diagnosed as lupus nephritis patient has been treated with steroids,azathioprin,mycofenolate mofetil and other supportive measures.

P-135 Prevalence of Major Depressive Episodes in Patients with Chronic Kidney Disease and End Stage Renal Disease: A Cross Sectional Study at Tertiary Care Teaching Centre of Western India. Sambada Vishal, Vaishnav Bhalendu, Leuva Alpa, Shah Maulin, Verma Jagdish Department of General Medicine, Pramukhswami Medical College, Karamsad, Gujarat, India Corresponding E-mail: [email protected]

Introduction: Chronic kidney disease (CKD) is a progressive disease that causes a permanent impairment of renal function and premature mortality. CKD patients are at high risk of depressive disorders because of considerable psychological stress due to physical and social changes brought on by disease. The present study intended to provide information regarding prevalence and variance in psychiatric morbidity with demographic variable, CKD and comorbity variables. Aims: To find out prevalence of major depressive episodes in patients with chronic kidney disease and end- stage renal disease in Shree Krishna Hospital, Karamsad. To find out variance in psychiatric morbidity with demographic variable, CKD and comorbity variables. Methods: We analysed data of 50 adult patients presented to Shree Krishna Hospital. Recipient of a kidney transplant, psychotic depression, dementia, or unable to participate in interview due to any other reason was excluded from the study. Demographical, disease characteristic and outcome-based parameters were recorded and analysed. Results: Out of 50 patients included in study, 62% of them were male, Majority belonged to upper lower class 50%, 22% were employed, 44% were regularly engaged in exercise, 52% belonged to CKD stage V, 44% had at least two or more comorbidities and 40% had diabetes. On screening with PHQ-9, 42% of patients had depression symptoms and out of 42% on doing DSM-V interview with psychiatrist, 12% had major depressive disorder, 22% had adjustment disorder and 8% had anxiety disorder. Conclusion: All patients who screened positive were diagnosed with some psychiatric morbidity by DSM V criteria. Prevalence of psychiatric morbidity was found more in male, age group of 41-59 years, unemployed and lower SE class IV. Proportion of psychiatric morbidity were increasing as CKD progresses. This study found statistically significant association between presence of psychiatric morbidity and substance use (p = 0.001),

103 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 not doing regular exercise (p=0.014), having more than or equal to 2 chronic co-morbidities (p=0.006) and having diabetes (p=0.001). This study reveals that depressive symptoms are common in CKD, this indicate that there is a need to undertake psychiatric assessment of all patients with CKD, so as to identify patients in need of treatment for depression.

P-136 A Case of Neurolathyrism- A Rare Neurologic Disorder Miruliya Mayur , Patel Shivani Department of General Medicine, B. J. Medical College , Civil Hospital, Ahmedabad , Gujarat Corresponding Email ID: [email protected]

Neurolathyrism is a rare neurologic disorder clinically manifested by weakness of the lower limbs. It progresses slowly as spastic paraplegia causing stiffness and paralysis of the muscles of the lower extremities. Lathyrus sativus- also known as khesari dal or grass pea which is used as a staple food in many parts of India although having good nutritious quality but due to presence of toxic substance i.e. BOAA (Beta-Oxalyl- Amino Alanine) and ODAP( N- Oxalyl-2,3- diamino propionic acid). These toxic substances cause neurotoxic symptoms lead to motor neuron degeneration resulting in spastic paraparesis. A 23 year old male presented to Emergency ward with difficulty in walking and frequent fall downs while walking with difficulty in holding objects for 1 year. On examination patient had normal temperature with BP- 130/80 mm of Hg and RR-14/min with pulse rate of 82/ min. General examination revealed gluteal muscle atrophy with supraspinatus atrophy with. He was a matric pass graduate with an average IQ of 110. He had no recent or remote history of seizure or fever. No significant family history could be elicited. On detailed evaluation, he was found to be taking khesari dal as staple diet. On neurological examination, all cranial nerves were apparently normal with normal higher mental function. Tone in all 4 limbs was normal. Power was grade 4 in all limbs with grade 2 at hip extensors. There was no sensory deficit. Vibration sensation was intact with impaired proprioception. The stance was normal with lurching gait. All cerebellar signs were absent except for tandem walking test which was positive. Romberg sign was positive. EMG NCV was suggestive of normal study. MRI Brain was showing bilateral cerebellar atrophy. MRI cervical spine was normal. Patient had normal blood biochemistry with S.B12 of 158. Thyroid profile was unremarkable. CSF study for HTLV I & II was negative with normal routine microscopic study.2D ECHO and ultrasonography were unremarkable. Patient was non- diabetic non –hypertensive. Patient was non-reactive for HIV, HbSAg and HCV. As serum BOAA toxin level & ODAP level testing kits were unavailable so after ruling out all other neurologic disorders clinical diagnosis of neurolathyrism was made. Patient was given high doses of vitamin C with B12 supplementation. Physiotherapy was given to patient and explained for physiotherapy and restraint from khesari dal. Patient followed up after a month and had improved on treatment and physiotherapy.

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P-137 A Rare Case of Seizure due to Acute Intermittent Porphyria Artwani Ekta, Dudhrejiya Praful Department of Medicine, P.D.U Medical College, Rajkot Corresponding Email ID: [email protected]

A 18 year old muslim patient named Vashilaben Junedbhai Bhutti presented with chief complaints of Involuntary movement of all 4 limbs with frothing from mouth since 1 hr followed by loss of consciousness for 15 minutes after which patient gained consciousness. Patient has a history of repeated convulsions since 2 years for which she was taking Tab Sodium Valproate 200mg 2-1-2 and Tab Phenytoin 100mg 1-0-2 . But patient was still having convulsion . Majority of such episodes always occur before menstruation. On further investigating, patient found to have history of repeated episodes of cramping abdominal pain & insomnia since 1-2 year. Her vitals were showing high blood pressure 156/98 with pulse rate 120/ minute with normal RS and CVS examination . CNS examination shows no cranial abnormality with power 5/5 in all four limbs with absent Planter Reflex. All routine investigations CBC, LFT, RFT, K+, Cu+2 were normal except serum Na+ 126 mg/dl. Her EEG done one month back between in intact period was normal and MRI Brain with epilepsy protocol was normal. Ultrasound abdomen was normal. Patient was advised Urinary porphyrinogen which was high 156 mg/24hr . Urinary ALA was 82 mg/24hr. Fecal Porphyrins were normal. A diagnosis of Acute Intermittent Porphyria made and patient was given Tab Levitracetam 500 mg 1-0-1 after loading dose and patient was given Inj. D25 75mg (300ml) IV every 6 hourly for 4 days. Patient was improved and plan to add GnRH analogue of convulsion occur in premenstrual presentation.

P-138 A Rare Case of Tuberous Sclerosis Patel Keyur, Upadhyay Kamlesh Department Of Medicine,B.J.Medical College, Civil Hospital,Ahmedabad Corresponding Email ID: [email protected]

Tuberous sclerosis is a autosomal dominant genetic disorder. It is also known as BOURNE VILLE’S DISEASE. Characterised by the triad of mental retardation,seizure and facial angiofibromas. Small bening tumors develops in the brain as well as in visceral organs like kidneys and liver. Neurological manifestations of the disorder are due to involvement of brain. A 40 years old female presented with facial angiofibroma,renal angiolipomas and sub ependymal nodules. Considering all the findings patient was diagnosed as tuberous sclerosis. As such tuberous sclerosis is rare disorder,I present this case as a academic interest.

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P-139 A Rare Presentation of Renal Tubular Acidosis with First Time Detected Sjogren's Syndrome Rajput Abhishek Singh, Panchal Manisha Department of Medicine, P.D.U. Medical College , Rajkot. Corresponding Email ID: [email protected]

A 22 year old female patient named Naseemben Abdullah presented with chief complaints of Inability to walk, Inability to use both lower limbs, Inability to use both hand since 2 days without any history of loss of consciousness and seizure with no significant past history. She was clinical examined and found normal vitals, normal RS and CVS examination . CNS examination reveal Flaccid Quadriparesis with grade 2/5 power in all four limbs as well as neck muscle. Deep Tendon Reflexes were absent and sensations were intact. No bowel or bladder involvement. No cranial nerve abnormality with bilateral absent Planter reflexes. Her investigations showed profound hypokalemia K-1.8 Mg-1.2 with hypophosphatemia with elevated ESR - 86 mg/ dl. On questioning, she admitted to having symptoms of dryness of mouth and irritation of eyes since last one year and required water for chewing food. Ultrasound KUB was normal . Urine routine microscopy was normal. Urine K+ was 20 mmol/day with Metabolic Acidosis Schirmer test was positive and ANA titre done by Immunofluorescence was significant ANA (1:160) with Anti SSA and Anti SSB positive . Patient was given syrup Potrate MB6 with content of potassium and magnesium citrate 15 ml QDS * 5 days and patient improved within 2-3 days. Conclusion : Patients presenting with RTA should be evaluated for Sjogran’s Syndrome.

P-140 A Case of Neurotoxic Snake Bite in Pregnancy with Good Outcome M Boopathi, Patel Chirag Department of Emergency Medicine, B.J. Medical College,Civil Hospital, Ahmedabad,Gujarat Corrosponding E-mail ID: [email protected]

Introduction: Snake bite in pregnancy carries significant fetal was tage and maternal morbidity and mortality. Mother and fetus need close surveillance and effective management.The main purpose of this case review is to discuss as cenario of a snake bite to a pregnant lady, its clinical presentation and emergency management. The big four poisonous snakes in India are common cobra, common krait, russel viper,saws caled viper. Case Presentation: A 24 years old female Manishaben with 36 weeks of a menorrhoea presented with A/H/O snake bite over left dorsum of foot (double fangmark) at around 7am at her home on 16th June 2019. On admission the patient was conscious oriented and vitally stable. Due to Confirmed snakebite, Patient was given 1st dose of inj. AS V10 vials. After 3hours of giving 1st Dose of ASV patient developed heaviness of both eyelids, blurring of vision, weakness of Both lower limbs, difficulty in swallowing, breathlessness and no table to speak.

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Patient was Not maintaining spo2 with respiratory rate 40/min , blood pressure 120/74 mmhg, pulse rate 130/min, so patient was intubated in emergency medical ward with inj. Thiopentone sodium As induction agent and patientputon IPPV mode of Mechanical ventilation. Even after 1st Dose of ASV patient detoriated ,So2nd dose of inj. ASV 10 vials and inj. Neostigmine given. After 3hrs of intubation patient delivered a female baby by normal vaginal delivery. Baby Shifted to NICU for observation. After 2nd doses everity of neurotoxic signs were reduced, Patient was gradually weaned off over 5days , patient was extubated after 5 days of intubation, then transferred to ward. Patient and baby discharged after8 days of hospitalisation. Conclusion: Snake bite (poisonous) carries high risk of fetal was tage and maternal mortality. But timely recognition of signs of detoriation and intervention accordingly can prevent fetal and maternal mortality.

P-141 A Case of Hemicrania Continua –Trigeminal Neuralgia Syndrome Rajput Sanjay, Dut Jayesh, Patel Khushali, Mod Jaydev Department of General Medicine, Smt. NHL Municipal medical college,Ahmedabad,Gujarat Corrosponding E-mail ID: [email protected]

The coexistence of two different primary headache disorders is usual, like coexistence of migraine with tension-type headache (TTH) which is very common in the general population1. However, the coexistence of two rare primary headaches is scarce. Trigeminal Neuralgia (TN) may coexist with various primary headache disorders, including trigeminal autonomic cephalalgias (TACs)9. The diagnosis is important as both headaches may respond to two different classes of the drugs1. TN frequently coexist with cluster headache ( cluster-tic syndrome). Herein, we are reporting a case of hemicranias continua-tic syndrome. A -31-year old female patient came with a 2 years history of left-sided continuous mild to moderate head pain with paroxysmal exacerbations. There was continuous background pain. The exacerbations used to occur 10–30 times a day and the duration of exacerbations varied from a few seconds to a few minutes. The characteristics of exacerbations varied from excruciating stabbing pain associated with ipsilateral conjunctival injection in about few of the attacks. Agitation and pacing activity was associated with the exacerbations. And occasionally precipitated by chewing and eating. Physical and neurological examinations were normal. Routine haematological and biochemical parameters were normal. MRI brain did not reveal any abnormality. Prior treatments with various drugs produced minimal or no effect. We suspected a possibility of HC as the patient fulfilled ICHD criteria for HC. Indomethacin was started at a dose of 25 mg tds and was increased to 50 mg three times a day. There was a marked response. The background headache stopped along with reduction in frequency of the exacerbations. The patient never had such improvement with any drug in the past. The exacerbations noted by the patient as very severe and only for few seconds. There were no ‘longer duration’ exacerbations. A diagnosis of HC-partially responsive to indomethacin was made. However, a possibility of co-existent TN was also suspected as patient noted that precipitation of some attacks by eating and chewing increases the possibility of associated TN. Carbamazepine was added to indomethacin. The patient showed almost complete improvement with the combination therapy of indomethacin (50 mg tid)

107 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 and carbamazepine (200 mg bid). Further tapering of indomethacin led to the relapse of continuous headaches and exacerbations of longer duration attack. Tapering of carbamazepine was not successful and it always led to the relapse of the neuralgic pain. The patient was well controlled with this combination.

P-142 A Case of Para-Aniline Nitrate Gas Inhalation Management in Emergency Department Virani Devanshi, Sangani Devanshi, Patel Chirag Department of Emergency Medicine, B. J. Medical College, Civil Hospital, Ahmedabad , Gujarat Corrosponding E-mail ID: [email protected]

Introduction: Para-aniline nitrate is a substance used in making artificial dyes commercially used as hair dyes and textile dyes. It causes reduction of iron in heme group of haemoglobin from ferrous to ferric which leads to production of methaemoglobin which can not bind to oxygen. It is bluish chocolate-brown in colour. Methaemoglobin more than 5% in blood presents as cyanosis. Case Presentation: A 50 year old male patient brought by 108 personnel in Emergency Medicine Department with difficulty in breathing and drowsiness after accidental inhalation of Para-aniline Nitrate Gas while working for a chemical company. Patient presented with complain of breathlessness at rest, drowsiness and had central cyanosis with normal temperature, pulse rate 122/min, blood pressure 116/78mmHg, respiratory rate 34/min and SpO2 56% on air. Patient was immediately started on supportive care of oxygen via non re-breathing mask at 15L/min, IV fluids and patient's blood sample was sent for arterial blood gas analysis which was suggestive of partially compensated respiratory alkalosis. Patient was then treated with methylene blue intravenous injection as 10mg diluted in 500ml normal saline. Patient started improving and became conscious with resolving central cyanosis and improving O2 saturation. After injecting two such vials in 12 hours duration, patient became fully conscious with normal temperature, pulse rate 84/min, blood pressure 114/72mmHg, respiratory rate 14/min and SpO2 96% on room air. Patient was discharged after continuous monitoring and supportive therapy for 36hours after getting stabilized. Conclusion: Patient presenting in ED after getting exposed to gases containing anilines can be treated with injection methylene blue and stabilized in ED. Methylene blue acts by reducing methaemoglobin to haemoglobin by combining with NADPH in presence of NADPH reductase.

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P-143 A Case of Hyperthyroid Myopathy in 37 Year Old Male Patient Parmar Jinal, Anadkat Meghal Department of Medicine, P.D.U Medical Collage, Rajkot Corresponding Email ID : [email protected]

Case Report : A 37 year old male patient presented with complain of sudden onset of bilateral lower limb weakness. on examination patient's higher functions were normal. cranial nerves were normal. upper limb was also normal. no involvment of bowel and bladder. tone of both lower limb was decrease, power of both LL was 3/3, reflexes were sluggish. there was presence of tremor on all over body and fassiculations were also present. all routine investigation was normal. ncv study was also done. by blood investigation patients was first time diagnosed hyperthyroidism. usg neck was done which was suggestive of increase vascularity of thyroid gland. Mri whole spine was done which was normal. after diagnosis of hyperthyroidism we had started treatment of hyperthyroidism and gradually patient was improved and discharged after 7 day. patient was diagnosed as hyperthyroid myopathy.

P-144 Hyponatremia in ICU Patients Patel Dhruv, Rimpi, Shah Asha, Prajapati Vipul, Ansari Rizwan Department of General Medicine, GCS Medical College, Ahmedabad, Gujarat Corrosponding E-mail ID: [email protected]

Objectives: Hyponatremia defined as plasma sodium level <135 mM, commonly occurring in hospitalized patients and more common in ICU admissions. It’s a cross sectional study used to approach the etiology, clinical features, low sodium correlation with serum uric acid level, treatment and outcome of the patients. Aim: Ÿ To determine incidence of hyponatremia in total number of ICU admissions. Ÿ To define etiology and clinical profile of hyponatremia in patients with ICU admission Ÿ To study correlation of serum uric acid level in hypovolemic, euvolemic and hypervolemic hyponatremic patients. Methods: This was an observational, cross sectional study in tertiary care hospital, in this study ICU admissions screened for hyponatremia over a period of 2 months who satisfied inclusion criteria. Serum sodium level, urinary sodium level and serum osmolality were studied in all ICU admissions. Serum uric acid level was studied in all Hyponatremic ICU patients. Outcome was studied in terms of duration of ICU stay, discharge and death. Results: In this study 10.78% of total ICU admissions had hyponatremia. SIADH criteria was met in 45.45% of hyponatremic patients, being the leading cause of hyponatremia. 31.81% patients had hypervolemic hyponatremia, 18.18% patients had hypovolemic hyponatremia and 4.5% had psuedohyponatremia. In hyponatremic study, the clinical profile was nausea (59.09%), headache (18.18%), drowsiness (18.18%), altered sensorium (13.63%) and convulsion (4.5%). In SIADH 70% patients had Hypouricemia (p value 0.001)

109 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 whereas in Hypervolemia 85.71% had hyperuricemia (p value 0.001). Overall mortality in hyponatremic group was 18.18% Conclusion: Most common cause of hyponatremia in ICU patients was SIADH. Nausea, the most common and convulsion, the least common symptom in hyponatremic group. Most of SIADH patients had Hypouricemia and Hypervolemic patients had hyperuricemia.

P-145 A Case of Coombs Negative Autoimmune Hemolytic Anemia Goel Arti, Vora Jyoti,, Patel Monila, Shah Sneha Department of General Medicine, Smt. NHL Municipal Medical College,Ahmedabad,Gujarat Corrosponding E-mail ID: [email protected]

Auto immune hemolytic anemia (AIHA) can occur as a primary (idiopathic) disorder or it can co-exist with another disease, known as a secondary AIHA. .Idiopathic auto immune hemolytic anemia, they cause derangement of the mechanism of immunologic tolerance resulting into destruction of red cells. Common causes of secondary AIHA are lymphoproliferative diseases, connective tissue or collagen vascular diseases of following infection.All of these patients require some form of immunosuppressive therapy.. Auto immune hemolytic anemia (AIHA) usually has a positive direct Coombs test however, gradually, reports of Coombs negative AIHA is being added to literature. Exact frequency of Coomb’s negative AIHA is not known. In such patients other causes of hemolysis needs to ruled out. Negative DCTs in this patient could be due to low levels of antibodies on red cell membrane or low sensitivity of conventional tube method or hemolysis due to IgA or E antibodies, which his not detected by conventional DCT. Like DCT positive AIHA, DCT negative AIHA patients also response to immunosuppression. Steroid remains the main stay of therapy. Here, we report a case of 50 year old female presenting with chief complain of generalised fever, weakness, icterus, hemoglobin of 3.2 gm% with biochemical features of hepatorenal syndrome (total bilirubin 55, creat 1.5, urea 105) She was extensively investigated for hemolytic anemia with investigations including Retic, ANA, DCT, Viral markers, Osmotic Fragility test (tail was positive), G6PD, Urine for Hemoglobin, hemosiderin, Heinz bodies, HbH and workup came out to be essentially negative and non-conclusive (G6PD and Osmotic Fragility).In view of acute fall in hemoglobin with features suggestive of hemolysis (high retic, LDH, Bilirubin) diagnosis of (?) Coombs negative autoimmune hemolytic anemia was considered. She was given a trial of steroids (Pulse methylprednisolone followed by oral prednisolone(1mg/kg/day) after documenting normal bone marrow aspiration and biopsy, chest x-ray and USG abdomen to rule out any malignancy. After 21 days of steroids her hemoglobin has reached to 10 gm/dl with Retic count of 6 gm% supporting the diagnosis of Coombs negative autoimmune hemolytic anemia.

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P-146 A Case of Hereditary Hypoparathyroidism Sanjad Sakati Syndrome Khatri Akshay, Patel Shivani Department of General Medicine, B. J. Medical College , Civil Hospital, Ahmedabad , Gujarat Corrosponding E-mail ID: [email protected]

Sanjad Sakati Syndrome is an Autosomal Recessive disorder found exclusively in people of Arabic origin. The condition is caused by mutation in gene encoding tubulin protein specific chaperone. The syndrome consists of Congenital hypoparathyroidism, severe growth retardation, low intelligence quotient and facial dysmorphic features. Typical facial features include - deep set eyeballs, bowed nose, large ears, long philtrum, thin pointed nose, thin lips, long thin tapering fingers, clinodactyly, microcephaly and small hands and feet. The children born with this disorder are born IUGR and present with hypocalcemic tetany or seizures due to hypoparathyroidism at an early age. Blood Investigations for identifying electrolyte abnormalities in the form of serum calcium or phosphate levels and parathormone levels is important. Treatment consists of giving anti epileptics, correcting hypocalcemia by calcium supplements or parathyroid agonists and giving phosphate chelators.

A 13 year old Muslim girl presented to emergency department with complain of generalized tonic clonic convulsions that had increased in frequency since last 2 months. She was a known case of epilepsy disorder since the age of 5 years, but had only 1-2 episodes per year of convulsions. Her seizure episodes had increased to 6-8 per month since last 2 months despite good compliance with her medications. On examination, she was vitally stable with pulse of 86/min, respiratory rate of 16/min and blood pressure of 110/80 mm hg. She was conscious oriented. General examination revealed typical facial dysmorphic features I.e. bowed nasal bridge, pointed nose, large ears, thin upper lip and head circumference of 48cm. She also had carpopedal spasm with inability to hold objects firmly with hands or extend her phalanges. She was a school dropout with an IQ of 60. Family history revealed similar condition in one of her paternal male cousin. Her lab reports included: total serum calcium levels of 5.6 gm/dl, ionized calcium 1.92 mg/dl, magnesium of 1.3mg/dl, phosphate 7.85mg/dl, parathormone levels of 4 pg/ml and vitamin D3 levels of 51.5 IU. Her renal functions, liver functions, complete blood count and thyroid profile were all unremarkable. There was no complain of fever or recent or remote past history of head trauma. MRI Brain revealed hyperintensity in both basal ganglia. Thus, putting together all parameters of clinical history, general examination findings, relevant laboratory findings and ruling out other organic causes - a diagnosis of Congenital Hypoparathyroidism (Sanjad Sakati Sybdrome) was made. She was given a single subcutaneous injection of teriparatide (20mcg), with intravenous calcium gluconate, and anti epileptics, during her indoor stay. Her serum calcium levels gradually increased and she was relieved of carpopedal spasm. She was subsequenly continued with once a week injection of teriparatide, phosphate chelators and vitamin D3 supplements. She was then followed up after a month when her S.Calcium levels were 9.2 with S.Phosphate of 4.1.

Thus, Diagnosis of Sanjad Sakati Syndrome, requires typical clinical features, which is further supported by characteristic lab findings of reduced serum calcium and parathormone levels with incresed phosphate levels.

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P-147 Anesthetic Management of Ischemic Heart Disease with Ejection Fraction of 35% in Patient of Fracture of Neck Femur Sorthiya Ankit, Prasad Ramnandan, Thacker Mandakinee, Patel Jaldeep Department of Anesthesiology,Gujarat Adani Institute of Medical Sciences,GAIMS,Bhuj Corresponding Email ID: [email protected]

Introduction: Ischemic Heart Diesese (IHD)is leading cause of mortality &morbidity in perioperative complications in cardiac patient. Patient of IHD requires identification of risk factor, pre oprarative evaluation ,monitoring and appropriate anesthetic technique &drug. Case Report: 65 year old male patient with known case of IHD and Hypertention diagnosed to have neck of femur fracture was posed for Austin moor prosthesis.patient had undergone angioplasty 4 years back and was on antihypertensive and antiplatelet mediction . all laboratory investigation with in normal range.ECHO shows EF 35% with left ventricular systolic dysfuction. Discussion: Anesthetic goal for patient with IHD are stable hemodynamics,to prevent MI by proper myocardial oxygen supply and reducing oxygen demand.in this case patient was taken under epidural anesthesia to avoide trachycardia ,and hypertention due to stress response during laryngoscopy and tracheal intubation associated with General anesthesia.

P-148 A Case of Recurrent Anaemia Diagnosed as a Ulcerative Colitis by Capsule Endoscopy Amin Viral, Acharya Harshit, Department of General Medicine, GCS Medical College Hospital and Research Centre, Ahmedabad, Gujarat Corrosponding E-mail ID: [email protected]

Ulcerative Colitis is a chronic inflammatory bowel disease that causes irritation, inflammation, and ulcers in the digestive tract; usually affects innermost lining of the large intestine and rectum. Clinical forms range from mild to severe. Having Ulcerative Colitis puts a patient at increased risk of developing colon cancer. We report a case of 15 Year male patient admitted to our hospital with history of recurrent anaemia and repeated blood transfusion were given for the same four times in last one year; diagnosed as Ulcerative Colitis by Capsule Endoscopy and confirmed with histopathological correlation. After treatment with Glucocorticoids and 5- Aminosalicylic Acid, patient was gradually improved and anaemia was corrected in next few weeks.

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P-149 A Case of Tuberculous Vasculitic Infarct with Japanese Encephalitis Amin B, Nandaniya Bharat, Dhanani K Department of Internal Medicine, B. J. Medical College , Civil Hospital, Ahmedabad , Gujarat Corrosponding E-mail ID: [email protected]

Introduction: Tuberculous Meningitis is a mycobacterium tuberculosis infection of the meninges. TB Meningitis is the most severe type of extra-pulmonary tuberculosis. TBME induced inflammatory reaction is associated with severe complications include cardiovascular disease, cranial nerve palsy, hydrocephalus and infarct. Tuberculous vasculitis infarct occurs in 6-7% of cases with TBME. Japanese Encephalitis is neurological infection caused by the JE virus, a flavivirus. It is spread by bites of culex mosquitoes. JE will cause neurological problem like fever, headache, seizures, neck stiffness and altered sensorium etc. Case Presentation: A 36 year old male patient presented in the medical emergency with chief complain of low grade fever, anorexia and weakness in right upper limb and lower limb since 1 month. Patient had high grade fever with chills associated with headache, 2 episodes of convulsions and vomiting since 3 days. On examination patient was febrile, temperature 1030F, pulse 110 bpm , blood pressure 140/86 mm of Hg with GCS E2V1M4 (7/15). Neurological examination revealed hyperreflexia in right upper and lower limb with right extensor plantar reflex. MRI brain with contrast was suggestive of tuberculous cerebral vasculitic infarct in left fronto-parietal region. Patient was simultaneously screened for viral encephalitis in view of acute symptoms. CSF IgM for JE was positive. The patient was diagnosed as a case of tuberculous vasculitic infarct with Japanese encephalitis. He was treated with AKT, steroids and supportive management and discharged after 21 days of inpatient injectable treatment. On follow up patient was having aphasia and behavioural disturbance which was possibly the neurological sequele of JE. Conclusion: Although symptomatic Japanese encephalitis (JE) is rare, the case-fatality rate among those with encephalitis can be as high as 30%. As there is no antiviral treatment for Japanese encephalitis, proper vaccination and screening of patients with febrile neurological disturbances in endemic areas should be encouraged to prevent the transmission of this disease and for early diagnosis and management.

P-150 A Case Report of Pycnodysostosis Rathod Nirav, Patel Snehal, Vasavda Halak, Patel Purvi Department of Pediatrics, Shardaben Hospital, Ahmadabad, Gujarat Corrosponding E-mail ID: [email protected]

Introduction: ‘Pycnodysostosis’ word is derived from greek, meaning ‘puknos’- dense, dys -defective, and ostosis-condition of bone, is a rare autosomal recessive disorder, characterised by increase in bone density that manifests as short limbs, an open anterior fontanel, occipital bossing, short and broad hands and feet and the nails may be dysplastic. It is caused by a mutation in the gene that codes the enzyme cathepsin K on chromosome 1q21.

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Case Report: A 7 yr old male child presented with complaint of poor weight gain and short stature. On examination, his height was below 3rd centile and weight was in 3rd centile, he had short limbs and deformed fingers of both hands with open anterior fontanel and separated sutures. Investigations showed iron deficiency anaemia, normal calcium, phosphate, and alkaline phosphatase levels. Xray hand and carpal bones showed increased bone density and bone age of 3 years, with partial agenesis of distal phalanges. X ray spine showed fish mouth vertebrae and X ray skull showed wormian bones and persistent wide and open coronal, sagittal and lambdoid sutures. With these clinicoradiological features child was clinically diagnosed to have Pycnodysostosis. Conclusion: Children presenting with short stature and increased bone density can be diagnosed as pycnodysostosis based on clinicoradiological features and the other differential diagnoses such as osteopetrosis, renal dystrophy, hypervitaminosis A&D and Caffey disease should be ruled out. Keywords: Pycnodysostosis, stature, X-Ray

P-151 Mixed Connective Tissue Disorder: A Case Report Patel Harita, Ahmadi Basir, Trivedi Jayesh Department of General Medicine, GAIMS, Bhuj. Corrosponding E-mail ID: [email protected]

Introduction: Mixed connective tissue disorder is rarely reported in India. It is a disease with overlapping features of many connective tissue disorders and the presence of anti-U1RNP. We present a case with dyspnea and generalized swelling as the initial presentation that led to the diagnosis of mixed connective tissue disorder. Case Report: A 25-year-old female came with initial complains of progressive dyspnea limiting her daily activities, palpitations, generalized body swelling since 15 days and fever since one week. Detailed history and physical examination revealed bluish discoloration of fingers on exposure to low temperature, dysphagia and difficulty opening the mouth and sclerodactyly. Laboratory workup and radiography concluded the diagnosis of mixed connective tissue disorder. Pulmonary function tests suggested restrictive lung disease and two- dimensional echo showed pulmonary hypertension. Our patient followed both the Alarcon-Segovia's criteria and Kasukawa diagnostic criteria for mixed connective tissue disease (MCTD). Conclusion: Pulmonary hypertension presents late in the illness when other clinical signs are easily recognizable and should be treated aggressively as most deaths in mixed connective tissue disorders are due to heart failure caused by pulmonary arterial hypertension. Keywords: Mixed connective tissue disorder (MCTD), Raynaud's phenomenon, Sclerodactyly, Anti-U1RNP antibody, Scleroderma

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P-152 A Case Report of Pediatrics Holt Oram Syndrome Fuletra Deep, Patel Snehal, Vasavda Halak, Patel Purvi Department of Pediatrics, Shardaben Hospital, Ahmadabad, Gujarat Corrosponding E-mail ID: [email protected]

Introduction: Holt Oram Syndrome is rare inherited Autosomal dominant disorder involving mutation of TBX5 Gene.This Syndrome includes Cardiac anomalies (Asd,Vsd,Pda, conduction block) And Limb deformity(Thumb may be absent,hypoplastic,triphalangeal), Shortening of ulna radius, aplasia of radius ,phocomelia,dysmorphism of carpal bone). Treatment involves cardiac and limb deformity corrective surgeries. Case Report: A three year old male child came to paediatrics opd for pre op fitness for wrist tendon transfer on right side. On detailed history patient was found to have bilateral hand deformity since birth and was admitted in Nicu for 2 days for breathing problem. He was diagnosed to have large ostium secundum Asd left to right,dilted RA RV at 8 month age and was on anti heart failure treatment. At 1year age he consulted orthopaedic surgeon for hand deformity and advised to undergo cardiac management before any invasive orthopaedic surgery. At 2 year age he underwent closure of atrial septal defect with autologous pericardial patch. At 2 year 3 month age he consulted orthopaedic surgeon for bilateral absent thumb, right arm in pronation, bilateral valgus deformity. X-ray finding were right sided proximal humeral epiphysis absent, ulnar shortening with radio ulnar stenosis,monous valgus present, pronation attitude. Based on this features presumptive diagnosis of Holt Oram Syndrome was kept. Discussion: Thumb absent with ASD with radial aplasia favours diagnosis of Holt Oram Syndrome. Any patient with this type of cardiac and limb anomalies should be evaluated, so that mortality and morbidity due to this syndrome can be prevented if diagnosed earlier. And it helps in genetic counselling regarding disease inheritance.

P-153 Dermatomyositis: Diagnostic Dilemma Shah Bhaumik, Solanki Bhagirath Department of Medicine, B. J. Medical College, Civil Hospital, Ahmedabad, Gujarat Corrosponding E-mail ID: [email protected]

Dermatomyositis is an inflammatory myopathy which causes significant morbidity and mortality with increased risk of progression to ILD and malignancy , which requires close monitoring. Diagnosis of dermatomyositis requires characteristic rash and other criteria like proximal muscle weakness and elevated muscle enzymes , but muscle biopsy is central for establishment of definitive diagnosis . As dermatomyositis is a rare disorder and having nonspecific presentation , diagnosis is usually missed or delayed . Here , I want to present a case of 40 year old female , who was initially misdiagnosed as hypothyroidism and later on found to have dermatomyositis and treated successfully with immunosuppressant.

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P-154 Azathioprine for Remission in Autoimmune Hepatitis Type 1 : A Pediatric Case Report Patel Shuchi, Patel Snehal, Vasavda Halak, Patel Purvi Department of Pediatrics, Shardaben Hospital, Ahmedabad, Gujarat Corrosponding E-mail ID: [email protected]

Introduction : Autoimmune liver disease, common in girls characterized by hypergammaglobulinemia, presence of circulating autoantibodies, necroinflammatory histology on biopsy and response to immunosuppressive agents. It is of two types: Type1 most common (60-70% cases) with presence of antinuclear antibody and/or anti-smooth muscle antibody and type 2(20-30% cases) with presence of anti- LKM antibody. It may progress to acute hepatic failure particularly in children with type 2 disease. Case Report: A 11 year old female child presented with h/o recurrent jaundice since 3 yr of age (3 to 4 times). At 7yr of age she was investigated and found to have altered liver function test with negative viral markers and normal S.ceruloplasmin. S.Immunoglobulin level was high. Antinuclear antibody negative & Antismooth muscle antibody was positive. So diagnosis of autoimmune hepatitis type1 was made, oral corticosteroids (Prednisolone @2mg/kg/day) was started and discharged. But patient was a defaulter( took only for 3 months). Now presented again with jaundice. On evaluating S.Bili T-9.2 D-7.1 I-2.1 SGPT 2804 S.AlkPO4 1012 viral markers were negative. Oral Corticosteroid (1mg/kg/day) & Azathioprine (1.5mg/kg/day) was started. On flup after 20 days she was found to have steroid facies hence gradually steroid was tapered and Azathioprine was continued. Patient is better and remained asymptomatic since last 5 months. Conclusion: Any patient who presents with recurrent jaundice with absence of any known etiology (viral, Drug, Biliary) should be investigated for Autoimmune Hepatitis and can be treated with immunosuppressive. Though steroids are 1st line of choice, Azathioprine is useful and effective to maintain remission avoiding steroid side effects.

P-155 A Case Report on Goldenhar Syndrome at a Tertiary Care Institute Mehta Heli, Patel Snehal, Vasavda Halak, Patel Purvi Department of Pediatrics, Shardaben Hospital Ahmedabad, Gujarat Corrosponding E-mail ID: [email protected]

Introduction: Goldenhar Syndrome is a rare congenital autosomal dominant defect also known as oculo- auriculo-verbal syndrome.It is characterized by common clinical features include Eye (Limbal dermoid, Strabismus), Ear (Microtia, Preauricular skin tag, Deafness), Bone (Scoliosis, Mandibular abnormalities), Other (Cardiac & Renal abnormalities) secondary to anomalous development of 1st and 2nd brachial arch.It affects between 1 in 3500 & 1 in 5600 live births, with a male to female ratio of 3:2. Case Report: A 2.2 Kg, Female child, full term newborn baby normal vaginal delivered at a tertiary care hospital was found to have abnormal left upper eyelid with partial cleft palate.Patient is referred to ophthalmology department where baby was found to have GOLDENHAR SYNDROME with feature of limbal dermoid.Baby has

116 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 pre auricular tag and found to have mild hearing loss in BERA. She had normal complete blood counts, normal renal and liver function tests, normal ultrasonography of abdomen and cranium.Baby was operated at 1 month for surgical repair of eyelid and admitted in NICU for postoperative care.After discharge baby had regular follow up in ophthalmology department which remained uneventful. Conclusion: Any child suspected with Goldenhar Syndrome can be treated with corrective surgeries, hearing aids, glasses according to clinical condition to improve the quality of life.

P-156 Pulmonary Renal Syndrome – A Rare Case Report of Good Pasture Syndrome from Kutchh, Gujarat Jivani Krish, Trivedi Jayesh, Chauhan Yesha, Sathvara Jayanti Department Of Medicine, Gujarat Adani Institute Of Medical Sciences , Bhuj Corrosponding E-Corresponding Email ID: [email protected]

Goodpasture's syndrome, or anti-glomerular basement membrane (anti-GBM) disease, is a systemic autoimmune disorder defined by anti-GBM antibody (mainly immunoglobulin G-1)-mediated damage to alveolar and glomerular basement membrane. Linear Ig G deposits along the glomerular and pulmonary basement membranes by direct immunoflouresence and demonstration of antiglomerular basement membrane antibodies, are diagnostic of the disease. We report a case of Good pasture syndrome presented in stage of Rapidly progressive glomerulonephritis (RPGN ) without pulmonary alveolar haemorrhage Which was manifest later. Diagnosis was made by summation of S. Anti GBM , Renal Biopsy and CT chest. Eventually plasma pheresis was not done and patient was put on maintenance hemodialysis for Renal damage. Introduction: In 1958, Stanton et al. published a manuscript entititled “Goodpasture’s syndrome (pulmonary hemorrhage associated with glomerulonephritis)”[1]. They described nine young men with a pulmonary-renal syndrome similar to that described in an earlier report by Ernest W. Goodpasture’s in 1919 of pulmonary hemorrhage associated glomerulonephritis [2,3]. Since then, it has been established that immune-mediated injury to collagen IV disrupts the function of attached epithelia, leading to kidney and sometimes lung impairment [4]. This review defines patients with Goodpasture’s disease as those with the classic triad of detectable serum anti-GBM antibodies, crescentic glomerulonephritis, and diffuse alveolar hemorrhage (DAH), although retinopathy may occasionally also be found [5,6]. On rarer occasions, DAH may occur in the absence of frank renal impairment, although some urine abnormalities may be found. Anti-GBM antibodies are still present. Therefore, the term “anti-GBM disease”is regarded as synonymous with Goodpasture’s disease for the purposes of this review. In contrast, Goodpasture’s syndrome describes the constellation of diffuse alveolar hemorrhage and glomerulonephritis from any cause [7,8]. Renal biopsy is needed to confirm the diagnosis and reveals a crescentic glomerulonephritis and fibrinoid necrosis. Treatment for Goodpasture’s Syndrome includes steroids, hemodialysis, and plasmapheresis. Disease progression can be halted with medical intervention; however, renal and pulmonary damage can be permanent. Case Report: A 17 year old male was good in health till December , 2018. In first week of January,2019 he

117 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 presented in emergency department of G.K. General hospital , Bhuj with chief complain of fever , vomiting , burning micturition and generalized anasarca since 7 days. He was hospitalized immediately. When questioned , fever was high grade in nature without any chills or rigor and persist whole day and not relieved by any medication. It was associated with vomiting which occurs immediately after meal ( 3 to 4 episode of day ). He had also complain of burning micturition with yellowish to reddish discoloration of urine associated with decrease in urine output gradually. During course of 7 days of illness he felt generalized weakness and dyspnea grade III NYHA on 6th day. The patient's history was negative for allergies, recent sore throat, nocturia, or exposure to drugs & any industrial toxins and any chronic disease. Physical examination revealed pitting edema of the hands and feet with slight periorbital puffiness with presence of severe pallor. Tachypnea and crepitations were heard bilaterally. Blood pressure was 160/90 mmhg in supine position with pulse rate 108/min with regular rate , rhythm & volume, a respiratory rate of 30 breaths/min and a tempof 101 F. His oxyhemoglobin saturation on room air was 80% using finger oximetry ( non invasive ventilator support advised ). A chest film on admission showed inhomogenous areas of opacities noted in bilateral middle and lower zone predominantly on right side suggestive of consolidatioin. CT chest findings suggestive of consolidation in right lower lobe with ground glass opacities in both lungs which are s/o pneumonitis and also small airway infection with bilateral pleural effusion. No any evidence of alveolar haemorrhage at the time of admission but after that hemoptysis was occurred later in course. USG KUB s/o bilateral small size kidneys with raised echopattern with preserved CMD. Echocardiography revelled global LV hypokinesia with possibilities of dilated cardiomyopathy. Corticosteroid was given to the patient but eventually plasmapharesis was not done and patient was put on maintenance haemodialysis ( thrice weekly ). Patient had severe respiratory distress in regular follow up . Patient was died after 6 month during treatment due to respiratory failure at home.

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Discussion:

Conclusion: We conclude that GPS is a rare but serious disease. Prognostic factors include the level of renal function and the degree of renal injury ( presence of crescents) at the time of presentation, besides the degree of pulmonary injury. The clinical management should be aggressive in order to have the best prognosis. And require further study to know to association of cardiomyopathy and thyroid function in a case of Good pasture syndrome. Keywords: Pulmonary Renal Syndrome, Good Pasture, Rpgn, Haemodialysis

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P-157 A Case Report of Carbon Baby Syndrome Rathva Payal, Patel Snehal, Vasavda Halak, Patel Purvi Department of Pediatrics, Shardaben Hospital Ahmedabad,Gujarat Corrosponding E-mail ID: [email protected]

Introduction : Universal acquired melanosis also termed as Carbon baby syndrome is an uncommon Phenomenon where Pigmentation is usually present from early infancy but it may be progressive . It Is often diffused and generalised but may latter become rather mottled. Diagnosis is made on the basis of clinic- histological feature. Case Summary : A 1.5 year female child presented with progressive diffuse hyperpigmentation noticed Since 9 month of age. Initially started on trunk and gradually increased to involve both upper and lower limb sparing cheeks and forehead. There was no history of drug intake, local applications prior to the onset. No history of excessive sun exposure, photosensitivity, past and family history. On examination generated diffuse dark black hyperpigmentation of skin all over the body except face which showed patchy area of normal skin. The skin texture and sweat secretion were normal. There was no evidence of primary and secondary skin changes suggesting infection or inflammation. Investigation showed normal blood count ACTH, cortisol levels were normal. Thyroid function test and vitamin B 12 leval was normal. Skin biopsy from Hyperpigmented skin revealed excessive melanin Pigmentation of basal and supra basal layer of epidermis with no altered size and shape of melanocyte. The number of melanocytes was normal. On the basis of clinic-histological feature a diagnosis of carbon baby was made. Chid was treated symptomatically with sunscreen to avoid UV light exposure. Discussion : Carbon baby syndrome is rare condition with diffuse Pigmentation usually presenting since infancy. Diagnosis made after excluding other conditions of generalised diffuse hyperpigmentation. Treatment is only symptomatic.

P-158 A Case of Multiple Sclerosis in a Known Case of Systemic Lupus Erythematous Dhanani Ketan, Amin Bipin Department of Medicine, B. J. Medical College, Civil Hospital, Ahmedabad, Guajarat Corrosponding E-mail ID: [email protected]

Introduction: Multiple sclerosis and Systemic Lupus Erythematous are autoImmune disorder.The Co- Excistance of which Is uncommon In patients. Multiple sclerosis is an autoimmune disease of central servous system characterised by chronic Inflammation ,demyelination,gliosis(Plaque Or Scarring) and neuronal loss. Systemic Lupus Erythematus is an autoimmune disease In which tissue and organ damage Initially mediated bY tissue binding autoantibodies and immune complexes. Privelance of SLE in India is 3.2 cases per 100,000 population.

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Privelance of MS in India is Approx 1.33cases per 100,000 population Case Presenatation: A 28 Year old female patient was known case of systemic lupus erythematous, presented in emergency with complain of bilateral lower limb weakness with loss of sensation and urinary retention. Patient has one episode of blurring vision In right eye and dizziness 2 year ago. neuro Imaging MRI brain with dorso-lumber spine contrast T2 weighted image suggestive of multiple bright signal abnormality In periventricular white matter suggestive of demyelinating chages and in dorsal spine T2 weighted Image demonstrate fusiform high signal Intensity lesion In mid thoracic spine. CSf analysis suggestive of few pleocytosis And OligoClonal band were present in CSF. vitamin B12 level and LDH level were In normal Limits. Vitamin D level were lower.patient had been treated with I.v MethylPrednisolone (1000mg/day for 5 days) and resulting in complete recovery.

P-159 A Case of Moyamoya Syndrome Presenting as Isolated Intraventricular Hemorrhage Desai Vedang, Mod Jaydev Smt. NHL Municipal medical college, Ahmedabad, Gujarat Corrosponding E-mail ID: [email protected]

Introduction: While intraventricular haemorrhage is frequently found in association with intraparenchymal or subarachnoid haemorrhage, isolated intraventricular haemorrhage (IIVH) is rare in adults and seldom described. Awareness of possible causes is important in order to guide patient management. After elimination of a traumatic cause, numerous aetiologies remain possible. The most frequently found underlying lesions are arteriovenous malformations and aneurysms, but other vascular causes should also be sought, including cavernous malformations and moyamoya disease. Arterial hypertension, anticoagulant use, coagulopathies and certain toxic substances are also associated with IIVH. Finally, iIVH may be caused by intraventricular tumours. In a high number of cases, the cause remains unknown. Moyamoya disease is a rare, progressive cerebrovascular disorder caused by blocked arteries at the base of the brain in an area called the basal ganglia. The name “moyamoya” means “puff of smoke” in Japanese and describes the look of the tangle of tiny vessels formed to compensate for the blockage. In the concerned patient, all relevant investigations to rule out a secondary cause were made, out of which the most likely cause was Hyperthyroidism (Grave’s disease). Keywords: Moyamoya Disease, CT Brain With Angiogram, Hyperthyroidism, Puff of Smoke, Intraventricular Hemorrhage

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P-160 Solitary Pulmonary Nodule Later Diagnosed as a Pulmonary Artery Aneurysm Doshi Kinnar, Sisodia Jitendra Government Medical College & SSG Hospital, Vadodara, Gujarat, India. Corresponding Email ID: [email protected]

Introduction: Pulmonary artery aneurysms are rare entities in the spectrum of pulmonary artery diseases. The etiology of these aneurysms is varied and patient present with non specific symptoms which make their diagnosis difficult and less often considered. Their prevalence is unknown but they represent potentially life threatening condition and can present a challenge for prompt diagnosis and treatment. Case Report: A 30 yrs old female, a housewife, with past history of pulmonary tuberculosis 1 year back presented with c/o right sided chest pain & Dry Cough since 15 days. On general examination clubbing grade 1 was present. Respiratory examination was unremarkable. Chest radiograph revealed homogenous round shaped radio-opacity in right lower zone. Sputum for AFB staining and gram stain with culture sensitivity was performed which did not grow any organism. CECT Chest with pulmonary angiography was done S/O pulmonary artery aneurysm. 2D ECHO was done which revealed patent ductus arteriosus. Discussion: pulmonary artery aneurysm can present as solitary pulmonary nodule in chest radiograph which can easily be misdiagnosed as either infective etiology (like pulmonary tuberculosis) or neoplasm. Thorough evaluation of patient is required to reach at final diagnosis. Conclusion: pulmonary artery aneurysm can rupture which can cause sudden cardiac death. Therefore, early diagnosis and treatment are crucial for patient survival and optimal outcomes.

P-161 Spectrum of Acute Kidney Injury in Critically Ill Patients Siddharth Bakrania, Maulin Shah, Bhalendu Vaishnav Department of Medicine, Pramukhswami Medical College, Karamsad, Anand Corresponding Email ID: [email protected]

Introduction: Acute kidney injury (AKI) is common in intensive care unit (ICU) and carries a high mortality rate. Reliable and comparable data about the clinical spectrum of AKI is necessary for optimizing management. The study is conducted with specific focus on diagnosis using KDIGO criteria, requirement of Renal Replacement Therapy with Outcome. Methodology: We prospectively analysed data of 100 adult patients admitted to ICU with AKI or who developed AKI in ICU and followed up to 3 months. Patients with pre-existing renal disease, renal transplant recipients were excluded. Clinical, etiological, outcome-based parameters were recorded and analysed. Results: AKI was predominantly encountered in older males. Hypertension, diabetes, coronary artery disease were the most commonly prevalent comorbidities. Sepsis was the most common cause of AKI, accounting for 19% of patients. 47% belonged to KDIGO Stage 1, 20% to KDIGO Stage 2, 33% to KDIGO Stage 3, class of the KDIGO criteria. Renal replacement therapy (RRT) was required in 22% of patients. About 70% recovered

122 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 complete renal function. Chronic kidney disease (CKD) was a sequel in 7% of patients. Crude mortality rate was 23%. Conclusion: In critically ill patients elderly age, male sex, with pre-existing hypertension along with a primary diagnosis of sepsis were most commonly associated with AKI. Majority of the patients recovered complete renal function. Outcome in KDIGO I, II, III as regards mortality is 2%, 2% and 19% respectively and as regards CKD is 1%, 3%, 3% respectively.

P-162 Sequential Organ Failure Assessment (SOFA) Score as Predictor of Outcome in Patients with Severe Sepsis in Medical Intensive Care Unit at Tertiary Health Care Centre Dave Nisarg, Upadhyay Aakash Department of Medicine, Smt. NHL MMC and Sheth V.S General Hospital, Ahmedabad, India. Corresponding Email ID: [email protected]

Introduction: Evaluation of patient’s status before admitting into ICU is essential for ensuring correct interventions and proper management of hospital resources. Critical care predictive scoring systems serve as a helpful tool at admission in predicting the course of the patients in the ICU. Though their main goal is prognostication of patient’s status, they also help in assessment of various interventions and quality of care. The present study was planned to assess the ability of SOFA scoring to predict mortality in the ICU settings at the tertiary care centre. Most of the scoring system use numerous variables which may prove both tedious and inconvenient in a setting where evaluation needs to be fast paced to match the rapidly changing medical condition of patients. SOFA uses simple measurement of major organ function derived from routine investigation to calculate a severity score. SOFA score is used to track a person’s status during the stay in an ICU to determine the extent pf a person’s organ function or rate of failure. An increase in SOFA score during the first 24 to 48 hours in the ICU predicts the mortality rate of at least 50% up to 95%. Scores less than 9 give predictive mortality at 33% while above 11 can be close to or above 95%. Aims and Objectives: To calculate Sequential organ failure assessment score on admission, after 48 hours and delta sofa score. To corelate sequential organ failure assessment score on admission, after 48 hours and delta SOFA score with outcome. To evaluate the predictive value of mortality in severe sepsis patients using sequential organ failure assessment score on admission and after 48 hours and delta SOFA score. Materials and Methods: The present study comprises 54 patients, with severe sepsis, admitted in Medical ICU, At tertiary care centre from March 2018 to September 30th ,2019. Study design is prospective cohort study. Inclusion criteria: A) Patients admitted in medical ICU of both sex with age more than 18 years. B) Patients with sepsis fulfilling following criteria (acc. To ACCP/CCM). Laboratory and clinical data were collected and the SOFA score was calculated on admission and at 48 hr of presentation to medical ICU. The delta SOFA was calculated as the difference between the SOFA score at 48 hr and the score on the day of admission to the ICU. The different SOFA scores were compared to outcome of the patient in ICU with severe sepsis using independent sample t tests and the paired sample tests. A Chi square test and Fischer’s exact test was used to evaluate statistical significance of categorical variables. P value <0.05 was considered statistically significant.

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Results: The total SOFA score calculated on admission in non-survival group was 5.96±2.6 compared to survived group which was 4.75±1.82. The study corelated statistically with mortality (p <0.024) as also suggested by Ferreira et al. The SOFA score was then calculated 48 hours after admission. Mean SOFA score in non-survival group was 8.90±2.66 compared to survived group which was 3.28±1.83. The study corelated statistically with mortality (p<0.001). Ferreira et al. also concluded that the mean SOFA score had a better prognostic value than the other SOFA derived variables. The mean Delta score in non-survival group was 2.96±2.16 which was significantly in relation to mortality as compared to delta score in survival group which was -1.15+1.83 statistically (p<0.001) which was also concluded in study of Ferreira et al., Vincent et al., Machado et al and Hiroshi et al where delta SOFA was also significantly associated with outcomes. Conclusion: SOFA score on admission has shown a strong correlation with the outcome, and can help triage patients. In this study, SOFA score after 48 hours of admission was a better predictor of mortality (p<0.001) than the score at admission. These results reinforce the available evidence and point towards a potential use of the SOFA score predict outcome in ICU patients with severe sepsis. However, further studies are needed to confirm these findings on a larger scale, and a longer duration and follow-up.

P-163 Medical Dilemma – SLE Presented as Cardiac Tamponade Shah Jay, Agrawal Rahul Department of General Medicine, GCS Medical College, Hospital and Research Centre, Ahmedabad, Gujarat, India Corresponding Email ID: [email protected]

SLE is an auto-immune multi-system involving disease in which organs and cells undergo damage initially mediated by auto-antibodies and immune complexes that are tissue binding. SLE affects most commonly women of child bearing age; people of all gender, ages and ethnic groups are susceptible. We report a case of 18 years old female who came to emergency with Anasarca, Dyspnea, Chest Pain, Palpitation and Syncope – 2D ECHO done in ER revealed Cardiac Tamponade. This patient was previously treated as Tuberculous pericardial effusion without response. Pericardiocentesis done. Also, routine Blood, Urine and ANA/IF, C3, C4 levels, ANCA, 24-hour urinary protein reports sent. ANA By IF – strongly positive. So, Auto-Immune profile was sent which came Positive for SLE. In view of altered RFTs, AKI and SLE, kidney biopsy was done which revealed LUPUS NEPHRITIS. Patient started on Prednisolone to which the patient responded well and discharged in a stable condition. In India every pericardial effusion should not be taken as tuberculous pericardial effusion. One should have high index of suspicion for other etiologies particularly in young patients for mixed connective tissue disorders.

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P-164 A Case of Polycythemia Vera Solanki Umesh, Parmar Kartikeya Department of Medicine, B. J. Medical College , Civil Hospital, Ahmedabad , Gujarat Corresponding Email ID : [email protected]

Polycythemiavera is a rare myeloproliferative disease in India. The ultimate phenotype JAK2 (janus kinase) V167F mutation. Classical presentation of polycythemia vera is erythrocytosis raised hematocrit and haemoglobin, raised platelets and associated with splenomegaly.It can leads to multiple symptoms due to thrombo-embolic complications .We reported a case of 39 year old female who presented with complaint of 3- 4 episodes of convulsion and long time headache since 12 years. On routine investigations, CBC was s/o isolated erythrocytosis, Hb (22 g/dl), raised hematocrit and raised RBC count. ULTRASONOGRAPHY was suggestive of only splenomegaly and fatty liver. After routine investigations, erythropoietin (2.26IU/L) was done which was decreased. Bone marrow biopsy and JAK 2 mutation done which led to the diagnosis of Polycythemia vera.

P-165 Spironolactone Induced Bilateral Painful Gynecomastia: A Rare Case Report Nagar Jatin, Patel Meghna, Rami Kiran Department of Pulmonary Medicine, GMERS general hospital, Sola, Ahmedabad, Gujarat Corresponding Email ID: [email protected]

Gynaecomastia is unilateral or bilateral breast enlargement in males associated with benign hyperplasia of the glandular, fibrous and adipose tissue resulting from oestrogen-androgen imbalance.1 Asymptomatic gynaecomastia is a common finding in healthy male adults and does not have to be treated, while symptomatic gynaecomastia might be the symptom of many pathological conditions and requires meticulous diagnosis and therapeutic management.2 Medical history plays an importanat role in the diagnosis of drug induced gynecomastia. A large variety of drugs have been implicated in its pathogenesis and they may induce gynecomastia by decreasing testosterone production ,increasing peripheral conversion of testosterone to estradiol and displacing estradiol from sex hormone binding globulin. We present a case report of 72 years old male patient affected by spironolactone induced gynecomastia.

P-166 Presentation of Refractory Status Epilepticus in Pregnant Female Nayak Mit, Patel Chirag M.D.Emergency Medicine, B.J.Medical College, Civil Hospital, Ahmedabad,Gujarat. Corresponding Email ID: [email protected]

Introduction: Status Epilepticus is a single seizure lasting>5minutes in length or two or more seizures with out recovery of consciousness between the seizures. Status epilepticus is a rare but potentially life threatening

125 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 complications that epileptic female can experience during her pregnancy. During pregnancy the risk of fetal malformation, miscarriage, perinatal death is increased and even worsening of seizure frequency can occur. During pregnancy, the volume of distribution and hepatic metabolism of Antiepileptic drugs is increased, with decreased drug compliance. Here we are discussing “A case in which there is unusual presentation of pregnant women with Refractory status epilepticus”. Case Presentation: A 25 year old female (G1P0A0) with 5 months of a menorrhea with K/C/O EPILEPSY since childhood (Treatment defaulter) presented to Emergency Department with multiple episodes of convulsions, which was generalized tonic clonic type since 1 day follow by altered Sensorium. Patient first taken to Kathwada private hospital where primary treatment given then referred to Civil Hospital, Ahmedabad.On presentation T: Normal by palpation, pulse: 96/min, RR: 38/min, BP: 110/72 mmHg, Spo2: 76% on O2 via venti mask at 6- 8L/Min. Patient was intubated in emergency department with prop of ol100mg IV stat given and shifted to ICU for mechanical ventilation. Patient developed convulsion again, so Inj. Diazepam 10mg IV was given. Patient had continuous seizures to which Inj valproate 1g IV was given. As patient’s seizure activity was not controlled, Inj. Levetiracetam 2g IV was given and Inj. Thiopentone Sodium drip (3mg/kg/hr) was started in infusion pump. Antinatal Sonography: Single Live Intra-uterine fetus is seen with variable presentation with gestational age of 22 week 5days. Pt was extubated after 6 days and gradually weaned to oxygen support in 2 days. Patient was then shifted to ward. Conclusion: Non compliance & no response to 1st line Antiepileptic therapy and inappropriate treatment may lead to worsening of the seizure control and to the status epilepticus in pregnancy so it has to be diagnosed early with prompt treatment to avoid further complications.

P-167 A Case of Sjögren’s Syndrome Presented with Hypokalemic Periodic Paralysis with RTA Type 1 Patel Ansh , Chavda Avani Department of Medicine, AMC MET Medical College & LG hospital, Ahmedabad, Gujarat Corresponding Email ID: [email protected]

Introduction: Sjögren’s syndrome is a chronic, slowly progressing autoimmune disease characterised by lymphocytic infiltration of the exocrine glands resulting in xerostomia and dry eyes. The syndrome has unique features since it presents with a wide clinical spectrum from organ-specific autoimmune exocrinopathy to systemic disease.Renal tubular acidosis is a common extra glandular manifestations of this condition which leads to hypokalemia.Although RTA with hypokalemia reported earlier, periodic paralysis as the initial manifestation of the disease is rare.Middle-aged women (female-to-male ratio, 9:1) are primarily affected, although Sjögren’s syndrome may occur at any age, including childhood. The prevalence of primary Sjögren’s syndrome is ~0.5–1%, while 5–20% of patients with other autoimmune diseases suffer from Sjögren’s syndrome (secondary). Clinical Profile: 46 year old female presented In the emergency with complaint of difficulty in moving all 4 limbs

126 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 since morning from the day of admission which was generalised and gradually progressive in nature.Patient had a similar episodes in 6-8 months but this time she had marked weakness.On further examination patient was vitally stable but all the deep tendon reflexes are absent and power was 1/5 in all 4 limbs. Her sensory examination was normal and pupils were 3-4 mm bilaterally equal reacting to light. Planters were bilaterally flexors.Her serum electrolytes were checked and serum potassium comes 2.3 mmol/l while S.Ca and S.Mg levels were normal. After that potassium correction was given and there was a marked improvement in power of all 4 limbs within 24 hours. Arterial blood gas analysis suggestive of normal anion gap metabolic acidosis and urinary pH comes out 7.5 with urinary potassium level of 20 mmol/l suggestive of type 1 renal tubular acidosis. Afterwards ANA was done which comes out positive along with anti SS-A, SS-B suggestive of Sjögren’s syndrome.

P-168 Psychomotor and Cognitive Analysis of Patients on Anti-Epileptic Drugs Patel Dhiren , Patel Kamlesh ,Shah Shalin , Rana Devang, Malhotra Supriya Department of Pharmacology, Smt. NHL Municipal Medical College, Ahmedabad Corresponding Email ID: [email protected]

Introduction: Antiepileptic drugs (AEDs) can adversely affect cognitive function by suppressing neuronal excitability or enhancing inhibitory neurotransmission. The main cognitive effects of AEDs are impaired attention, vigilance, and psychomotor speed, but secondary effects can manifest on other cognitive functions. Since the cognitive impact of AEDs can be serious, clinicians should be alert to adverse events by evaluating cognitive function using screening tests. Adverse cognitive and psychomotor effects of AEDs can be avoided by slow titration to the lowest effective dosage and by avoiding poly-therapy. Objective: To study drug utilization pattern of antiepileptic drugs and to evaluate psychomotor and cognitive effects of antiepileptic drugs in the epileptic patient in a tertiary care teaching hospital. Methodology: A Prospective, Observational Cross-sectional study began after the Institutional Review Board approval of protocol and written informed consent from the patients. Patients of either sex, between the age group of 18-75 yrs., diagnosed to be suffering from epilepsy and meeting the inclusion and exclusion criteria were enrolled in the study. Data were collected for the duration of 5 months and was entered in the prescribed Case Record Form. The impact of antiepileptic drugs on psychomotor function will be assessed by the Bender Gestalt Test (BGT) and Cognitive function will be assessed by Addenbrooke’s Cognitive Examination – (ACE-3) Test. Results: A total of 28 patients were involved in the study. The mean age of the patients was 34.57±12.38 years, with a male: female ratio of 9.3:1.Amongst the drugs prescribed, clobazam was the most common medication (75%) followed by oxcarbazepine (42.85%) and levetiracetam (42.85%). An average number of the drug prescribed to the patient were 2.79±1.20. The mean score of BGT in patients was 3.18±2.29. Mean score of each domain of ACE-3 test in patients Attention, Memory, Fluency, Language, Visio-spatial domains were 15.21±2.17, 17.39±5.07, 6.79±1.60, 22.35±3.55, 12.29±2.55 with total Mean score of 73.75±11.83. According to Bender Gestalt Test scoring, patients had score ≥ 5 shows brain impairment with marked effects on attention(13.5±2.74) memory ( 13.16±2.99) fluency(5.33±1.03), language(19.33±2.58) and visuospatial

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(10.16±2.64) domains with total of(61.5±9.16) compared to rest of patient having score of(15.68±1.78), (18.54±4.94), (7.18±1.50),(23.18±2.42),(12.86±2.25) respectively with total score of(77.09±10.26) with statistically significant difference (p<0.05) between the two. Out of 28 patients, only 3 patients had MRI with conclusive evidence of changes in the brain. In 11 patients who had EEG done, showed non-conclusive changes in EEG. Conclusion: In our study, anti-epileptic drugs clobazam and oxcarbazepine showed strong evidence of brain impairment affecting memory and Visio-spatial domains as evident by Bender Gestalt Test and Addenbrooke Cognition Examination (ACE) in 21.48% of the enrolled patients. Keywords: Antiepileptic drug; Cognition; Psychomotor function.

P-169 Abnormal Uterine Bleeding and its Impact on Women’s Quality of Life : A Prospective Observational Study Pandya Amee, Shah Shushma , Malhotra Supriya Department of Pharmacology, Smt. NHL Municipal Medical College, Ahmedabad Corresponding Email ID: [email protected]

Background : Abnormal uterine bleeding(AUB) is one of the most common reason that reproductive‐aged women seek health care.1 AUB and its sub group, heavy menstrual bleeding, are common conditions affecting 14–25% of women of reproductive age and may have a significant impact on their physical, social, emotional and material quality of life and constitute about one-third of all outpatient gynaecological visits.2,3 Aim: Evaluation of prescription pattern of drugs, efficacy and health related quality of life (HRQOL) in patients diagnosed to suffer from Abnormal uterine bleeding(AUB). Methods: A prospective observational study was conducted for a period of 8 weeks at a tertiary care teaching hospital in Ahmedabad. The prescription pattern of drugs was analysed depending on underlying cause of AUB. Females were followed up from exposure to treatment for the development of an outcome of interest to evaluate efficacy of drugs, which was studied using the Visual Analog Scale(VAS), Pictorial Bleeding Assessment Chart (PBAC) and WaLIDD (working ability, location, intensity, days of pain) scale. Variables of quality of life before and after been diagnosed with AUB were assessed using the SF-36 Questionnaire. Results : A total of 118 subjects were enrolled in the study. The mean age of females presenting with AUB was 34.31±6.52 years. Ovulatory causes (75.86%) were most common in women in their 20s, while Leiomyoma(Fibroid) was the most common cause in their 30s (31.03%) and 40s (53.3%). Amongst the drugs prescribed, Tranexamic acid (n=91, 77.1%) was the most common medication prescribed followed by Oral contraceptive pills (n=71, 60.1%) and Oral progestins (n=68, 57.62%). Treatment was efficacious in 78 (66.10%) patients, with change from baseline to 8 weeks in VAS scores was 5.22±3.89 to 2.69±2.35 , PBAC score was 132.09±22.65 to 93.4±17.19 and WaLIDD score was 4.5±2.97 to 3.75±3.25, while 40(33.89%) patients did not improve with medication and were advised surgery. In all domains of SF-36 questionnaire, quality of life of women was negatively affected after been diagnosed with AUB than that before, with significant differences between the two. (p<0.05) Physical domain (n=64, 54.23 %) was the most commonly affected domain followed by emotional domain (n=35, 29.66%). Conclusion: Abnormal Uterine Bleeding of any cause significantly affects quality of life in women which often goes unnoticed, predisposing to long term morbidity. Treatment must be individualized and tailored

128 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 depending on impact of symptoms and fertility requirements. Thus the policy makers as well as the healthcare professionals need to increase awareness of the impact of this benign gynaecological disorder, to induce women to seek assistance and thus improve their quality of life. Keywords: Abnormal Uterine Bleeding, Prescription Patterns, Quality of life

P-170 Inflammatory Myopathy Sheth Vidish, Sharma Seema General Medicine Department, B. J. Medical College , Civil Hospital, Ahmedabad , Gujarat Corresponding Email ID: [email protected]

Inflammatory Myopathy is a heterogeneous group of disorders that usually presents with symmetric and proximal weakness that worsens over several weeks to months. It also can be associated with skin rashes, myocarditis, vasculitis, interstitial lung disease. HEREBY 15 yr old female presented with bilateral symmetrical proximal upper limb and lower limb weakness followed by distal muscle weakness over a period of 1 month. Patient was diagnosed on basis of CPK TOTAL, ELECTROMYELOGRAPHY STUDY, MUSCLE MRI, ANA, ANA PROFILE and MUSCLE BIOPSY. Patient was treated with injection Methyl Prednisolone 1 gm for 3 days followed by tab Prednisolone 1 mg/kg and tab Methotrexate 15 mg once/ week. Patient was improved on follow up after 1 month.

P-171 Anaesthetic Management of 22y/F Patient with Severe Anemia (Hb <5) having Blood Group B Negative Presented with Abdominal Pain Diagnosed as Acute on Chronic Ruptured Ectopic Pregnancy Posted for Emergency Laprotomy . Kalotra Kaushal, Solanki Nayna, Chhanwal Heena, Kheskani Divya Dept of Anaesthesia , GCS Medical College,Ahmedabad, Gujarat Corresponding Email ID: [email protected]

Aim: Ÿ to maintain hemodynamic stability and oxygen carring capacity peri operatively. Ÿ to replace adequate blood volume according to blood/volume loss intra operatively. Ÿ to detect the complication related to multiple blood transfusion early and it’s management peri operatively. Methods: 22/f presented with abdominal pain was diagnosed as acute on chronic ruptured ectopic pregnancy. Laprotomy was planned, first proper pre anaesthetic check up was done. Patient’s haemoglobin was 5, so o2 4 litre/minute , iv fluids were started outside 1 pcv was given pre operatively. Pre op. Patient was having hr136-140, rr 20/minute, patient had blood group b-ve , as it is rare pcvs were arranged from outside blood bank because pcvs were not available in hospital’s blood bank. Surgery was induced after proper arrangement of pcvs. Patient was induced under ga and surgery was started. And to correct heoglobin and to replace the intra op. Blood loss, pcv was running intra operatively. Towards the end of surgery while giving pcv patient had a blood transfusion reaction , patient became unstable hemodynamically sudden hypotension and

129 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 bradycardia occurred , and typical features of blood transfusion reaction were there with including hemolysis and hematuria, pcv stopped immediately and after flushing viggo with ns patient was given inj avil, dexona , hydrocort, tranexa,mephentermine, atropine, calcium gluconate and lasix. Inj dopamine was also started with iv fluids to flush kidneys, to prevent aki. Mean while cbc , rft, lft , serum ldh were sent urgent medical refrence was done. Surgeons were allowed to complete the surgery . Patient was observed for 1 hour in ot. And then shifted to icu intubated with noradrenaline support .pcvs and urine were sent to re cross match it. For 24 hours no blood products were given and patient kept in icu on ventilator. Then patient was monitored continuously and stabilised . And then extubated after stabilisation. And patient was shifted to ward after being stable, and discharged after full recovery. Results: after severe blood transfusion reaction , early recognition was done and patient was managed accordingly, patient was stabilised and recoverd fully from it with supportive treatment. Conclusion: since diagnosis and treatment of incompatible transfusion reaction are uniquely difficult when patient was under ga and in the immediate postoperative period, the authors stress the more adequate Preparation of the patient with regard to pre-operative blood volume replacement and more judicious use of blood during operation to decrease incidence of mulptiple blood transfusion related complications. Acute haemolytic transfusion reaction can present as acute-onset hematuria in an anesthetized patient. A high index of suspicion and vigilance for signs of transfusion reactions after taking aforementioned precautions are essential for early diagnosis and management of this life-threatening complication.

P-172 Takayasu Arteritis- A Rare Medium and Large Vessel Vasculitis Patel Krunal, Parikh Jitendra General Medicine Department, B. J. Medical College , Civil Hospital, Ahmedabad , Gujarat Corresponding Email ID: [email protected]

Takayasu Arteritis is characterized by inflammatory and stenotic disease of medium and large size vessel with strong prediction for the aortic arch and its branches. This disease is panarteritis with inflammatory mononuclear cell infiltrate and occasional giant cells. Here by 15 yr old female presented with absence of pulse in right upper limb , inability to speak and left upper limb and lower limb weakness for 1 day. Diagnosis was supported by MRI angio brain and neck vessels, CT angio aorta and four vessel Doppler. Patient was treated with injection Methyl Prednisolone 1 gm for 3 days followed by tab. Prednisolone 1mg/kg and tab. Methotrexate 12.5 mg once/week. Patient improved after 1 month on follow up.

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P-173 A Case of Viral Hepatitis - An Induced Myocarditis in Elderly Female Patel Nirav, Patel Naimish Department of General Medicine, GCS Medical College Hospital and Research Centre, Ahmedabad Corresponding Email ID: [email protected]

Myocarditis is an inflammatory process that primarily involves the myocytes and can be a manifestation of severe infection caused by almost any infectious agent. The viral myocarditis is the most common cause of heart failure in previously healthy children and adolescents. Clinical expression of acute myocarditis ranges from inapparent disease to fulminant cardiac failure with rhythm abnormalities. Hepatotropic viruses rarely cause acute myocarditis. We report a case of 52 year female patient admitted to our hospital with chief complain of abdominal pain and yellow discoloration of sclera since 4 days diagnosed as viral hepatitis A infection get complication of myocarditis. with treatment of vasopressin supports and inodilators for myocarditis and with adequate nutritional therapy patient gradually improved. Liver enzymes get within normal limits in next few days.

P-174 A Rare Association of Chronic Inflammatory Demyelinating Polyneuropathy with Inflammatory Bowel Disease Shah Sahaj, Patel Jagdish Department of General Medicine, B. J. Medical College , Civil Hospital, Ahmedabad , Gujarat Corresponding Email ID: [email protected]

Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) is acquired, immune mediated neuropathy affecting peripheral nerves characterized by relapsing-remitting or progressive course. CIDP has a rare association with inflammatory bowel disease (IBD). We reported a case of a17-year-old male admitted with first episode of ascending weakness of both lower extremities that had progressed for about 3-4 days. Motor nerve conduction study (NCS) showed demyelinating type of poluneuropathy. Patient was treated with 5 cycles of plasmapheresis and after improvement patient was discharged with high dose of steroids with tapering dose. After 3 months patient presented with bilateral upper limb, lower limb weakness and diarrhea with blood, mucus and fever. Patient was investigated with Stool RM, USG , CECT abdomen, colonoscopy (biopsy taken) suggestive of IBD and repeat NCS was done suggestive of CIDP. Patient was treated with high dose of steroid with tapering dose, 5-ASA, mesacol and immunosuppressive agents. Patient improved clinically with marked neurological improvement was seen.

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P-175 GCS and Rotterdam Score in Predicting the Mortality and ICU Stay in Moderate to Severe TBI Adult Victims in ED Patel Prakruti , Thakor Advait, Patel Rushi Emergency Medicine Department , Smt. N.H.L. Municipal Medical College, Ellis Bridge, Paldi, Ahmedabad, Gujarat, India-06. Corresponding Email ID: [email protected]

Background: Traumatic brain injury is a burning health issue in patients with trauma. RTAs (59%), Fall down (25%) and Violence (10%) are major aetiology of head injury 1,4. In 2017, latest year for which data is available 1,47,913 people died and 4,70,975 people got injured in road accident in India. Highest number of RTAs occurred during year 2017 in Tamilnadu followed by Madhya Pradesh and Karnataka. Gujarat is at 10th position in occurrence of RTAs in India. At the global level, annual incidence and mortality from TBIs is 200 and 20 per 1 lakh per year, respectively 1. GC Scale and Rotterdam CT scan score can predict in-hospital mortality in TBI victims. Materials and Method: The observational, descriptive study was conducted on 50 adult (age≥18 years) TBI patients with GCS <13 who presented in ED. Non-ionic contrast CT (NCCT) scan brain as a part of radiological investigation in trauma patients after resuscitation was done and Rotterdam scoring applied. Data was collected from iHis and analysed in Stata 13.0 and Epi (version 7.3.2.1) CDC software. P <0.05 was considered statistically significant. Results: The mean Rotterdam CT score and GCS was 3 and 10 respectively for ICU stay, mean age was 39.24±18.33, M: F sex ratio 3.9:1, RTAs was the most common mode of injury in 70% TBIs victims with mortality of 24% and mean ICU stay of 8.64±14.81 days. Mean GCS was 8.25±2.60 for un-favourable and 10.95±1.71 for favourable outcome. Mean Rotterdam CT score was 4±1.52 for predicting mortality outcome.

P-176 A Case Presentation on Fabry Disease Patel Chaital , Upadhyay Kamlesh Department of Medicine, B. J. Medical College , Civil Hospital, Ahmedabad , Gujarat Corresponding Email ID : [email protected]

Introduction: Fabry disease is an x-linked recessive lysosomal storage disease resulting from deficient ion activity from enzyme alpha-galactosidase – A, which leads to systemic accumulation of globotriaosylceramide and related glycosphingolipids in the plasma and in tissue lysosomes. Males are primary affected, while female are carrier. In typical male manifest in childhood ,with patient typically presenting with acroparesthesias, burning tingling pains in upper and lower extremities, which trigger by fever, exercises, stress and changes in whether. Sweating and anhydrosis are typical presentation. With advance age progressively lysosomal gl-3 accumulation in vascular endothelial leads major organ damages.

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Case presentation : 22 Year old male patient recide at mahesana, Gujarat. C/o :-Left side weakness, facial weakness, left leg weakness, generalize weakness, headache, voming, fever with chill, vertigo on admission. H/o : Mentally retarded from birth. N/h: of Chest Pain/Palpitation/Breathlessness/Convulsion/TB/DM/HTN/Surgery. Personal History : No addiction, having normal sleep pattern, with altered bowel movement. Examination : Having normal temperature. 110/min pulses with 110/80mmhg BP. Maintain SpO2 92% on air. In general examination having bilateral angiokaratoma on trunk, around umbilicus, bilateral thigh, scrotum, penis. Multiple erythmatous papules in oral mucosa, enlargement of lips, wide nasal bridge. Systemic examination : RS : BL air entry present , spontaneous respiration. CVS : S1S2 P/A : Soft. CNS : Patient was malnourished, conscious, normal tone, power, with well coordination with intact sensory. B/T/S/K/A/reflex are present b/l. Investigation : HB : 10.70 TC : 6900 PC : 222000 SGPT : 38.0 Direct bilirubin : 0.31 Total bilirubin : 1.14 USG Abdomen : 6-7 mm calculi noted in gallblader, other are no significant. MRI angio s/o mild to moderate narrowing of m1 segment of right middle cerebral artery and its anterior sylvian branches. Sub acute infract in right insular region. 2D echo s/o normal LV size and function. skin biopsy s/o atrophic epidermis with dilated capillaries in papillary dermis s/o angiokeratoma corporis diffusum. MRI brain s/o normal study: NCCT brain s/o mucosal thickening in bilateral maxillary sinus with deviated nasal septum with bony spur towards right side. There is no active management from psychiatric department and gastrologist advised by specialist. Treatment : Symptomatic treatment like anti emetics with multivitamins are given. Discussion : Fabry disease is a rare inborn error of glycosphingolipid catabolism. The incidence of the classic phenotype is

133 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 about 1:40,000 to 1:60,000 males. In Slovenia there are at least 50 classically affected males with Fabry disease. The patient reported here was the first case diagnosed in Slovenia. Early diagnosis of Fabry disease is important. Because of the typical skin lesions, dermatologists are often the first to make the diagnosis. Prior to 2001, treatment of the disease was limited to palliative and non-specific treatment of the renal, cardiac, and cerebrovascular complications. However, enzyme replacement therapy (ERT) for Fabry disease was introduced in Europe in 2001. ERT has been shown to clear the accumulated GL-3 in the blood vessels as well as in the cells of the heart, kidney, and skin. Clinically, ERT has resulted in stabilized renal function, decreased abdominal cramping, decreased cardiac mass, and markedly improved quality of life .

P-177 Evaluation of Quality of Life, Pharmacoeconomics and Cardiovascular Risk in Patients of Type-2 Diabetes Mellitus: A Prospective Observational Study Harkhani Jolly, Sood Shikha, Arya Vivek, Marwah Tiven, Malhotra Supriya Department of Pharmacology, Smt. NHL Municipal Medical College, Ahmedabad Corresponding Email ID: [email protected]

Background: Diabetes mellitus is a chronic, metabolic disease, which leads over time to serious damage to the heart, blood vessels, eyes, kidneys, and nerves. Diabetes is one of the leading causes of death, as per research around 463 million people worldwide, which will add on more 300 million people by 2045. Diabetes particularly in low- and middle-income strata and may have a significant impact on their physical, social, emotional and material Quality of life (QoL). As diabetes is a lifelong condition it is an expensive aliment for a very large fraction of people in a developing country, which ultimately affects quality of life. Individuals with type 2 diabetes mellitus (T2DM) have a twofold increased risk for cardiovascular disease so estimation of cardio vascular risk in T2DM is also as much as important. Objective: To evaluation Drug prescribing pattern, Quality of Life, Pharmacoeconomics and Cardiovascular Risk in Patients of Type-2 Diabetes Mellitus. Methods: Data were collected for a period 24 weeks at Medicine Department, SVP Hospital. Patients diagnosed with Diabetes mellitus Type II and conforming to the inclusion criteria were enrolled in the study. Drugs prescribed to the patients were noted along with doses and duration. After physician consultation, the patients were subjected to the MDQOL-17(modified Diabetes quality of life -17). Cost were calculated from hospital Formularies, from patient’s original bills and if original bills are not available cost was calculated by using current version of IDR. To estimate Cardio vascular risk assessment which is done by UKPDS Risk Engine version 2. Result: A total of 126 Patients were included in the study. Mean age of patients was 62.11± 10.96 years with 57(45.2%) male & 69(54.7%) females. Most common complications encountered due to Diabetes Mellitus were Ischemic Heart Disease (n= 23, 18.25%) followed by Nephropathy (n= 9, 7.1%) and Neuropathy (n=8,

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6.3%). Amongst the drugs prescribed, 41 (32.53%) patients were prescribed Metformin + Glimepiride combination followed by Insulin + Oral Hypoglycaemic in 23(18.25%) patients. Mean MDQoL -17 Score was 58.17± 15.23. Significant difference (0.004) was found in quality of life of males (62.42 ± 16.13) as compared to females (54.64± 13.58), with low quality of life in female patients. Out of 126 patients, 22 patients were eligible for UKPDS risk engine. The average 10 year estimated risk of CHD was 14.49% and that of stroke was 6.61%. Average cost of INR 5548.91 ± 5177.05 per month which included Registration, investigations, treatment & transportation cost. Conclusion: The QoL of patients in type II Diabetes Mellitus is moderately affected in spite of receiving 5± 2 average number of drugs for the treatment. The average cost is INR 5548.91 ± 5177.05 per month also affect QoL. Thus, proper management and strict glycemic control is necessary to prevent progression and occurrence of complications to maintain a better QoL as well as patient’s education & lifestyle modification is also important for better QoL. Keywords: Cardiovascular Risk, Diabetes Mellitus type II, Pharmacoeconomics, Quality of Life

P-178 Anaesthetic Challenges in Patient with Carotid Body Paraganglioma Excision with Secondary Polycythemia Vera Gohil Shivrajsinh, Raval Bhavna Department of Anesthesiology, B. J. Medical College , Civil Hospital, Ahmedabad , Gujarat Corresponding Email ID: [email protected]

Introduction: Carotid body paraganglioma are rare, nonchromaffin tumour arise from chemo receptor cell of carotid body. This tumours are mostly benign, can turn out as a malignant, and infiltrate or exert pressure on the adjacent neurovascular structure. Anesthesia for excision poses several challenges because The CBPs are highly vascular and firmly adherent to carotid bifurcation and accompanied with peri operative morbidity of 20 to 40%. Case report: 30 year old male patient weighting 57kg presented with swelling on the right side of neck since last 5 year. The lump was painless slowly growing, firm, non tender, non pulsatile (28*29*33mm) in size adjacent to bifurcation causing splying of ICA and ECA. surgery was planned,under general anesthesia tumour excised safely with intra operative monitoring except single episode of bradycardia during excision. Conclusion: Anesthesia for excision of CBP is a challenge and as a operative mortality of 20 to 40% yet with meticulous perioperative assessment and planning using techniques to minimize blood loss, to prevent arrhythmias and cerebral protection regimes in the event of brain ischemia intra operatively with intensive surveillance post operatively anaesthesia and can be managed successfully for excision of CBP. Keywords: General Anaesthesia , benign tumour, excision, paraganglioma, secondary polycythemia vera

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P-179 Infection in Trauma Patients – Focus on Types of Infection , Antibiotic Usage and Cost Analysis: A Prospective Study at Emergency Medicine Department of a Tertiary Care Hospital Lad Deshna, Gupta Sapna, Rana Devang , Malhotra Supriya Department of Pharmacology, Smt. NHL Municipal Medical College, Ahmedabad Corresponding Email Id: [email protected]

Introduction: Infections are one of the most common and fatal complications following trauma and complicates the recovery of patients admitted in Emergency Medicine department. The country has a high incidence of vehicular accidents (6% of global vehicular accidents) contributing to trauma which can predispose to Infections. Objectives: Evaluation of Injury Severity Score(ISS), Systemic Inflammatory Response Syndrome(SIRS) score, Antibiotics usage and its cost in variety of infections in traumatic patients and types of infection. Method: A prospective review of all trauma patients’ presenting in Emergency Medicine Department was conducted over a 8 week period. The records were assessed after taking written consent of patients or their relatives. Detailed history with mechanism, site of trauma, ISS, SIRS were recorded. All patients were followed for investigations and treatment until discharge or transferred to other wards. Among them those who developed Infection diagnosed by clinical signs and symptoms and/or microbiological culture were analysed for type of infection and treatment prescribed to them. Other patients who did not developed infection after Trauma were analysed for Prophylactic Antibiotics. Statistical analysis was carried out using IBM® SPSS Version 25.0 and Microsoft Excel 2019. P value less than 0.05 was considered as statistically significant. Results: A total of 31 trauma patients were recruited in the study. Mean age was 46.218.2 years with male to female ratio of 9.3:1. Most common mechanism of trauma was Road Traffic Accident (27,87.09%) which included (4,12.9%) pedestrian injury and (23,74.19%) vehicular accidents. Most common site of trauma was Head and Neck (27,87.09%). Around 21(67.74%) patients had an ISS was >18 that suggestive of polytrauma and 17(54.83%) patients had SIRS score of ≥ 2 out of which 8(47.05%) developed infection. Most common organism identified was Klebsiella pneumoniae in 4 patients (50%), found in tracheal secretions which suggestive of most common infection in trauma patient is Ventilator Associated Pneumonia(VAP). Amongst Prophylactic antibiotics, Metronidazole(24,27.41%) followed by Cefoperazone + Sulbactam combination(20,64.51%) were most commonly prescribed. For treatment of infection according to culture and sensitivity, 4 patients received colistin in combination with vancomycin/tigecycline/levofloxacin. There was a statistically significant difference(p<0.05) in duration of stay in ICU and cost analysis between Non-infectious trauma patients and patient of trauma who developed infection. Conclusion: Early prevention of Infection for trauma patients can improve outcome, decrease mortality, decrease duration of stay and cost of treatment. Although many research studies about infection prevention in trauma patients have been published, there is a lack of guidelines for antibiotics after trauma, and some of the results are controversial. A new combination of measures can be generated to improve post-traumatic

136 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 outcome. Early prediction of infection can be done by encouraging use of SIRS score for trauma patients which was found in our study. Keywords: Antibiotic usage, Injury Severity Score, Systemic Inflammatory Response Syndrome Score, Trauma, Ventilator Associated Pneumonia

P-180 Anaesthetic Challenges in Patient with Huge Swelling in Anterior Region of Neck Karkar Sanket, Maheshwari Bhaarat Department of Anesthesiology, B. J. Medical College , Civil Hospital, Ahmedabad , Gujarat Corresponding Email ID: [email protected]

Introduction: Difficult airway is a great challenge to an anesthesiologist.we are reporting a case of huge anterior neck swelling measuring (17*13*16.5cm) in size with history of breathing difficulty in lying down position.no history of stridor in lying down position.laryngomalacia can be present in such cases leading to respiratory obstruction. Case report: 52 year old female patient with anterior neck swelling measuring (17*13*16.5cm) in size since 12 year having breathing difficulty in lying down position.surgery was planned.we managed to induce patient and intubation was successful in first attempt with conventional laryngoscopy. Conclusion: Huge swelling in anterior region of neck can be a difficult airway management for an experienced anesthesiologist this case emphasizes the need for careful pre op workup of anticipated difficult airway in huge anterior neck swelling to minimize any peri operative and post operative complications. Keywords: Difficult airway,huge anterior neck swelling

P-181 Treatment Outcome of Ovulation Inducing Agents; Letrozole vs Clomiphene Citrate: A Prospective, Observational Study Parikh Nehal, Sood Shikha,Shah Sushma, Malhotra Supriya Department of Pharmacology, Smt. NHL Municipal Medical College, Ahmedabad Corresponding Email ID : [email protected]

Background: According to WHO “Infertility is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.” Infertility currently affects about 10-14% of the Indian population. Nearly 27.5 million couples suffer from infertility in India. Objective: Comparative evaluation of efficacy between the drugs used in female infertility with Focus on Clomiphene citrate and Letrozole. Methods : A prospective observational study was conducted for a period of 12 months at a tertiary care teaching hospital in Ahmedabad. Study was approved by the Institutional Review Board. The informed

137 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 consent was taken. The prescription pattern of drugs was analysed and efficacy of drugs were studied. Patients received either Letrozole or clomiphene citrate with or without adjunctive therapy [Inj. Human menopausal gonadotropin(HMG), Metformin]. Monitoring for changes in follicular size and number, endometrial thickness and ovulation as done by transvaginal ultrasound. Statistical analysis was carried out using IBM SPPS version 25.0 and Microsoft excel 2019, P < 0.05 was considered statistically significant. Result: A total of 91 females were involved in this study. Mean age was 26.93±3.72 years. Average duration of infertility was 3.58±1.29 years. Out of total 91 females, 49(53.84%) were diagnosed with primary infertility and 42(46.15%) were diagnosed with secondary infertility, with 32(35.16%) diagnosed as Polycystic ovarian syndrome(PCOS). Amongst the drug prescribed letrozole (n=45,49.4%) was the most common drug for infertility followed by clomiphene citrate(n=32,35.1%) and letrozole + Inj. HMG (n=13,14.2%). Significant statistical difference (p<0.05) was found in change in follicle size (from 23.86±3.74 to 27.53± 3.44), number(from 7.75±2.59 to 9.13±1.94) and endometrial thickness (from 7.79±0.55 to 9.11±0.57) in patients receiving letrozole as compared to Clomiphene citrate after three consecutive cycles. Ovulation was observed in total 14(15.38%) females, 7(7.69%) receiving letrozole alone, 5(5.49%) receiving letrozole + Inj. HMG and 2(2.19%) receiving clomiphene citrate alone. Successful conception was found in 6(6.59%) females, 4(4.39%) receiving letrozole alone, 1(1.09%) receiving clomiphene citrate alone and 1(1.09%) receiving letrozole + Inj. HMG. Ovulation Rate was Statistically significant in letrozole group as compared to Clomiphene Citrate group (p<0.05). Conclusion: As compared with Clomiphene Citrate, Letrozole was associated with higher ovulation induction rate among infertile women. The treatment outcome of Letrozole is better than Clomiphene Citrate in terms of ovulation and conception. Keywords: Clomiphene Citrate, Female Infertility, Letrozole, Ovulation induction P-182 Anaesthetic Management of Patient Having Mucolipidosis Type 2, 3 Undergoing Herniotomy Shaikh Khalid, Goswami Shakuntala, Patel Chirag Department of Anaesthesia, B. J. Medical College , Civil Hospital, Ahmedabad , Gujarat Corresponding Email ID: [email protected]

Introduction : Mucolipidosis represents a group of rare Autosomal recessive lysosomal storage disorders associated with skeletal malformations and accumulation of inclusion bodies and glycosaminoglycans (GAGs) in tissues and organs causing progressive cellular damage and associated clinical manifestations. Most important concern of an Anesthesiologist is about securing airway of such patient because of distorted Anatomy and situation such as ‘Can not intubate Cannot ventilate’ posing life threatening risk for patient undergoing simple operative procedures. Many a times we have to resort to alternative methods for providing anaesthesia to such patients. Aims and Objectives: To safely and effectively provide Anesthesia to this patient without compromising Airway. Method of Study: We are presenting our experience of managing patient with Mucolipidosis with Caudal block and Sedation.

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Case: We are presenting a case of 12yr old male patient presenting with left inguinal hernia associated with mucolipidosis. Patient was having large tongue and short neck along with fusion of cervical vertebras , so we decided to proceed with Caudal block and Sedation(Oxygen+Sevoflurane through mask) for the procedure of herniotomy. Result: Caudal block was successfully administered with adequate effect and check ventilation did not pose any difficulty. Conclusion : Patient with lysosomal storage diseases should be provided with anesthesia which should avoid airway manipulation as far as possible because of high instances of failed endotracheal intubation and ensuing complications. Keywords: Mucolipidosis, Difficult Airway, Caudal block, Sedation

P-183 Clinical Profile and Etiology of Severe Anemia among Hospitalized Individuals of more than 18 years of Age: A Cross Sectional Study at Tertiary Care Teaching Centre of Western India Patel Arpit, Vaishnav Bhalendu, Patel Arpit Department of General Medicine, Pramukhswami Medical College, Karamsad, Gujarat, India Corresponding Email ID: [email protected]

Introduction: Anemia is a global public health problem of the rich and poor alike. Many studies are available which characterised its etiology, clinical profile and therapeutic interventions in vulnerable populations such as preschool children, pregnant women and non-pregnant women. But There is no sufficient data available in hospitalised adult and elder population with severe anemia, which is at once an indicator of poor health and nutrition. Recent studies in India have revealed that in addition to nutritional deficiency, anemia secondary to haematological and non-haematological malignancy and chronic diseases are also common etiology. Aims: To study clinical, hematological and etiological profile of severe anemia among adult, hospitalized individuals. Methodology: Fifty adult individuals having Hb<8.0 gm/dl were prospectively studied as regards their clinical, etiological, hematological profile. Additional tests were done as per clinical requirement. Patients of acute blood loss, thalassemia major, pregnancy and diagnosed case of haematological malignancy were excluded. Stastical Analysis: Descriptive statistical analysis was carried out. Results: Females were found more affected than males, commonest age group was 18-30 years, mostly belonging to lower socio-economoic class. Nine percent patients had hemoglobin of < 4 gm/dl. Commonest cause of severe anemia was nutritional iron deficiency anemia, most common peripheral smear characteristics of anemia was microcytic anemia. Females had higher rate of recurrent anemia and need of blood transfusion. 30-40% patients had non-nutritional etiology and non-communicable co-morbidities of severe anemia.

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Conclusion: Female gender, age between 18-30 years, poor socioeconomic conditions are important risk factors for severe anemia in hospitalised patients at our rural based tertiary care centre. Non nutritional etiologies for severe anemia are also common. Pre-morbid haemoglobin/nutritional status dominate the characteristics of anemia among hospitalised individuals with severe anemia. Diabetes is an important comorbidity.

P-184 Evaluation of the Diastolic Dysfunction of Heart in Type 2 Diabetes Mellitus Patients Parekh Malay, Saboo Bansi, Panchal Dharmendra, Goklani Rutul, Chavda Vipul, Hasnani Dhruvi, Patel Vidisha, Prajapati Akash Dia Care, Ahmedabad Corresponding Email ID: [email protected]

Background & Aims: To study the normotensive asymptomatic type 2 diabetes mellitus patients with diastolic dysfunction of heart and correlate it with glycosylated hemoglobin (HbA1c), duration of diabetes, diabetic retinopathy. Materials & Methods: Asymptomatic normotensive (Blood pressure < 130/80 mm /hg) diabetic patients reported in our clinic were included in this study. They all are evaluate for diastolic dysfunction with clinical history, biochemical investigation and 2-dimensional transthoracic echocardiography. Results: On echocardiographic assessment of 100 patients, 72 cases (72%) had diastolic dysfunction of which 58 cases had impaired relaxation, 8 cases had restricted filling and 6 cases had pseudo normal pattern. Patients who had HbA1c >7.5%, 77.64 % developed diastolic dysfunction which was statistically significant. Diastolic dysfunction was highest in patients age 50-60 years (83.2%) compared to 40-49 years (58.7%) and 25-39 years (47.6%). In our study population 32% had retinopathy of which 91.81 % developed diastolic dysfunction. Diastolic dysfunction had significant correlation seen with duration of diabetes > 5 years. Conclusion: Type 2 Diabetes Mellitus patients have higher frequency of lest ventricular diastolic dysfunction compare to who are free of clinically detectable heart disease. So diastolic dysfunction significantly correlates with patient’s age, duration of diabetes, HbA1c level >7.5 and diabetic complications especially retinopathy.

P-185 Dengue Myocarditis: A Case Report Baman Divyapal, Chaudhari Kaushika, Dabhi Leena AMCMET Medical College And LG Hospital Corresponding Email ID: [email protected]

Dengue, an arboviral disease caused by a flavivirus is transmitted by the Aëdes aegypti mosquito. Dengue virus has four antigenically distinct serotypes (DEN 1, DEN 2,DEN 3, and DEN 4). Dengue may remain asymptomatic

140 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 or manifest as undifferentiated fever (or viral syndromes),dengue fever, dengue shock syndrome (DSS), or denguehaemorrhagic fever (DHF),dengue myocarditis. An increasingnumber of cases of dengue are being reported with atypical presentations as frequent epidemics are occurring. As awareness of this disease is increasing, rare manifestations are also being reported. We present here a case of a twenty three-year-old male with dengue haemorrhagic fever (DHF). Patient developed hypotension and pulmonary oedema that was aetiologically conferred to be myocarditis (based on raised cardiac enzymes and global hypokinesia on echocardiography). Patient improved clinically with resolution of cardiac dysfunction with supportive management.

P-201 A Case Report of Takayasu Arterits Presented as Aortic Regurgitation Patel Urvi, Naik Kamalchandra, Patel Dipika Department of General Medicine, Surat Municipal Institute of Medical Education and Research Corresponding Email ID: [email protected]

Takayasu arteritis also known as “pulseless disease” is a rare, systemic, inflammatory large vessel vasculitis of unknown etiology most commonly affecting female of child bearing age group. It is characterized by strong prelidection for aortic arch and its branches, leading to stenosis and aneurysms. Presentation is with constitutional symptoms preceding the clinical manifestation due to arterial involvement. A case of 26 year old hindu female admitted with complain of pedal oedema and progressive dyspnoea on exertion found to have diastolic murmur with hypertension with wide pulse pressure and heaving apex. Chest x-ray suggestive of soft tissue opacity in left paraspinal region at the level of T4 to T8 vertebra causing widening of superior mediastinum through which hilum is visible, most likely aortic aneurysm. CT angiogram suggestive of fusiform dilation of distal arch of aorta, multiple saccular aneurysm arising from descending thoracic aorta with thrombus, hypertrophy of left ventricular wall, marked luminal narrowing of left renal artery. 2D echo- moderate to severe aortic regurgitation, dilated left ventricle, left ventricular hypertrophy,LVEF-50-55%.ESR- 100. A diagnosis of Takayasu arteritis was made based on ACR Criteria and patient was started on glucocorticoid and improved clinically . An uncommon case of 26 year old female with symptomatic presentation of aortic regurgitation on detailed investigation of laboratory tests and imagings lead to identification of takayasu Arteritis as underlying etiology .Takayasu arteritis should be considered as a differential diagnosis for young Asian females presenting with valvular etiologies.

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P-202 Unusual Presentation of Adenocarcinoma Lung Presenting as Non-resolving Pneumonia Koyani Brijesh, Vithalani Kamlesh Department of Respiratory Medicine, PDU Medical College, Rajkot Corresponding Email ID: [email protected]

Introduction: Non resolving Pneumonia is defined as a slow or delayed resolution of clinical symptoms despite adequate course of antibiotic therapy. This case highlights a noninfectious cause that mimic infectious pneumonia. Case Report: A 42-year-old female patient came to department with 4 to 6 weeks history of fever, cough, chest pain and weight loss. She had already taken antibiotics from private clinic. Patient had similar episode of pneumonia 8 months back & treated with Antibiotics. Examination: Patient was hemodynamically stable, febrile, digital clubbing present. On Auscultation reduced breath sound on left inter and infra scapular region. Investigations and Management: CXR demonstrated left middle Lower zone infiltrates with blunting of left CP Angle. CECT showed multifocal infective consolidation in left lung with enlarged mediastinal lymph nodes overall findings suggested possibility of atypical / fungal pneumonitis or tuberculosis with endobronchial spread of infection. Video bronchoscopy done at earlier institute showed MRSA in BAL culture, gene expert was negative for M.TB, No malignant cells in cytology. Initial differential diagnosis were include BOOP (Bronchiolitis obliterans organizing pneumonia) or Broncho Alveolar Malignancy. Patient underwent CT guided lung biopsy which showed Adenocarcinoma with lepidic pattern. Patient was referred to oncologist. She is now on chemotherapy. Conclusion: Patients with persistent symptoms and pulmonary infiltrates, despite higher antibiotics require diagnostic re-evaluation and the clinician should include lung cancer as a differential diagnosis. Careful assessment and timely interventions could lead to early therapeutic intervention.

P-203 Guillain Barre Syndrome and Acute Hepatitis E: A Rare Case Report Patel Ravi, Naik Kamalchandra, Patel Dipika Department of General Medicine, Surat Municipal Institute of Medical Education and Research Corresponding Email ID: [email protected]

Introduction: Guillain-Barré syndrome (GBS) is an autoimmune, acute polyradiculoneuropathy. Approximately 70% of cases of GBS occur 1–3 weeks after an acute infectious process, usually respiratory or gastrointestinal.GBS are preceded by infection with Campylobacter jejuni. A similar proportion is preceded by

142 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 a human herpes virus infection, often CMV or Epstein-Barr virus. Other viruses (e.g., HIV, hepatitis E, Zika) and also Mycoplasma pneumonia. Hepatitis E virus (HEV) infection, one of the most common causes of acute viral hepatitis. In symptomatic patients, HEV can cause fulminant acute hepatitis, fibrosis, & cirrhosis.Numerous extra-hepatic manifestations, including many neurological illnesses, are associated with acute or chronic hepatitis E Case Report: A 30 years old male presented with jaundice for 5days with anorexia and abdominal pain.After 3 days he developed bilateral lower limb weakness which was symmetrical with normal upper limb, cranial nerve,and higher function.on examination patient has icterus.On abdominal examination, there is no ascites or organomegaly with normal cardiovascular and respiratory system.there is no edema or stigmata of chronic liver disease.On CNS examination power 1/5in both lower limb and 5/5 in both upper limb.SBC(single breath count ) on admission was 18.gradually power in upper limb became 3+/5(decreased) and SBC decreased to 12 by day 3 .LAB DATA : normal haemogram with SGPT-520u/l(n;o-55u/l)& SGOT- 661u/l.& total bilirubin 8.4 mg/dl with direct billirubin 6.6mg/dl.Viral marker like HIV,HBsAg,HCV non reactive but REACTIVE for IgM anti HEV (ELISA method).CSF syggestive of 62 mg% protein, 55 mg% sugar , total cells -15 with 30% polymorph &70% lymphocytes.NCV(nerve conduction study) suggestive of acute motor sensory generalised demyelinating and axonal polyradiculopathy. LFT improved by day 4 with SGPT of 70u/l with total bilirubin 4.2mg/dl and direct billirubin 2.5mg/dl. Conclusion: we suspected GBS by clinical symptoms and confirmed by NCV study , it may follow unusual infection like HEPATITIS E in our case and managed by plasmapharesis and power was improved in both upper limb(4+/5) and lower limb(3+/5) by 5th cycle of plasmapharesis.

P-204 A Short Case Study of Peripartum Cardiomyopathy at Tertiary Care Centre Shah Harshil, Kataria Yogesh Department of General Medicine, P.D.U. Medical College, Rajkot Corresponding Email ID: [email protected]

Peripartum cardiomyopathy is the most common cardiomyopathy in pregnancy. Its defined as an idiopathic cardiomyopathy that presents with heart failure secondary to left ventricular (LV) systolic dysfunction towards the end of pregnancy or in the months after delivery, in the absence of any other cause of heart failure. This is short case study of eight patients admitted in the Department of Gynecology and Obstetrics at Civil Hospital, Rajkot in third trimester of pregnancy with labor pain. These all patients who had Labor pain with nearby 9 months of amenorrhea had developed breathing difficulty on minimal exertion to at rest within duration of 3 to 4 days and for that physician opinion was done. All patient underwent for history, physical examination, routine investigations and two-dimensional echocardiography and findings were found suggestive of peripartum cardiomyopathy without any structural abnormality and valvular heart disease. With treatment patients were improved and normal vaginal delivery were carried out and follow up after 3 months

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2D ECHO shows partial improvement and after 6 months 2D echo shows near to full recovery among most of patients. Results: From 8 cases, most of patients (6 cases) had age more than 35 years, whereas 5 cases were multiparous (more than 2 pregnancies) and tow cases had severe anemia and two cases had cardiogenic shock during the course which was recovered with inotropic therapy and monitoring. Conclusion: Early diagnosis of Peripartum cardiomyopathy has crucial importance to save life of mother and fetus. Diagnosis of PPCM with helps to determine course of further management plan of obstetrician and physician both.

P-205 Dengue Encephalitis: No More a Rare Phenomenon, Increasing Evidence for Dengue Virus Neurotropism Chandrasekharan Arjun, Vadhvana Sneha Shri M.P Shah Government Medical College, Jamnagar Corresponding Email ID: [email protected]

Dengue fever has a variable clinical spectrum ranging from simple febrile illness or even asymptomatic state to life threatening Dengue haemorrhagic fever and Dengue shock syndrome. Among all the major complications, neurological complications are rare in Dengue fever. It can be encephalopathy, meningitis, encephalitis, stroke and GBS. Among which, encephalopathy has been reported most commonly and is usually associated with multiorgan dysfunction that occurs in severe Dengue infection where acute liver and kidney failure with shock leads to indirect brain damage. Dengue virus is classically taught to be a non-neurotropic virus, but recent researches gives an increasing evidence for Dengue virus neurotropism, suggesting that there may be factor of direct viral encephalitis. Considering the recent Dengue outbreak, we came across many cases of Dengue fever with neurological manifestations, out of which 3 cases were diagnosed as Dengue encephalitis with help of MRI, positive Dengue serological markers (NS1 or IgM) and CSF study (routine analysis and positive Dengue immunological markers). These patients were treated conservatively and were discharged with no residual neurological deficits. Understanding the pathophysiology of Dengue encephalitis is crucial in its management and should always considered as a differential diagnosis in cases of fever with altered sensorium or convulsions especially in parts of our country where incidence of Dengue fever is high.

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P-206 A Case of Adult Onset Still’s Disease Ramani Rajesh, Trivedi Arti Department of Medicine, P.D.U. Medical College & Hospital, Rajkot, India Corresponding Email ID: [email protected]

We report the case of 33 year old male who presented with high grade fever, joint pain(knees & shoulder), pain abdomen, itching for last 15 days. On examination his liver was palpable along with erythema over trunk and arms. 1-2 pea sized lymphnodes on right side of the neck present. Respiratory, cardiovascular & CNS findings unremarkable. His CBC showed mild anemia along with neutrophilic leukocytosis and elevation of ESR & CRP. LFT, KFT, Thyroid profile, Lipid profile, RBS, urine routine, HbsAg, HIV, HCV, VDRL were normal. RA factor & ANA were negative, but his S.Ferritin level was significantly elevated. Blood and urine cultures were sterile on multiple occasions. FNAC of lymphnodes showed reactive inflammatory changes. X-ray chest was normal and USG showed hepatomegaly. CT neck showed sub centimeter right level 2 lymphnodes. CT(Abdomen+Pelvis) revealed enlarged liver with few sub centimeter mesenteric lymphnodes. The patient was diagnosed with Adult onset Still’s disease as per diagnostic major and minor criteria’s.

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P-207 Body Composition, Physical Activity, Lipid Profile and Hs-CRP in Diabetic Patients Sonkar Chetankumar, Bhattacharya Amalkumar Department of Medicine, Parul Sevashram Hospital, Vadodara, Gujarat, India Corresponding Email ID: [email protected]

Prevalence of cardiovascular disease is on higher side in both developed & developing countries in all income groups and in both genders in diabetes. Apart from traditional risk factors, Hs-CRP a non specific marker of inflammation as associated with cardiovascular risk and knowledge may help in direct preventive efforts. Aim and Objectives: This study is to prevalence of obesity, dyslipidemia , hypertension, hs CRP and physical activity and its interrelationship in diabetes. Material and Methods: 30 participants from Parul Sevashram Hospital, Vadodara having diabetes were enrolled. Diseases which can interfere with results were excluded. Dietary, physical activity and life type pattern assessed. FBS, lipids and CRP-hs done. Result: Mean Ht, Wt, WC, WHR, WHtR were: 163 cm, 67 kg, 84 cm, 0.84, 0.85 respectively, mean BMI: 25 kg/m2. 2/3 of participants were overweight & obese. For WC, WHR, WHtR: 44%, 32% and 63% were found to be at risk for cardiovascular disease respectively. Abdominal obesity were found higher in female, whereas hypertension in male. 5% had abnormal LDL, 51% had low HDL. According to hs CRP: 38% were at moderate risk, 24% at higher risk. 95% were sedentary, 5% moderate activity category. No correlation between physical activity level, anthropometric measurement, lipids and hs-CRP. Conclusion: WHtR is a simple, easy, accurate and age independent index with high applicability to screening overweight and obesity in diabetes. Abdominal obesity (in terms of WHtR) can be regarded as the best predictor of cardiovascular diseases followed by WC and BMI. Keywords: Cardiovascular, Inflammation, Predictor, Prevalence.

P-208 A Case Report of Wilson’s Disease Ramani Rajesh, Trivedi Arti Department of Medicine, P.D.U. Medical College & Hospital, Rajkot, India Corresponding Email ID: [email protected]

Wilson disease is a rare autosomal recessive but major metabolic disorder involving copper metabolism and is primarily involve the liver and brain. Hepato-lenticular degeneration (Wilson disease) occurs more frequency in male, is usually detected during adolescence, half of the patients have onset before 16 years of age. 40% patients first show hepatic dysfunction, remaining are present with neuro-psychiatric disorder. Incidence rate is 1 in 40000 individuals. 27 year old male patient presented with complain of low grade fever since 3 month and difficulty in walking since 15 days, slow stepping gate, resting tremor in right hand thumb and index finger with irrelevant talking since 3 days with past history of chronic liver disease .On examination pallor, hepatomegaly and splenomegaly

146 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 present. Neurological examination showed hypertonia and resting coarse tremors. On further evaluation 24 hours urinary copper is 334 mcg / 24 hours , serum ceruloplasmin is 4.73 mg/dL and Hb 6.5gm% . Ophthalmoscopic examination revealed Kayser-Fleischer rings in both eyes. Ultrasonography of abdomen showed liver parenchymal disease, splenomegaly, dilated splenic vein suggestive of portal hypertension. Upper gastrointestinal endoscopy showed large esophageal varices. A diagnosis of Wilson’s disease with portal hypertension and iron deficiency anemia was made on the basis of serum ceruloplasmin level and 24 hour urine copper level. Patient was treated with chelating agent penicillamine and zinc and propranolol and other medications given on basis of symptoms. Keywords: Wilson’s disease , Neuro-psychiatric disorder , kayser-fleischer ring , 24 hours urinary copper, serum ceruloplasmin level.

P-209 A Case Report of Non responding Immune Thrombocytopenic Purpura in Pregnancy Sakariya Nirav, Srivastav Vipul, Patel Dipika, Patel Mohnish Department of General Medicine, Surat Municipal Institute of Medical Education and Research Corresponding Email ID: [email protected]

Introduction: Immune thrombocytopenic purpura (also called idiopathic thrombocytopenic purpura) is an acquired autoimmune disorder defined by a low platelet count secondary to accelerated platelet destruction or inhibition of platelet release from the megakaryocyte. ITP is usually characterized by low platelet count with an otherwise normal peripheral blood smear associated with mucocutaneous bleeding in the form of petechiae, purpura, retinal haemorrhages, heavy menstruation and life-threatening bleeding may also occur. ITP is termed secondary if it is associated with an underlying disorder like autoimmune disorder particularly systemic lupus erythematosus and infection such as HIV and Hepatitis C. Case Report: A 34 years old female with 8 months of amenorrhoea, bilateral pedal oedema for 10 days and purpura over both arms and over both thighs for 10 days. She was also having pregnancy induced hypertension. Her systemic examination was normal and lab reports were as following; Hb- 12.5 , WBC – 9,700 and Platelets – 7000 with large platelets noted in peripheral blood smear. RFT, LFT and PT,INR,aPTT - normal S.ANA – negative. HIV and HCV - negative. Her bone marrow examination was normal. Fundus examination was normal too. She was started on iv steroids(dexamethasone 40mg for 4 days) and even after 10 days was not responding so she was put on IV immunoglobulin(1 g/kg) and azathioprine(200mg BD) therapy and were transfused 2 units of SDP as she developed complain of bleeding PV. She didn’t respond to this treatment too and then she was given a thrombopoietin analogue – Romiplostim 250 mg s.c. once a week. To which she responded and her platelet count increased up to 47000.

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Conclusion: A 34 years old, pregnant female was diagnosed of having Idiopathic Thrombocytopenic Purpura which was not responding to initial therapy of steroids and IV immunoglobulins, finally responded to thrombopoietin analogue.

P-210 A Case of Spontaneous Coronary Artery Dissection Solanki Parth, Ayoleyi Omojoye, Thubelihle Koffi, Roy Rajesh Department of Cardiology, Parul Sevashram Hospital, Vadodara, Gujarat, India Corresponding Email ID: [email protected]

Spontaneous coronary artery dissection is no doubt one of the fastest but yet silent cardiac killers. It has emerged as an important cause of coronary syndrome, myocardial infarction and sudden death. Spontaneous Coronary Artery Dissection (SCAD) is a non-iatrogenic, non-traumatic dissection of an epicardial coronary artery and /or intramural hematoma formation which leads to partial or complete occlusion of the coronary artery. The arterial wall has three layers the tunica adventitia, tunica media and tunica intima. When a tear occurs in the media, blood is able to pass from it into the media becoming trapped and bulge inward. The trigger is thought to be either an intimal tear or bleeding from the vasa vasorum resulting in intramural hematoma. Pressure driven expansion of the hematoma causes propagation of the dissection of the true lumen and a thrombus containing false lumen. SCAD occurs in patients with few or no cardiovascular risk. Patients with SCAD are usually healthy .The mean age for SCAD in women is reported as 42 to 53 years, while for men it occurs at any age. Clinical case study: 57 year male ex-smoker was brought to the emergency department of PSH with c/o Headache - 6 years Anxiety - 6 years Unstable angina - 5 days Left sided weakness Past history: 1987 (30 years) patient had appendectomy 2008 (10 years) patient had stroke (hemiparesis) O/E: Patient was conscious and well oriented Pulse: 84 bpm' BP 120/70mmHG, SpO2 99% at room air Investigations & findings: Lab report: All lab test were normal, Troponin- negative CT scan: Chronic ischemic infarct noted involving left sided high posterior parietal lobe, parenchymal and insular cortex. Echo: EF 40%, No RWMA, mild LV hypertrophy, RV systolic dysfunction. Coronary angiography: Showed right dominant circulation, LMCA normal, LAD showed diffuse disease in proximal part up to 80 %, to

148 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 mid LAD, ectasia, severe stenosis, and also showed extended dissection. LCX showed long dissection extending to major OM3, LCX showed 90 % lesion in mid part, RCA showed mild disease.

Treatment: Patient was placed on aspirin, clopidogrel, nikoran and beta blockers followed by levofloxacin. Furtheron patient underwent CABG and was placed on vasopressors and heparin treatment. CABG report: LIMA - RADIAL - Y, LIMA TO LAD GRAFTING, RADIAL TO OM GRAFTING Classification of Spontaneous Coronary Artery Dissection: Type 1: It has a classic appearance of contrast dye staining of arterial wall with multiple radiolucent lumen. There is dye hold up in the false lumen after the clearance of the true lumen (29% to 48%). Type 2: Diffuse smooth and long stenosis (typically>20 -30mm) that may vary from mild stenosis to complete occlusion (52% - 69%). Type 3: Has focal or tubular stenosis that mimics atherosclerosis, typically requiring intracoronary imaging to differentiate the cause (2% - 3. 9%) and prove the presence of intramural hematoma or double lumen. Although any artery can be affected by SCAD, the LAD is mostly affected in 32% - 42% of the cases. In terms of territories the LAD, diagonal and septal branches are affected in 45 – 61%of the cases. The circumflex, ramus and obtuse marginal in 15 – 45% of cases. The RCA, acute marginal, and post lateral artery is affected in up to 4% of cases of multi vessel SCAD can occur in 9 – 25% of cases. Conditions associated with the rising of SCAD: Predisposing factors include – fibro muscular dysplasia, emotional stressors, extreme high blood pressure, illegal drug use (smoking, cocaine etc.) ,extreme physical exercise such as aerobics, blood vessel problems( e.g. lupus and polyarteras nodosa) that cause inflammation of the blood vessel, genetic connective tissue disorder (vascular Ehlers-Danlos syndrome and Marfan syndrome.

Management of SCAD: Management depends on the patient's clinical presentation, hemodynamic stability, coronary out flow and the affected coronary artery. This is based on observations that SCAD vessels tend to heal and intramural hematomas resolve over time. The time course for healing typically occurs by one month. For patients with hemodynamic instability and malignant arrhythmias, revascularization should strongly be considered.

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Revascularization can either be PCI or CABG. Conservative medical therapy with low dose aspirin for at least one year, beta blockers (if tolerated) and heart failure guideline – directed medical therapy is recommended. Use of dual antiplatelet agents, heparin and beta blockers to preserve potency of the true lumen and prevent thrombotic occlusion. Glycoprotein IIb/IIIa inhibitor have also been used without complications. Systemic hypertension and coronary artery tortuosity have been associated with recurrent events. Reoccurrence rate is 30%, because of the high rate of occurrence most patient end up having ischemic cardiomyopathy. Discussion: In our case we had a case of LAD and LCX dissection along with severely diseased LAD and LCX vessels. Patients also had past history of large cerebral infarct. Conclusion: Such cases are rare phenomenon and if the patient is symptomatic and having diseased vessels, the patient should undergo revascularization procedure.

P-211 Awareness and Beliefs Regarding Renal Replacement Therapy(RRT) and Assessment of Quality of Life(QoL) in Chronic Kidney Disease(CKD) Patients Patel Prins, Shah Maulin, Pandya Himanshu Department of General Medicine, Pramukhswami Medical College, Karamsad, Gujarat, India Corresponding Email ID: [email protected]

Introduction: Earlier recognition of CKD could slow progression, prevent complications, and reduce cardiovascular-related outcomes. However, current estimates of CKD awareness indicate that both patient and provider level awareness remain unacceptably low. There is need to educate patients in order to enable them to participate in making appropriate choices for all therapeutic options. CKD and the methods of its treatment play an important role in shaping the QoL of patients receiving dialysis. As a result, kidney failure causes many limitations in patient's physical, mental, and social activities. Aim: To study the awareness and beliefs regarding renal replacement therapy and the quality of life in CKD patients. Methods: Fifty patients of CDK5D were included, who were visiting dialysis centre of Shree Krishna Hospital. QoL was measured with Kidney Disease Quality of Life(KDQOL) questionnaires, short form, version 1.3 (KDQOL- SFTM 1.3). For awareness and Beliefs, A self administered questionnaire was given to 50 patients. The questionnaire has 25 questions regarding basic knowledge about chronic kidney disease, RRT, dietary modification in CKD, legislation regarding renal replacement therapy. Results: Majority of the patients were aware about the haemodialysis as treatment of choice. Ninety two percent of the patients were not aware about Continuous Ambulatory Peritoneal Dialysis (CAPD) and automated peritoneal dialysis. Fifty tow percent of the participants were aware about the organ transplantation. Seventy eight percent of the participants did not have knowledge about medical management in early stages of CKD. Ninety percent of the patients were in follow up with nephrologist or physician. Eighty eight percent of people had heard about RRT through a hospital or from a doctor and 12 % of the people had knowledge about RRT through a Internet / online resource. Patients had good deal of knowledge regarding dietary modification. Assessment of QoL showed poor outcome in all fields in CKD5D patients. There is

150 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 negative correlation between age and Physical composite score and positive correlation between haemoglobin and serum albumin with quality of life. Conclusion: This suggest awareness is low regarding CKD and RRT except dietary management and there is profound impact CKD has on HRQOL.

P-212 Bronchogenic Carcinoma Under Cap of Bronchial Asthma Chavada Surbhi, Gambhir Rahul Department of General Medicine, PDU Medical College, Rajkot, Gujarat Corresponding Email ID: [email protected]

Introduction: Bronchogenic carcinoma is a malignant neoplasm of lung, arising from epithelium of bronchus. This case reveals underdiagnosed case of bronchogenic carcinoma, that repeatedly precipitates bronchial asthma. Case Report: A 40year female, known case of bronchial asthma ,presented to the department with acute exacerbation, associated with cough with expectoration , low grade fever, dull aching chest pain ,anorexia and weight loss since last 2 months with history of repeated hospitalization for similar complaint since last 1year. Examination: Patient was hemodynamically stable. Digital Clubbing present. No any palpable lymphnodes. On R\S auscultation, bilateral extensive wheezing present. Investigations & Management: CXR (PA) view was normal. CXR (AP) view demonstrated left lower zone solitary lung nodule. Sputum AFB and GeneXpert were negative. Culture for bacterial and fungal hyphae were negative. Serum Absolute Eosinophil Count, Serum Totla IgE, Serum IgE specific for aspergillus were raised. Bronchoalveolar Lavage (BAL) culture positive for klebsiella pneumonia and BAL cytology was negative for malignant cells.Overall findings suggested possibility of ABPA (Allergic Bronchopulmonary Aspergillosis),atypical/fungal pneumonitis.Patient underwent USG Chest suggestive of left lower zone posterior aspect 23x25mm sized solitary lesion.USG Neck suggestive of bilateral enlarged supraclavicular lymphnodes. CECT Thorax-Abdomen suggestive of left lung bronchogenic carcinoma with metastatic mediastinal and supraclavicular lymphadenopathy with renal,liver and bony secondaries. CT guided Lung Biopsy was performed which revealed adenocarcinoma lung.Patient referred to oncologist for further management. Conclusion: Patient with persistent symptoms,despite adequate medical therapy for asthma requires diagnostic re-evaluation for early therapeutic interventions.

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P-213 Epithelioid Sarcoma Misdiagnosed as Non-Small Cell Carcinoma Patel Umang, Chauhan J. Government Medical College & SSG Hospital, Vadodara, Gujarat, India. Corresponding Email ID: [email protected]

Introduction: Epithelioid sarcoma (ES) is a rare, high-grade, slow growing malignancy that represents the most common primary soft tissue sarcoma. It is seen less than 1% of all soft tissue tumors. ES most commonly strikes young adults. The disease has a tendency to develop local recurrences and metastasis. Because of its epithelial and mesenchymal differentiation, this tumor was often mistaken for chronic inflammatory processes, necrotizing granulomas and various fibrohistiocytic tumors. Case Report: A 39yrs old female known case of ES in left leg presented with c/o right sided chest pain, Breathlessness since 1 month. On respiratory examination ,air entry decreased in right infrascapular area .H/O Excision of left popliteal swelling and radiotherapy taken before 1 year. Chest radiograph revealed homogenous radio-opacity in right mid and lower zone. Sputum for AFB staining and gram stain with culture sensitivity was performed which did not grow any organism. CECT Chest was done S/O soft density lesion 11.7x10x11 cm size in right side right lower lobe likely malignant neoplastic etiology? Then ct guided lung biopsy was done, HPE S/O non-small cell carcinoma but IHC s/o Epithelioid Sarcoma. Discussion: The lungs are the principal site of metastatic disease. Both local recurrence and regional nodal metastases resulted in increased distant metastatic disease, thus decreasing overall survival. Conclusion: This malignancy can easily be mistaken for a benign process due to its often innocuous presentation. Because of its potential for aggressive behavior, clinicians must be aware of the presenting behavior of ES in order to avoid misdiagnosis.

P-214 A Study Correlating Left Main Size by IVUS (Intravascular Ultrasound) v/s QCA (Quantitative Coronary Angiography) in Indian Population: A Tertiary Care Centre Experience Vora Parshva, Goel Pravin, Khanna Roopali, Sudeepkumar, Garg Naveen, Tewari Satyendra, Kapoor Aditya Department of Cardiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UP, India Corresponding Email ID: [email protected]

Background: There is very limited data regarding coronary artery diameter assessment using IVUS and QCA techniques in Asian-Indian population1. Some older studies have shown Asian-Indians to be having relatively smaller coronary artery diameter compared to Caucasians, which might be the cause for an increased incidence of coronary artery disease (CAD) in this population1. The role of correct vessel sizing plays a crucial role in LM intervention and even more than in any other intervention. We therefore tried to assess LM body,

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Ostio-Proximal LAD and Ostio-Proximal LCX coronary artery diameters in atheroma free segments by IVUS and QCA in Indian patients and look for a correlation between two techniques. Materials and Methods: We retrospectively analyzed data of patients who underwent PCI with IVUS guidance in a tertiary care centre SGPGIMS, Lucknow, India from January 2008 to December 2017, in which LM was intervened and sizes of Left Main body, Ostio-Proximal LAD artery and Ostio-Proximal LCX were analyzed in 186, 177 and 44 cases respectively using both IVUS and QCA. IVUS was done in all above mentioned patients using ilab (Boston Scientific, 20 MHz Atlantis SR Pro), and pullback from disease free segment distal to the stenotic lesion up to the proximal most disease free segment in Left main artery, Ostio-Proximal LAD and Ostio- Proximal LCX artery was done and measurements were done offline with Qivus software(Medic medical imaging). Angiographically the dimensions of above mentioned coronary arteries at same sites were measured using standard quality control analysis(QCA) software in two orthogonal views. Measurements were uniformly taken in diastole, in the disease free segment and the widest dimension in each segment was analyzed. Patients with sub-optimal images/measurements by IVUS and QCA were excluded from the study. Conventional risk factors were also assessed. Mean diameter of Left Main body, Ostio-Proximal LAD and Ostio-Proximal LCX were measured and diameters obtained by two techniques were compared. Results: Left Main, Ostio-Proximal LAD and Ostio-Proximal LCX were analyzed in 186, 177 and 44 patients respectively who underwent PCI under IVUS guidance. In all three LM, LAD and LCX groups, majority patients were males (86%), mean age of 57.6+9.6years, mean BMI was 24.3+3.6 kg/m2, diabetics were 35%, hypertensive were (51%), and 70% had stable coronary artery disease. Mean diameter assessed by IVUS was for- Left main body (4.33+0.32 mm), Ostio-Proximal LAD(3.61+0.21 mm),Ostio-Proximal LCX (3.31+0.16mm). Mean diameter by QCA measured at same site for LM body (3.89+0.25 mm), Ostio-Proximal LAD (3.36+0.28 mm), Ostio-Proximal LCX (2.85+0.27 mm). Plotting the two values on a scatter plot showed a correlation between the two techniques in an equation of straight line which was for Left Main Y=1.68 + o.69* X (correlation r=0.545), Ostio-Proximal LAD: Y=1.91+0.53*X (correlation r=0.748), and for Ostio-Proximal LCX Y=1.93+ 0.49*X (correlation r=0.844). There was no significant difference in mean coronary artery diameter between different subgroups. Mean coronary artery diameter was larger in males as compared to females with no statistically significant difference. Conclusion: We conclude that Left Main, Ostio-Proximal LAD and Ostio-Proximal LCX vessels sizes are truly underestimated on angiography and could be correlated to true size (IVUS based) using a straight line equation derived from our study. Keywords: LM- Left Main, LAD- Left Anterior Descending, LCX- Left Circumflex, IVUS- Intravascular Ultrasound, QCA- Quantitative Coronary Angiography, PCI- Percutaneous Coronary Intervention, CAD- Coronary Artery Disease

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P-215 Empirical AKT in Pleural Effusion, How much Reliable ? Nayee Chirag, Chauhan J Government Medical College & SSG Hospital, Vadodara, Gujarat, India Corresponding Email ID: [email protected]

Introduction: Pleural effusion is an accumulation of fluid in the pleural space, indicates an imbalance between pleural fluid formation and removal. Malignant pleural effusion is one of the leading cause of exudative effusion. Studies have demonstrated that 42-77% of exudative pleural effusion are secondary to malignancy. Case Report: A 68 years old male, chronic smoker, presented with complaints of dry cough, right sided pleuritic chest pain. Patient is on AKT since 2 month from outside for pleural effusion. On examination having grade I clubbing, diminished chest movements on right side. Chest x ray suggestive of right sided pleural effusion, USG guided therapeutic tapping done and sent for biochemical and cytological evaluation. After rapid filling, CECT chest was done which s/o infection but pleural fluid biochemical examination revealed lymphocytic predominance with high protein, low glucose and borderline ADA, highly suspicious for malignancy and finally cytology s/o Adenocarcinoma. Discussion: lung cancer is the most common metastatic tumour to the pleura in men and breast cancer in women. Together, both malignancies account for 50 to 65% of all malignant effusion. In our study, pleural fluid biochemical, cell counts and cytology give sufficient information for diagnosis. A cytological evaluation can confirm the presence of malignant pleural effusion in 40-87 % cases. Conclusion: Pleural fluid analysis for biochemical examination and cytology should continue to be the first line of investigation in patients presenting with pleural effusion. It is reasonably safe procedure that shows reasonably good sensitivity and specificity in diagnosing primary as well as metastatic pleural malignancies

P-216 A Case Presentation of Female Patient with First Time Diagnose Hemophilia A Sailor Tejas, Gadhvicharan S. Department Of Medicine, P.D.U. Medical College & Hospital, Rajkot. Corresponding Email ID: [email protected]

Introduction: Hemophilia A (HA) results from the partial or complete deficiency of functional factor VIII (FVIII) protein caused by a wide range of heterogeneous mutations in the factor 8 (F8) gene. Being an Xlinked recessive disorder, females are generally not affected, although they can be carriers of this disorder. A classical female hemophilia is possible only when a carrier female marries a hemophilic male & Few other case of homozygous female HA are mainly due to de novo mutations in one or both the X chromosomes. Case Report: A 22 year old female patient Named Nitaben presented with chief complaints of black colour stool since 1 day & blood in vomiting 2-3 episode ,with past history of uncontrolled bleeding during childhood while hit by cow and on and off joint swelling followed by minor trauma which was not concert by her parents with family H/O having similar complain in past to her two male siblings and with no such H/O to both her parents

154 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 and her female sibling. On clinical examination patient having tachycardia with feeble pulse, mild pallor, no icterus, clubbing, cyanosis,, Normal RS, CVS, & CNS examination, P/A Soft, Mild tenderness + in epigastrium region, no hepatosplenomegaly & no ascites. Initially Patient managed conservatively, RT- RT lavage with cold water done, lavage fluids contains blood mixed with fluid with few clots. Trenexamic acid for bleeding control, 1unit of PCV transfused for correction on Anaemia. Meanwhile her investigations collected showing Hb. 6.5 with Normal TC, platelets, normal bleeding and clotting, PT/INR suggestive of isolated raised aPTT (58.3 sec), Normal Ultrasound KUB & CXR PA view. Then Factor VIII level done suggestive of 10% with rest investigation within normal limit. Patient was given Factor VIII 1000 i.u and then RT- aspirate showing clear fluid on 2nd day and 1 unit PCV transfused on 2nd day , RT was removed and work up done for Hemophilia pedigree analysis, factor VIII level of Patents then Karyotypic of Patient done but all remains inconclusive then patient discharged with stable condition. Conclusion: Female Patients presenting with bleeding diathesis or on and off joint swelling after minor trauma having family history of Haemophilia needs to be rule out for Haemophilia A.

P-217 Case Study of Two Successful Pregnancies in Sheehan Syndrome Patel Kaivan, Patel Vivek Observeship Department of Medicine, Ahmedabad, India. Corresponding Email ID: [email protected]

Sheehan’s Syndrome (SS) is Postpartum Hypopituitarism which is caused by the Ischemic Necrosis of the Pituitary gland. It is usually the result of severe Hypotension or Shock caused by massive Hemorrhage during or after delivery. Patients with this disorder have varying degrees of Anterior Pituitary Hormone Deficiency. In rare cases it may occur in Posterior Pituitary. Its frequency is Decreasing worldwide and it is a rare case of Hypopituitarism in developed countries owing to advances in obstetric care. However, it is still frequent in the Underdeveloped and Developing countries like India, especially the Northern states. As this disorder evolves slowly, it is often diagnosed late. History of Postpartum Hemorrhage, cessation of menses and failure to lactate are some important clues to diagnosis. Early diagnosis and appropriate treatment are important for the reduction in the Mortality and Morbidity of the patients. We report an unusual case of a 34-year-old female who had Two normal deliveries while her underlying Sheehan Syndrome remained undiagnosed. The woman presented Hypothyroidism and severe headaches during her visit to our clinic and was later found to be suffering from Sheehan’s Syndrome. She was diagnosed as having Sheehan’s syndrome by clinical manifestations, laboratory tests and MRI. Detailed Endocrinological studies were performed after patient complained of Amenorrhea (failure to have normal periods). In addition to these studies, a critical review of the Literature was undertaken to more clearly define the clinical and laboratory features of Pregnancy in Sheehan's Syndrome. We provide recommendations for diagnosis and management of the disease. Keywords: Sheehan’s syndrome, Agalactia, pituitary necrosis, postpartum hemorrhage, pregnancy

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P-218 Rarest of Rare Cases of Pulmonary Sequestration Chavada Poonam, Pandey A. , Daxini Arvind Department of Pulmonary Medicine, Smimer Hospital, Umarvada, Surat, India Corresponding Email ID: [email protected]

Introduction: Pulmonary sequestration is a mass of pulmonary tissue that does not communicate with the central airway through normal bronchial connection and serves its blood supply via an anomalous systemic artery. It is of two types: intra-lobar and extra-lobar. It contributes around 0.15 to 6.4 percent of all congenital pulmonary malformation. Case Report: A 19 year old female came with complaints of haemoptysis and right side chest pain since 3 years with history of ATT twice and history of VATS guided biopsy from right lung mass which was inconclusive. On Chest X-ray, non-homogenous opacities were found in right hilar region. We had done CT Angiogram which showed that multiple feeders from right internal mammary artery were supplying sequestrated segments of lung. After that we had performed Bronchoscopy, in which, we found only two segments in right upper lobe. Embolisation of two major feeding branches from right internal mammary artery was done. And after Embolisation, patient became asymptomatic. Conclusion: Though Congenital Pulmonary Anomalies are rare, it needs to be ruled out in young adults who present with chronic symptoms and unresolved radiological opacities.

P-219 Cardiovascular Disease in Patients with Chronic Kidney Disease Patel Prashastee, Patel Aditya, Amalkumar Bhattacharya Parul Institute of Medical Science and Research, Vadodara Corresponding Email ID: [email protected]

Introduction: The prevalence of chronic kidney disease (CKD) has been increasing over the years. CKD progresses through stages. Patients are more likely to die due to complications than to progress to end-stage renal disease. The presence of risk factors predisposes this group of patients to premature cardiovascular mortality. Though being a common entity, prevention, diagnosis and treatment of cardiovascular diseases in CKD are mired with controversies. Many of the well-established diagnostic modalities and treatment strategies have not been studied in detail in patients with CKD. Aim: To assess the systolic &diastolic dysfunction in patients of Chronic Kidney Disease (CKD). Methods: Fifty patients with CKD were subjected to two-dimensional and M mode echocardiography for determination of systolic and diastolic dysfunction. All patients were evaluated clinically, biochemically and radiologically and were diagnosed as chronic kidney disease (CKD). The left ventricular ejection fraction (LVEF) and fractional shortening (FS) were taken as measures of left ventricular (LV) systolic function. Diastolic function was determined by measuring E/A ratio by spectral Doppler LV inflow velocity. Echocardiographic findings of hypertensive and normotensive patients were compared.

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Results: Out of 50 patients studied, there were 35 males (70%) and 15 females (30%). Hypertension (60%) was leading cause of CKD. Echocardiography showed that left ventricular hypertrophy (LVH) was present in 74%. Systolic dysfunction as measured by reduced fractional shortening (< 25%) and decreased LVEF (< 50%) was present in 8 % and 12 % respectively. Diastolic dysfunction as denoted by E/A ratio of less than 0.75 or more than 1.8 was present in 60 % of patients. Regional wall motion abnormality (RWMA) was present in 12 %. Pericardial effusion was noted in 14 % of patients. Valvular calcification was noted in 8 % of CKD patients. Mean left ventricular internal diameter in diastole was 41 ± 6 mm. Mean Interventricular septum diameters in systole was11.9 ± 1.21 mm. Mean left atrium diameter was 29 ± 4 mm. Normotensive group was compared to hypertensive group. Statistically significant difference was noted in LVH and E/A ratio in hypertensive group as compared to normotensive group. Conclusion: Patients with hypertensive ESRD had higher prevalence of diastolic and systolic dysfunctions compared to normotensive counterparts.

P-220 Multiple Drugs and Health Consequences in Type 2 Diabetes Mellitus Singh Garima, Upadhyay Aakash, Singh Sunita, Bhattacharya Amalkumar Parul Institute of Medical Sciences and Research, Vadodara Corresponding Email ID:[email protected]

Introduction: Use of more medications than are clinically indicated, or when a medical regimen includes at least one additional medication. Polypharmacy may be unavoidable, given that multiple drug therapy has become the standard of care in most chronic conditions. The comorbidities of diabetes commonly include coronary artery disease, hypertension, dyslipidemia, depression, and coagulopathies, require one or more drugs for adequate control. Diabetes accompanies hypothyroidism, heart failure, and osteoporosis, and the total number of possible medications needed becomes significant. Aim: To find the association between polypharmacy and health consequences in type 2 diabetes mellitus. Methods: 50 patients with multiple drugs (two or more) and morbidity, glycemic control, macrovacular complications, hospitalization, GI disorders, cost of medicine etc studied. History, physical examination, relevant investigation and consequences of drugs studied.. Results: Male to Female: 21:9. Average age: 44 years. Findings were: Hyperglycemia in seen in 34 patients, Hypoglycemia in 2, Retinopathy in 10, Coronary artery disease by ECG & 2D Echo in 12, old myocardial infarction in 3, renal function test abnormality in 6. Stroke in 2, hypertension in 15, dyslipidemia in 13, hypothyroidism in 3 and hospitalization due to any of the above in 5. Conclusions: Despite polypharmacy, patients of diabetes type 2 were associated with increased in morbidity, macrovacular complications and hospitalization to control the disease or its complications. Delicate balance is required to add drugs to control the disease and avoid adverse drug effect. There is a need for critical decision that tilt the balance of benefits in favour of the patients when add on required and to avoid harms in multiple medicines prescribing.

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P-221 Adult Presentation of Dyke-Davidoff-Masson Syndrome: A Case Report Padma Deepika, Sanjay Prakash, Patel Jay Department of Medicine, Smt.B.K Shah Medical Institute & Research Centre, Sumandeep Vidyapeeth, Pipariya, Vadodara. Corresponding Email ID: [email protected]

Dyke-Davidoff-Masson syndrome (DDMS) is a rare neurological disease which is clinically characterized by hemiparesis, seizures, facial asymmetry and mental retardation. The classical radiological features include cerebral hemiatrophy, clavarial thickening, and hyperpneumatisation of the sinuses. This disease is a rare entity and it mainly presents in childhood. Adult presentation of DDMS is unusual. We are reporting a case of 32year old female patient who presented with generalized tonic clonic seizures and rightsided weakness since 8 years. MRI brain suggestive of left sided cerebral hemiatrophy, hyperpneumatisation of left side paranasal sinuses and increase in thickness of left side calvarium. The diagnosis of DDMS was made on clinical findings and radiological features.

P-222 Anesthesia Management of a Patient with Dilated Cardiomyopathy Posted for Proximal Femur Nailing (PFN) using Continuous Epidural Infusion Mehta Rishita, Mehta Jigisha, Desai Jayshri Department of Anesthesiology, SBKS MC and RI, Vadodara Corresponding Email ID: [email protected]

Introduction: Spinal anesthesia which is a standard mode of anesthesia in lower limb surgeries causes profound vasodilatation and fall in blood pressure (BP) due to sympathetic blockade which cannot be effectively compensated in a cardiac compromised patient. Compared to this lumbar epidural anesthesia has better stability as it does not cause rapid fall in BP, reduces intra and post operative myocardial oxygen demand and also decreases myocardial reaction to catecholamine release due to the surgery. Case Report: A 71 years old female presented with history of domestic fall and chief complaints of severe pain in left leg and hip and inability to move the affected limb. Patient was diagnosed with left Intertrochanteric Femur fracture and was posted for Closed Reduction and Internal Fixation (CRIF) and PFN insertion. ECG showed complete Left Bundle Branch Block and Cardiac 2D Echography showed dilated Left ventricle, LVEF 30%, significant Left ventricular dysfunction, Grade II Mitral Regurgitation, mild Tricuspid Regurgitation (RVSP- 40mmHg) and mild Pulmonary Artery Hypertension. After arrival in operation theatre, patient was connected to multichannel monitor and Heart rate, non-invasive measurements of Systolic, Diastolic and Mean Arterial Pressure, continuous ECG and Oxygen Saturation by pulse oximeter (SpO2) was monitored. An 18 gauge venous cannula was secured and intravenous fluid Ringer lactate was started. Patient was premedicated with Inj. Glycopyrrolate 0.004mg/kg i.v. and Inj. Ondansetron 0.1mg/kg i.v. Under all aseptic and antiseptic

158 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 anesthetic precautions Epidural Catheter was inserted at the L3-L4 space. Inj. Levobupivacaine 0.5% 10ml bolus was given after negative aspiration followed by infusion of Inj. Levobupivacaine 0.125% and Inj. Fentanyl 2µg/ml at 4-6ml/hour according to haemodynamic stability. Adequate sensory and motor blockade was achieved. Vitals were stable throughout the surgery. Infusion was continued till 4 hours after the completion of surgery for post operative analgesia. Conclusion: Epidural anesthesia is an ideal method which can safely be used in cardiac patients. Continuous infusion of drugs is a safer option as it prevents the side effects of a larger dose given at one time. Post operative pain relief is also successfully achieved using this method. Key words: Continuous epidural infusion, Dilated Cardiomyopathy.

P-223 Fibromuscular Dysplasia in Young Male: A Rare Case Report Soni Jinit, Dosi Rupal, Rana Himanshu, Ambailya Aniruddh Department of Medicine ,Government Medical College, Vadodara, India Corresponding Email ID: [email protected]

Fibromuscular dysplasia is non inflammatory disorder seen typically in females and predominantly involving medium and large arteries mainly renal, carotid and vertebral arteries. Its Prevalence is very rare. This case is about 16 year old male who presented to us with short history fever with headache for 7 days and decreased vision for 5 days .On examination of vitals, he had blood pressure of 250/120 mm Hg. Fundoscopy revealed changes of Hypertension Retinopathy. Usg Kub with renal Artery Doppler revealed small atrophic left kidney with dampened spectral waveform. After thorough investigations to rule out other causes of hypertension we came to the diagnosis of bilateral renal stenosis secondary to fibromuscular dysplasia. Patient was treated with antihypertensives, following the blood pressure control the vison improved and patient was referred to higher center for renal artery angioplasty. This case report is about the rare variant of fibromuscular dysplasia seen in males. It signifies the importance of keeping Fibromuscular Dysplasia as a Differential Diagnosis in young patients presenting as severe hypertension.

P- 224 Creutzfeldt-Jakob Disease Presenting as Stroke: A Case Report and Systematic Literature Upadhyaya Taniya, Kumawat Dalchand Geetanjali Medical College and Hospital, Department of General Medicine, Udaipur, India Corresponding Email ID: [email protected]

Creutzfeldt-Jakob disease is a rare neurodegenerative disorder of unknown etiology that causes rapidly progressive dementia. This disease is uniformly fatal and most patients die within 12 months. Clinical findings include myoclonus, visual disturbances, and cerebellar and pyramidal/extrapyramidal signs in addition to rapidly progressive cognitive and functional impairment. Ten percent of cases may present atypically, both

159 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 symptomatically and in respect to initial investigations. We present case of 65-year-old woman, a known case of Type 2 Diabetes and Hypertension who presented with left sided hemiparesis; initial MRI Brain with Angiography was suggestive of small acute infarct of right caudate nucleus. Following failure of medical management and rapidly progressive symptoms of behavioral disturbances, memory loss, bilateral pyramidal signs, left side hemianopia and myoclonic jerks, repeat MRI Brain showed bilateral caudate nucleus diffusion restriction suggestive of Creutzfeldt-Jacob disease. CJD develops primarily within a population in whom stroke risk factors are common and represents a rare but important stroke mimic. Negative vascular imaging in elderly patients with apparent acute stroke syndromes should prompt diagnostic review including consideration of prion diseases.

P-225 Nutritional Assessment with Diabetes Mellitus Rana Komal, Upadhyay Aakash, Bhattacharya Amakumar Parul Institute of Medical Science and Research, Vadodara Corresponding Email ID: [email protected]

Introduction: Diabetes is a chronic illness that requires a comprehensive and holistic approach to prevent progression of disease, reduce/retard both acute and long-term complications. Nutritional management for diabetic patients has been evolving for many years. Nutrition therapy is important for diabetic patients to achieve adequate glycemic control. Aims: To find the nutritional status with diabetes mellitus, considering their socioeconomic status. Methods: 30 diabetic patients attending Parul Sevashram Hospital, Vadodara. were studied. Range of age: 35- 65 years. Collected: History, physical examination, sociodemographic, general health and lifestyle data. The Nutritional Assessment was used to screen nutritional status. Results: Participants’ mean age was 38 ± 6.5 years, and there was a predominance of men (66%). The mean duration of diabetes was 11.1 years (±5.6 years). Patients aged 60 years or older presented with higher risk of malnutrition, and those who were uneducated exhibited higher risk of malnutrition. Nutritional status (Obesity) was significantly associated with coronary artery disease, hypertension and dyslipidemia. Conclusion: Malnutrition in diabetic patients precipitate/exacerbates underlying diseases-comorbidities and may contributes to adverse prognosis/complications, particularly in the oldest old group and in individuals with low levels of education.

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P-226 Overview of Clinical and Microbiological Profile of Ventilator Associated Pneumonia at A Tertiary Care Hospita Arvind Ankur, Vora Alpesh Department of General Medicine, Government Medical College, Bhavnagar, Gujarat, India. Corresponding Email ID: [email protected]

Background: Ventilator associated pneumonia (VAP) is defined as pneumonia occurring more than 48hours after endotracheal intubation/initiation of mechanical ventilation or pneumonia developing even after extubation. VAP occurs in 9–27% of all intubated patients. VAP may be caused by a wide spectrum of bacterial pathogens, viral and fungal. There are two types of VAP early onset and late onset. Common pathogens causing VAP includes Pseudomonas Spp. Escherichia coli, Klebsiella pneumonia and Staphylococcus aureus with varying prevalence. Due to the increased incidence of MDR organisms in intensive care units(ICU), early and correct diagnosis of VAP is mandatory. Material and Methods: This prospective study was conducted on 50 patients, who were on mechanical ventilator for more than 48 hour admitted in critical care unit at Sir Takhtasinhji General Hospital, Bhavnagar, during study period of 1 year from June 2018 to May 2019 Observations and Results: Ÿ The study was conducted on 50 patients who were suspected to have VAP admitted in critical care unit at Sir Takhtasinhji General Hospital, Bhavnagar, during the study period of 1 year. Ÿ Out of 50, 38 patients were diagnosed to have VAP based on Clinical Pulmonary Infection Score. Ÿ In our study the most frequently isolated organism in early and late onset VAP were Klebsiella (31.6%), Escherichia coli (23.7%) and Pseudomonas aeruginosa (18.4 %). Ÿ The organisms causing VAP were different in different study groups mainly because of geographical variation. The present study helped to know the commonest organisms causing VAP at our hospital. Ÿ The overall mortality in our study was 36.8 %. In early onset VAP it was 28.6% and in late onset VAP was 41.6%. In other studies mortality varied from 30% to 50%. Ÿ Higher rate of mortality in late onset VAP in our study is because of longer duration of mechanical ventilation and underlying co-morbid conditions. Conclusion: VAP is a serious problem in CCU leading to prolonged hospitalisation, its associated financial implication and high mortality rate. Out of 198 patients, 50 patients admitted to the CCU of Sir T, General hospital, Bhavnagar under medicine department on mechanical ventilation more than 48 hour were studied, of which 38 patients devloped VAP. Incidence is 19% and the most common offending organisms isolated in our patients were Klebsiella (31.6%), Escherichia coli (23.7%) and Pseudomonas (18.4%). They were sensitives to broad spectrum antibiotics like Meropenem (84.2%), Gentamycin (76.3%) and Amikacin (71%). In our study,overall 63.2 % patients of VAP were recovered. 36.8 % patients of VAP were expired. Preventive strategies should be followed in critical care units to decrease the prevalence of VAP. The emergence of MDR pathogens can be prevented by adopting an antibiotic policy and dose de-escalation regimens.

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P-227 Anaesthetic Management with Graded Epidural Anaesthesia of a Case of Ischemic Heart Disease with Dilated Cardiomyopathy Posted for Proximal Femoral Nailing: A Case Report Behl Archana, Thomas Sara, Desai Jayshri, Chauhan Dinesh Department of Anaesthesiology, SBKS Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, Gujarat, India Corresponding Email ID: [email protected]

Introduction: Ischemic Heart Disease (IHD) with Dilated Cardiomyopathy (DCMP) having associated decreased ejection fraction impose a serious risk to patients posted for major surgery as it has an impending risk of congestive heart failure, arrhythmias and sudden hemodynamic instability. In such patients, for lower limb surgeries, graded epidural anaesthesia has an advantage over subarachnoid block in that it is associated with less severe or sudden hypotension. Use of an epidural catheter also helps to give titrated dose of local anaesthetic agent and the level of motor and sensory blockade can be gradually increased to the desired level which gives better hemodynamic stability. Case Report: A 65 year old male patient,70kgs presented with diagnosis of Left Intertrochanteric fracture femur was posted for Proximal Femoral Nailing (PFN).Patient had a history of Hypertension and IHD with DCMP with Echocardiogram showing Ischemic DCMP, regional wall motion abnormality, ejection fraction 35% and mild pulmonary artery hypertension. Procedure was explained and written informed high risk consent was taken. Graded epidural anaesthesia was planned. In operation theatre intravenous (IV) line was secured, Injection Voluven was started, multi-para monitors were attached and baseline vitals were noted. Injection (Inj) Ondansetron(4mg) IV was given. Under aseptic precautions epidural catheter was inserted in L2-L3 intervertebral space and fixed at 9cm.After negative aspiration, a total of 12 ml of Inj. Lignocaine (2%) with Adrenaline and Inj. Bupivacaine (0.5%) in equal proportions was given in epidural space in “graded” doses of 6ml every 10 minutes under closed monitoring of vitals. Sensory level of T11 and complete motor blockade was achieved. After 2 hours of surgery epidural top up with 2ml of Inj. Lignocaine(2%) with Adrenaline and 3ml of Inj. Bupivacaine(0.5%) was repeated. Vitals were stable throughout the surgery. Post operatively, Injection Tramadol 50mg diluted to 10ml was given epidurally for analgesia. Conclusion: Graded epidural anaesthesia ensures adequate motor and sensory blockade with good haemodynamic stability which is of utmost importance in patients with existing IHD and low ejection fraction. Keywords: Graded epidural anaesthesia, Ischemic Heart Disease, Dilated Cardiomyopathy

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P-228 Glycemic Control and Body Mass Index in Type 2 Diabetes Mellitus Bhattacharya Amakumar, Patel Prashastee, Upadhyay Aakash, Rana Komal Parul Institute of Medical Sciences and Research, Vadodara, Gujarat Corresponding Email ID: [email protected]

Introduction: In general, recommendations of the HbA1c target level at <7.0% to ensure prevention of diabetic microvascular complications. Obesity has association with increased risk of complication of diabetes. Obesity is a metabolic disorder, prevalence is increasing. Bodyweight within normal limits based on dietary recommendation is non pharmacological treatment method for type 2 diabetes. This may lead to the prevention of diabetic complications. Body mass index (BMI) ≥25.0 kg/m2; is obesity/overweight, leads to increased risk of obesity- related complications such as hypertension, dyslipidemia, and hyperglycemia, chronic kidney disease, stroke. Aim: This study examined the association among the onset of diabetic kidney disease (DKD), blood glucose levels (HbA1C), and body mass index (BMI) in Japanese patients with type 2 diabetes mellitus. Methods: 50 patients for this study enrolled those with type 2 diabetes who visited the Hospital. History, physical examination including BMI, relevant investigation carried out. HbA1c was also done. Results: From the analysis of the reports of the patients, they were classified into different categories according to the glycemic control based on HbA1c < 7.0% (Control) or > 7.0% higher (High)), and BMI (>25 kg/m2 (Overweight/obese) or < 25 kg/m2r (Normal)), Study also measured age of the patients, sex, duration of diabetes, and medication for comorbidities, dyslipidemia;. with consideration on control of diabetes. Conclusion: Keeping the glycemic control- HbA1c value lower than 7.0% and a BMI lower than 25 kg/m2 was determinant for the development of diabetic complications with patients with type 2 diabetes mellitus. HbA1c level and BMI influence the outcome of the complications in diabetic patients.

P-229 Airway Management with Sub-Mental Intubation Technique in a Patient with Reduced Mouth Opening with Pan-Facial Fracture Posted for Open Reduction Internal Fixation and Plating of Mandible and Nasal Reconstruction – A Case Report. Jha Soumya, Chauhan Dinesh, Mehta Malini, Thomas Sara Mary Department of Anaesthesiology, S.B.K.S. Medical Institute & Research Centre, Vadodara, Gujarat. Corresponding Email ID: [email protected]

163 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 securing the airway where oro-tracheal and naso-tracheal intubation cannot be performed. Case Report: A 48yr old male patient with history of polio since childhood and Diabetes Mellitus- type II for 9yrs, on Inj. Insulin subcutaneously according to sliding scale, presented with pan-facial fracture after a road traffic accident. Airway assessment showed reduced mouth opening (2 ½ fingers), edentulous. As the surgery required reduction of the mandibular fracture and nasal bone reconstruction, sub-mental intubation was considered. After standard oro-tracheal intubation, a passage was created by blunt dissection through the floor of the mouth. The proximal end of the cuffed endotracheal tube (flexometallic 8.5) was pulled through the sub-mental incision after the pilot balloon. The endotracheal tube was subsequently fixed with sutures, At the end of the surgery, the tube was pulled back through the sub-mental incision into the usual oral route. Conclusion: Sub-mental intubation is a useful alternative technique of airway management in patients with pan-facial fractures. It is safe and quick to execute and not requiring specialized equipments or skill.

P-230 A Rare Case of Methemoglobinemia due do Inhalation of Unknown Substance Patel Utsav Corresponding Email ID: [email protected]

Methemoglobin is an altered configuration of hemoglobin in which the ferrous state is oxidized to the Ferric state. Ferric heme in methemoglobin is unable to bind oxygen resulting in altered structure and left shift of oxygen dissociation curve, interfering with oxygen delivery to tissues. Preexisting conditions like anemia, heart disease, lung disease and G6PD deficiency and ensuing hemolysis may exacerbate its toxicity. Acquired methemoglobinemia becomes symptomatic when methemogobin comprises more than 10% of total hemoglobin. Levels of more than 30% to 40% are considered as life threatening and are associated with severe symptoms of hypoxia which can be fatal. We report a case of 25 year old female who presented to the emergency department with chief complaints of giddiness headache & vomiting after inhalational exposure to some unknown substance. On clinical examination, vital signs were within normal limit except oxygen saturation which was 75% on room air. On further investigation, Peripheral smear, complete blood count, liver function test were within normal limit but methemoglobin level at time of admission was 41.7%. She was given IV Methylene blue 50 mg (1mg/kg) along with high flow of oxygen at 10 Lt/min for 7 days. Her methemogloin level decreased to 12.4% during this period. Patient remain stable in ward under close monitoring and oxygen saturation by pulse oximetry improved to 93% on room air at time of discharge.

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P-231 Neuromyelitis Optica (NMO; Devic’s Disease) Maliwad Nitin, Hadiyel Ila Department of General Medicine, Government Medical College, Bhavnagar, Gujarat, India. Corresponding Email ID: [email protected]

Background: Neuromyelitis Optica is an aggressive inflammatory disorder characterized by recurrent attack of optic neuritis and myelitis.Autoimuune disease associated with highly specific antibody directed against Aquaporin 4,that is present in sera of ~70% of patients with clinical diagnosis of NMO.Aquaporin 4 Is localized to the foot process of Astrocytes in close opposition to the endothelial surface as well as at paranodal region near nodes of Ranvier.Prevalence is <1 to >4/Lac.Females are commonly affected than Males[>3:1];Typically begins in Adulthood. In patients with NMO,attacks of Optic Neuritis can be Bilteral and can produce severe visual loss[uncommon in Multiple Sclerosis]. Myelitis can be severe and transverse[rare in multiple sclerosis] and is typically longitudinally extensive, involving 3 or more contiguous vertebral segments. Also, in Contrast to Multiple Sclerosis,Progressive symptoms do not occur typically in NMO. Case Presentation: A Case of 18 year old Female admitted with chief complain of:Bilateral Lower limb weakness since 4days along with tingling sensation in both upper limbs, Abdominal pain and Urine/stool incontinence . On Examination Powe in Both LL: 1/5 with Absent Deep Tendon Reflex and touch, Pain sensations. MRI Spine S/O:An Area of Incresed signal intensity in more than 3 vertebral segments[c3 to c5] .Possibility of Transverse Myelitis. Patient Underwent 7 cycles of Plasamphresis following which patient had power in B/L Lower limb:2/5 after which she was referred to higher centre where IVIG was given ,after which she regained power of 4/5.After 25 days,again she was admitted with C/O: Lowerlimb weakness and blurring of vision.On Fundus Examination patient had S/O:Optic Neuritis.Patient was tested for Anti MOG and Anti Aquaporin4 antibodies that came Positive;and diagnosed with Devic’s disease.Treated with Steroid.Patient improved Gradually. Conclusion: Whenever Young patient has Paraplegia with Optic Neuritis,NMO or Multiple sclerosis to be suspected which can be distinguished by thorough investigation.NMO can be managed by either steroid or plasmaphresis ,And disease can be kept under control with regular treatment.

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P-232 Tobacco Use in Type 2 Diabetes Mellitus Patients Patel Aditya, Patel Prashastee, Bhattacharya Amakumar Parul Institute of Medical Science and Research, Vadodara Corresponding Email ID: [email protected]

Introduction: An association between tobacco use and type 2 diabetes mellitus (T2DM) is well known. However, there was a need to studt tobacco use among T2DM patients at local level. Smoking is one of the modifiable risk factors for many chronic diseases, such as cardiovascular disease (CVD), cancer, chronic obstructive lung disease, asthma, and diabetes. The hazards of smoking on diabetes have been under recognized. Smoking cessation is recommended as one of the important steps in preventing the cardiovascular complications of diabetes. Smoking reduces body weight, but cause central obesity. Smoking cause inflammation and oxidative stress, damages β-cell function and impairs endothelial function. Aim: Incidence of smoking in patients with type2 diabetes was studied. Age of the patients and type of tobacco use was also studied. Methods: We studied the prevalence of tobacco use in T2DM patients attending Parul Sevashram Hospital, Vadodara. Results:50 patients were studies attending hospital, Prevalence of tobacco use in T2DM was 16% and was higher in the rural area, uneducated and low socioeconomic status group, compared to urban, educated and higher economic group. In studies which compared prevalence of tobacco use in patients to aged-patients, aged patients with T2DM were more likely to use tobacco compare to young. Chewing was seen in four and smoking in one patient. Conclusion: Tobacco is used by one in six T2DM patients in our study, but usage is less likely in patients in young- patients. Tobacco cessation strategies indicated to reduce progression of disease. Chewing tobacco is common, may be due to cost and easy use and avialability

P-233 A Rare Case Report of Disseminated Histoplasmosis in Immunocompetent Host Shah Dhaval, Budhrani Deepmala Department of General Medicine , PDU Medical college, Rajkot Corresponding Email ID: [email protected]

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Material and methods: A 54 years old male farmer patient, presented with complaints of low grade fever and generalised bodyache since 15 days and complaint of abdominal pain since 8-10 days. Patient was known case of diabetes mellitus. On general examination, vitals were normal with pallor present and no any lymphadenopathy. On per abdomen examination – liver (2 cm) and spleen (4 cm) was palpable. The remainder of his physical examination was with in normal limits. Blood investigations shows anemia with thrombocytopenia with altered liver enzymes. Peripheral smear was suggestive of pancytopenia without any evidence for malaria or any other parasites. Serum Widal and serum Dengue IG M antibody test was also negative. Antibodies for HIV 1 and HIV 2 were negative. USG abdomen+pelvis and CT abdomen reports were suggestive of gross splenomegaly. Bone marrow aspiration was done and report was suggestive of fungal infestation by histoplasma capsulatum. Then after anti fungal therapy was started in form of tab itraconazole (200 mg) twice a day for 12 weeks. Patient was improved and anemia and thrombocytopenia also cleared in follow up reports. Conclusion: BM can be helpful in cases of pyrexia of unknown origin with hematological abnormality and Histoplasmosis is challenging to diagnose, should be considered in patients with fever, hepatosplenomegaly and pancytopenia even in nonendemic areas as well as immunocompetent individuals.

P-234 Syndrome of Inappropriate Secretion of Antidiuretic Hormone Associated with Idiopathic Normal Pressure Hydrocephalus : A Rare Case Report Patel Ruby, Trivedi Jayesh, Ahmadi Bashir, Baldania Deepak Depeartment of General Medicine, Gujarat Adani Institute of Medical Sciences GAIMS, Bhuj Corresponding Email ID: [email protected]

Normal pressure hydrocephalus is a rare condition which is clinically characterized by triad of gait disturbance, incontinence of urine and decline in cognitive function resulting from ventriculomegaly without elevated CSF pressure. The disorder of SIADH is due to non physiological release of hormone from the neurohypophysis due to low plasma osmolality. Here is a case of elderly female with typical clinical features and brain imaging consisting with NPH accompanied by hyponatremia due to SIADH is presented. Purpose: To Study and prompt clinicians to consider the syndrome of inappropriate in differential diagnosis of hyponatremia in patients with idiopathic normal-pressure hydrocephalus(NPH). Method: A case report of an elderly woman with the clinical and radiological features of NPH accompanied by hyponatremia is presented. Result: A 78-year-old woman was being evaluated for hyponatremia; she presented with gait disturbance, decline in cognitive function, and urinary incontinence, which constitute the classic triad of NPH, and brain magnetic resonance imaging showed ventriculomegaly and other features consistent with this syndrome. The serum sodium was 122 mEq/L, with osmolality of 258 mOsm/kg, and urine osmolality was 280 mOsm/kg.

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Serum uric acid level was normal, and urea was low. Other metabolic workup was negative; renal, adrenal, and thyroid functions were normal. Cardiac workup was negative. Chest and brain imaging results were negative for an occult malignancy. SIADH was diagnosed. Based on the patient’s preference, a conservative treatment was instituted for both SIADH and NPH, a novel approach for this clinical scenario; it resulted in modest improvement of the hyponatremia. Conclusion: SIADH is an extremely rare metabolic manifestation of NPH, should be considered whenever hyponatremia is present, and it is treatable.

P-235 Basedow’s Paraplegia: A Rare Entity of Thyrotoxic Paraplegia Shah Bhavik, Anadkat Meghal Department of General Medicine, PDU Medical College, Rajkot Corresponding Email ID: [email protected]

A 37 years old male patient presented to a tertiary care teaching hospital with complaints of weight loss, increased appetite, fine tremors in both upper hands while holding objects for last four months; followed by difficulty in moving both legs for one day. The patient had no history of any other known comorbidities. On admission, the patient had tachycardia with pulse rate of 130 per minute, with all other vitals within normal limit. On a detailed neurological examination, the patient was fully conscious and oriented with bilateral flexor planters, decreased tone in both lower limbs with power 3/5; deep tendon reflexes (DTRs) in ankle and knee were found to be +1, without any evident abnormalities in both upper limbs and all the cranial nerves. On further evaluation, the patient was found to be having normal electrolytes, however, his Thyroid Profile was suggestive of hyperthyroidism with TSH of <0.005 IU/ml and FT4 of >7.77 ng/dl with NCS findings suggestive of demyelinating type of pure motor polyneuropathy in both lower limbs. Other investigations like MRI (whole spine screening), serum Vitamin B12 levels, and CPK (Total); to rule out remaining causes of paraplegia were found to be within normal limit. Considering a rare but plausible diagnosis of Basedow’s Paraplegia, the patient was started on tablets Carbimazole and Propranolol along with other supportive measures. The patient started improving within a couple of days and was discharged with a regular follow up.

P-236 Controlled Ventilation Combined with Intravenous Drugs and Muscle Relaxants give the Best Results for Bronchoscopy Patel Dhrumin Corresponding Email ID:[email protected]

Introduction: Dilated tortuous and thickened veins are known as varicose veins. Severity of the disease may vary from telangiectatic veins to venous ulceration. Perforating veins perform a normal function in transporting superficial venous blood inward to the deep veins for further transit to the heart. If perforating veins become incompetent and transmit outward flow, it may lead to chronic venous insufficiency. Deep

168 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 venous reflux accompanies superficial venous reflux in 20 % of limbs with varicose veins . The usual starting point of this retrograde circuit is the saphenofemoral junction, but it may start from one of the perforators like mid-thigh Hunterian or the anteromedial Boyd perforator or a calf perforator. This circuit must be broken by removing the superficial part of the circuit and by ligating the incompetent perforators. They need ligation either by open surgery or by subfascial endoscopic perforator surgery (SEPS). Subfascial endoscopic perforator surgery has the advantage of better wound healing in an already compromised skin. Objective: To report A case of 45 yr old male patient with Bilateral varicose veins, Treated by Subfascial Endoscopic Perforator Surgery of right lower limb. Case Presentation: A 45 year old male patient presented with multiple dialated bilateral lower limb veins since 6 months. With presence of non healing ulcer over bilateral lower limbs. Xray chest and Bilateral lower limb : NAD Both lower limb venous doppler study: No evidence of superficial or deep vein thrombosis noted. Multiple superficial varicose veins with perforators as mentioned and marked. Bilateral spheno femoral junction appear mild dialated and incompetent. Result: The results from admission to Discharge were uneventful. Patient was mobilised after application of crepe bandage on the evening of the operation day. Discharged on post op day 2nd. Patient was followed up in opd which showed healing of ulcer in 2 months. Conclusion: Subfascial endoscopic perforator vein surgery is a safe and effective method for treating incompetent perforating veins.Major advantage of SEPS was fewer incidences of wound complications which is considerably high in the open ligation techniques because of incisions in the already compromised skin. SEPS should be added to varicose vein surgery for the management of incompetent perforators to reduce long-term recurrences and better immediate wound healing.

P-237 A Case of Thyroid Storm Paul Saurav, Panjwani S. Department of Medicine, Government Medical College, Bhavnagar Corresponding Email ID: [email protected]

Background :Thyroid storm is a rare life threatening condition occurring in untreated or undertreated case of hyperthyroidism with only (1-2%) prevalence among hyperthyroid patients.If not treated promptly then it becomes a fatal condition. Case Report: A 30 year male patient admitted with five days history of breathlessness,abdominal pain, cough with expectoration, vomiting and exaution. He had a swelling over neck since last six months but he was reluctant for further work up.On clinicalexamination he was found to febrile(102F),dehydrated, lethargic, agitated and his pulse was 150/min,blood pressure was 90/60.His thyroid gland was enlarged with engorged thyroid veins. BURCH and WARTOSFKY diagnostic score was more than 45.Hence this was a case of thyroid storm.

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Conclusion: Thyroid storm is a rare endocrine emergency.It might be difficult to distinguish between storm and infection in thyrotoxic patient as presentation is similar. Early diagnosis and prompt therapy will reduce fatality.

P-238 Glycemic Status Evaluation in Newly Diagnosed Type 2 Diabetes Mellitus(T2DM) Adult Indian Patients and Requirements of Insulin Therapy at Time of Diagnosis Desai Arsh Corresponding Email ID: [email protected]

Aims and objective: To study the value of HBA1C in Indian patients at the time of diagnosis of T2DM to know glycemic status of Indian patients with T2DM at the time of first presentation and requirement of insulin at the time of diagnosis. Methods: From 1st July 2017 all patients attending OPD are studied. Patients who are diagnosed to have T2DM on clinical grounds were subjected for further investigation like FBS/PP2BS/HBA1C prior to any treatment for DM .All anemic patients and critically ill patients were excluded from study. FBS/PP2BS were done with GOD/POD method and HBA1C was done with HPLC method in laboratory. Result: Total 298 patients are diagnosed to have T2DM based on standard diagnostic criteria. In 14 patients HBA1C was not done due to financial constraint hence excluded. HBA1C was >9% in 189 patients(63.2%) and >10% in 160 patients(53.5%). So according to ADA standards of medical care in diabetes 2018 guidelines more than 50% of Indian adults with T2DM will require injectable insulin therapy at the time of diagnosis. Conclusion: HBA1C value in Indian patients of newly diagnosed T2DM is very high(very poor glycemic control). Indian T2DM patients seek medical care very late after their symptomatic status. We can label this as an awareness inertia. Recommendation: To increase awareness in general population to seek medical care early and early diagnosis of DM and early insulin therapy in T2DM.

P-239 Scorpion Sting Causing Acute Severe Myocarditis: A Rare Complication Dasare Anand, Vora Alpesh Department of Medicine, Government Medical College, Bhavnagar, Gujarat, India Corresponding Email ID: [email protected]

Scorpion bites are common in India as well as in other countries. There are about 1,500 species of scorpions worldwide, out of these 50 are dangerous to human. Among 86 species in India, Mesobuthus tamulus and swammerdami species are of medical importance. Scorpion sting causes a wide range of manifestation, from local skin reaction to neurological, respiratory complications, cardiovascular effects like myocardial damage, peripheral circulatory failure, pulmonary edema. These clinical manifesta¬tions, result in a syndrome of fuel energy deficits and inability to use the existing metabolic substrate by vital organs cause multisystem organ failures and death . Scorpion envenoming syndrome results in severe autonomic storm with massive release of

170 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 catecholamines, increased levels of angiotensin2, and increase in glucagon, cortisol, thyroid hormones; either suppressed insulin levels or hyperinsulinemia (insulin resistance), hyperglycemia: increased circulating free fatty acid level. These hormonal alterations could be responsible for the patho¬genesis of variety of clinical manifestations. We here in report a case of scorpion sting that presented with acute severe myocarditis, pulmonary odema and reversible cardiomyopathy which are rare complications of scorpion sting. Introduction: Scorpion stings are common in our country, particularly in the rural areas. Among 86 species of scorpions present in India, Mesobuthus tamulus (Indian red scorpion) and Heterometrus swammerdami are of medical importance1.Almost all lethal scorpions except Hemiscorpius species, belong to the scorpion family called Buthidae. The lethal member of Buthidae include genera Buthus, Parabuthus, Mesobuthus, Tityus, Leiurus, Androctonus and Centruroides. Scorpions live in warm dry regions throughout India. They commonly inhabit the crevices of dwellings, underground burrows, under logs or debris, paddy husk, sugarcane fields, coconut and banana plantations. Their distribution is more in regions with abundant red soil. They hunt during night and hide in crevices and burrow during the day to avoid light. Scorpion stings increase dramatically in summer months and are lower in winter. Though local symptoms including severe pain and burning sensation at the site of the sting are common, systemic complications can ensue2. Cardiovascular manifestations are particularly prominent following stings by the Indian red scorpion.3 Case Report: An 19-year-old boy was stung by a scorpion on the dorsum of the right foot and presented with intense pain and swelling on the local site. He was admitted with the following vitals : heart rate 140 beats/minute, and blood pressure 70/40 mmHg respiratory rate 30/min, temp:99 degree Fahrenheit, all systems examination was normal. Symptomatic treatment was given. But the patient’s condition continued to worsen, and in less than 24 hrs of admission he developed respiratory distress, bilateral basal crepts were heard on auscultation and cardiovascular examination revealed a loud S3 gallop at the apex. Laboratory results were as follows: Hemoglobin was12.6 g/dl, white blood cell count was 24,380 cells/mm3, platelet count was 1,80,000 cells/mm3 and urine microscopy showed hematuria. Blood urea:71 mg/dl(17-43 mg/dl), serum creatinine:1.03 mg/dl (0.8-1.3 mg/dl), CK-MB:18 ng/ml (0-5 ng/ml). An electrocardiogram (ECG) revealed sinus tachycardia and ST-T wave changes (Fig.1) Chest X-ray demonstrated bilateral fluffy shadows indicative of pulmonary edema (Fig.2). Echocardiography revealed global hypokinesia of the left ventricle with reduced ejection fraction(35%) In accordance with these symptoms and findings, a diagnosis of acute heart failure with pulmonary edema was made. Dopamine, dobutamine, diuretics and steroids were given. With treatment, patient’s status improved. Repeat chest X-ray was clear within 24 hours of initiating this treatment. A repeat ECHO showed improvement in the ejection fraction on the fourth day and it was 45% . Discussion: Scorpion venom contains multiple toxins like neurotoxin, cardiotoxin, nephrotoxin and hemolytic toxin. The primary targets of scorpion venom are voltage-dependent ion channels. The long-chain polypeptide neurotoxin causes stabilization of voltage dependent sodium channels in the open state leading to continuous, prolonged, repetitive firing of the somatic, sympathetic, and parasympathetic neurons resulting in autonomic and neuromuscular overexcitation symptoms due to release of excessive neurotransmitters such as epinephrine, norepinephrine, acetylcholine, glutamate and aspartate. Meanwhile, the short polypeptide

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neurotoxin blocks the potassium channels. Scorpion sting usually has a good prognosis. However, occasionally potentially fatal complications such as myocarditis, pulmonary edema and shock occur. Among these, myocarditis and resultant pulmonary edema are important causes of death. Venom can cause myocardial damage by several pathogenetic mechanisms:- 1. Myocardial ischaemia by coronary spasm: Release of vasoactive, inflammatory and thrombogenic peptides and amine constituents (histamine, serotonin, bradykinin, leukotrienes, thromboxane), which act on the coronary vasculature and induce coronary artery vasospasm and facilitate platelet aggregation as well as thrombosis4. 2. The unopposed effects of alpha-receptor stimulation lead to myocarditis. 3. Direct cardiotoxic effect of the venom causing toxic myocarditis by reduction of Na-K-ATPase and adrenergic myocarditis by releasing adrenaline and noradrenaline from neurons, ganglia, and adrenals, thereby increasing myocardial oxygen demand by direct inotropic and chronotropic effect on already compromised myocardial blood supply5. 4. Anaphylactic reaction: Release of allergenic proteins causes anaphylactic shock leading to hypotension with vasodilatation and decrease of intravascular volume reduces myocardial perfusion. 5. Scorpion venom inhibits angiotensin converting enzyme (ACE), resulting in accumulation of bradykinin, which is implicated in the development of pulmonary oedema6. We report here the case of a 19-year-old boy who developed life-threatening, acute toxic myocarditis, pulmonary edema and cardiomyopathy after a scorpion sting. Aggressive medical treatment with inotropic agents, diuretics and parenteral corticosteroids resulted in rapid clinical resolution. Conclusion: Cardiomyopathy due to myocarditis following scorpion sting can threaten life due to left ventricular sys¬tolic dysfunction. This consequence has been attributed to increased catecholaminergic activity or direct effect of toxin to myocardial fibers. ECG must be performed, cardiac en¬zymes must be monitored and echocardiography must be done to evaluate cardiac involvement in cases of scorpion sting. Severe cases must be taken to the intensive care unit in order to monitor respiratory and circulatory systems. Aggressive medical treatment with inotropic agents, diuretics and parenteral corticosteroids can result in rapid clinical resolution.As there was no evidence of coronary vascular insufficiency.This was probably due to direct toxic effect of the scorpion venoum on the myocardium or secondary to venom induced catecholamines release from the adrenals or sympathetic nerve endings. Figure 2. Figure 1. ECG Chest X-ray showing bilateral fluffy shadows

Keywords: Scorpion sting, severe myocarditis, pulmonary edema and cardiovascular collapse.

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P-240 Rare Presentation of Myaesthenia Crisis in a Case of Syringomyelia Patel Miltan Department of General Medicine, GMC Bhavnagar, Gujarat Corresponding Email ID: [email protected]

Myaesthenic crisis is a rare clinical presentation in case a myaesthenia gravis and it affects one third to one fifth of generalized myaesthenia grevis. Co-existence of myasthenia grevis and syringomyelia is an extream rare entity. Case Report: A 55 year old male patient who is known case of syringomyelia was admitted with complaints of Difficulty in breathing and weakness in both upper limb and cough with expectoration, On examination Patient was afebrile , drowsy and his Respiratory rate 36/min PR was 116/min and Blood pressure was 130/84, subsequently patient was put on Ventilatory support, Patient had similar history of 2 time hospitalization and ventilatory assistance. patient had history of frequent fall dawn after a short period of walking.MRI whole spine screening of patient was done and it suggestive of same old changes of syringomyelia, On further evaluation patient's acetylcholine receptor antibody titre report send and it came to be positive. Patient was treated with 5 cycles of plasmapheresis and oral pyridostigmine therapy. There after patient improved clinically and gradually weaned off from Ventilatory support. Conclusion: One should consider neuromuscular disorders in case of unexplained respiratory failure. Prompt diagnosis and early therapeutic intervention reduce fatal outcome of myaesthenic ctrisis.

P-241 Posterior Reversible Encephalopathy Syndrome in Dengue Fever Mandaliya Bheeshm, Panjwani Sunil Department of General Medicine, Government Medical college, Bhavnagar, Gujarat, India. Corresponding Email ID: [email protected]

Dengue an arthropod born disease can represent with mild febrile illness to life threatening dengue haemorrhagic fever but posterior reversible encephalopathy syndrome (PRES) which usually seen in hypertensive emergencies is rare in the setting of dengue. Case Report: A 55 years old man non-diabetic and non-hypertensive presented with history of continuous fever without chills for 5 days and altered sensorium since 2 days and one episode of generalised tonic clonic convulsion .1 day before admission patient had tachycardia, hypertension, high respiratory rate, elevated temperature, a puffy facies and poor GCS (7/15). Patient had no focal weakness, deep tendon reflexes were normal but bilateral planter extensor. Empirical treatment was started on the day of admission with broad spectrum antibiotics with antiviral and steroid, fluid and inotropic support, an antimalarial (I.V artesunate) and anticonvulsants given. Blood reports showed, Leucocyte count of 4300/µL, Platelets 36000/µL, Haemoglobin 13.7gm%. Dengue Ns1 and IgM: - positive, Malarial parasite: - Negative.

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Patient was not showing any improvement in sensorium. After 4 days of treatment MRI brain with contrast done which suggestive of posterior reversible encephalopathy syndrome (PRES). Conclusion: Out of the varies manifestations of dengue fever, posterior reversible encephalopathy syndrome (PRES) can be an atypical and rare presentation.

P-242 A Case of Patent Ductus Arteriosus with Infective Endocarditis Complicated with Splenic Abscess Machhar Amit, Dhangar Vandana, Dangde Vinod Department of General Medicine, Surat Municipal Institute of Medical Education and Research, Surat Corresponding Email ID: [email protected]

Introduction: The ductus arteriosus is a vessel leading from the bifurcation of the pulmonary artery to aorta just distal to left subclavian artery. Persistence of this vascular Channel after birth is known as Patent Ductus Arteriosus (PDA) The leading causes of death in adults with PDA are cardiac failure and infective endocarditis. Infective endocarditis is due to microbial infection of heart valve or the lining of cardiac chamber (endothelium). Splenic abscess is a well-described but rare complication of infective endocarditis. Here a case exhibiting all three entities simultaneously has been discussed. The case was followed during the entire stay in hospital and also on follow-up A Case Report: 24 year old female patient came to our centre with complaints of fever, high-grade, with chills and rigours occurring every 2-3 days since last 6 months and every day since last 7 days. Over the period of 6 months she developed dyspnea on exertion which gradually progressed to difficulty in doing activity like riding bicycle (Grade 2) . She took treatment from multiple facilities during these 6 months , including anti-malarial and anti-tubercular therapy. But no significant improvement was noted. On examination, she appears poorly nourished and anaemic. Cardiovascular examination revealed shift of apex beat to 6th ICS downwards and laterally, continuous machinery murmur at upper left sternal border associated with thrill. On per abdomen examination , tenderness was present in left hypochondriac region. Investigations : Blood routine showed Hb=7.2 gm% with PBF and iron profile supporting iron- deficiency anaemia; rest were normal. Blood c/s from left and right upper limb growed gram +vecocci , Staphylococcus hominis spp. Urine routine was normal. Sputum AFB stain and C/S were –ve. ECG : sinus tachycardia. Fundus examination revealed B/L venous dilatation with mild tortuous veins. R/E had single Roth’s spot. Echocardiography showed moderate PDA(5mm) with LàR shunt, ACHD, Good biventricular function, multiple vegetations on pulmonary valve and PDA and MPA. Discussion and Conclusion: PDA is a congenital heart disease with about 1/2000 incidence in term neonates. In preterm neonates, the incidence is far greater. Infective endocarditis(IE) is one of the worst complications of PDA and is often life-threatening. Estimated incidence of IE is atleast 17000/100000 patient per year in India. The spleen maybe affected either by bacteraemia seeding an infarcted splenic zone or directly through seeding of the spleen by infected embolized vegetations of the heart valve. Splenic abscesses are associated with high morbidity and mortality rates but easy recognition of symptoms and prompt treatment should allow for a

174 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020 favourable outcome. Usually conservative medical management is sufficient but in some cases surgical intervention may be require. It is important that the patient receives timely expert care and thus reduction in overall morbidity and mortality maybe achieved

P-243 CNS Toxicity of Metronidazole - A Rare Case Report Parikh Sankalp, Gadani Zalak AMC MET Medical College and LG hospital, Department of Medicine, Ahmedabad, Gujarat, India Corresponding E-mail ID: [email protected]

Metronidazole is of the nitroimidazole class. It inhibits nucleic acid synthesis by disrupting the DNA of microbial cells. This function only occurs when metronidazole is partially reduced, and because this reduction usually happens only in anaerobic bacteria and protozoans, it has relatively little effect upon human cells or aerobic bacteria. Metronidazole, is an antibiotic and antiprotozoal medication. It is primarily used to treat: bacterial vaginosis, pelvic inflammatory disease (along with other antibacterials like ceftriaxone), pseudomembranous colitis, aspiration pneumonia, rosacea (topical), fungating wounds (topical), intra-abdominal infections, lung abscess, periodontitis, amoebiasis, oral infections, giardiasis, trichomoniasis, and infections caused by susceptible anaerobic organisms such as Bacteroides, Fusobacterium, Clostridium, Peptostreptococcus, and Prevotella species. It is also often used to eradicate Helicobacter pylori along with other drugs and to prevent infection in people recovering from surgery. Common side effects include nausea, a metallic taste, loss of appetite, and headaches. Occasionally seizures or allergies to the medication may occur. Some state that metronidazole should not be used in early pregnancy, while others state doses for trichomoniasis are safe. It should not be used when breastfeeding. Common adverse drug reactions (≥ 1% of those treated with the drug) associated with systemic metronidazole therapy include: nausea, diarrhea, weight loss, abdominal pain, vomiting, headache, dizziness, and metallic taste in the mouth. Intravenous administration is commonly associated with thrombophlebitis. Infrequent adverse effects include: hypersensitivity reactions (rash, itch, flushing, fever), headache, dizziness, vomiting, glossitis, stomatitis, dark urine, and paraesthesia.[13] High doses and long-term systemic treatment with metronidazole are associated with the development of leucopenia, neutropenia, increased risk of peripheral neuropathy, and central nervous system toxicity. Common adverse drug reaction associated with topical metronidazole therapy include local redness, dryness and skin irritation; and eye watering (if applied near eyes). Metronidazole has been associated with cancer in animal studies. Here we encountered a case of a 57 year old male who presented to the emergency department with ataxia and a broad gait. Patient was conscious and oriented to time, place, person. There was slurring of speech since 1 day. On examination, planters were extensors, pupils were reactive to light, reflexes were normal, cerebellum signs were normal. There was no history of fever. Patient was admitted before 3 months for liver abscess due to chronic alcoholism and was discharged on T. Metronidazole(400) 1-1-1 for 3 months. All routine investigations were normal. MRI brain(plain) revealed symmetrical hyper intense signals involving Tectum and bilateral dentate nuclei, possibility of metronidazole toxicity. T. Metronidazole(400) was immediately stopped and supportive treatment like high dose intravenous multivitamins were given. Patient responded within 3 days of treatment, with improvement of gait and speech.

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P-244 A Rare Case of Acquired Hemophilia Tajpara Akshay BJ Medical College, Ahmedabad, Gujarat Corresponding Email ID: [email protected]

Acquired Hemophilia is a rare bleeding disorder characterized by autoantibodies against endogenous clotting factors, mainly Factor VIII/IX. It typically presents in middle age and beyond, in contrary to classical disease manifesting in childhood. It manifests as spontaneous mucosal bleeds in form of extensive cutaneous purpura without any known history of bleeding disorder but may cause life threatening bleeding, especially in elderly patients with underlying comorbidities. A case was reported of a 63 year old male patient who presented with complain of hematoma over left flank and buttock following trivial trauma. On investigating, patient was found to have low Hemoglobin with normal PT and prolonged aPTT. Patient had decreased titre of Factor VIII assay and increased titre of Factor VIII inhibitor. Patient was transfused Recombinant Factor VIIIa(Eptacog alpha) and patient showed favourable response.

P-245 A Case of Acute Myocardial Infarction in Pregnant Female Due to Protein S Deficiency Parmar Vijay, Kotak Charmi Department of Medicine, P.D.U. Medical college Rajkot Corresponding Email ID: [email protected]

Introduction: Protein S is a Vitamin K dependent plasma glycoprotein serve as anticoagulant factor . Protein S deficiency leads to hypercoaguability state and generally causes venous thrombosis but here we present uncommon presentation that is case of arterial thrombosis. Case History: Here we report a case of 25 year old female primipara with 6 week of pregnancy presented with chest pain for 2 days followed by a episode of convulsion. On examination, vitally stable and ecg suggestive of acute myocardial infarction (q with biphasic t wave in v1to v6 with ST depression in I avL).

Investigations: CBC shows hypochromic microcytic anemia with leukocytosis, RBS RFT LFT LIPID PROFILE ELECTROLYTES PT APTT INR were within normal range with TROPONIN I positive and serum CKMB level 456IU/L. On further investigations her HOMOCYSTEINE ANA APLA IGg and IGM PROTEIN C ACTIVITY were within normal range but her SERUM PROTEIN S ACTIVITY was low 37%. 2D ECHO suggestive of CAD-RWMA (Hypokinetic Mid Distal Anterior wall, Mid Distal IVS) with aneurysmal IAS and Moderate LV systolic Dysfunction, LVEF 35-40%. MRI BRAIN shows hyper intensity on T2 FLAIR and DWI images involving right anterior Perisylvian insular and frontal cortex suggestive possibility of subacute ischemia-postictal edema. Patient was diagnosed as acute myocardial infarction due to PROTEIN S deficiency associated with pregnancy.

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P-246 Dengue Fever with Acute Disseminated Encephalomyelitis Doshiyad Vrushti, Panjawani S.J Department of General Medicine, Government Medical College,Bhavnagar,Gujarat,India. Corresponding Email ID: [email protected]

Dengue is the most common arboviral disease affecting many countries worldwide. With endemicity of the disease and huge burden, atypical clinical presentations occur posing high diagnostic and therapeutic dilemma. Emerging neurological complications in dengue fever are reported in recent past Acute disseminated encephalomyelitis(ADEM) is an immune mediated acute demyelinating disorder of the central nervous system following recent infection or vaccination and characterized by multifocal white matter involvement. Early suspicion and diagnosis of such complication is clinical dilemma and it further complicates the clinical scenario. This case report highlights occurrence of such uncommon manifestation of ADEM in commonly occurring dengue fever along with its diagnosis and successful management in a young individual. Case Report: A 20 years old male presented with history of high grade fiver with chills, sine 5 days. With altered sensorium. Patient was febrile , with tachycardia with GCS score E2V1M2 on presentation. Patient kept on mechanical ventilation. BP & PR were normal Pupils were normal in size reacting to light. No neck rigiding 1 episode of generalised tonic cronic seizure occured Blood Report: hemoglobin -10.0 g/dl, RBC- 3.0lakhs/cumm, TLC -18000/cumm, PLATELET – 7200/cumm, SGPT – 1200IU/L, SGOT – 1432IU/L, S.BILIRUBIN – 0.9mg/dl, Dengue – NS-1-Antigen & Igm Antibody Positive MRI Brain finding suggestive of Acute disseminated encephalomyelitis secondary to dengue fever. Patient put on supportive measures & steroids Methylprednisolone started at dose of 1gm/day Patient’s sensorium improved in 72 hours. Conclusion: High index of clinical suspicion is required to warrant attention for uncommon manifestations of a common disease – neurological manifestation in classical dengue fever. Rapid and efficient diagnosis with timely management and close monitoring of such fatal post infectious complications is sine qua non to curb further potential clinical complications and to achieve best possible clinical outcome.

P-247 Reversible Cardiomyopathy in Case of Aluminium Phosphide Ingestion Kataria Yogesh, Shah Harshil, Trivedi Aarti Department of General Medicine, PDU Medical College, Rajkot, Gujarat Corresponding Email ID: [email protected]

Introduction: Cardiac Dysfunction due to Morphologically and Functionally Abnormal Myocardium in absence of any other structural disease, due to Aluminium Phosphide Toxicity. Case Report: A 52year Male Patient brought to an Emergency department with Aluminium Phosphide Ingestion 30min before presented with Emesis, Diaphoresis, Palpitation and Acute onset of Dyspnoea, without any significant Past and Personal history of Medical illness.

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Examination: Patient was Hemodynamically Unstable, having Tachycardia (PR-120/min), Hypotension (Systolic BP-60mmhg), Tachypnoea (RR-44/min), Spo2-70%on room air. On R/S Auscultation bilateral lower zone Crepitation present. Investigation & Management: ECG suggestive of Sinus Tachycardia, RBBB, ST-T changes in lead II, III, avF with broad qrs. ABG shows Metabolic Acidosis. Serum Creatinine raised, Cardiac biomarker- CKMB raised with negative Troponin-I. Patient was manage in Intensive Care Unit with Invasive mode of ventilation with Correction of metabolic acidosis, Inotropic support, Antiarrhythmic treatment given. On Stabilization, 2D Echo suggestive of Segmental wall motion abnormality, EF~35% with Systolic dysfunction, Coronary Angiography was Normal. On repeat 2D Echo, on 14th day suggestive of EF~55% with no regional wall motion abnormality. Conclusion: Aluminium Phosphide Poisoning, can cause Severe Cardiac Toxicity (Cardiomyopathy), which is reversible , provided patient receive Intensive Hemodynamic support during initial insult period.

P-248 A Rare Encephalopathy Reversible with Steroid Therapy: Hashimoto’s Encephalopathy Upadhyay Himarshi, Lakhani Krishna Department of General Medicine, Sir T Hospital and Govt Medical College , Bhavnagar, Gujarat Corresponding Email ID: [email protected]

Hashimoto’s encephalopathy (HE) is a rare autoimmune disorder with neurological and neuropsychiatric manifestations and elevated titres of anti-thyroid antibodies. Here we are reporting a case of HE in a 14-year- old girl who presented with ataxia, tremors, behavioural disturbances . Patient did not respond to antipsychotics and anticonvulsants. On further investigation, patient was found to have high serum anti- thyroperoxidase antibodies of about 472 U/mL and anti-thyroglobulin antibody of about 500 U/mL with euthyroid status, which supported a suspicion of HE. Our consultant confirmed the diagnosis and she was started on injection of methylprednisolone 500mg OD. Since patient started showing clinical improvement, her antipsychotic medications were tapered off. On follow-up, patient has recovered and is functioning well. Since HE is a diagnosis of exclusion, very high anti-TPO antibodies and good response to steroids supported the diagnosis of HE in this patient after excluding other etiological possibilities. This case has been reported because the clinical presentation was predominantly neurobehavioural manifestations which is uncommon with HE. Keywords: Hashimoto’s encephalopathy, glucocorticoid therapy, follow-up.

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P-249 Tracheomalacia : A Rare Complication Occuring in Long Standing Goiter after Thyroid Surgery Gopani Mansi, Prasad Ram Nanadan, Patel Jaldeep, Fumakiya Pooja Department of Anaesthesiology, Gujarat Adani Institute of Medical Sciences, Bhuj Corresponding Email ID: [email protected]

Introduction: Tracheomalacia is defind as dynamic reduction in luminal diameter of trachea by 50% during expiration .It may be due to congenital immaturity of tracheal cartilage called primary tracheomalacia or previous normal cartilage undergo degenerative changes by extrinsic compression called secondary tracheomalacia .Secondary tracheomalcia is more common with long standing large thyroid mass. Case Report: We report a case of 50 year old female patient having thyroid mass since 14 year posted for subtotal thyroidectomy under general anaesthesia , who after reversal and extubation diagnosed with tracheomalacia by bronchoscopy and managed with tracheostomy. Discussion: Tracheostomy is perfomed on basis of clinical judgement . The definitive diagnosis is made by bronchoscopy and during bronchoscopy the anterior wall can be observed to collapse against posterior wall. It is rare but known complication after thyroidectomy in patient with enlarged thyroid.

P-250 Anesthetic Management of a Case of Severe Pre-Eclampsia with Pulmonary Edema for Caesarean Section Kansagra Meet, Ram Nanadan, Fumakiya Pooja Department of Anesthesiology, Gujarat Adani Institute of Medical Sciences, Bhuj Corresponding Email ID: [email protected]

Introduction: Pulmonary edema rarely occurs in normal pregnancy. Its incidence increases with the presence of obstetric complications like pre-eclampsia or during the treatment of preterm labor. Case report: We report anesthetic management of 25 year old primigravida with difficulty in breathing and labor pain with severe pre-eclampsia which is complicated with pulmonary edema posted for caesarean section. Discussion: A multi modal treatment that ensures an optimal oxygenation with ventilatory support, stable hemodynamics and fluid restriction. To reduce maternal and fetal complications, management is based mainly on the treatment of symptoms and signs of the secondary effects of pre-eclampsia. The management of these patients should ideally be multidisciplinary and the anesthetist should be involved in the care of patient.

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P-251 Neuromyelitis Optica Spectrum Disorder: A Case Report Machhar Nilay, Panchal Manisha Department of Medicine, P.D.U. Government Medical College and Hospital, Rajkot Corresponding Email ID: [email protected]

A 35 years old female patient with history of pyrexia with altered sensorium 15 days ago, admitted at some hospital, after routine investigations, CSF and CT brain, treated as bacterial meningitis; was discharged asymptomatic and conscious oriented. After 10 days she developed tingling and numbness in bilateral lower limbs and sudden onset bilateral lower limb weakness and complain of retention of urine for 3 days and admitted at P.D.U. Civil Hospital, Rajkot. On clinical examination patient was having 3/5 power in bilateral lower limbs and bilateral absent knee and ankle reflexes, with normal sensory examination. At fundoscopy there was bilateral papilloedema without any ocular symptoms or optic neuropathy. MRI brain was suggestive of hyper intensities without diffusion restriction involving bilateral cerebral peduncle, midbrain and medulla oblongata. MRI Whole spine screening with detailed study of affected spine was suggestive of Long segmental myelopathy from cervicomedullary junction to D10 level. Test for NMO-IgG (AQP4-antibody) was negative. Patient was given treatment in form of injectable steroids with positive outcome as improvement in power in lower limbs.

P-252 Fahr’s Syndrome: A Rare Case Report Nandaniya Puja, Trivedi jayesh, Ahmadi Bashir, Chauhan Vinayak, Chudasama Chanda, Thacker Deep Department of General Medicine, Gujarat Adani Institute of Medical Science, Bhuj Corresponding Email ID: [email protected]

Introduction: Fahr’s syndrome is a rare, neurological disorder characterized by idiopathic calcification of the basal ganglia and cerebral cortex with clinical manifestations in the form of neuropsychiatric, extra pyramidal & cerebellar symptoms, convulsive seizures, parkinsonian features, dementia and speech disorders. Method: we report a case of 29 years male with clinical neurological features and radiological features of Fahr’s syndrome characterized by calcification of basal ganglia. Result: while rare, fahr’s syndrome should be considered as a differential diagnosis for seizures, movement disorders, or cognitive impairment. Classically, bilateral calcification of the basal ganglia is seen on CT. Endemic infections, metabolic and toxic causes should be excluded.

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P-253 Airway Management with Sub-Mental Intubation Technique in a Patient with Reduced Mouth Opening with Pan-Facial Fracture Posted for Open Reduction Internal Fixation and Plating of Mandible and Nasal Reconstruction – A Case Report. Jha Soumya, Chauhan Dinesh, Mehta Malini, Mehta Malini, Thomas Sara Mary Department of Anaesthesiology, S.B.K.S. Medical Institute & Research Centre, Vadodara, Gujarat Corresponding Email ID: [email protected]

Introduction: Airway management in patients with complex maxillofacial injuries is a challenge as anaesthesiologist and surgeon compete for the same space. Oral intubation may interfere with proper maxilla- mandibular reduction. Sub-mental intubation is a useful technique that is less invasive than tracheostomy in securing the airway where oro-tracheal and naso-tracheal intubation cannot be performed. Case Report: A 48yr old male patient with history of polio since childhood and Diabetes Mellitus- type II for 9yrs, on Inj. Insulin subcutaneously according to sliding scale, presented with pan-facial fracture after a road traffic accident. Airway assessment showed reduced mouth opening (2 ½ fingers), edentulous. As the surgery required reduction of the mandibular fracture and nasal bone reconstruction, sub-mental intubation was considered. After standard oro-tracheal intubation, a passage was created by blunt dissection through the floor of the mouth. The proximal end of the cuffed endotracheal tube (flexometallic 8.5) was pulled through the sub-mental incision after the pilot balloon. The endotracheal tube was subsequently fixed with sutures, At the end of the surgery, the tube was pulled back through the sub-mental incision into the usual oral route. Conclusion: Sub-mental intubation is a useful alternative technique of airway management in patients with pan-facial fractures. It is safe and quick to execute and not requiring specialized equipments or skill.

P-254 Anaesthetic Management of Hydatid Cyst of Neck Ramoliya Rinkal, Patel Jaldeep, Padhiyar Bharat, Prasad Ram Nanadan Department of Anaesthesiology, Gujarat Adani Institute of Medical Sciences, Bhuj Corresponding Email ID: [email protected]

Introduction: Hydatid cyst is parasitic infection caused by echinococcus granulosus. The encysted larva of echinococcus granulosus commonly found in liver (50-70%), lungs (18-30%).Though it is endemic in some part of world, more common in developing countries. It can involve any organ. we report a successful management of rare case of Hydatid cyst in neck under general anaesthesia without any adverse events. Case Report: A 13 year old male patient having a right side neck swelling since 4 years, on examination there was a 7cm x 6 cm non - mobile, non - tender, cystic swelling in right posterior triangle of neck. Patient had a history of exposure to dog. There was no liver or lung involvement as seen on USG abdomen – KUB and chest x – ray. All reports were within normal limit. Discussion: Ruptured Hydatid cyst can lead to anaphylactic shock during surgery. Even considered as rare event, it can be life threatening which manifested by hypotension and circulatory collapse leading to death. So, Anesthetist should always be vigilant that anaphylaxis can occur despite of absence of rupture of cyst or spillage of cyst into the circulation.

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P-255 A Rare Case of Takotsubo Cardiomyopathy Vyas Aditya, Patel Ramesh Geetanjali Medical College and Hospital, Department of General Medicine, Udaipur, India Corresponding Email ID: [email protected]

Cardiomyopathy is a disease affecting the heart muscle, accounting for 5-10% of cases of heart failure. The traditional classification of cardiomyopathies into a triad of dilated, restrictive, and hypertrophic was based initially on autopsy specimens and later on echocardiographic findings. The primary causes are then divided into genetic, mixed genetic and acquired, and acquired. The major causes of dilated cardiomyopathy are from infective, non-infective causes, toxic, metabolic, familial and miscellaneous causes. Dilated cardiomyopathy produces systolic failure commonly, associated with mitral regurgitation and functional impairment. A 70-year- old male presented with complains of chest pain since two days associated with shortness of breath. His ECG showed changes of acute coronary syndrome – AWMI. He was evaluated with coronary angiography, found to have normal coronaries, but echocardiography showed regional wall motion abnormality in the apex which was hypokinetic with poor ejection fraction of 35%. The patient was managed with antihypertensives and discharged. Following ten days after discharge his echocardiography showed no regional wall motion abnormality and a normal ejection fraction.

P-256 Anaesthetic Management of Patient having Disseminated Intravascular Coagulation(DIC) with Liver Hematoma in Pregnancy. Asodariya Nidhi, Thacker Mandakinee, Patel Jaldeep, Fumakiya Pooja Department of Anaesthesiology, Gujarat Adani Institute of Medical Sciences, Bhuj Corresponding Email ID: [email protected]

Introduction: Pregnancy is a physiological condition resulting in numerous anatomical and physiological changes. DIC is reflection of coagulation system disorder along with pro-coagulant activation, fibrinolytic activation and consumption coagulopathy which results in organ damage and death. DIC represents one frequent complication of HELLP (hemolysis,elevated liver enzymes, low platelet count)syndrome with reported occurance in 15% to 20%. Subcapsular liver hematoma(SLH) has been reported <2% pregnancy complicated by HELLP syndrome. Method: We report successful anaesthetic management of a case posted for exploratory laparotomy of 27 year old multiparous women with 7 month pregnancy having DIC with liver hematoma had taken under general anaesthesia. Discussion: DIC along with pregnancy can result in challenging case scenario in terms of increased perioperative bleeding, difficult intubation, gastric aspiration, increased sensitivity to anaesthetic drugs, fetal compromise and chances of spontaneous abortion.So it demands cautious and vigilant perioperative management of a case.

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P-257 Title: Lung Cancers Associated with Cystic Air Spaces Sumanth G, Chauhan J.B Government Medical College & SSG Hospital, Vadodara, Gujarat Corresponding Email ID: [email protected]

Introduction: Early lung cancers associated with cystic airspaces are increasingly being recognized as a cause of delayed diagnoses. Several morphologic subtypes of cancers associated with cystic airspaces exist and exhibit variable patterns of progression as the solid elements of the tumor grow. Understanding of the pathogenesis of these malignancies is limited. Several tumor types are represented in these lesions, with adenocarcinoma predominating. Features of cystic airspaces differ among cases and include emphysematous bullae, congenital or fibrotic cysts, subpleural blebs, bronchiectatic airways and distended distal airspaces arising de novo from small cancers owing to obstruction. These abnormalities are often initially misinterpreted as inflammatory changes or infection. These lesions pose a diagnostic challenge as their small size makes difficulty to biopsy, and their position adjacent to cystic areas increase the risk of pneumothorax. Case Report: A 43yrs old male, farmer by occupation with 20 pack years of smoking history, presented with c/o right sided chest pain, Dry Cough since 2 months. On general examination clubbing grade 2 present. On respiratory examination air-entry decreased bilaterally right more than left. Chest radiograph revealed homogenous radio-opacity in right upper zone at sub-pleural location. Sputum for AFB staining and gram stain with culture sensitivity was performed which did not grow any organism. CECT Chest was done S/O Fibrocavitatory lesion in right upper lobe possibility of KOCHs, Multiple cysts like changes in upper and middle lobe of lung with basal sparing P/O emphysematous changes. Then CT guided lung biopsy was done, HPE S/O non-small cell carcinoma most probably Squamous cell carcinoma. IHC was suggestive of squamous cell carcinoma. Discussion: As lung cancer is one of the leading cancers in INDIA. It is emphasized that all patients with chronic cough, chest pain, blood in sputum, weight loss, loss of appetite should be encouraged to visit a doctor in the earliest for early diagnosis and management. Conclusion: In a significant smoking history, early screening techniques like low dose CT can be done to search for any nodule and all lung nodule should be biopsied as in this presentation misdiagnosis and delayed diagnosis is more common. Early detection is all the more crucial for patient survival.

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P-258 A Case Report of Awake Retrograde Nasal Intubation in Commando Surgery for Carcinoma of Bucal Mucosa Kavad Jay, Parmar Sameer Department of Anaesthesiology , Government Medical College, Bhavnagar, Gujarat, India. Corresponding Email ID: [email protected]

Introduction: Endotracheal intubation is one of the most important airway management skill. Endotracheal intubation in patients with limited mouth opening always remains a challenge, especially in the absence of a flexible fiberoptic bronchoscope, however retrograde intubation is a good, additional airway management technique in an anticipated difficult airway. Case Report: Ÿ A 45 year old male patient weighing 58 kg presented in ENT OPD with the complain of progressively increasing swelling involving the right side of cheek and also had difficulty in mouth opening since 3 months. Ÿ Patient was diagnosed as a case of Ca buccal mucosa and posted for commando surgery. Ÿ On the day of surgery, patient was examined in pre anesthetic check up room for vitals and general condition. Ÿ Patient was 6 hours NBM and her routine investigations and vital parameters were within normal limit. Ÿ Informed written consent of anesthesia was taken under ASA grade III and possibility of tracheostomy was explained. Examination of the airway Ÿ Mouth opening was 0.5 finger breadth. Ÿ Mallampati grade IV. Ÿ Temporomandibular joint subluxation, thyro-mental and mento-hyoid distance were within normal limits. Patient was taken in operation theater, difficult airway cart and standby arrangement of emergency tracheostomy were kept ready.As fiberoptic bronchoscope of our department was under repair, we opted for retrograde nasal intubation. Intraoperative monitoring was done by Pulse oximetry(SPO2), ECG, Non invasive blood pressure(NIBP), Capnography(ETCO2) Pre-medication was done with Inj.ondansetron 4 mg i.v, Inj.Glycopyrrolate 0.2 mg i.v, Inj.Fentanyl 100 mcg i.v. Preparation of Patient: Ÿ Anaesthesia of nose, nasopharynx was achieved with 4% lignocaine nebulization

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Ÿ Anaesthesia of oropharynx was achieve with lignocaine 10%spray. Ÿ Bilateral superior laryngeal nerve was blocked with 2 ml of 2% lignocaine at 1 cm below lateral cornu of hyoid. Ÿ Trans-tracheal 3 ml of 2% lignocain was given.

Procedure: Ÿ After explaining the procedure to the patient, he was given supine sniffing position with the neck fully extended. Anterior aspect of neck was aseptically prepared and draped. Ÿ Cricothyroid membrane puncture was performed with 16 G tuohy needle, tracheal lumen was confirmed by using seldinger’s technique. Ÿ A stainless steel guide wire was advanced cephaled through the needle and was retrieved succesfully from nasal cavity. Ÿ A flexometallic endotracheal tube no. 7.0 was railroaded over the guide wire into the trachea, guide wire was pulled outside from its proximal end. Ÿ Bain’s circuit was connected to ET tube and tracheal intubation was confirmed by bilateral auscultation of breath sound and capnography. Ÿ Induction of general anaesthesia was done with inj. Propofol and maintained with oxygen, nitrous oxide, sevoflurane and inj. Atracurium. Ÿ Intraoperative period was uneventful. Ÿ At the end of surgery intubated patient was shifted to ICU after giving pharmacological reversal. Ÿ Patient was extubated succesfully on the next day on airway exchange catheter as it was a potential difficult airway.

Discussion: Ÿ The 1st retrograde intubation was done by BUTLER and CIRRILO in 1960, the procedure was originally described by waters. Ÿ The appropriate level of analgesia and sedation prior to procedure is challenging because overdose of medication can results in a loss of spontaneous respiration, can be disastrous in a difficult airway, and

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insufficient medication may result in patient discomfort, pain, coughing, tachycardia, making the tracheal intubation technically more difficult to even impossible. Ÿ The possible complications of procedure are hypoxemia before securing the airway, bleeding at cricothyroid puncture, sore throat, bronchospasm, laryngospasm, epistaxis, infection. Ÿ It is still a safe, reliable, simple technique to secure the airway where spontaneous respiration and natural airway patency can be preserved. Conclusion: Ÿ An anesthesiologist should examine each patient’s airway carefully, identify difficult airway, devise a plan for its management and have a backup plan immediately available. Ÿ In our study , we found that blind awake retrograde intubation is still a viable option to secure the difficult airway in an unfortunate situation, where fiberoptic intubation facility is unavailable. References: Ÿ Reed AP.Preparation for intubation of the awake patient. Mt sinai J Med 1995;62:10-20 Ÿ Bhattacharya p, Biswas BK, Baniwal s. Retrieval of a retrograde catheter,in patients who can not open their mouth.Br J Anaesth 2004;92:888-90(PUBMED). Ÿ Butler F S cirillo A.Retrograde tracheal intubation.Anaesth Analg 1960;39:333-338. Ÿ http://www.ijaweb.org/text.asa?2008

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P-259 Changing Trends:Plasmodium Vivax Infection in First Time Diagnosed Sickle Cell Disease Oswal Harshal , Gadhavicharan S. Department of Medicine, P.D.U. Medical College , Rajkot Corresponding Email ID: [email protected]

Sickle Cell Disease is the prototype of hereditary hemoglobinopathies; characterized by production of structurally abnormal hemoglobin. Oxygen free radicals formation in sickle cell disease; retards the growth and damages the Plasmodium parasite. Homozygous HbS red cells produces excess of hemin which damages parasites. A case of 13years old female patient named Shivaniben Rameshbhai Parmar resident of Tankara district was referred from Tankara PHC with complaints of fever with chills and yellowish discoloration of eyes since 3 days and no significant past medical or family history. She was clinically examined and found normal vitals , normal RS, CVS, CNS examination. Mild splenomegaly present , pallor present, icterus visible. Her referral chit mentioned P.vivax Positive. On Expert PSCM; patient had Hb=4.4, TLC=8200, PC= 1.66lacs. Retic count = 1.5, Sgot 72, Sgpt 22, Total Bilirubin= 1.7, sickle solubility test and sickling test was positive. Ultrasonography of abdomen revealed borderline hepatomegaly and moderate splenomegaly with P/o splenic infarcts. HPLC was done and suggestive of HbS sickle cell (Homozygous). Patient was treated with artesunate and discharged after 4days with primaquine course. Conclusion: Concomittant presentation of sickle cell disease with malaria is rare but, proves that sickle cell disease is not always immune to malaria.

P-260 A Rare Presentation of Dengue Haemorrhagic Fever with Leukemoid Reaction Kansagara Dhrumil General Medicine Department, Guru Gobindsingh Government Hospital, Jamnagar, India. Corresponding Email ID: [email protected]

Dengue is a mosquito-borne viral infection causing a severe flu-like illness and sometimes causing a potentially lethal complication called severe dengue. The incidence of dengue has increased 30-fold over the last 50 years. Up to 50-100 million infections are now estimated to occur annually in over 100 endemic countries, putting almost half of the world’s population at risk. Severe dengue (previously known as dengue haemorrhagic fever) was first recognized in the 1950s during dengue epidemics in the Philippines and Thailand. Today it affects Asian and Latin American countries and has become a leading cause of hospitalization and death among children and adults in these regions. The CBC in dengue patients change by the day of the fever, specifically on days 3 to 8, starting with progressive leukopenia followed by thrombocytopenia and haemoconcentration due to plasma leakage. Normoleukocytosis or mild leucocytosis may be found in early dengue infection. When body temperature declines, most patients experienced leukopenia from bone marrow suppression. Stress in accompanied with shock may somehow cause leucocytosis. This is to describe that there is a rare presentation of Dengue Haemorrhagic fever with leukocytosis to the level of Leukemoid Reaction

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P-261 A Case of Tuberous Sclerosis with Status Epilepticus Gupta Pranav, Shrimali Lalit Department of General Medicine, Geetanjali Medical College And Hospital, Udaipur, India Corresponding Email ID: [email protected]

Tuberous sclerosis or Tuberous Sclerosis Complex (TSC) is an autosomal dominant disease which comes under a group of diseases known as Neurocutaneous syndromes or phakomas. Incidence of TCS is around 1 in 6000. It is characterized by the growth of numerous hamartomas in several organs including the brain, heart, skin, eyes, kidney, lung and liver. The affected genes are TSC1 and TSC2 encoding hamartin and tuberin respectively. Here, we are presenting a case of 27 year old female admitted in medical ICU ward with the history of fever since 4 days and continuous convulsions since 24/12/18 morning 7 am GTCS type. Mother gave history of patient having mental retardation since childhood with devlopmental delay with history of seizures since past 4 years. On physical examination patient had angiofibroma present over the face and shagreen’s patch over back. Radiological investigation showed . This case report emphasizes the importance of complete evaluation of a case presenting with seizures and inclusion of TSC (Tuberous Sclerosis Complex) as a differential diagnosis in patients presenting with seizures, developmental delay.

P-262 A Case of Acute Respiratory Distress Diagnosed with Bulbar Myasthenia in Young Male Hathiari Farida, Rathod Mahesh Department of Medicine, P.D.U Medical College, Rajkot Corresponding Email ID: [email protected]

Case History: A 30 year old male patient presented with complaint of sudden onset respiratory distress since one day with past medical history significant for on and off complaint of dysphagia for which he was managed as an outdoor patient by local private practitioners.Vitals were stablilised by rapid institution of mechanical ventilatory support .Further clinical assessment showed normal cardiovascular system minimal creps in basal lung fields and exaggerated deep tendon reflexes with intact sensations and bowel bladder functions.Routine blood panels showed neutrophilic leucocytosis with normal liver and renal function tests and electrolytes .First and serial ABG were consistent with type 2 respiratory failure with significant improvements with the MV. In order to rule out bulbar palsy taking in to consideration prior symptom MRI brain was done which was normal and cect thorax suggested bulky thymus.With these clinical cues emg-ncv study was conducted which showed low CPAP.Acetylcholinesterase antibodies value was evaluated in plasma which came out to be 17.93nmol/l which led to the definitive diagnosis of myasthenia. Patient was further stabilized with anticholinesterase,high dose of steroids and mechanical ventilation. Bulbar myasthenia is predominantly seen in old age patients but sometimes in hospitals we may be dealing with the minor but significant population who are frequently misdiagnosed due to wide range of weavering symptoms of the disease.

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P-263 A Case Report of Dialysis Disequilibrium Syndrome in a Patient of Haemodialysis in Acute Kidney Injury Kanani Tushar, Srivastav Vipul, Doctor Nilesh, Shah Hemant Department Of General Medicine, Surat Municipal Institute of Medical Education and Research, Surat. Corresponding Email ID: [email protected]

Introduction: Dialysis Disequilibrium Syndrome is serious neurological complication of haemodialysis associated with cerebral oedema and irreversible brain injury. more common in younger patient and in who had under gone rapid haemodialysis. The symptoms involve the neurologic system and are similar to symptoms that occur with increased ICT or acute hyponatremia, such as restlessness, headache, mental confusion and coma. Because these symptoms are not specific for the DDS, other diagnoses that must be considered and ruled out are, 1. Hypoglycemia 2. Uremia 3. Nonketotic hyperosmolar coma 4. Hyponatremia 5. Dialysis dementia 6. Subdural hematoma 7. Acute cerebrovascular event 8. Malignant hypertension Case Report : A 18 years old female pt came with fever with chills and burning micturition since 2 weeks difficulty in breathing since 12 hr. nosignificant past history. On Admission Temperature increased 102 F Pulse 100/min Respiratory rate 30/min BP 104/70 mmhg Spo2 98 Pt fully conscious oriented to time place person Bilateral renal angle tenderness present WBC 26000 Urine rotine micro shows 12-15 pus cell Serum creatinine 8.4 mg/dl Urea 130 mg/dl Na+ /K+ /Cl- 147/4.9/107 mmol/l ABG shows severe metabolic acidosis

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Ph 7.018 PCO2 14 mmhg HCO3 7mmol/l increased anion gap USG abdo show bilateral pyelonephritis CXR NAD Treated as urosepsis But pt had refractory acidosis after 12 hr Repeat ABG Ph 7.018 PCO2 20mmh HCO3 10mmol/l Serum creatinine 9.1mg/dl Urea 148mg/dl Na+ /K+ /Cl- 148/5.0/102 mmol/l Pt became disoriented to time and place likely caused by uremic encephalopathy and pt put on HD Dialysis started , about 1hr after pt started complaining about headache and nausea RBS was normal BP 110/70 mmhg HD was hold. Just after holding HD, pt started GTCS. Injection lopez given IV Inj 3% NaCl started S urea 130mg/dl S.calcium 10.8 mg/dl Na+ /K+ /Cl- 142/4.6/100 mmol/l pt gain consciousness after 30 min Radiological investigation done pt had cerebral edema. Conclusion : Dialysis disequilibrium can occur in any patient undergoing hemodialysis, but it is more often seen when patients are undergoing their first treatment. Slow removal of urea during the first several treatments is critical for avoiding this syndrome. If a patient shows signs or symptoms of dialysis disequilibrium, steps to lower intracranial pressure can help reduce morbidity and mortality.

P-264 A Rare Presentation of Renal Tubular Acidosis Type 4 with Paraparesis Gangdev Abhay , Dudharejia Praful Department of Medicine, P.D.U. Medical College , Rajkot Corresponding Email ID: [email protected]

A 55 year old female patient named Shantaben Govindbhai presented with chief complaints of Inability to walk, Inability to use both lower limbs since 4 days without any history of loss of consciousness and seizure with past history DM2 and IHD. She was clinical examined and found normal vitals, normal RS and CVS examination . CNS examination reveal Flaccid paraparesis with grade 2/5 power in both lower limbs . Deep Tendon Reflexes were absent and sensations were intact. No bowel or bladder involvement. No cranial nerve abnormality with bilateral absent Planter reflexes. Her investigations showed profound hyperkalemia 7.5 Mg-1.2 with normal phophate with bicarbonate level 20 and pH.7.3. On questioning, she admitted to having symptoms of sudden lower limb weakness since 4 days. Ultrasound KUB was S/o bilateral CMD increased with loss of echotexture plus fundus examination S/O DMR changes present. Urine routine microscopy was Albumin +2 and sugar +3. NCV test of both lower limb normal and MRI L-S spine not significant . Patient was given pottasium correction with IV calcium gluconate to prevent cardiac arraythmia and IV insulin plus glucose infusion to enhance pottasium influx in cell and pottasium sparing drug hold as tab spironalcatone and ACE inhibitors.patient gradually improved in next 5 days. Conclusion : Patients presenting with paraparesis with potassium imbalance should be evaluated for RTA.

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P-265 Rare Case of Rathke’s Cleft Cyst Presenting as Hyponatremia Haideri Shahid, Basu Abhijit Geetanjali Medical College and Hospital, Department of General Medicine, Udaipur, India Corresponding Email ID: [email protected]

Rathke's cleft cyst is a benign growth found on the pituitary gland in the brain. It is specifically a fluid-filled cyst in the posterior portion of the anterior pituitary gland. It occurs when the Rathke's pouch does not develop properly, and ranges in size from 2 to 40mm in diameter. Asymptomatic cysts are common and are detected during autopsies of 2–26% of individuals. Symptomatic cysts are rare and only approximately 150 cases have been reported. Symptomatic cysts can trigger visual disturbances, pituitary dysfunction and headaches. A 58 yr old male was admitted in ICU with complain of on and off headache which was severe in intensity, non projectile vomiting, hiccups since 5 days and irrelevant talking since 1 day. On evaluation the patient was found to have hyponatremia, for which treatment was started. Further investigations revealed low levels of serum cortisol, serum IGF 1 and serum TSH. MRI was done which showed Rathke’s cleft cyst. After steroid and thyroxine replacement patient developed polyuria/polydipsia because of unmasking of diabetes insipidus and was started on desmopressin replacement. His condition gradually improved and patient is being followed up on regular OPD basis.

P-266 Type 1 Spinocerebellar Ataxia in a Middle-Aged Man: A Rare Case Report Gavli Nayan, Shastri Minal Department of Medicine, Government Medical College, Vadodara, India Corresponding Email ID: nayangavli52@ gmail.com

The spinocerebellar ataxias (SCAs) are genetically heterogeneous group of autosomal dominant inherited progressive disorders; the clinical hallmark of which is loss of balance and coordination accompanied by slurred speech. The global prevalence of SCA is 0.3-2 per 1,00,000 population with type 3 being the commonest worldwide and type 2 being the commonest in India. SCA 1 is rare and characterized by progressive cerebellar ataxia, dysarthria and eventual bulbar dysfunction with abnormal CAG trinucleotide repeat expansion of the SCA 1 gene in chromosome locus 6p23. This is a case of 40-year-old male who developed imbalance on walking- insidious in onset and gradually progressive, which progressed to difficulty in standing and tendency to fall sideways that progressed over a period of 1.5 years. Tremor, which was insidious in onset, gradually progressive involving bilateral upper limbs with difficulty in trying to reach and hold objects and associated with scanning speech. Family history of similar affection in mother who died at the age of 50 years, youngest sister who died at the age of 32 years and 45 years old eldest sister who is alive, with two normal children. After thorough examination, we came to a clinical diagnosis of Spinocerebellar Ataxia type 1, which was confirmed by genetic screening. Most SCA mutations cause prominent damage to cerebellar Purkinje neurons with consecutive cerebellar atrophy, although Purkinje neurons are only mildly affected in some SCAs. As there is currently no treatment to slow or halt SCA (many SCA lead to premature death), the clinical care of patients with SCA focuses on managing the symptoms through physiotherapy, occupational therapy and speech therapy.

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P-267 Disseminated Koch’s Involving Mediastinal, Cervical Lymph Nodes and Right Knee Joint – Case Report Patel Keyur, Rami Kinjal, Chatterjee Iva, Ghanchi F Government MP Shah Medical College and GG Hospital, Jamnagar. Corresponding Email ID: [email protected]

Introduction: Disseminated TB is contagious mycobacterium infection in which mycobacterium spread from lung to other parts through lymph or blood.it account for about less than 2%of all cases of TB in Immunocompetent and upto 20%in extrapulmonary TB. Case Report: A 24 year old male referred to GG hospital in sept 2019 for having complain of right side knee joint pain with inflammation since 1month,mild fever 1wk.clinical worsening inspite of injectable antibiotics for 14 days and completed AKT CAT 1 for Koch's mediastinal lymphadenopathy from jan 19 to Aug 19 one month omitted in between from private clinic. Chest xray and CECT thorax s/o mediastinal lymphadenopathy with Rs B/l clear. Reports: Bronchoscopy guided TBNA cyto: focal Epithelioid Granuloma. Transbronchial lung biopsy: epithelioid granuloma with focal necrosis. BAL : AFB not seen, culture negative. MRI Right knee: marrow edema with cortical erosion,head neck of right fibula with periosseous intramuscular collection infective? USG local right knee: irregular hypoechoic collection with internal anechoic with strip thickness 2cm internal vascularity extending superiorly up to distal end of femur and inferiorly upto mid third of leg in intramuscular plane. Xpert: aspiration from periosseous collection knee joint (fibula)MTB Detected, Rifampicin resistance : detected Pus: culture for MTB: positive DST pattern: INH Resistant, Rifampicin resistant,Quinolone: Resistant,Second line injectable: sensitive. Started bedaquiline with optimized background regimen. Discussion: This case represent extra pulmonary presentation of an uncommon disease process in an immunocompetent host. This is result of direct hematogenous or Lymphatic spread From primary focus presentation indolent with pain,joint swelling and stiffness. Diagnosis is difficult,as biochemistry of join collection not help full AFB is positive only in 20% . culture can be positive in 80% cases.Delayed diagnosis can be avoided by high clinical suspicious where patient have constitutional symptoms,focal joint inflammatory pathology and travel history in tb endemic region,ziehl neelsen staining, culture if tb is differential.

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P-268 A Rare Case Report of Pulmonary Alveolar Proteinosis Patel Mayur, Trivedi Jayesh , Chudasama Chandan Gujarat Adani Institute of Medical Science, Bhuj, India Corresponding Email ID: [email protected]

Case Report : A 25 years old male patient was admitted to emergency department with the complaints of shortness of breath at rest, progressive in nature since last 2 months, cough with minimal mucoid sputum since 2 months and no other chief complaints. The physical examination revealed bilaterally inspiratory fine crackles on auscultation. The chest radiographs showed bilateral diffuse consolidation, having a perihilar and basal distribution.The patient was a non-smoker and had no environmental and occupational organic or inorganic dust exposure. It is an unusual lung disorder of unknown etiology characterized by the accumulation of large amounts of a phospholipoproteinaceous material in the alveoli that stains positive by using the Periodic acid- Schiff (PAS) method. More recently, the role of granulocyte-macrophage colony stimulating factor (GM-CSF) has been described in the pathogenesis of the PAP.2 A deficiency in GM-CSF activity results in defective macrophages and reduced clearance of surfactant from the lungs. Anti–GM-CSF antibodies have also been found in most patients. Discussion And Conclusion : Wang et al. suggested that actual lung tissue, obtained via transbronchial biopsy or open lung biopsy, remains the ‘‘gold standard’’ of diagnosis but is not necessary except in problematic cases. They proposed that, when several clinical features (eg, symptoms, laboratory test results, chest radiographs, and HRCT findings) suggest PAP, BAL alone was generally sufficient to exclude other conditions. According to clinical symptoms, blood gas results, radiolographic findings, BAL findings and exclusion criteria for other possible diseases; Our case was considered primary PAP since the case was non-smoker and had no environmental or occupational exposure. Although the radiological findings are very extensive in some PAP patients, the respiratory symptoms may be relatively mild. A young, non-smoker male presenting with extensive radiological alveolar opacifications and crazy paving pattern on HRCT, PAP should be considered although the disease is rare. References : 1. Rosen S, Castleman B, and Liebow A 1958. Pulmonary alveolar proteinosis. N. Engl. J. Med. 258:1123–11421. 2. Shah PL, Hansell D, Lawson PR, Reid KBM, Morgan C. Pulmonary alveolar proteinosis: clinical aspects and current concepts on pathogenesis. Thorax 2000;5:67–77. 3. Ioachimescu OC, Kavuru MS. Pulmonary alveolar proteinosis. Chron Res Dis 2006;3:149–59. 4. Trapnell BC, Whitsett JA, Nakata K. Mechanisms of disease: pulmonary alveolar proteinosis. N Engl J Med 2003;349:2527–39 5. Wang BM, Stern EJ, Schmidt RA, Pierson DJ. Diagnosing pulmonary alveolar proteinosis. A review and an update. Chest 1997;111:460–6

193 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020

P-269 Black Water Fever: A Fatal Complication of Malaria – A Case Report Sethi Sandeep, Gadhavicharan S PDU Medical College and Civil Hospital, Rajkot, Gujarat, Corresponding Email ID: [email protected]

Introduction: Blackwater fever is a grave complication of P. Falciparum malaria infection in which red blood cells burst in the bloodstream (haemolysis), releasing haemoglobin directly into the blood vessels and into the urine, and further leads to renal failure. The disease was first linked to malaria by the Sierra Leonean physician Dr John Farrell Easmon in his 1884 pamphlet entitled “The Nature and Treatment of Blackwater Fever”. Easmon coined the name "black water fever" now it is also called as malarial haemoglobinuria, one of the less common yet one of the most dangerous complications of malaria. It occurs almost exclusively with infection from the parasite Plasmodium falciparum. Blackwater fever has a high mortality. Clinical Presentation: A 50 years old male patient referred from some private hospital Rajkot presented in casualty with chief complain of acute onset of breathlessness associated with history of high-grade fever with chills, vomiting and difficulty in micturition with dark coloured urine. Patient was chronic smoker for 30 years and was conscious and fully oriented. His SpO2 was 70% with Oxygen support with normal vitals except Respiratory system examination s/o B/L M/Z and L/Z crepitations. USG screen was normal except for bilateral mildly enlarged kidneys with increased echogenicity. Results: Total blood counts were suggestive of septicaemia and urine with plenty of pus cells and normal renal functions as per outside investigations. In our setup his consecutive three blood samples were reported to be lysed by pathologists. Renal function was very poor with high serum creatinine, BUN and hyperkalaemia. Peripheral blood smear from finger prick sample exam was positive for malarial parasite infested red blood cells with evidence of hemolysis and thrombocytopenia. Repeat Urine exams suggested few pus cells but NO red blood cells. MP by Card positive for P. falciparum malaria. So, it was clearly a case of black water fever due to plasmodium falciparum malaria infection complicated with acute renal failure with ARDS. Patient was managed with injection Artesunate, higher antibiotics, Inj. Steroids with non-invasive ventilatory support and 8 cycles of hemodialysis with 14 units of blood products. Finally, patient was discharged after 21 days in hemodynamically stable condition. Discussion: Blackwater fever (BWF), a rarely encountered clinical entity, is known to occur predominantly in nonimmune individuals residing in P. falciparum-endemic areas and receiving inadequate doses of the anti- malarial drugs. This medical emergency is characterised by sudden and severe intravascular haemolysis leading to haemoglobinaemia and haemoglobinuria and clinically manifested by anaemia, passage of dark urine and often oliguric renal failure. Though the underlying pathogenesis is poorly understood, association with partial immunity to malaria, G6PD-deficiency with subsequent oxidative-drug exposure, use of amino- alcohols particularly quinine and severe falciparum malaria with normal G6PD levels have been documented. PBS usually documents low levels or absence of P. falciparum parasiteamia, as they are destroyed by the haemolytic crisis like in this case. Conclusion: This report describes a case of classic blackwater fever without prior history of malaria infection nor usage of anti-malarial prophylaxis. Strong clinical suspicion is the cornerstone of early diagnosis and management to reduce mortality and morbidity.

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P-270 Rare Presentation of Cerebrovascular Event after Scorpion Sting Baldaniya Laljee, Kamdar Panna Department of General Medicine, Government Medical College, Bhavnagar. Corresponding Email ID: [email protected]

Background: Scorpion sting is potentially life threatening medical emergency. Cerebrovascular manifestation with focal deficit are uncommon presentation of scorpion sting. Vasospasm and autonomic storm due to scorpion envenomation is a possible explanation of this event. Case report: We noticed a 22year young male farmer patient admitted, with complaints of vomiting, breathlessness, perspiration, local site pain, numbness after scorpion sting on left lower limb. On third day after admission, patient develops weakness of left upper and lower limbs. On examination, he was conscious and oriented, his right radial, brachial, subclavian and carotid pulses were not palpable, while those on the left were normal. Blood pressure could not be recorded over the right arm but was 120/70 mmHg on the left arm. The lower limb pulses and the blood pressures were normal and equal on both sides. His right upper limb was cooler compared to the left, although there was no pallor, cyanosis or gangrene. The systemic examination of respiratory, cardiac and abdomen were normal. He had left hemiparesis (power 2/5 in the upper and 1/5 in the lower limb). All the hematological investigations (coagulation profile),blood biochemistry, fundus, electrocardiogram, chest x-ray and 2d echo color doppler were also within normal limits. Contrast enhanced CT scan showed multiple bilateral triangular watershed cerebral infarcts involving the frontoparietal regions anteriorly and temporo-occipital regions posteriorly in the distribution of the middle cerebral artery especially on the right side. The patient was treated with iv fluids, steroid, diuretics and anti ischemic medications and physiotherapy. Patient was improved slowly over next 2 weeks and able to walk with support with residual left hemiparesis. Conclusion: Multiple bilateral asymmetric watershed cerebral infarcts on CT brain, as seen in the present case are likely to be due to reduced blood flow in the carotid arterial system. The reduced carotid blood flow in the present case can perhaps be explained by severe vasospasm related to autonomic storm following the scorpion bite. Look for possible causes of cerebrovascular event and early detection and treatment of cerebrovascular event after scorpion sting prevent stroke associated morbidity and mortality. So physician should aware of this unusual presentation after scorpion sting.

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P-271 A Rare Case Report of Disseminated Histoplasmosis in Immunocompetent Host Shah Dhaval , Budhrani Deepmala PDU Medical College, Rajkot. Corresponding Email ID: [email protected]

Introduction: Histoplasmosis is a disease of worldwide occurrence caused by dimorphic fungus Histoplasma capsulatum. In India, till now only sporadic cases are reported. This disease primarily affects the lungs, but eventually other organs like bone marrow, spleen, liver, adrenal glands etc are also involved, called Disseminated histoplasmosis. Histoplasmosis is most commonly seen in immunocompromised individual. Material and Methods: A 54 years old male farmer patient, presented with complaints of low grade fever and generalised bodyache since 15 days and complaint of abdominal pain since 8-10 days. Patient was known case of diabetes mellitus. On general examination, vitals were normal with pallor present and no any lymphadenopathy. On per abdomen examination – liver (2 cm) and spleen (4 cm) was palpable. The remainder of his physical examination was with in normal limits. Blood investigations shows anemia with thrombocytopenia with altered liver enzymes. Peripheral smear was suggestive of pancytopenia without any evidence for malaria or any other parasites. Serum Widal and serum Dengue IG M antibody test was also negative. Antibodies for HIV 1 and HIV 2 were negative. USG abdomen+pelvis and CT abdomen reports were suggestive of gross splenomegaly. Bone marrow aspiration was done and report was suggestive of fungal infestation by histoplasma capsulatum. Then after anti fungal therapy was started in form of tab itraconazole (200 mg) twice a day for 12 weeks. Patient was improved and anemia and thrombocytopenia also cleared in follow up reports. Conclusion: BM can be helpful in cases of pyrexia of unknown origin with hematological abnormality and Histoplasmosis is challenging to diagnose, should be considered in patients with fever, hepatosplenomegaly and pancytopenia even in nonendemic areas as well as immunocompetent individuals.

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P-272 A Rare Case of Henoch Schonlein Purpura in Adult Female Patient Sodala Ashokbhai, Vora Chitralekha General Medicine Department, B . J . Medical College , Civil Hospital, Ahmedabad , Gujarat Corresponding Email ID: [email protected]

I describe a case of an adult female with Henoch-Schonlein Purpura (HSP) , presenting with cutaneous, renal and gastrointestinal manifestations. Biopsies revealed a leukocytoclastic vasculitis in the skin. Steroid therapy led to complete resolution of the symptoms .HSP is the most common childhood vasculitis, and is characterized by the classic tetrad of non thrombocytopenic palpable purpura, arthritis or arthralgias, gastrointestinal and renal involvement. It is a systemic disease where antigen-antibody, (IgA) complexes activate the alternate complement pathway, resulting in inflammation and small vessel vasculitis. Mild disease resolves spontaneously and symptomatic treatment alone is sufficient. Systemic steroids are recommended for moderate to severe HSP. The prognosis depends upon the extent of renal involvement ,which require close followup.

P-273 A Rare Case of Tuberculosis Associated Aortitis Lakum Akash, Kumawat Dalchand Department of General Medicine, Geetanjali Medical College and Hospital, Udaipur, India Corresponding Email ID: [email protected]

Aortitis is a term referring to inflammatory disease of the aorta. It may be caused by large vessel vasculitides such as Takayasu’s arteritis and giant cell arteritis, rheumatic and HLA-B27–associated spondyloarthropathies, Behcet’s syndrome, antineutrophil cytoplasmic antibody (ANCA)–associated vasculitides, Cogan’s syndrome, Erdheim-Chester disease, IgG4-related systemic disease, and infections such as syphilis, tuberculosis, and Salmonella, or may be associated with retroperitoneal fibrosis. Aortitis may result in aneurysmal dilation and aortic regurgitation, occlusion of the aorta and its branch vessels, or acute aortic syndromes. A 17 years old female patient came with history of giddiness and headache and fever with chills since 15 days, and also complained of intermittent claudication since 6-7months. On admission, her blood pressure was 160/90mmHg and peripheral pulses were absent in bilateral lower limbs and abdominal bruit was present. CT angiography showed circumferential thickening of upper abdominal aorta with luminal stenosis extending downwards from the level of diaphragm up to origin of celiac trunk suggesting aortitis. Mantoux test, ESR and CRP levels suggested tubercular infection for which ATT and oral steroids were started. On 1 month follow up of the patient, she was symptomatically better, her BP was 130/80mmHg and all peripheral pulses became palpable. Thus, aortitis in this patient was proved to be due to tuberculosis.

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P-274 A Cross Sectional Study on Comparative Effect of Atorvastatin vs Rosuvastatin on Galectin-3 in Heart Failure Patient’s S Lavanya, D Jayashree, Daniel Jacintha, Christan M, Daniel Christy, Dharamsi Abhay Department of Pharmacy Practice ,Parul Sevashram Hospital, Vadodara, Gujarat, India. Corresponding Email ID: [email protected]

Galectin-3 has the role to play in fibrogenesis, inflammation, tissue repair, and cell proliferation. Recently, it has been suggested that galectin-3 may play a role in the pathophysiology of HF through promotion of myocardial fibrosis and inflammation, two related processes involved in myocardial remodelling. Increased galectin-3 may, therefore, be a marker for patients with a poor prognosis related to excessive and potential irreversible myocardial fibrosis. The importance and clinical use of repeated measurements of galectin-3 have not yet been reported. Aim and Objectives: To assess the concentration of Galectin-3 and identify the effectiveness on statin therapy in heart failure patients. Methods and Results: 50 study participants diagnosed with heart failures were assessed and separately two groups with 25 each were administered with either atorvastatin or rosuvastatin. Galectin-3 was measured in plasma. There was an interaction between baseline galectin-3 and rosuvastatin on the primary endpoint (P- value for interaction = 0.036). Among patients with below the median plasma concentrations of galectin-3 (≤ 19.0 ng/mL), those assigned to rosuvastatin had a lower primary event rate [hazard ratio (HR) 0.65; 95% confidence interval (CI), 0.46-0.92; P= 0.014], lower total mortality (HR 0.70; 95% CI, 0.50-0.98; P= 0.038), and lower event rate of all-cause mortality and HF hospitalizations (HR 0.72; 95% CI, 0.54-0.98; P= 0.017) compared with atrovastatin, but no benefit was observed in patients with higher levels of galectin-3. Galectin-3 levels assessed were found to be decreasing in patients administered with rosuvastatin with respect to atorvastatin. Conclusion: Patients with systolic HF who have galectin-3 values <19.0 ng/mL may benefit from rosuvastatin treatment compared to atrovastatin. Keywords: Heart failure, Galectin-3, Rosuvastatin, Atrovastatin

P-275 Rare Presentation of Tethered Cord Syndrome with Aqueductal Stenosis in an Adolescent Patient Savaliya Shyam, Jhala J Geetanjali Medical College And Hospital, Dept Of General Medicine, Udaipur , India Corresponding Email ID: [email protected]

Tethered spinal cord syndrome is a neurologic disorder caused by tissue attachments that limit the movement of the spinal cord within the spinal column. These attachments cause an abnormal stretching of the spinal cord. It can be caused by myelomeningocele, lipomyelomeningocele,dermal sinus tract, diastematomyelia, lipoma, tumor, thickened filum terminale, etc. The symptoms usually appear in infancy and childhood. This is a case of

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18 year old male patient admitted with chief complaints of Bilateral leg pain since urine incontinence since 6 months, and giddiness followed by loss of consciousness 1 day back. Patient's general and neurological examination were insignificant. Blood investigations was normal. MRI revealed tethered spinal cord upto L4-L5 with aqueductal stenosis. Laminectomy at L3 to S1 was done with excision of lipoma and detethering was done. VP shunting was done for hydrocephalus. Post operatively he had marked neurological improvement and gained gradual self control on his bladder. Early diagnosis, timely and adequate surgical release is an important for successful management.

P-276 A Case of Hypokalemic Periodic Paralysis Banthia Nilesh Neo Clinic, Navi Mumbai Corresponding Email ID: [email protected]

A 40yrs old male patient presented with history of weakness all 4 limbs, with inability to walk. Patient gave a history of fever, with heavy physical work, followed by weakness. O/E P 120/min, BP 130/80mmhg, general examination normal, had fever, 101 degree F. On CNS examination the patient had quadriparesis, with power of 3/5 in all 4 limbsPatients higher functions were normal, and had no cranial nerve palsies, but had neck weakness, his sensations were normal, and the reflexes were reduced, but present, and the plantars were flexors, bowel and bladder were normal. So patient had a diagnosis of acute quadriparesis, with D/D of GBS or Hypokalaemic periodic paralysis. He had no h/o any injections or vaccinations taken outside. Had no history of similar episode in the past. He had no history of vomitting, or diarrhoea or any drug intake. He only had a h/o fever for 1 day and over exertion. We investigated him and found out that he had low Potassium levels, 2.9mg%, and his other reports were normal. We started potassium correction with IV potassium drips of 20meql in 100ml NS over 1 hr 3 drips per day. His sugars were also normal. He had no history of vomitting, or diarrhoea or any drug intake. He only had a h/o fever for 1 day and over exertion. We investigated him and found out that he had low Potassium levels, 2.9mg%, and his other reports were normal. We started potassium correction with IV potassium drips of 20meql in 100ml NS over 1 hr 3 drips per day. His sugars were also normal. Gradually his potassium increased to 4.7, and the weakness recovered, and the patient was planned to be discharged the next day. Only abnormality he had was persistent tachycardia. We also did his ABG which was normal, and did not show Acidosis or alkalosis. So the patient had hypokalemic periodic paraslysis, which improved with potassium correction. This must be percipitated by fever and physical exertion. The cause for hypokalemia was not found, as the pt had no GI loss of K+, and he was not on diuretics, and had no Metabolic acidosis or alkalosis. Also there were no cause for transcellular shifts. Only other way renal loss of k+. There was no cause found out for renal K loss also as his renal K loss was less than 1.5meql/l. As the patient was OK, he was discharged, with k+ supplements, and was told to avoid heavy Carbohydrate meals, and physical overexertion. But when he came for follow up he had persistent tachycardia and sweating, but had no limb weakness, and he also gave a history of weight loss. So we asked him to get a Thyroid test done

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Hid Thyroid reports were s/o hyperthyroidism , mostly graves disease, with low TSH and Very high T3 and t4 levels. We started him on neomercazole in thrice a day dosing, 10mg, and then sequentially repeated the Thyroid reports, and they started to be normalsied. We gradually reduced the dosing of neomercazole. The pt again never did have the quadriparesis. Mostly the cause of the paraparesis was hyperthyroidism. The condition has been linked with genetic mutations in genes that code for certain ion channels that transport electrolytes (sodium and potassium) across cell membranes. The main ones are the L-type calcium channel α1-subunit[1] and potassium inward rectifier 2.6;[3] it is therefore classified as a channelopathy.[3] The abnormality in the channel is thought to lead to shifts of potassium into cells, under conditions of high thyroxine (thyroid hormone) levels, usually with an additional precipitant. Treatment of the hypokalemia, followed by correction of the hyperthyroidism, leads to complete resolution of the attacks. HPP is potentially lethal complication of hyperthyroidism occurring in Asian men in the age group of 20 - 40 years. Early diagnosis and treatment will prevent serious cardiac complications. At the time of acute attacks, treatment should be started with low dose of potassium supplements. Serial monitoring of potassium levels is recommended in order to prevent rebound hyperkalemia. All efforts should be aimed at achievement of euthyroid status as early as possible. The definitive treatment is radioactive iodine or thyroidectomy.

P-277 A Rare Presentation of HSP in an Adult Female Patel Purvi, Anadkat Meghal Department of General Medicine, P D U Medical college, Rajkot Corresponding Email ID: [email protected]

IgA vasculitis (Henoch Schonlein Purpura) is a small vessel vasculitis characterised by palpable purpura most commonly distributed over gluteal region and lower extremities with arthralgia, gastrointestinal signs and symptoms and Glomerulonephritis. HSP is usually seen in children ( 4 -7 years of age). Pathogenic mechanism of IgA vasculitis is immune complex deposition in small vessels. Insiting Ag are upper respiratory tract infection, drugs, food, insect bites and immunization. Here is a case of 28 year old female patient presented with complaints of palpable purpura over gluteal region and lower extermities which occurred after 5-6 episodes of diarrhoea for 4-5 days. Patient was thoroughly investigated. All lab investigations were done. Skin biopsy was taken which confirmed leucocytoclastic vasculitis with immunofluorescence shwing IgA and C3 deposition, hence HSP was confirmed. Patient was treated with glucocorticoid therapy. On follow up after one month patient was improved.

200 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020

P-278 Bilateral Upper Limb Involvement in Parsonage Turner Syndrome: A Rare Case Report Bhavsar Smeet, Shastri Minal, Mistry Heti Department of Medicine, Government Medical College, Vadodara, India Corresponding Email ID: [email protected]

Parsonage Turner syndrome is a rare form of neuralgic amyotrophy which presents with sudden onset of unilateral shoulder and arm pain which increases in intensity, subsides and is followed by progressive weakness and in some cases atrophy of the affected muscles. Its incidence is as low as 1.6 cases per one lakh people. This is a case of 45-year-old male who developed sudden onset of excruciating shoulder and arm pain following a short history of fever. The pain started unilaterally and rapidly progressed to involve both the limbs, following which the pain subsided in a few days and rapid neuromuscular weakness developed in bilateral upper limbs. After thorough investigations to rule out other conditions with similar presentation, we came to a clinical diagnosis of Parsonage Turner Syndrome which was supported by electromyographic findings of brachial plexus neuritis. The patient was treated with analgesics and a course of steroids which resulted in significant improvement with little residual paralysis in form of winging of scapula. This case report is a relatively rare variant involving bilateral upper limbs. It illustrates the importance of strong clinical suspicion of Parsonage Turner syndrome in patients presenting with short history of pain and weakness of shoulder girdle and upper limbs.

P-279 A Case of Oculobulbar Myasthaenia Gravis in 56 year Old Male Patient. Kotak Charmi , Parmar Vijay, Gadhavicharan S Department of medicine, P.D.U.Medical college,Rajkot Corresponding Email ID : [email protected]

Case Report: A 56 year old male patient presented with complain of bilateral ptosis, dysphagia, regurgitation of food material and difficulty in neck holding for 4 days without any diurnal variation. On examination, patient‘s higher function were normal. Lower cranial nerve palsy (bulbar palsy) present. Tone, Power and Reflexes were normal. Upon ice pack test and tensilone test, there is improvement of ptosis. We had sent Acetylcholinesterase Antibody which came positive 24 nmol/L. Other investigations like CBC, RFT, LFT,TFT were normal. ECG and Xray Chest were normal. USG Neck suggestive of hypoechoic structure below the lower pole of thyroid suggestive of thymic pathology. CT Scan of neck suggestive of minimal enhancing soft tissue thickening in valleculla on left side. After treatement with steroid and pyridostigmine and intravenous immunoglobuline , there were improvement in symptoms completely in 7 days . Patient was discharged on prednisolone, azathioprine, and pyridostigmine. Patient was diagnosed as oculobulbar myasthenia gravis.

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P-280 The Case Report on Langerhans Cell Histiocytosis Patel Khushbu, Patel Snehal, Vasavada Halakh, Patlel Purvi Department of Paediatrics, Shardaben Hospital, Ahmedabad, Gujarat Corrosponding E-mail ID: [email protected]

Introduction: Histiocytosis syndrome of childhood are characterised by prominent proliferation or accumulation of the monocyte-macrophage lineage of bone marrow origin. The best known is Langerhans cell Histiocytosis, previously called Histiocytosis X. The Hallmark of LCH is presence of birbeck granules in the cytoplasm of lesional cell. The definative diagnostic feature of LCH is CD1a positivity of cells. LCH has extremely variable presentation with multiorgan involvement. Case Presentations: A 3 month old male infant presented to us with complain of swelling on right shoulder since 5 day and reddist papular skin lesion which heal leaving behind whitish lesion since birth. Baby was previously evaluated for poor weight gain at 15 day of life. Investigation were insignificant. On examination, he had tender swelling over right shoulder and multiple vesicular crusted lesion over palms and soles, multiple atrophic hypopigmented scar over both upper and lower limb, trunk,few crusted lesion over lower limb and abdomen. Investigations revealed severe anemia with normal counts, elevated ESR and CRP. X-ray was suggestive of pathological fracture. MRI of whole body showed skeletal involvement in left humerus and right radius in the form of cortical break and abnormal expansive lesion of mandibular condyle. Suggesting multiple and extensive bone involvement. Excision biopsy from skin lesion showed dense subepidermal infiltration of large sized mononuclear cells and few multinucleated cells with nuclear grooving and folding with eosinophils, lymphocyte and plasma cell, which were positive for CD1a. Hence, Baby was diagnosed to have LCH with multisystem involvement, chemotherapy was planned and referred to higher center. Conclusion: Any paediatric age group patient with multiple system involvement like skin lesion, bony swelling, chronic ear infection, enlarged lymph nodes, lung tissue infection should be investigated for LCH. Early initiation of treatment with prolonged continuation therapy showed greater survival rate with decreased reactivation in multisystem disease.

P-281 Gliomatosis Cerebri- A Rare CNS White Matter Malignancy Ramnani Juhi, Gadani Zalak Department Of Medicine, AMC MET Medical College and LG Hospital, Ahmedabad, Gujarat Corrosponding E-mail ID: [email protected]

Gliomatosis cerebri is a primary central nervous system (CNS) tumor. Gliomatosis cerebri refers to a special pattern of diffuse and extensive growth of glioma cells, invading multiple lobes of the brain. Gliomas of different grade and cell of origin (astrocytes, oligodendrocytes) can grow with this pattern, and very little is understood about the molecular basis of the disease.

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Gliomatosis cerebri commonly arises from glial cells in the brain. When seen under a microscope the tumor cells resemble glial cells and involve many areas of the cerebrum. This is why this is named gliomatosis cerebri. Gliomatosis cerebri occur most often in people between the ages of 46 and 53, but can occur at any age. Gliomatosis cerebri occurs slightly more often in males than females. The cause of gliomatosis cerebri is not known. Gliomatosis cerebri can spread to other areas of the CNS through cerebrospinal fluid (CSF). They can spread quickly and deeply into surrounding brain tissue. They do not spread outside the CNS. Symptoms related to a gliomatosis cerebri depend on the tumor’s location and patient’s age. Some possible symptoms include seizures, fatigue, mood changes, changes in thinking and memory, and headaches. The first treatment for a gliomatosis cerebri is surgery, if possible. The goal of surgery is to obtain tissue to determine the tumor type and remove as much of the tumor as possible without causing more symptoms for the person. Surgery is usually limited to a biopsy, as there is not a central mass for removal. Other treatments may include radiation, chemotherapy, or clinical trials going on for other modalities of treatment. Treatments are decided by the patient’s healthcare team based on the patient’s age, remaining tumor after surgery, tumor type, and tumor location. Here we encountered a case of a 48 year old Female patient k/c/o of Ischemic CVA presenting with seizure(gtcs), headache and Altered sensorium. On CNS examination patient was disoriented to time place and person, planters were flexors, pupils were reactive to light, deep tendon reflexes were normal. Patient had mood changes, easy fatiguability and speech difficulty.No cerebellar signs were present. Patient had no history of fever. Patient had bradycardia and other signs of raised ICT. Other vitals were normal. Routine investigations were otherwise normal. MRI brain plain of patient had findings of hyperintense signals involving white matter in frontal, bilateral occipito-fronto-temporal and right external capsule region predominantly subcortical in location and mass effect which makes acute demyelinating etiology likely. MR venography of patient is normal.MRI Contast showed no abnormal assessment. In csf analysis sugar and protein were raised. ANA was negative. 2D echo was also normal. Patient was treated for convulsion and increased intracranial pressure. Patient was given high dose steroid trial, having suspected acute demyelinating disease but patient worsened which confirmed that patient did not have acute demylinating disease rather was a suspected case of Gliomatosis cerebri. Biopsy is a must to confirm diagnosis but was not possible due to poor general condition of the patient.

P-282 Application of Rapid Ultrasound in Shock (RUSH) Protocol in Differentiating Causes of Shock in Emergency Department Gupta Himanshu Department of Emergency Medicine, SSG Hospital and Medical College, Baroda, Gujarat Corresponding Email ID: [email protected]

Background: Delivering early diagnosis of shock in resource limited setting is challenging, especially with limited availability of point-of-care laboratory and radiological diagnostic facilities. There is growing urgency to provide point-of-care diagnosis and treatment for time sensitive condition like shock.

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Aims: We tried to evaluate the application of point-of-care ultrasound (Rapid Ultrasound for Shock [RUSH] protocol) considering different disease cohort and practice realities in our setup. Settings and Design: This study was a single center prospective diagnostic study to check the diagnostic accuracy of point-of-care ultrasound (RUSH protocol). This study was approved by the ethics committee. Materials and Methods: The study was conducted at the emergency medicine department of a tertiary care government hospital in Central Gujarat from September 2018 to February 2019. All adult patients with clinical features of shock with systolic blood pressure <90 mmHg and shock index >1 presenting to emergency department were included as participants. The results of point-of-care ultrasound (RUSH protocol) were compared with the diagnosis given by consultants of respective department as per standard departmental practices. Statistical Analysis and Results: A total of 87 patients were enrolled in this study. Mean time taken to examine by the point-of-care Ultrasound (RUSH protocol) was 12 min (range 11–14 min). Kappa index was 0.860. This protocol was able to correctly diagnose 100% of obstructive shock, 96.3% of cardiogenic shock, 94.4% of hypovolemic shock, 80.9% of mixed type of shock, and 75% of distributive type of shock. Conclusion: This study highlights the role of point-of-care ultrasound (RUSH protocol) for early diagnosis of the shock etiology in emergency medicine department. Diagnosis using point-of-care ultrasound (RUSH protocol) significantly agreed with medical diagnosis. It showed good efficacy of point-of-care ultrasound (RUSH protocol) to differentiate causes of shock with good accuracy except distributive shock.

204 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020

P-283 Anaestheic Management in Case of Foreign Body in Cricopharynx Jani Sajita, Ramanuj Ronak Department of Anaesthesiology, GM Bhavnagar. Corresponding Email ID: [email protected]

Introduction: Rigid endoscopy under general anaesthesia has traditionally been used by otolaryngologist for diagnosis and management of a variety of disorders affecting the uppe digestive tract including removal of foreign body1. The advent of flexible endoscopes confined rigid endoscopy primarily to foreign body removal. Flexible nasopharyngolaryngoscopy (FNPLS) performed by otolaryngologist in the office- setting does not allow proper visualization of the cricopharynx and cervical oesophagus.which is the most common site of foreign body impaction2. Therefore patients suspected of having a foreign body of the oesophagus often require rigid endoscopy under general anaesthesia for diagnosis and removal. The procedure is not without risks especially oesophageal perforation1 which has a high morbidity and potential mortality. Besides the surgical risks the patients is also subject to anaesthetic risks

Case Report: An 5 year old male with 12 k.g., came to emergency ward of Sir-T hospital, Bhavnagar on 9/10/2019 9:30pm with history of accidental foreign body Aspiration (coin). CXR(PA view) showing coin in right side of cricopharynx.

Ÿ Informed written consent of Anaesthesia was taken under ASA grade III & Patient was shifted to operation theatre, for oesophagoscopy guided foreign body removal. Ÿ Monitoring done with Pulse oxymeter, NIBP and ECG. Ÿ Patient was premedicated with inj. Ondansetron 1mg, inj. Glycopyrolate 0.05 mg, inj. Midazolam 0.25mg, and nebulization given with Levolin.

205 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020

Ÿ Patient was induced with inj ketamine (20mg) + inj succinylcholine(20mg) IV. Ÿ Patient was intubated by portex endotracheal tube number 4.5 cuffed orally b/l air entry checked and fixed. Ÿ Patient was maintained through oxygen+nitrous+spontaneous respiration+ inhalational sevoflorane . Ÿ After completion of surgery patient was recovered spontaneously. Ÿ Extubation was done by through oropharyngealsuction all laryngopharyngeal reflex present.

Discussion: Ÿ Foreign body aspiration is potentially a life-threatening event and may also cause esophageal perforation if not properly managed. Children commonly ingest foreign bodies, especially coins, thus making it a frequent occurrence in the pediatric emergency and urgency departments1. Coins are the most common foreign bodies ingested by children and they usually lodge at the cricopharynx1. Complications related to foreign body ingestions are low, however morbidity may be severe, or even put the patients life in danger. Ÿ Younger children are more prone to accidental ingestion of foreign bodies because their dentition is not yet complete, the neuromuscular mechanisms related to swallowing and upper airway protection are not yet fully developed. Ÿ Complications rarely happen, however there may be aspiration and upper airway obstruction, mucosal damage, esophageal erosion and trachea- esophageal fistulas. Complications occur mainly because of invasive removal attempts

Key For Management: Ÿ Maintenance of adequate ventilation and oxygenation while maintaining a clear view and appropriate access for the bronchoscopist. Ÿ Adequate depth of Anaesthesia, amnesia, analgesia and sufficient muscle relaxation to allow easy passage of the instrument with abolition of cardio respiratory reflexes. Ÿ Minimization of secretions & Prevention of pulmonary aspiration. Ÿ Quick return of consciousness, respiratory drive and upper airway reflexes at the end of the procedure. Ÿ To allow longer time duration for the procedure.

Conclusion: Ÿ Oesophagooscopy requires a team effortto obtain an optimal condition for safe anaesthesia and successful procedure. Ÿ Rigid endoscopy is a useful method to diagnose and remove foreign bodies of the oesophagus or hypopharynx. It however does carry risks. It will continue to play a role in removal of foreign bodies especially in children as in these patients the nature of foreign bodies eg. coins and the lack of cooperation will required.

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References: Ÿ Accidental ingestion of coins by children: management of the ENT Department of João XXIII Hospital_Cheng T-PingI; Cassimiro Afonso NunesII; Gabriel Rabelo GuimarãesIII; João Penna Martins VieiraIV; Luc Louis Maurice WeckxV; Tanner José Arantes BorgesVI. Ÿ Brasin A, Elitsur Y. Esophageal stenosis, a rare complication of coin ingestion: case report. Gastrointest Endosc 2004;59(1):152-4. Ÿ Removal of Foreign-Bodies Under General Anaesthesia. A Review of Rigid Endoscopy for Foreign-Bodies of the Hypopharynx and OesophagusG Revadi MBBS, R Philip MBBS; MMED (ORHNS) (ORLHNS), S Gurdeep MBBS, MS (ORLHNS), MS (HNORI)Department of Otorhinolaryngology, Hospital Ipoh, Jalan Hospital, 30990 Ipoh

P-284 Tuberous Sclerosis – A Case Report Doshi Palak, Prakash Sanjay, Patel Jay, Rawat Kalu SBKS MIRC, Sumandeep Vidyapeeth, Vadodara, Gujarat, India. Corresponding Email ID: [email protected]

Tuberous sclerosis is a rare neurocutaneous disorder with multisystem involvement beyond the brain and the skin, important to diagnose because of its serious nature of manifestations and phenotypic variability. It is a disorder of cellular differentiation and proliferation, mainly in the form of hamartomas, affecting the brain, skin, kidneys, heart, lungs and eyes. We present a case of 40 year old male with tuberous sclerosis, who presented to us with adenoma sebaceum, shagreen patch, periungual fibroma and seizures but with normal mental status and intelligence. MRI brain with 3D flair confirmed diagnosis of tuberous sclerosis. The patient was started on Tablet Carbamazepine 800 mg/day in 2 divided doses by which a good seizure control was maintained. This case shows that Tuberous Sclerosis can present at any age, can have varied presentation and may not always have the classical triad of adenoma sebaceum, epilepsy and mental retardation.

207 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020

AUTHOR INDEX

Author Name Page No Author Name Page No

Abhay Dharamsi 198 Chandarana Anish 8, 24 Acharya Harshit 112 Chandrasekharan Arjun 144 Agarwal Anup 99 Chatterjee Iva 192 Agrawal Rahul 124 Chaudhari Kaushika 140 Agrawal Sachinkumar 86 Chaudhari Sagarbhai 82 Ahmadi Bashir 167, 180 Chauhan Dinesh 162, 163,181 Ambailya Aniruddh 159 Chauhan Hinali 84 Amin B 113 Chauhan J. 152, 154, 183 Amin Bipin 120 Chauhan Vinayak 180 Amin Viral 112 Chauhan Yesha 117 Anadkat Meghal 109, 168, 200 Chavda Avani 126 Ansari Rizwan 109 Chavda Poonam 156 Artwani Ekta 105 Chavda Vipul 140 Arvind Ankur 161 Chhanwal Heena 129 Arya Vivek 134 Christan M 198 Asodariya Nidhi 182 Chudasama Chanda 180, 193 Ayoley Omojoye 148 Chvada Surbhi 151 Bakrania Siddharth 122 D Jayshree 198 Baldania Deepak 167 Dabhi Leena 94, 140 Baldaniya Laljee 195 Dalal Bhavin 10, 24, 41, 44 Baman Divyapal 140 59, 71 Banthia Nilesh 199 Dangde Vinod 174 Basu Abhijit 191 Daniel Christy 198 Behl Archana 162 Daniel Jacintha 198 Bhansali Prashant 86, 87 Dasare Anand 170 Bhattacharya Amalkumar 146,156, 157 Datraniya Mohini 102 160, 163, 166 Dave Nisarg 123 Bhavsar Smeet 201 Daxini Arvind 156 Boopathi M 106 Desai Arsh 170 Brindis Claire 42 Desai Chirag 14 Brindis Ralph 21, 25, 31, 45, 54 Desai Dipak 75 Budhrani Deepmala 166, 196 Desai Jayshri 158, 162 Chag Milan 34 Desai Vedang 121

208 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020

AUTHOR INDEX

Author Name Page No Author Name Page No

Dhami Param 93 Gupta Pranav 188 Dhanani K 113 Gupta Sapna 92, 136 Dhanani Ketan 120 Gupta Satya 16, 27, 38, 63 Dhangar Vandana 174 Hadiyel Ila 165 Doctor Nilesh 189 Haideri Shahid 191 Doshi Kinnar 122 Harkhani Jolly 134 Doshi Palak 207 Hasnani Dhruvi 140 Doshiyad Vrushti 177 Hathiari Farida 188 Dosi Rupal 159 Hirani Balkrushna 82 Dudharejia Praful 105, 190 Jain Abhinav 14 Dut Jayesh 107 Jani Sajita 205 Dutt Jayesh 97 Jha Soumya 163 181 Fontos Geza 17, 19, 33 Jhala J 198 Fuletra Deep 115 Jivani Krish 117 Fumakiya Pooja 179, 182 Jose Jince 90 Gadani Zalak 175, 202 Kakadiya Dhara 92 Gadhavicharan S 187, 194, 201 Kalotra Kaushal 129 Gadhvicharan S. 154 Kamdar Panna 195 Gambhir Rahul 151 Kanani Tushar 189 Gamit Dileep 102 Kansagara Dhrumil 187 Gangdev Abhay 190 Kansagra Meet 179 Garg Naveen 152 Kapoor Aditya 152 Garg Pankaj 83, 95 Kapoor Vipul 16, 28, 39 Gavli Nayan 191 Karkar Sanket 137 Ghanchi F 192 Kataria Yogesh 79, 14, 31, 77 Goel Arti 110 Kavad Jay 184 Goel Pravin 152 Khanna Roopali 152 Gohil Jaldeepsinh 92 Khatri Akshay 111 Gohil Shivrajsinh 135 Kheskani Divya 92, 129 Goklani Rutul 140 Kotak Charmi 176, 201 Gopani Mansi 179 Koyani Brijesh 142 Goswami Shakuntala 138 Kumawat Dalchand 159, 197 Gupta Himanshu 203 Lad Deshna 136

209 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020

AUTHOR INDEX

Author Name Page No Author Name Page No

Lakhani Krishna 178 Padma Deepika 158 Lakum Akash 197 Panchal Dharmendra 140 Lavanya S 198 Panchal Keyur 52, 57 Leuva Alpa 103 Panchal Manisha 106, 180 Machhar Amit 174 Panchal Tarang 83 Machhar Nilay 180 Pandey A 156 Madan Surabhi 13, 43 Pandher Shweta 81 Maheshwari Bharat 137 Pandya Amee 128 Makani Janki 97 Pandya Himanshu 150 Malaviya Sangita 101 Panjawani S. 169, 177 Malhan Sundeep 83, 95, 194 Panjwani Sunil 173 Malhotra Supriya 90,127, 128 Parekh Malay 140 134, 136, 137 Parikh Ami 79 Maliwad Nitin 165 Parikh Jitendra 101, 130 Mandaliya Bheeshm 173 Parikh Keyur 4, 6, 20, 29 Mankad B 86, 96 39, 58, 60, 69 Marwah Tiven 134 Parikh Manas 100 Mehta Heli 116 Parikh Mital 99 Mehta Jigisha 158 Parikh Nehal 137 Mehta Malini 163, 181 Parikh Roosha 11 Mehta Neil 33, 44, 52 Parikh Sankalp 175 Mehta Rishita 158 Parmar Jinal 109 Miruliya Mayur 104 Parmar Kartikeya 125 Mistry Heti 201 Parmar Nachiketa 95 Mod Jaydev 97, 107, 121 Parmar Sameer 184 Nagar Jatin 125 Parmar Sarita 93 Naik Kamalchandr 141, 142 Parmar Vijay 176, 201 Nandaniya Bharat 113 Patel Aditya 83, 156, 166 Nandaniya Puja 180 Patel Adityakumar 83 Nayak Mit 125 Patel Aksh 89 Nayee Chirag 154 Patel Ansh 126 Oswal Harshal 187 Patel Arpit 139 Padhiyar Bharat 181 Patel Chaital 132

210 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020

AUTHOR INDEX

Author Name Page No Author Name Page No

Patel Chirag 93, 108, 125, 138 Patel Ravi 142 Patel Dhiren 127 Patel Ruby 167 Patel Dhrumin 168 Patel Rushi 132 Patel Dhruv 109 Patel Sachin 96 Patel Dipika 141, 142, 147 Patel Shivani 104, 111 Patel Dushyant 82 Patel Shuchi 116 Patel Harita 114 Patel Snehal 113, 115, 116 Patel Jagdish 85, 131 120, 202 Patel Jaldeep 112, 179, 181, 182 Patel Tarang 75 Patel Japan 99 Patel Tirth 87 Patel Jay 158, 207 Patel Tirthesh 72 Patel Jayesh 193 Patel Umang 152 Patel Kaivan 155 Patel Urvi 141 Patel Kamlesh 127 Patel Utsav 164 Patel Keyur 105, 192 Patel Vidisha 140 Patel Khushali 97, 107 Patel Vivek 9, 18, 62, 63 Patel Khushbu 202 Patel Vivek 155 Patel Krunal 130 Paul Saurav 169 Patel Mayur 193 Prajapati Akash 140 Patel Meghna 125 Prajapati Vipul 109 Patel Miltan 173 Prakash Sanjay 158, 207 Patel Mohnish 147 Prasad Ram 179, 181 Patel Monila 110 Prasad Ramnandan 112 Patel Naimish 131 Rajput Abhisheksingh 106 Patel Nirav 131 Rajput Sanjay 107 Patel Nishi 94 Ram Nanadan 179 Patel Parth 80 Ramani Rajesh 145, 146 Patel Prakruti 132 Ramanuj Ronak 205 Patel Prashastee 156, 163, 166 Rami Kinjal 192 Patel Prins 150 Rami Kiran 125 Patel Purvi 113, 115, 116 Ramnani Juhi 202 120, 141, 200, 202 Ramoliya Rinkal 181 Patel Ramesh 182 Rana Devang 127, 136

211 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020

AUTHOR INDEX

Author Name Page No Author Name Page No

Rana Himanshu 159 Shah Shalin 127 Rana Komal 160, 163 Shah Shushma 137 Rathod Mahesh 188 Shah Sneha 110 Rathod Nirav 113 Shah Sushma 128, 137 Rathva Payal 120 Shah Urmil 47, 65 Raval Bhavna 135 Shaikh Khalid 138 Raval Reema 90 Sharma Seema 129 Rawat Kalu 207 Shastri Minal 191, 201 Rimpi 109 Sheth Chintan 8 Roy Rajesh 148 Sheth Nirmit 85 Saboo Bansi 140 Sheth Vidish 129 Sailor Tejas 154 Shrimali Lalit 188 Sakariya Nirav 147 Shrivastav Puja 43 Sambada Vishal 103 Singh Garima 157 Sangani Shruti 93 Singh Sunita 157 Sanghavi Keval 85 Sisodia Jitendra 122 Sanjay Prakash 158 Sodala Ashokbhai 197 Sathvara Jayanti 117 Solanki Bhagirath 115 Savaliya Shyam 198 Solanki Nayna 92, 129 Sethi Sandeep 194 Solanki Parth 148 Shah Asha 109 Solanki Umesh 125 Shah Bhaumik 115 Somani Rushabh 101 Shah Bhavik 168 Soni Jinit 159 Shah Deepa 10 Sonkar Chetan 146 Shah Dhaval 166, 196 Sood Shikha 134, 137 Shah Harshil 79, 143, 177 Sorthiya Ankit 112 Shah Hemant 189 Srivastav Vipul 147, 189 Shah Jay 124 Sudeepkumar 152 Shah Maulin 99, 103, 122, 150 Sumanth G 183 Shah Neha 94 Tajpara Akshay 176 Shah Ravi 79 Tewari Satyendra 152 Shah Sahaj 131 Thacker Deep 180 Shah Shailja 90 Thacker Mandakinee 112, 182

212 2020 16th Annual Scientific Symposium JIC 25th Year of Academics January 3-5, 2020

AUTHOR INDEX

Author Name Page No

Thakkar Bhavesh 9 Thakkar Deepkumar 95 Thakkar Vipul 17 Thakor Advait 92, 132 Thomas Sara 162, 163, 181 Thubelihle Koffi 148 Trivedi Aarti 79, 145, 146, 177 Trivedi Jayesh 114, 117, 167, 180 Upadhyay Aakash 123, 157, 160, 163 Upadhyay Himarshi 178 Upadhyay Kamlesh 102, 105, 132 Upadhyay Taniya 159 Vachhani Karan 86, 96 Vadhvana Sneha 144 Vaishnav Bhalendu 99, 103, 122, 139 Vala Jasvin 92 Vasavda Halak 113, 115, 116 120, 202 Verma Jagdish 103 Verma Y. 89 Virani Devanshi 93 108 Vithalani Kamlesh 142 Vora Alpesh 161, 170 Vora Chitralekha 82, 197 Vora Jyoti 110 Vora Parshva 152 Vyas Aditya 182 Vyas Chintal 83, 95

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