Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

LOCAL ORGANIZING COMMITTEE

Conference Patron : Dr. Nitin Vora GMERS, Sola, Ahmedabad Conference Chairman : Dr. Keyur Parikh CIMS Hospital, Ahmedabad Chairman, Scientific Committee : Dr. Milan Chag CIMS Hospital, Ahmedabad Organizing Secretary : Dr. Satya Gupta CIMS Hospital, Ahmedabad Conference Advisor : Dr. Ajesh Desai GMERS, Sola, Ahmedabad Dr. H.R. Jadav GMERS, Sola, Ahmedabad ASSOCIATION OF PHYSICIANS OF AHMEDABAD Dr. G. R. Badlani President (APA) Dr. Kamlesh Fatania Hon Secretary (APA) CONFERENCE DIRECTORS & CO-ORDINATORS

CARDIOVASCULAR SYMPOSIUM CRITICAL CARE IN CHRONICALLY ILL SYMPOSIUM NEURO SYMPOSIUM

Dr. Hemang Baxi Dr. Gunvant Patel Dr. Sagar Betai Dr. Mayank Patel Dr. Amit Patel Dr. Bhagyesh Shah Dr. Parindra Desai Dr. Shalin Shah Dr. Niren Bhavsar Dr. Divyesh Sadadiwala Dr. Nitesh Shah Dr. Kalpesh Panchal Dr. T.K.B. Ganapathy Dr. Amit Chandan Dr. Vineet Sankhla Dr. Deven Zaveri Dr. Vipul Thakkar Dr. Pranav Joshi Dr. Anish Chandarana Dr. Urmil Shah Dr. Amit Chitaliya Dr. Dhiren Shah ONCOLOGY UPDATE Dr. Hiren Dholakia Dr. Shaunak Shah CARDIOVASCULAR HIGH RISK PREGNANCY Dr. Vipul Kapoor Dr. Chintan Sheth Dr. Darshan Bhansali Dr. Jayesh Patel OB SYMPOSIUM Dr. Devang Bhavsar Dr. Tarang Patel Dr. Pranav Modi Dr. Kashyap Sheth Dr. Maulik Bhensdadia Dr. Ashok Patel Dr. Ajay Naik Dr. Sneha Baxi Dr. Purna Patel Dr. Chirag Desai Dr. Natoo Patel Dr. Dhaval Naik Dr. Devang Patel Dr. Prapti Patel Desai Dr. Malhar Patel Dr. Tejas V. Patel Dr. Rahul Jaiswal Dr. Chintan Shah

ORGANIZING COMMITTEE

Dr. Keyur Buch Dr. Abhinav Jain Dr. Jitendra Nayak Dr. Vivek Patel Dr. Kirtan Shah Dr. Umakant Shah Dr. Parvin Chandarana Dr. Vikramjit Singh Kanwar Dr. Chintan Parekh Dr. Uday Patel Dr. Krati Shah Dr. Nimish Sharma Dr. Dipak Desai Dr. Surabhi Madan Dr. Maulik Parmar Dr. Mayur Patil Dr. Manisha Shah Dr. Reena Sharma Dr. Smita Dheer Dr. Sandeep Makani Dr. Tejendrasinh Parmar Dr. Nupur Patel Dr. Pranav Shah Dr. Rachit Sheth Dr. Manish Gandhi Dr. Chintan Mehta Dr. Chandni Patel Dr. Bhavini Shah Dr. Rechal Shah Dr. Samip Sheth Dr. Vrushti Gandhi Dr. Uma Mehta Dr. Krunal H. Patel Dr. Deepa Shah Dr. Rupesh Shah Dr. Puja Shrivastav Dr. Sneha Gohil Dr. Reedham Mehta Dr. Mayank Patel Dr. Gautam Shah Dr. Sanket Shah Dr. Kunal Soni Dr. Parth Goyal Dr. Ankita Midha Dr. Satish Patel Dr. Hemal Shah Dr. Sanjay Shah Dr. Bhavesh Thakkar

GMERS ORGANIZATION TEAM

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

Jointly Organized by

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

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Visit : http://www.gujarattourism.com/hub/destination/1/1

SABARMATI ASHRAM AHMEDABAD AKSHARDHAM TEMPLE WORLD HERITAGE KANKARIA LAKE CITY SCIENCE CITY ADALAJ VAV

SIDI SAIYAD MOSQUE

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FROM DESK OF ORGANIZING COMMITTEE

“Develop a passion for learning. If you do, you will never cease to grow.”

– Anthony J. D'Angelo

We proudly announce JIC 2019 (January 4-6, 2019) in Ahmedabad, India. Year after year, we make great herculean efforts to create a great learning experience for all the delegates who come to us. For we, believe, there is no greater force than learning to impact your profession. This year, we proudly announce the Highest Number of Lectures ever at JIC… more than 300 lectures over a span of just 3 days. A multiple array of Symposiums and Satellite Sessions over 3 days to ensure an exhaustive learning experience for all who attend. We are glad to see the number of attendees rising each year which inspires us to take this forum to better heights year after year. This year the Conference is highly case-based creating an interactive experience for all delegates. Discussions and debates lend an enthusiastic fervor to the academic ambience perpetuating our commitment to deliver the best knowledge to you all. We really would like to thank the entire medical fraternity for their support all these years. Your eager participation and interaction has inspired us to once again bring you JIC 2019. Bigger and Better.

We look forward to meeting you at JIC 2019.

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

CONFERENCE INFORMATION

CONFERENCE VENUE PANDIT DINDAYAL UPADHYAY AUDITORIUM Rajapth Club Road, Ahmedabad

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INTERNATIONAL FACULTY CARDIOVASCULAR SYMPOSIUM

Dr. Bhavin Dalal Prof. Uri Elkayam Dr. Ashit Jain Dr. Samir Kapadia Dr. Mikhail Kosiborod Dr. Peter Lin Oakland University William University of California Hospital Cleveland Clinic Saint Luke’s Mid Canadian Heart Beaumont School of Medicine Southern California Medical Corporation (USA) America Heart Institute Research Centre (USA) (USA) (USA) (USA) (CANADA)

Dr. Neil Mehta Dr. Steven Nissen Dr. Anuj Shah Dr. E. Murat Tuzcu Dr. Pranay Vaidya Cleveland Clinic Cleveland Clinic Foundation Hackensack Cleveland Clinic Hackensack University Medical Centre (USA) (USA) (UAE / USA) University Medical Centre (USA) (USA) INTERNATIONAL FACULTY ONCOLOGY UPDATE

Dr. Ashok Shaha Dr. Jatin Shah Memorial Sloan-Kettering Cornell University of Cancer Center Medical College (USA) (USA)

NATIONAL FACULTY

Dr. P. Arun Dr. Roop Gursahani Dr. Hrishikesh Kumar Dr. Jayanta Roy Dr. Shamit Chopra Dr. Shalaka Joshi Dr. Somshekar S. P. Dr. Jayprakash Shah Dr. Manjiri Dighe Dr. J. Kalita Dr. Parthamesh Pai Dr. Manjari Tripathi Dr. Mehul Damani Dr. Vikram Kekatpure Dr. Hemant Patel Dr. Y. K. Oza Dr. Alpesh Gandhi Dr. Dheeraj Khurana Dr. Sanjay Pandey Dr. Firoz Ghanchi Dr. Chaityanand Koppiker Dr. Gouri Pantvaidya Dr. Pawan Gupta Dr. Rahul Kulkarni Dr. Hygriv Rao

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10 New Emerging Cardiovascular Technologies in 2019 Dr. Keyur Parikh Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

The new emerging cardiovascular technological advancements, such as the stents, intravascular catheters, heart-lung machine and prosthetic valves have increased treatment options for patients and have created exceptional growth for hospitals and cardiac specialists. The point of highlighting the aforementioned opportunities is not to state that all of these patients will be treated with new devices but rather to emphasize that many patients remain underserved. Ultimately, the number of patients treated will be determined by the relative patient benefit and risk. By developing 10 new emerging technologies (STEMI, CHIP, TAVR, TMVR, TTVR, TEVR, PE, LAAO, Imaging-CTA and MRA and Artificial Intelligence), cardiac physicians/surgeons can meet the needs of many of these patients.

Cardiovascular physicians are in a unique position to lead the decision-making and treatment process for a number of reasons. First, cardiac physician and surgeons are most familiar with the relevant anatomy and pathophysiology. Second, cardiac physicians and surgeons can deliver the invasive procedure and operations that will continue to be important treatment options. Third, cardiac surgeons have the available capacity to perform these procedures. Finally, cardiovascular physicians are best suited to handle complications related to these treatments.

Pre-Hospital ECMO Study (APACAR2) in France

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Although initially posing a challenge to cardiovascular physicians, emerging technologies also represent a significant opportunity. Patients with structural heart disease will benefit from multiple treatment options offered by a multidisciplinary team that is led by uniquely skilled cardiovascular physicians. Given this new treatment paradigm, the future is promising for both cardiovascular physicians and their patients. Fig. 1: Mechanical Support for STEMI Fig. 2: From ECMO to eCPR

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Clinical Course : • Rapid clinical decompensation during case with severe cardiogenic shock • Impella CP or ECMO inserted • Transient arrest requiring vasopressors, continued severe hypoxemia and shock • Intubated and VA ECMO instituted • RPL and OM1 recanalization and DES placement • ECMO decannulated post-procedure day 2 • Extubated post-procedure day 3 • No further complications • Pre-discharge echo: MR 1-2+ and EF 45% • Discharged post-procedure day 10, fully ambulatory and w/o symptoms • First clinic visit: wo complications or symptoms • Planned LAD revascularization

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TEVR Percutaneous Pulmonary Embolus EVAS-Endovascular : Mechanical Thrombectomy

Level of Value : Artificial Intelligence : 1. Important goal for current and future healthcare economy 2. Cost of therapy, available technology practice patterns highly dynamic 3. Costs associated with unintended harm or complications 4. Evaluation of burden of cost based on varied perspectives (individual, third party, stakeholder, societal) Clinical Practice Guidelines : Challenges and Opportunities ? Perform Systematic Evidence Reviews ? Include patient/patient representative point of view ? Address Conflict of Interest (COI) ? Create “living” documents that lead rather than lag behind clinical practice

Systematic Review Using Standardized Protocols : • Evidence Review Committee • PICO(TS): population, intervention, comparator, outcomes, timing, setting • Formal peer and public assessment of the PICO(TS) question • Simultaneous publication of systematic evidence review (SR) and guideline

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FAME 2: Five-Year Outcomes with PCI Guided by Fractional Flow Reserve Dr. Milan Chag Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email Id: [email protected]

BACKGROUND We hypothesized that fractional flow reserve (FFR)–guided percutaneous coronary intervention (PCI) would be superior to medical therapy as initial treatment inpatients with stable coronary artery disease.

METHODS Among 1220 patients with angiographically significant stenosis, those in whom at least one stenosis was hemodynamically significant (FFR, ≤ 0.80) were randomly assigned to FFR-guided PCI plus medical therapy or to medical therapy alone. Patients in whom all stenosis had an FFR of more than 0.80 received medical therapy and were entered into a registry. The primary end point was a composite of death, myocardial infarction, or urgent revascularization.

RESULTS A total of 888 patients underwent randomization (447 patients in the PCI group and 441 in the medical-therapy group). At 5 years, the rate of the primary end point was lower in the PCI group than in the medical-therapy group (13.9% vs. 27.0%; hazard ratio, 0.46; 95% confidence interval [CI], 0.34 to 0.63; P<0.001). The difference was driven by urgent revascularizations, which occurred in 6.3% of the patients in the PCI group as compared with 21.1% of those in the medical-therapy group (hazard ratio, 0.27; 95% CI, 0.18 to 0.41). There were no significant differences between the PCI group and the medical-therapy group in the rates of death (5.1% and 5.2%, respectively; hazard ratio, 0.98; 95% CI, 0.55 to 1.75) or myocardial infarction (8.1% and 12.0%; hazard ratio, 0.66; 95% CI, 0.43 to 1.00). There was no significant difference in the rate of the primary end point between the PCI group and the registry cohort (13.9% and 15.7%, respectively; hazard ratio, 0.88; 95% CI, 0.55 to 1.39). Relief from angina was more pronounced after PCI than after medical therapy.

CONCLUSIONS In patients with stable coronary artery disease, an initial FFR-guided PCI strategy was associated with a significantly lower rate of the primary composite end point of death, myocardial infarction, or urgent revascularization at 5 years than medical therapy alone. Patients without hemodynamically significant stenosis had favourable long-term outcome with medical therapy alone.

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New Guidelines to Manage Ventricular Arrhythmia & Prevent SCD What You Need to Know? Dr. Ajay Naik Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

The American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Rhythm Society (HRS) have issued new guidelines for the treatment of adult patients with ventricular arrhythmias (VA) or who are at risk for sudden cardiac death (SCD). The new guidelines provide recommendations regarding general evaluation of patients with documented or suspected VA; treatments, therapies, and prevention of VA; acute management of specific VA; and VA in the structurally normal heart. Guidance on VA and SCD related to special populations is also provided, as well as recommendations on the use of implantable cardiac defibrillators (ICDs) in patients with left ventricular assist devices, use of subcutaneous ICDs, and the role of catheter ablation of ventricular arrhythmias. Among areas of interest in the guidelines: ŸIndications for ICDs for the treatment of VA and prevention of SCD are discussed. ŸIndications for catheter ablation of VA are discussed ŸRecommendations for interventional therapies, including ablation and the implantation of devices, apply only if these therapies can be implemented by qualified clinicians. ŸAll recommendations related to ICDs require that meaningful patient survival of >1 year is expected.

Case-Based Approach of Virtual Reality in Medicine and Its Application Dr. Neil Mehta Cleveland Clinic Lerner College of Medicine at Case Western Reserve University Corresponding Email Id: [email protected]

Virtual Reality is one of the hottest trends in technology and medicine. The term is often used to encompass technologies like “Augmented Reality”, “Mixed Reality” and “Virtual Reality”. Healthcare organizations are expected to spend up to 5 billion USD on AR/MR/VR by 2025. We will review the differences between these terms and look at use cases to apply these technologies in medical education, simulations, clinical practice (diagnosis, surgical preparation and rehabilitation) and patient education.

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Critical Care beyond ICU Discharge Dr. Bhagyesh Shah Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

It is obvious that with increasing technological advances in medical science the life expectancy has increased and so does ICU admissions. There is a huge burden of ICU patients in any good hospital in terms of resource utilisation and also in terms of cost of stay and treatment in illness. Over the years we have also realised that it is not only physical well-being but mental and psychosocial wellbeing are also important. So here we will talk about post intensive care syndrome or PICS. Which forms the base for planning utmost care for critical care patient beyond discharge? ŸTo define PICS is “New or Worsening impairment in Physical (ICU acquired neuromuscular weakness), Cognitive (thinking and judgement), or Mental health status arising after critical illness and persisting beyond discharge from the acute care setting.” When it affects the family it is also called PICS-F. There are multiple risk factors like hypoxia, hypoglycaemia, hypotension, prior cognitive issues, delirium, sepsis and renal replacement therapy which affect almost 25% patients with cognitive dysfunction. Other common factors can be female gender, lower education, use of sedation in ICU and lack of communication. Combination of Cognitive, Psychological and Physical signs and symptoms including but not limited to ŸGeneralized weakness ŸFatigue ŸDecreased mobility ŸAnxious or depressed mood ŸSexual dysfunction ŸSleep disturbances ŸMemory issues ŸConcentration and process issues ŸPrevention can be done with proper implementation of ABCDEF bundle. Which is as under: ŸAwakening – Use light or minimal sedation if at all required ŸBreathing – Spontaneous Breathing Trials ŸCoordinated Care and Communications ŸDelirium monitoring, assessment and management ŸEarly ambulation ŸFamily involvement Planning the better Critical care beyond ICU will need a multidisciplinary approach including but not limited to physical rehabilitation, psychosocial support, family involvement, nutritional plans and preventive vaccination. We have to be human enough to discharge a survivor not the Victim out of ICU.

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Antimicrobials in Adult Outpatient Infections Dr. Yogendra Oza Practicing Clinician, Jamnagar Corresponding Email ID: [email protected]

Antimicrobial use is rampant. Inappropriate use is common. Outpatient use is maximum. Emergence of antimicrobial resistance is catastrophic. A guideline to the use of antimicrobials in OPD is discussed .Drugs of choice and alternate choices are given. Relevance of use of appropriate antimicrobial, where required, for that particular condition is considered. Situations where antimicrobials are not required at all have been emphasised. A message is passed that simple common infections in OPD require either no antimicrobial or common appropriate simple antimicrobial.

Case Based Approach to Interpretation of Thyroid Function Tests Dr. Vivek Patel Care Institute of Medical Sciences, Ahemedabad, India Corresponding Email Id: [email protected]

Thyroid function tests are one of the most commonly requested laboratory investigations. Fortunately, many times the results are straightforward to interpret and confirm the clinical diagnosis of euthyroidism, hypothyroidism or hyperthyroidism. However, in a subgroup of patients the results of TFTs can seem confusing, either not correlating with the clinical picture or incongruent with each other (e.g. raised T3/T4 with non-suppressed TSH). In such cases, it is important first to revisit the clinical context and to consider potential confounding factors (e.g. Drugs).

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Headache Is Migraine, Unless Proved Otherwise. Dr. Pranav Joshi Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

Headache is, without question, one of the most common neurological symptoms that requires visit to a doctor. The clinical aim is to recognize the warning signals that raise red flags. In the absence of worrisome features in the history or examination, the next target is to diagnose the primary syndrome based upon the clinical features. Systemic symptoms, (such as fever, malaise, or weight loss); new neurological signs; a sudden or abrupt headache that peaks in seconds or minutes: any headache that begins after 50 yrs. of age or any headache that deviates significantly from a previous pattern should raise clinician’s alarm for secondary headache. Of all primary headaches, migraine is the most common disease, in day to day clinical practice and emergency room visits. The major criteria and associated symptoms required for the IHS diagnosis of migraine are well known; but no single criterion is essential to confirm a diagnosis of migraine. Pattern recognition is an invaluable diagnostic technique in clinical practice, particularly for heterogeneous disorders such as migraine.

Case-Based Approach to ABC of CBC Dr. Rahul Jaiswal Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

Dear Friends, all of us see CBC of our patients, in our day to day practise. Understanding basics of CBC report is very essential and very tricky. We get a lot of information from single report of CBC, and we may also miss a lot of information, if we don’t read it carefully. So we will focus on things, which we have to look in CBC report and learn how many things, we can interpret from a single report of CBC.

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Managing Patients with Hyperkalaemia Dr. Rechal Shah Care Institute of Medical Sciences, Ahmedabad, India. Corresponding Email ID: [email protected]

Hyperkalaemia represents one of the most important acute electrolyte abnormalities, due to its potential for causing life-threatening arrhythmias. In individuals with normal kidney function hyperkalaemia occurs relatively infrequently, but it can be much more common in patients who have certain predisposing conditions like age more than 65 years, patients having chronic kidney disease, diabetes, and/or chronic heart failure. The prevalence of hyperkalaemia in hospitalized patients is between 1 and 10 percent. Some retrospective US analyses have reported incidences between 2.5% and 3.2% in populations with diverse risk factors. Hyperkalaemia is defined as a serum potassium concentration of >5.5 mEq/L2. Hyperkalaemia is caused by inability of the kidneys to excrete potassium, impairment of the mechanisms that move potassium from the circulation into the cells, or a combination of these factors. The presence of typical electrocardiographic changes or a rapid rise in serum potassium indicates that hyperkalaemia is potentially life threatening. Urine potassium, creatinine, and osmolarity should be obtained as a first step in determining the cause of hyperkalaemia, which directs long-term treatment. Intravenous calcium is effective in reversing electrocardiographic changes and reducing the risk of arrhythmias but does not lower serum potassium. Serum potassium levels can be lowered acutely by using intravenous insulin and glucose, nebulized beta agonists, or both. Sodium polystyrene therapy, sometimes with intravenous furosemide and saline, is then initiated to lower total body potassium levels. In the last few years, two new promising agents have been developed to treat hyperkalaemia - patiromer and sodium zirconium cyclosilicate 9 (ZS-9). Both patiromer and ZS-9 have been shown to decrease potassium in patients with hyperkalaemia and then to maintain normokalemia. Although these newer drugs are very promising in terms of safety and efficacy, many questions remain unanswered.

A Case of DVT Dr. Satya Gupta Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Deep-vein thrombosis (DVT) is a common condition that can lead to complications such as postphlebitic syndrome, pulmonary embolism and death. The approach to the diagnosis of DVT has evolved over the years. Patients with low pre-test probability and a negative D-dimer test result can have proximal DVT excluded without the need for diagnostic imaging. The mainstay of treatment of DVT is anticoagulation therapy, whereas interventions such as thrombolysis and placement of inferior vena cava filters are reserved for special situations. The use of low-molecular-weight heparin allows for outpatient management of most patients with DVT. The duration of anticoagulation therapy depends on whether the primary event was idiopathic or secondary to a transient risk factor. Here is a case of acute DVT which was successfully managed with combined medical therapy and interventional strategy.

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Approach to Patient with Raynaud’s phenomenon and ANA Positivity Dr. Puja Srivastava Consultant Rheumatologist and Immunologist, CIMS Hospital and STAR Rheumatology Clinics, Ahmedabad Corresponding Email ID: [email protected]

Raynaud’s phenomenon is a common ailment in winter months. During an attack of Raynaud's, affected areas of your finger and toes usually first turn white. Then, they often turn blue and feel cold and numb. As you warm and circulation improves, the affected areas may turn red, throb, tingle or swell. Women are more likely than men to have Raynaud's disease, also known as Raynaud's phenomenon or syndrome. There are two main types of the condition. Primary Raynaud's, also called Raynaud's disease, is the most common, is generally seen in females less than 25 years of age. It is not associated with any underlying medical condition. It is often so mild that many people with primary Raynaud's don't seek treatment. Secondary Raynaud's, also called Raynaud's phenomenon, is generally associated with an underlying connective tissue disease. Although secondary Raynaud's is less common than the primary form, it tends to be more serious. Signs and symptoms of secondary Raynaud's usually appear after 30 years of age, and is associated with ANA positivity. Among Connective tissue diseases, systemic sclerosis and mixed connective tissue are most commonly associated with Raynaud's. Other diseases that increase the risk of Raynaud's include lupus, rheumatoid arthritis and Sjogren's syndrome. Other causes could be atherosclerosis, Buerger’s disease and primary pulmonary hypertension. Repetitive vibrating tools, wrist fracture, surgery or frostbite can be a rare cause of Raynaud’s. Certain medications like beta blockers, ergotamine or sumatriptan can also be associated with Raynaud’s. If secondary Raynaud's is severe and complicated, it can lead to digital pits, ulcers, gangrene and amputation. Treatment of Raynaud's disease depends on its severity and whether you have any underlying Connective tissue disease. See your Rheumatologist right away if you have a history of severe Raynaud's, digital pits or ulcers in fingers or toes. In my lecture at JIC CON 2019, I will elaborate more on how to approach patients with Raynaud’s phenomenon in a busy clinic.

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Managing Antiplatelet and Anticoagulants in Patients with GI Bleeding Dr. Abhinav Jain Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

Gastrointestinal (GI) bleeding is an infrequent but potentially disastrous complication in patients on antiplatelet and anticoagulants. After initial endoscopic management and haemostasis is achieved, the continuation of these agents needs to be reassessed. Proton pump inhibitors (PPI) are helpful in upper GI bleeding along with eradication of H Pylori when detected. Modification of the dose or change of antiplatelet agent from clopidogrel to low dose aspirin or vice versa may suffice. Re-introduction of oral anticoagulants may require bridging by heparin (conventional or low dose). The scenario necessitates revisiting of the original indication for the antiplatelet or anticoagulants. The risk of a recurrent GI bleed has to be balanced against the risk of thromboembolism in these patients and decision merits calculation of a risk: benefit ratio on an individual case basis.

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Management of Chronic Constipation when Laxatives fail Dr. Bhavesh Thakkar Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email Id: [email protected]

QUESTIONS Which of the following symptoms differentiates chronic constipation from irritable bowel syndrome with constipation (IBS-C)? 1. Abdominal pain or discomfort associated with bowel movement. 2. Bloating 3. Hard/lumpy stools 4. Fewer than three bowel movements per week CORRECT ANSWER: 1 Which of the following statements regarding chronic constipation in the elderly is false? 1. Pelvic floor dysfunction is second most common subtype of primary chronic constipation in elderly. 2. Elderly patients with chronic constipation have shown to have impaired quality of life 3. Laxatives are among the most common non-prescription medications used by elderly patients 4. Chronic constipation in the elderly is most common in men than in women Correct Answer: 4 Definition: symptoms of difficult, infrequent, incomplete defecation of sufficiently long duration and severe enough to force the patient to seek health care suggest CC. • Chronic Constipation: A. Primary B. Secondary Categorization of primary constipation by subtypes: 1. Transit Time a. Slow- transit constipation b. Normal transit constipation 2. Pelvic floor disorders a. Defamatory disorders like outlet obstruction, dysphasia, animus, obstructed defecation, pelvic floor dyssynergia. 3. Irritable bowel syndrome constipation- predominant (IBS-c) Various Investigation modalities available to evaluate patients with chronic constipation when laxatives fail: 1. Colonoscopy 2. Colon transit study 3. Balloon expulsion test 4. Anorectal Manometry 5. Defecography 6. Endoscopic Ultrasound.

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A Case of Medical Thoracoscopy - A Window to the Pleural Space Dr. Kalpesh Panchal Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email Id: [email protected]

Over last two decades, the increased incidence of pleural related disease has added a significant workload for pulmonologists. It is now accepted that medical thoracoscopy has become the cornerstone investigation for pleural diseases and allows accurate diagnosis, staging and therapeutic options. Indications: 1) Any undiagnosed pleural effusion ( malignant or non-malignant) 100% diagnostic accuracy 2) Pleurodesis with talc or doxycycline for recurrent benign pleural effusions, recurrent malignant pleural effusions, recurrent spontaneous pneumothorax 3) Parapneumonic effusions and Empyema With the help of ultrasound, modern anesthesia techniques and rigid thoracoscope, medical thoracoscopy can be done as a daycare procedure. When pleural fluid biochemistry, microbiology, cytology & cell block are inconclusive, medical thoracoscopy and pleural biopsy is excellent tool for diagnosis.

NORMAL PLEURAL SURFACE MALIGNANT NODULES ON PLEURAL SURFACE

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Management of Drug Sensitive Tuberculosis Dr. Amit Patel Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

India is one of the countries with high burden of Tuberculosis as per data of World Health Organization. Every year 2.79 million new cases are detected in India. Around 4.5 lakhs people die due to Tuberculosis in India. Considering high infection rate of Tuberculosis, proper treatment of Tuberculosis is very important. In this lecture/article we will discuss Drug regimen, duration and other management related issues in Pulmonary and Extra pulmonary Tuberculosis.

Managing case of Malaria, Dengue & its complications in Pregnancy Dr. Sneha Baxi Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Malaria is Dengue is common mosquito borne infections during pregnancy. Pregnant patients because of lowered immunity are at increased risk of developing the severe disease. Complicated Malaria and severe dengue lead to adverse maternal & perinatal outcome including mortality. Also there is increased risk of vertical transmission in both. Parenteral artemisinin based chemotherapy should be started without delay in severe malaria. There is no specific antiviral drug for Dengue. Treatment is mainly supportive & symptomatic. But proper monitoring & hospitalization is must.

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Diabetic Cardiomyopathy Dr. Vipul Kapoor Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email Id: [email protected]

Type 2 diabetes mellitus (T2DM) is a highly prevalent disease worldwide. Cardiovascular disorders generated as a consequence of T2DM are a major cause of death related to this disease. Diabetic cardiomyopathy (DCM) is characterized by the morphological, functional and metabolic changes in the heart produced as a complication of T2DM. This cardiac disorder is characterized by constant high blood glucose and lipids levels which eventually generate oxidative stress, defective calcium handling, altered mitochondrial function, inflammation and fibrosis.

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A Case of Shock - Inotropes & Vasopressors - What, When, Why Dr. Tejas Patel Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

• Inotropes: – A group of drugs that increase the myocardial contractility, thus increasing the cardiac output (CO) and the systolic blood pressure. • Vasopressors: – A group of drugs that produce widespread vasoconstriction and increasing the peripheral vascular resistance and the diastolic blood pressure through arteriolar vasoconstriction, and increasing the venous return to the heart and thus the (CO) by venular vasoconstriction. A case of Hypertriglyceridemia - current approach When compared with the western populations, Indians and migrant South Asians tend to have higher triglyceride levels and lower HDL cholesterol while total cholesterol levels are lower. High TG levels increase saddle fraction, in a study it was found that at fasting TG>250 mg/dl, 85% of population has predominant thermogenic saddle-C particles. It is important to know the association of Hyper with CAD and at what level of TG treatment is helpful to reduce the future CV events.

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All Fevers are Not Infectious Dr. Surbhi Madan Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

The etiology of fever ranges from various infections to autoimmune diseases to malignancies etc. With the advancement in medicine, new diseases are diagnosed with ease and hence the fever-syndromes, which used to be addressed with antimicrobial agents, are now diagnosed perfectly and then treated. This topic is chosen to discuss various close non-infectious mimics of infectious fevers, like Adult onset still’s disease, Kikuchi disease, SLE, lymphoma and other malignancies; and even drug fevers. The clinical presentation as well the lab diagnosis will be discussed in detail, with the example of real life cases. Knowing the exact diagnosis definitely helps in the proper management and also cuts down on the irrational use of antibiotics.

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Case-Based Approach of Insulin Therapy: Newer Ones and Future Developments Dr. Vivek Patel Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email Id: [email protected]

Insulin replacement therapy is integral to the treatment of T1DM and often required in the treatment of T2DM. The insulin-based therapies for type I and type II DM are quite complex and associated with various problems (injections, hyperglycaemia, hypoglycaemia and weight gain). These problems have motivated the development of ‘smart insulin’ technologies, which include oral/inhaled insulin, glucose-responsive insulin release systems, tissue specific insulins etc. With development of these technologies many problems with injectable insulin therapy will be taken care of and lead to better life quality for the patients without compromising glycaemic control.

Management of Drug-Resistant Infections Dr. Surbhi Madan Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

We are daily facing the challenge in treating the difficult, multidrug resistant gram negative and gram positive organisms. Though the issue of drug resistance has mainly created havoc in the treatment of gram negative infections, gram positive and fungal infections are also a challenge to treat on many occasions due to limited availability of the agents to treat. To worsen the situation, no new promising gram negative antibiotic is in the pipeline. We are relying mainly on Colistin, Polymixin B, Tigecycline, Fosfomycin and other “old antibiotics” which had to be revived to tackle this issue. Drug resistant infections are difficult to treat, and are associated with higher morbidity and mortality. This discussion aims to discuss in the optimal treatment of various drug resistant infections with the help of real life cases.

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Case-Based Role of Clinical Genetics in Today's Medical Practice Dr. Krati Shah Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email Id: [email protected]

Medical genetics involves the application of genetics to medical care, including research on the causes and inheritance of genetic disorders, and their diagnosis and management. It is estimated that 3-7% of the general population will be diagnosed with a recognized genetic disorder, NOT INCLUDING common disorders, such as cancer, diabetes, heart disease and psychiatric disorders. Understanding how variations in an individual’s DNA may affect disease and health is the focus of genomic medicine. This knowledge can lead to ways to diagnose disease, earlier detection, by identifying genetic predisposition to a particular disease, new approaches to treatment and development of drugs that target a pathway or its causative mutation. Three cases will be focussed in the talk – Spinocerebellar Ataxia, Fragile X syndrome, Breast and Ovarian Cancer. All three cases showcase the importance of Clinical Genetics in routine clinical practice. Breast and ovarian cancer are present in several autosomal dominant cancer syndromes, although they are most strongly associated with highly penetrant germline pathogenic variants in BRCA1 and BRCA2. Breast cancer screening strategies and risk reducing surgeries are definitely useful. The earlier we know about the disease, the better we can manage it. Genetics helps us to know about the diagnosis, and act accordingly.

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Cardiac MRI – A Guide to Physicians or Cardiac MRI: The Upcoming Gold Standard to Clinicians Or Cardiac MRI –One Stop Shop in Diagnostic Cardiology Dr. Deepa Shah Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email Id: [email protected]

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.

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Cardiogenic Shock Dr. Pranav Vaidhya Hackensack University Medical Centre, Heart and Vascular Hospital, Hackensack New Jersey, USA 07601 Corresponding E-mail id: [email protected]

Cardiogenic shock is a physiological state of inadequate blood flow to vital organs and tissue hypoxia secondary to cardiac dysfunction. Incidence of cardiogenic shock is increasing due to aging population and increasing incidence of coronary artery disease in this population. Myocardial infarction remains the most common cause of cardiogenic shock and without early and aggressive appropriate interventions it carries a very high mortality and morbidity Despite recent advances in medical therapy, early revascularization and mechanical circulatory support, over all out come in cardiogenic shock has not improved significantly. Recently regional system of care combined with algorhythm has shown that early interventions with appropriate timing and temporary mechanical circulatory support may be the ultimate solution to improve out come and survival in cardiogenic shock.

Psychopharmacology and Cardiovascular Disease Dr. Parth Goyal Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

Mental disorders are very closely related to the risks of developing cardiovascular illnesses. These disorders present with a challenge as they act as risk factor for future cardiac events also. Most common mental disorders include depression, anxiety, bipolar spectrum disorders and substance abuse. All these mental illness and their medications can have a profound effect on the course of the cardiac illness and can have significant clinical drug-drug interaction with cardiac medicines. Thus it is important to keep in mind these various, clinically significant, points while treating a patient with cardiovascular illness for mental disorders and vice versa. This talk covers a host of clinical and theoretic scenarios illustrating the same.

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POET: Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis. Dr. Milan Chag Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email Id: [email protected]

BACKGROUND Patients with infective endocarditis on the left side of the heart are typically treated with intravenous antibiotic agents for up to 6 weeks. Whether a shift from intravenous to oral antibiotics once the patient is in stable condition would result in efficacy and safety similar to those with continued intravenous treatment is unknown.

METHODS In a randomized, noninferiority, multicentre trial, we assigned 400 adults in stable condition who had endocarditis on the left side of the heart caused by streptococcus, Enterococcus faecalis, Staphylococcus aureus, or coagulase-negative staphylococci and who were being treated with intravenous antibiotics to continue intravenous treatment (199 patients) or to switch to oral antibiotic treatment (201 patients). In all patients, antibiotic treatment was administered intravenously for at least 10 days. If feasible, patients in the orally treated group were discharged to outpatient treatment. The primary outcome was a composite of all-cause mortality; unplanned cardiac surgery, embolic events, or relapse of bacteremia with the primary pathogen, from the time of randomization until 6 months after antibiotic treatment was completed.

RESULTS After randomization, antibiotic treatment was completed after a median of 19 days (interquartile range, 14 to 25) in the intravenously treated group and 17 days (interquartile range, 14 to 25) in the orally treated group (P = 0.48). The primary composite outcome occurred in 24 patients (12.1%) in the intravenously treated group and in 18 (9.0%) in the orally treated group (between-group difference, 3.1 percentage points; 95% confidence interval, - 3.4 to 9.6; P = 0.40), which met noninferiority criteria.

CONCLUSIONS In patients with endocarditis on the left side of the heart who were in stable condition, changing to oral antibiotic treatment was noninferior to continued intravenousantibiotic treatment.

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NOACs: What a Physician Should Know? Dr. Ajay Naik Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

1. Know the differences between the NOACs The NOACs are new oral anticoagulants, or sometimes called non-vitamin K antagonist (VKA) oral anticoagulants (since they are no longer that new). There are three NOACs currently licensed for use in India:

Renal

*different dosing regimens are indicated depending on the indication. **Each NOAC has specific guidance on dose adjustment depending on creatinine clearance and in some cases other factors such as age and body weight.

2. Be clear on the indications for the NOACs By far the most common use is for non-valvular AF (by which people mean not rheumatic valve disease or metallic valve replacements where people still use warfarin). They should be offered first line alongside warfarin.

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30 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

They are also licensed for venous thromboembolism prophylaxis following hip or knee surgery as well as treatment of deep vein thrombosis and venous thromboembolism. Rivaroxaban is also licensed as prophylaxis of atherothrombotic events following acute coronary syndrome in combination with dual antiplatelet therapy.

3. Switch patients on warfarin with difficult to control INR to a NOAC The NOACs have each undergone a single large randomised controlled trial comparing them to warfarin in the context of AF and they have all been shown to be at least as effective as warfarin in prevention of thromboembolic stokes and at least as safe as warfarin. There is a tendency towards lower rates of bleeding with NOACs, in particular intracerebral bleeding. Overall mortality was actually lower for both apixaban and edoxaban compared to warfarin. Patients on warfarin who have difficult to control INR or have a time-in-therapeutic range of <65% derive little, if any, benefit from warfarin and are at increased risk of bleeding. These patients have the most to gain from changing to a NOAC and it is poor practice to continue with warfarin in these patients nowadays. There are ongoing studies looking at identifying patients who would benefit from changing from warfarin to a NOAC.

4. Take an individualised approach to starting patients on NOACs We would advocate an individual approach to each patient in whom you start a NOAC – taking into account their age, renal function, comorbidities, current medications and risk of bleeding. Rivaroxaban is once daily medication, which might make it easier for some patients to adhere to. As dabigatran has a predominantly renal mode of excretion, it would be better to choose another NOAC in patients with moderate renal impairment

5. Remember to check renal function. All NOACs are excreted renal to some extent and they all have dose adjustments according to renal function. Dabigatran is contraindicated if creatinine clearance is <30ml/min and the others are contraindicated at <15ml/min. It is best to look up specific indications for dose reduction in each NOAC as they differ slightly for each. Realistically, the creatinine clearance will fluctuate a little, so if the GFR is <30 ml/min, many physicians choose not to prescribe a NOAC and stick with warfarin.

6. Be aware of contraindications and interactions when starting NOACs Patients with ‘valvular AF’ (including rheumatic heart disease or those with metal valves) should take warfarin rather than a NOAC. Patients with severe renal impairment and those on renal replacement therapy cannot take NOACs. Severe liver disease and cirrhosis is a contraindication to either warfarin or a NOAC. A high bleeding risk and advanced malignancy really rules out both also.

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7. Be aware of how to manage bleeding Bleeding is of course a risk with all oral anticoagulants. However, trial data suggests that there is a trend towards lower bleeding rates with NOACs compared to warfarin, in particular decreased rates of intracerebral haemorrhage. Management of bleeding is straight forward if it does occur. Dabigatran has a specific reversal agent (idarucizumab) that rapidly and completely reverses its effect. The other NOACs are completely reversible by giving clotting factors (as you would for warfarin). NOACs are also much more straightforward to start and stop following bleeds or planned operations because of their rapid onset and offset.

8. Check baseline screening tests annually The effects of NOACs are much more predictable than those of warfarin so no monitoring is necessary. Conventional clotting studies, including INR, are not reliable markers of anticoagulation and so are not useful. A baseline CBC, RFT, LFT should be performed prior to starting treatment and then annually to ensure patients have not developed any contraindications to NOACs or anticoagulation in general. Renal function should be monitored more closely in patients with known impairment and in patients with an intercurrent illness that may affect renal or liver function.

9. Consider the overall cost when weighing up the benefit of NOACs over warfarin The annual cost of NOACs is higher compared to warfarin, although there is some cost modelling suggesting that by the time one has accounted for INR monitoring, the difference is in fact fairly small. This cost also assumes equivalence and takes no account of the lower rates of intracerebral haemorrhage with NOACs, lower rates of stroke (apixaban, edoxaban, dabigatran), and lower overall mortality (apixaban and edoxaban).

10. Use the CHA2DS2-VASc system to determine stroke risk in AF patients The CHA2DS2-VASc scoring system is currently recommended. Patients score a point for congestive heart failure, hypertension, age ≥ 75 years (two points), diabetes, stroke (two points), vascular disease (either peripheral or coronary), age ≥ 65 years and female sex. Patients with a score of zero are low risk and do not require anticoagulation. Patients do not score a point for female sex alone (in the absence of other points). Antiplatelet have little if any effect in AF and should not be used. Anticoagulation is advised for those with a score ≥ 1. As a rule of thumb, the stroke risk as a percentage per year is approximately equal to the CHA2DS2 VASc score. This usually sounds small to patients but is annualised, so the risk over a five year period is at least five times this number. For example a CHA2DS2-VASc score of two gives an annualised stroke rate of approximately 2%, which equates to one in 10 over five years.

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Artificial Intelligence and Cardiology Dr. Keyur Parikh Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Artificial Intelligence (AI) is a general term that implies the use of mathematical algorithms which give machines the ability to reason and perform cognitive functions such as problem solving, object/word recognition and decision-making.

Artificial intelligence and machine learning are poised to influence nearly every aspect of the human condition. AI is a field of computer science that aims to mimic human thought processes, learning capacity, and knowledge storage. Over the past decade, several machine-learning techniques have been used for cardiovascular disease diagnosis and prediction. In the near future, AI techniques, such as machine learning, deep learning, and cognitive computing, may play a critical role in the evolution of cardiovascular (CV) medicine to facilitate precision CV medicine.AI may play a critical role in the evolution of CV medicine to facilitate precision CV medicine.

Fig. 1: Artificial Intelligence AI might significantly impact clinical care, Big Data research, image and intra-procedural video analysis, evidence-based, real-time clinical decision support, and robotics. Currently, AI is not a replacement for human intellect. Rather, it has the potential to complement and reinforce it. Cardiologists and Physicians need to be prepared for the upcoming AI era. In the field of clinical cardiology, so far one study has shown that deep learning algorithms clearly outperformed clinicians in predicting prognosis and future events in patients with pulmonary hypertension. In another study, machine learning has helped to develop a clear phenotypic classification of heart failure patients with preserved ejection fraction. Further cardiovascular research based on artificial intelligence tools is underway. Because of its potential to change the way of how we generate knowledge, interpret data and make decisions, artificial intelligence may trigger uncertainties and reservations among healthcare providers and clinicians

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Cardiology Need Artificial Intelligence emerged because more familiar algorithms can often be improved on for real-world tasks.

Google Maps: Crowsourced Traffic App (Waze) Prediction of Traffic Patterns UBER: Virtual Transportation App Prediction of Trip’s Performance TESLA - Auto-Pilot Driverless Automotives Surrounding Imaging-Object Analytics Fig. 3: AI and Deep Machine Learning are Already Fig. 2: Traditional Statistics versus Machine Learning Disrupting Our Daily Living Activities

Fig. 4: Robotics Artificial Intelligence Fig. 5: Artificial intelligence and machine learning Artificial intelligence and machine learning are poised to influence nearly every aspect of the human condition. Artificial Intelligence in Precision Cardiovascular Medicine • Artificial intelligence (AI) is a field of computer science that aims to mimic human thought processes, learning capacity, and knowledge storage • Over the past decade, several machine-learning techniques have been used for

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cardiovascular disease diagnosis and prediction. • In the near future, artificial intelligence (AI) techniques, such as machine learning, deep learning, and cognitive computing, may play a critical role in the evolution of cardiovascular (CV) medicine to facilitate precision CV medicine • may play a critical role in the evolution of cardiovascular (CV) medicine to facilitate precision CV medicine • AI can classify new genotypes or phenotypes of heart failure (HF) with preserved ejection fraction (HFpEF), and novel diagnostic echocardiographic parameters could potentially lead to novel targeted therapy • Big data refers to extremely large datasets that cannot be analyzed, searched, interpreted, or stored using traditional data-processing method • Big data include data from mobile phone applications, wearable technology, social media, environmental and lifestyle-related factors, sociodemographics, “omic” data (e.g., genomics, metabolomics, proteomics), and data from , standardized electronic health records (EHRs) or precision medicine platforms. • Whereas big data by themselves are useless, the processing of big data to make predictions or decisions using AI has the potential to transform the current practice of clinical care • Big data analytics using AI may potentially facilitate identification of novel genotypes or phenotypes of heterogeneous syndromes, such as – HFpEF,, Takotsubo cardiomyopathy, hypertrophic cardiomyopathy, primary pulmonary hypertension(PH), hypertension (HTN), and coronary artery disease, leading to personalized, targeted therapy • Big data analytics has the potential to identify unknown risk factors for acute coronary syndrome (ACS), spontaneous coronary artery dissection (SCAD), or Brugada syndrome, and even the controversial issue of statins in the older population (age>75 years) Why Does Cardiology Need Artificial Intelligence? • AI emerged because more familiar algorithms can often be improved on for real- world tasks.

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• Despite its gradual penetration of medicine and biology in general, most Cardiologists and Physicians s and Physicians today are more likely to associate the term artificial intelligence with a futuristic phenomenon rather than with an engineering tool that is just about to conquer medicine, including cardiovascular medicine. • Machine learning strategies can be broadly split into either unsupervised or supervised learning. • Unsupervised learning focuses on discovering underlying structure or relationships among variables in a dataset, Supervised learning often involves classification of an observation into 1 or more categories or outcomes e.g., Does this electrocardiogram represent sinus rhythm or ventricular fibrillation?” Clinicians generally work with dichotomized outcomes (e.g., “Should we give this patient a statin or not?”) Supervised learning thus requires a dataset with predictor variables (“features” in machine learning parlance) and labeled outcomes

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Aspirin for Primary Prevention 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. 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? Recent research shows this question is particularly relevant to the “healthy elderly”. We will look at the evidence and a simple app that helps in decision- making by helping answer these questions.

Hypertension Guidelines Dr. Vipul Kapoor Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email Id: [email protected]

Hypertension is the leading cause of death and disability-adjusted life-years worldwide Meta-analyses of observational studies have shown that elevated blood pressure (BP) and hypertension are associated with an increased risk of cardiovascular disease (CVD), end-stage renal disease, subclinical atherosclerosis, and all-cause mortality. A person's risk of hypertension is influenced by various genetic and environmental factors, such as being overweight or obese; diet; alcohol intake; and fitness level. Estimates of the prevalence of hypertension are greatly influenced by the choice of cut-offs used to categorize elevated BP and hypertension, the methods used to establish the diagnosis, and the population studied. The prevalence of hypertension among adults is substantially higher when the definitions in this guideline are used vs. the definitions in the Seventh Report of the Joint National Committee, but nonpharmacological therapy would be recommended for most patients with newly diagnosed hypertension based on the current guideline.

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Impact of Lipids on CV Health “Primordial Prevention” Dr. Keyur Parikh Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

People with ideal cardiovascular (CV) health have a low lifetime risk of CV disease. This requires shifting the focus from “treating disease” after it develops to “preventing CV events” before they happen by slowing the progression of atherosclerosis. IVUS studies show that the “rate” of atherosclerotic plaque progression and “total” atherosclerotic plaque burden is directly proportional to the “absolute and total plasma LDL levels” over “lifetime” of the person and proportional to “cumulative” exposure to LDL and other Apo B–containing lipoproteins, It can be approximated by multiplying a person’s age by the LDL concentration for an estimate of Cumulative LDL exposure measured as and m g - y e a rs ( a g e * ) L D L - C measured in mg/dl or mmol-years LDL-C. 5,000 mg-years or 130 mmol-years appears to be the minimum threshold of cumulative LDL exposure necessary to develop a sufficiently large total atherosclerotic plaque burden to increase the risk of experiencing a myocardial infarction. Eventually the enlarging atherosclerotic plaque burden reaches a critical mass beyond which the disruption of a plaque can lead to an overlying thrombus that acutely obstructs blood flow resulting in unstable angina, NSTEMI, myocardial infarction, or death. If lipid levels are at optimal levels, then continue on the current diet, and lipid levels assessed every 3 to 5 years. If lipid levels are higher than the optimal threshold, then consider conducting a series of trials to discover the diet that effectively reduces Apo B–containing lipoproteins for each person. Randomized trials involving total food replacement have consistently demonstrated that reducing saturated fats can reduce LDL-C levels and have demonstrated that eating nuts, plant phytosterols, and foods rich in fiber can also reduce LDL-C. Maintaining optimal lipid levels throughout life is a necessary component of ideal CV health and has the potential to reduce dramatically the lifetime risk of developing atherosclerotic CV disease. If 1 or more “high-risk” features are present then lipid-lowering therapy should be added to slow plaque progression in an attempt to modify the atherosclerotic disease course. Most people are born with an LDL-C level of approximately 40 to 60 mg/dl. This level rises to approximately 70 mg/dl during the first 2 years of life. Then rises more gradually during childhood and the teen years to approximately 110 to 120 mg/dl by early adulthood. Ideally, the magnitude of the potential clinical benefit of maintaining optimal lipid levels would be tested in a long-term randomized trial starting age 20 or so.

PRIMORDIAL PREVENTION Primordial prevention can be defined as the prevention of suboptimal lipid levels (Preventing > 40 or 50 or 60 level!!) on the basis of the natural history trajectory of lipid levels.

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Definition of primordial prevention should be preventing (or minimizing) the acquired burden of LDL and other apo B–containing lipoproteins from the outset before even the atherosclerotic plaque begins! Strategies for the primordial prevention of suboptimal lipid levels must begin during childhood and adolescence.

PRIMARY PREVENTION Primary prevention is defined as lowering lipid levels to achieve more optimal levels to prevent CV events in people who do not have clinical evidence of CV disease. Because the risk of CV events depends on the cumulative lifetime exposure to LDL and other apo B–containing lipoproteins, primary prevention strategies designed to lower lipids closer to optimal levels should be initiated in early adulthood. The objective of both primordial prevention and primary prevention is delay the development of advanced atherosclerotic plaques that can cause clinical CV events. The optimal lipid level for the AHA for ideal CV health is for untreated total plasma cholesterol level of of 200 mg/dl with an LDL-C level of 120 mg/dl and a non–HDL cholesterol level (an estimate of the circulating concentration of all apo B–containing lipoproteins) of 150 mg/dl. However, this threshold for optimal lipid levels may not be adequate to achieve ideal CV health.

Effect of Primary and Primordial Prevention on Progression of Differential Vulnerability to Retaining LDL and Atherosclerosis and Risk of Acute Cardiovascular Events Other Apo B-Containing Lipoproteins

Life Course Trajectory of LDL and Implications for Primordial Prevention

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Fig. 1: Central Illustration Clinical Pathway to Achieve Optimal Levels

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Cardiovascular Health Promotion an Issue That Can No Longer Wait Dr. Keyur Parikh Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

There are 3 critical pathways for preventing Table 1: NHLBI Strategic Agenda – 2025 the development and progression of cardiovascular disease (CVD). The Primordial prevention, is to prevent the development of cardiovascular risk factors; Primary prevention, is to prevent the onset of CVD in persons with cardiovascular risk factors and no known disease and Secondary prevention, is to prevent the recurrence of cardiovascular events or complications of CVD in persons diagnosed with CVD.

American Heart Association’s (AHA’s) goals (applicable to Indians too ) for cardiovascular health (CVH) promotion and disease reduction. The power of primordial prevention; The evidence that CVD and its risk factors often develop early in life; and The balance between population-level approaches for health promotion and disease prevention and Individualized high-risk approaches. Majority of people will continue to develop CVD—first sub clinically and then clinically during their lifetime. Behavioral considerations that impact CVH are nutrition and diet, healthy weight, exercise and physical activity, tobacco-free lifestyle, blood pressure, cholesterol, blood sugar, psychological health.

Atheroscler, VP/HRP Burden Disease 1980-2000 2000-2015 2015-2020

Fig. 1: focus in Atherosclerosis Fig. 2: Calcification of the Coronary Arteries (CAC)

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Detection of subclinical atherosclerosis by non invasive testing , would motivate patients to change their lifestyle. In PESA (Progression of Early Subclinical Atherosclerosis) study, plaque burden—identified through 3-D vascular ultrasound in the femoral territory—was directly associated with cardiovascular risk independently of the number of plaques or territories affected. Moving From the Vulnerable PlaqueTo The Vulnerable Patient 1. Vulnerable Plaque – Invasive Approach ? A) Restricted Population with Complex Disease B) Mild Angiography, Significant IVUS & Pathology 2. Vulnerable Patient – Non-invasive Burden Approach A) Large Population with Silent Disease B) RF + Burden of Disease at 3D-US & CAC C) What is next ?

Fig. 3: Carotid Plaque Burden, mm 3 3D US - Manual Sweep 2D vs Transducer and Focal structure into the arterial lumen of at least 0.5 mm or 50% of surrounding IMT value. 37% missed at Classical 2D

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DECLARE-TIMI-58: Dapagliflozin and Cardiovascular Outcomes in Type 2 Diabetes. Dr. Milan Chag Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email Id: [email protected]

BACKGROUND : The cardiovascular safety profile of dapagliflozin, a selective inhibitor of sodium– glucose cotransporter 2 that promotes glucosuria in patients with type 2 diabetes, is undefined. METHODS : We randomly assigned patients with type 2 diabetes who had or were at risk for atherosclerotic cardiovascular disease to receive either dapagliflozin or placebo. The primary safety outcome was a composite of major adverse cardiovascular events (MACE), defined as cardiovascular death, myocardial infarction, or ischemic stroke. The primary efficacy outcomes were MACE and a composite of cardiovascular death or hospitalization for heart failure. Secondary efficacy outcomes were a renal composite (≥ 40% decrease in estimated glomerular filtration rate to <60 ml per minute per 1.73 m2 of body-surface area, new end-stage renal disease, or death from renal or cardiovascular causes) and death from any cause. RESULTS : We evaluated 17,160 patients, including 10,186 without atherosclerotic cardiovascular disease, who were followed for a median of 4.2 years. In the primary safety outcome analysis, dapagliflozin met theprespecified criterion for noninferiority to placebo with respect to MACE (upper boundary of the 95% confidence interval [CI], <1.3; P<0.001 for noninferiority). In the two primary efficacy analyses, dapagliflozin did not result in a lower rate of MACE (8.8% in the dapagliflozin group and 9.4% in the placebo group; hazard ratio, 0.93; 95% CI, 0.84 to 1.03; P = 0.17) but did result in a lower rate of cardiovascular death or hospitalization for heart failure (4.9% vs. 5.8%; hazard ratio, 0.83; 95% CI, 0.73 to 0.95; P = 0.005), which reflected a lower rate of hospitalization for heart failure (hazard ratio, 0.73; 95% CI, 0.61 to 0.88); there was no between-group difference in cardiovascular death (hazard ratio, 0.98; 95% CI, 0.82 to 1.17). A renal event occurred in 4.3% in the dapagliflozin group and in 5.6% in the placebo group (hazard ratio, 0.76; 95% CI, 0.67 to 0.87), and death from any cause occurred in 6.2% and 6.6%, respectively (hazard ratio, 0.93; 95% CI, 0.82 to 1.04). Diabetic ketoacidosis was more common with dapagliflozin than with placebo (0.3% vs. 0.1%, P = 0.02), as was the rate of genital infections that led to discontinuation of the regimen or that were considered to be serious adverse events (0.9% vs. 0.1%, P<0.001).

CONCLUSIONS : In patients with type 2 diabetes who had or were at risk for atherosclerotic cardiovascular disease, treatment with dapagliflozin did not result in a higher or lower rate of MACE than placebo but did result in a lower rate of cardiovascular death or hospitalization for heart failure, a finding that reflects a lower rate of hospitalization for heart failure.

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

The amount of information is growing at an incredible pace. Physicians must keep up with new advances in medicine and medical literature and the patient medical records including imaging data. In addition, they will soon have to keep track of data like patient activities, patient genomics etc. Computer systems developed using natural language programming and machine learning will be essential to help physicians in managing these information streams to take care of their patients. Recently advances have been made in visual imaging specialties like radiology, dermatology and pathology which with transform how these are practiced. We will review some key advances in machine learning that will change medicine in the next decade.

Optical Pharmacotherapy of Acute Coronary Syndrome Dr. Anish Chandarana Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Acute coronary syndrome-Non ST segment Elevation Myocardial Infarction has been an important and a high-risk cardiac situation. Progress made in early and precise diagnosis of NSTEMI in emergency room, use of more effective anticoagulant and antiplatelet agents and better definition of features suggestive of high-risk situation helping to decide for early invasive strategy – all have improved the care and prognosis of patients suffering from NSTEMI. Our knowledge has improved to understand that both – early ischemic and major bleeding events are bad prognostic markers for not only long-term morbidity but also long- term mortality. Selecting right combination of anticoagulant and antiplatelet agents and using them for a proper period of time in a given patient to achieve a smart balance between ischemic vs bleeding risk is always a major decision point. This presentation will review various existing guidelines on the topic and help to derive carry home messages.

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Role of Biomarkers Dr. Urmil Shah Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

What is the role of biomarkers in Heart Failure (HF)? All the most recent national and international guidelines recommend the Natriuretic Peptides (NPs), and in particular the peptides related to the B-type cardiac peptide hormone (such as BNP and NT-proBNP), as the first line biomarkers for the diagnosis of both acute and chronic Heart Failure (HF). Recent 2017 ACC/AHA/HFSA (Figure 1) guideline recommend the BNP and NT-proBNP measurement for the diagnosis or exclusion of HF in patients with acute dyspnoea and de-compensated chronic or HF and also for prognosis of HF with the maximum degree of recommendation - class I. (with level of evidence A). Concentrations of the natriuretic peptides are typically higher in patients with HF (new-onset as well as de-compensated chronic HF) and higher values have reasonably high positive predictive value to diagnose HF whereas lower values confidently exclude the presence of HF. Importantly, higher concentrations of BNP and NT-proBNP are also strongly predictive of adverse outcomes in patients with HF; lower levels correlate with improved outcomes Bio-marker to is not only useful for diagnosis and prognosis, it also is very helpful in guiding heart failure treatment. NPs guided HF therapy is Class IIb indication at present. Could you elaborate on the interaction of biomarkers with HF management? Figure 2 is a schematic presentation of how NPs are produced and released in patients with HF. Increased ventricular wall stretch is the primary inciting event causing a cascade of biomarker release which can be measured to monitor disease severity and ongoing myocardial insult, a quantitative marker of HF. Pro-BNP cleaved in to Active BNP & Inactive NTpro BNP in 1:1 molar ratio Natriuretic peptide levels are best interpreted as a continuous variable. The higher the value, the greater the likelihood that the dyspnoea is due to heart failure. The clinical implications of natriuretic peptide use in AHF revolve around their ability to differentiate cardiac dyspnoea from non-cardiac dyspnoea. NPs levels have been shown to correlate with New York Heart Association (NYHA) functional classes and are inversely related to the calculated EF of the LV. Moreover, BNP levels directly correlate with the measured pulmonary capillary wedge pressures, thus providing an almost accurate estimation of LV

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systolic dysfunction. Similarly, NTproBNP levels are fast gaining a stronghold in the management and diagnosis of heart failure patients. With a longer half-life when compared to BNP, NT-proBNP survives longer in the plasma and provides similar information regarding heart failure severity and disease progression. Elevated BNP and NT-proBNP reflect a wide array of cardiac pathophysiology such as diastolic function, right ventricular size and function, valvar heart disease, Increase filling pressures, heart rhythm disturbance, and coronary Ischemia. Although natriuretic peptide levels are unable to distinguish systolic from diastolic heart failure, recent ESC guideline (Figure 3) recommend use of bio-marker NPS even before ECHO cardiograph and advocate doing ECHO Cardiograph to identifies patients of heart failure with preserved systolic function or with reduce systolic function. Thus, their use has gained widespread acceptance as standard of care for the management of heart failure patients, also for many other cardiac conditions. NPs are useful for risk stratification in patient with sub-massive pulmonary embolism, patient with Idiopathic Pulmonary Hypertension and Acute Coronary Syndrome The reference values of Brain-type Natriuretic Peptide (BNP) and N-Terminal (NT) proBNP are different to exclude or confirm a diagnosis of heart failure. These values also depend on age and gender and are higher in elderly persons and women. In general, the following cut off values may be employed for acutely dyspnoeic patients: BNP < 100 pg/mL - HF unlikely >400 pg/mL - HF likely 100-400 pg/mL - Use clinical judgment NT-proBNP < 300 pg/mL - HF unlikely Age < 50 years, NT-proBNP >450 pg/mL - HF likely Age 50-75 years, NT-proBNP >900 pg/mL – HF likely Age >75 years, NT-proBNP >1800 pg/mL – HF likely

Co-morbidities can also influence the interpretation of biomarkers. For example, patients with abnormal renal function and atrial fibrillation typically have higher levels of BNP and NT-proBNP, while obesity decreases the levels of these markers. Because bio-markers can be influenced by co-morbidities, we should be very careful interpreting bio-marker in these associated co-morbid condition a specially atrial fibrillation and altered renal function.

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Conditions associated with elevated BNP other than CHF are as follows: • Acute Renal Failure and Chronic Renal Failure • Accelerated Hypertension (HTN) • Pulmonary Diseases such as Pulmonary Hypertension, severe Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, Pulmonary Embolism, Adult Respiratory Distress Syndrome (ARDS) • Cardiac causes -Myocardial Infarction, Atrial Fibrillation, Acute Coronary Syndrome, Cardioversion, Valvar Heart Disease, Myocarditis • Older age • Female sex • Liver cirrhosis • Hyperthyroidism • Sepsis • Chemotherapy Conditions associated with lower than expected BNP are as follows: • Obesity • Flash Pulmonary Edema • Pericardial Constriction

Do the newly available HF treatments, valsartan / sacubitril and ivabradine, impact biomarker use? Sacubitril /valsartan (ARNI) is recom-mended as a replacement for an ACEI to reduce further the risk of HF hospitalisation and death in ambulatory patients with HFrEF who remain symptomatic despite optimal treatment with an ACEI, a beta-blocker and a MRAa especially with high NP levels. In the pivotal PARADIGM HF trial, patients treated with sacubitril / valsartan also had a rapid and sustained reduction in NT-proBNP levels compared with patients treated with the ACE inhibitor alone. In addition, a modest increase in BNP level was also seen in patients treated with the drug. The reason for the differential effect on BNP and NT-proBNP levels relates to the mechanism of action of sacubitril (Figure 3). Sacubitril inhibits the breakdown of vasoactive peptides, including Atrial Natriuretic Peptide (ANP), BNP, and C-type natriuretic peptide; in contrast, NT-proBNP is not a substrate for neprilysin. Consequently, endogenous levels of BNP are elevated due to effects of the drug, while NT-proBNP concentrations are unaffected by the direct action of sacubitril. Accordingly, the decrease in NT-proBNP seen with treatment is, in fact, a reflection of the treatment effect of sacubitril / valsartan on the heart.

Where are we in terms of biomarker testing and management of patients with acute HF? Given the impact of acute HF on the healthcare system, there is a need for biomarker testing to help improve diagnostic accuracy and understand acute prognosis, inpatient HF care, and outcomes of patients with decompensated HF. During the course of inpatient acute HF management, there is often a significant

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reduction in concentrations of NPs. These reductions are accompanied by better outcomes. Conversely, patients with worse outcomes typically do not have a significant reduction in their biomarker concentrations. This has led to the idea of using biomarkers to gauge a patient's risk at hospital discharge. Both the decrease in natriuretic peptide level from admission level as well as the absolute discharge value are prognostic, with the latter being the more prognostic than the admission level. A relative decrease of less than 30% (Figure 4) in natriuretic peptide level is generally associated with bad short-term prognosis. Careful follow-up is needed in this group of patients With careful disease management, many patients experience stabilization of HF in the outpatient setting. What are the clinical considerations in evaluating - managing optimally these stable patients at follow-up? Stability in HF is an ephemeral concept. Patients who are

asymptomatic or mildly symptomatic and who have not been Figure 4 recently hospitalized might be considered stable, but remain at risk for adverse events. In the recently completed PARADIGM-HF trial, at 1 year nearly 8 to 10% of patients have cardiovascular death or HF hospitalization despite optimal medical treatment in this kind of relatively stable patient. A key clinical consideration in stable patients is recognizing that these patients have some degree of unattended residual risk that may not be revealed by their professed symptom burden or quality of life - NP Level may additionally help in identifying this high risk group patients. The time when patients are stable is the time to consider optimization of their long-term HF regimen in order to provide them with the best possible long-term outcomes. Optimization generally refers to initiation and titration of established GDMTs (such as an ACE Inhibitor, Aldosterone Receptor Blocker (ARB), beta blocker, or aldosterone antagonist), but also requires integration of novel therapies, such as sacubitril / valsartan and ivabradine (Figure 4). There is also the need to reconsider and intensify device-based therapies, including defibrillators and cardiac resynchronization devices, which have been shown to provide benefit even in these more stable populations. Latest 2017 recommendation suggest that BNP / NP- proBNP is Class I indication for patient presenting with acute dyspnoea in ER and Ambulatory patient with new onset of dyspnoea as diagnostic workup and also for relatively stable looking patient having NYHA Class II - IV and hospitalized patient with Acute Heart Failure for prognosis and improving long term outcome for patient having heart failure with wider availability of measuring NPs, bio-marker - BNP/NTpro BNP must be used in our day

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to day practice to improve diagnosis of patient suspected of HF, to know the prognosis of our patients and optimize treatment in high risk patients to improve long term out come in this deadly disease.

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What is CHIP in Cardiology? Why is it important for us to know about CHIP? Dr. Keyur Parikh Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

With recent advances in PCI technology and techniques there is currently a whole new era in Interventional Cardiology that can offer minimally invasive percutaneous solutions to patients with complex coronary anatomy, severe co-morbidities, and/or poor hemodynamics. However, because of the clinical complexity of many of these patients and procedures, it is critical to develop dedicated specialists within interventional cardiology who are trained with the cognitive and technical skills to select these patients appropriately and to perform these procedures safely. The Complex Higher-Risk Interventional Procedures (CHIP) which encompasses all aspects of complex and high-risk PCI from procedural training, patient screening to post-procedural care, as well as dedicated research. CHIP is a rapidly growing sub-specialty which requires specialized training in advanced technical and cognitive skills to assess and treat a high-risk/complex group of underserved patients! There is a large population, who make it to the hospital alive that can benefit from revascularization rather than focusing on low- risk patients who may be “easy to treat”, we need to focus upon higher -risk patients who have the most to gain The development of specialists trained with advanced technical and cognitive skills to treat these patients is clearly needed. CHIP embraces using a strategy or algorithm based approach to manage complex problems (structured but flexible/dynamic). Take advantage of the special wisdom of experienced operators – EBM is helpful, but case-based tips/tricks are invaluable! The CHIP ‘heart team’ is composed of specially trained CHIP operators, surgeons, clinical cardiologists, HF specialists, imaging experts, and most importantly, the patient! Mechanical Support for STEMI :

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Identifying a potentially underserved high risk population. Raise awareness in the general and specialized Physician community of this high-risk, underserved, population. Promote educational initiatives for enhanced cognitive and technical skills in the interventional cardiology community to effectively treat these patients. Initiate disease and procedure based research to better define the treatment population assess outcomes. Fig. 3: Treatment of Calcified Lesions: Options Fig. 2: The Modern Era of PCI

Fig. 1: Definition of the CHIP Population: Complex Higher-Risk (and Indicated) Patients

These patients are being undertreated! Clinical Course : • Rapid clinical decompensation during case with severe cardiogenic shock • Intubated • MCS-Impella CP or ECMO inserted • Transient arrest requiring vasopressors, continued severe hypoxemia and shock • RPL and OM1 recanalization and DES placement • ECMO decannulated post-procedure day 2 • Extubated post-procedure day 3 • No further complications • Pre-discharge echo: MR 1-2+ and EF 45% • Discharged post-procedure day 10, fully ambulatory and w/o symptoms • First clinic visit: wo complications or symptoms • Planned LAD revascularization

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The “modern era” of PCI : • Apprpriate clinical indications for PCI therapy (clinician vs. proceduralist) • Advanced PCI skills (training, case experiences, embrace collective wisdom) • Use of intravascular imaging –OCT and IVUS • Use of physiologic lesion assessment-FFR • Use of mechanical circulatory support • Commitment to evidence-based validation of new devices and therapy approaches

A new era of CHIP partnership for patient screening, completion of the procedure and assessment of the results :

To be CHIP Program to manage High Risk Intervention you need the following: • Heart Team Interventional cardiologists, On site Cardiac Surgeon, On site anesthesiologists • Fully equipped state of the art CathLab • ECMO/Impella capabilities • OCT • IVUS • CT and MRI on site Tips for SVG Interventions

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• Avoid treating chronically occluded grafts • Assess likelihood of acute and long-term success of long-term patency - Native vessel • PCI may be a better choice • For SVGs > 1 year old, always use embolic protection devices and copious vasodilators • Choose a guiding catheter which engages coaxially and provides backup support • Very old, calcified SVGs may require atheroablative techniques • Don’t overdilate !

CHIP Updates • CHIP embraces using a strategy or algorithm based approach to manage complex problems (structured but flexible/dynamic). • Take advantage of the special wisdom of experienced operators – EBM is helpful, but case-based tips/tricks are invaluable! • The CHIP ‘heart team’ is composed of specially trained CHIP operators, surgeons, clinical cardiologists, HF specialists, imaging experts, and most importantly, the patient !

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Cardiac MRI- An Emerging Modality Dr. Vipul Kapoor Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email Id: [email protected]

Its spatial resolution is better than that of the nuclear scans and its image quality is more consistent than that of the echocardiography CMR allows for gold standard level quantification of volumes and flow. CMR first-pass perfusion has been shown to at least match the diagnostic accuracy of SPECT. CMR also has the highest native tissue contrast and thereby contrast agents are not always necessary.

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NOACs: Practical Points for Practising Physicians Dr. Ajay Naik Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

1. Use of NOACs is contraindicated for AF patients with mechanical prosthetic valves or moderate- severe mitral stenosis (usually of rheumatic origin). Although there are limited data for patients with bio prosthetic valves, mitral valve repair, or Trans catheter aortic valve replacement, use is acceptable. 2. Structured follow-up is recommended for patients on chronic NOAC use. This includes documentation of anticoagulation indication, checking baseline laboratory studies (haemoglobin, renal and liver function, coagulation panel), providing education, and coordinating follow-up with at least once-yearly laboratory studies. Repeat laboratory testing should be performed more frequently for patients with baseline renal dysfunction or the elderly. 3. It is important to calculate renal function using the Cockcroft-Gault equation. This is used to appropriately dose NOACs. Use of NOACs is not recommended for patients with creatinine clearance <15-30 ml/min or on dialysis. Apixaban is dosed based on serum creatinine level, weight, and age. Both Apixaban and Rivaroxaban are FDA approved for use with dialysis. 4. It is also important to check baseline liver function before starting NOACs. NOACs are contraindicated for patients with Child-Pugh category C hepatic insufficiency. Rivaroxaban is also contraindicated in Child-Pugh category B hepatic insufficiency. 5. When switching from Warfarin to a NOAC, the NOAC should be started when the international normalized ratio (INR) is <2.5. When switching from a NOAC to warfarin, warfarin should be started and the NOAC continued until the INR is ≥ 2. Repeat the INR 1-3 days after stopping NOAC to ensure INR remains therapeutic. 6. Although NOACs have fewer drug-drug interactions than warfarin, there are still important drug- drug interactions to monitor. These include the P-glycoprotein and CYP3A4 interacting medicines. Important examples include avoiding concurrent use of dronedarone, rifampin, many HIV protease inhibitors, itraconazole, ketoconazole, and dexamethasone. 7. In the case of a nonlife-threatening major bleeding event, plasma levels of NOACs should normalize within 12-24 hours for patients with normal renal function. It may take longer for patients with renal insufficiency, particularly for Dabigatran. 8. In the case of a life-threatening major bleeding event, patients on dabigatran can be given idarucizumab 5 mg IV in two doses no more than 15 minutes apart. Patients taking factor Xa inhibitors should be given prothrombin complex concentrate 50 U/kg. All patients should receive supportive measures, including mechanical compression and endoscopic or surgical hemostasis (if applicable).

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9. Following a major gastrointestinal bleeding event, NOACs should be restarted as early as feasible (usually 4-7 days) if the risk of stroke persists and outweighs the risk of recurrent bleeding. 10. Most patients taking NOACs can safely undergo surgical procedures with a 24- to 48-hour pre- procedure hold. Longer hold times may be necessary for patients taking dabigatran who have chronic kidney disease. No bridging heparin is needed for NOAC-treated patients. Resume full- dose NOAC within 72 hours post-procedure, once the bleeding risk is appropriate. 11. For patients taking NOAC who present with an acute coronary syndrome, primary percutaneous coronary intervention (PCI) can be performed (preferably using a radial approach) emergently for ST-segment elevation myocardial infarction (STEMI) patients or delayed for 24-48 hours in stable NSTEMI patients. Consider a proton pump inhibitor for patients taking combined NOAC with antiplatelet medications. 12. For patients taking NOAC with single or dual antiplatelet therapy, shorter courses of antiplatelet are recommended. Patients with elective PCI may benefit from dual therapy (NOAC plus clopidogrel from discharge through 1 year). Patients with acute coronary syndromes who undergo PCI should receive triple therapy for up to 3 months, and then switch to dual therapy (NOAC plus clopidogrel) until 1 year. After 1 year, all patients should continue on NOAC monotherapy. 13. For patients taking NOAC who present with an acute ischemic stroke, proceed with thrombolysis if the NOAC plasma level is below the lower limit of detection or if the last intake was >48 hours prior and renal function is normal. Otherwise consider thrombolysis in select patients after NOAC reversal or use of endovascular therapy. 14. For patients taking NOACs who present with an acute ischemic stroke, consider re-starting NOACs after 3-14 days, depending on the degree of neurologic deficit and excluding any haemorrhagic transformation on brain computed tomography.

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Preventing SCD Post Hospital Discharge for STEMI Dr. Ajay Naik Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Thirty-day mortality has significantly reduced in STEMI patients due to extensive development of PCI. However, the long-term mortality and event rates after AMI were underestimated and the 6-month mortality rate is still as high as 12%. SCD was the main or the leading cause of death in all the cases of deaths, even if revascularization was completed it accounted for 24%–40% of the total deaths. The high incidence of SCD in the early stage after AMI (within 30–40 days) resulted in high-risk of sudden death. However, more than half of the SCDs were not caused by arrhythmias, but by re-infarction or mechanical complications that were due to LV rupture and acute MR. in DINAMIT study, only 50% of SCDs were attributed to arrhythmia, while the rest were due to the mechanical complications of the heart. In the VALIANT trial, 80% of the causes of SCD were re-infarction or cardiac rupture in the 1st month after the onset of AMI, and only 20% were speculated to be caused by arrhythmia. Thus, there was no benefit for the early implantation (within 40 days) of ICD after AMI, in patients caused by non-arrhythmia which accounted for the most in the early stage of SCD. Although the arrhythmic death can be reduced, there was no improvement in the overall mortality. The risk of SCD is significantly increased if a polymorphous VT or VF occurred after AMI and revascularization. Under these circumstances, the progression of myocardial ischemia and the possibility of re-infarction or acute stent thrombosis should be first considered. Coronary angiography should be performed immediately if this possibility cannot be excluded. Malignant ventricular arrhythmias are also common in patients combined with cardiogenic shock and severe heart failure. Secondary Prevention of SCD Post MI: 1. After 48 h of onset of AMI, if there is no sustained VT or VF within 40 days, then it is not related to the progress of myocardial ischemia and re-infarction, and no other amendable reasons that caused VT can be found, then ICD can be implanted or wearable cardioverter defibrillator (WCD) can be used. 2. 48 h after the onset of AMI and within the 40 days, if polymorphic VT or VF occurs, then ICD implantation and WCD should be considered if revascularization is incomplete and the patients have left ventricular dysfunction and decreased LVEF before AMI. 3. 48 h after the onset of AMI, based on revascularization and the optimal drug therapy, radiofrequency catheter ablation should be considered if VT/VF or electrical storm still occurs repeatedly. 4. 48 h after the onset of AMI and within the 40 days, if sustained VT occurs, then catheter ablation should be considered to treat VT in experienced centres.

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What Physicians Need to Know about OCT, FFR and IVUS? 2019: Case Base Examples for Physicians to Recommend Dr. Keyur Parikh Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Coronary angiography remains the most commonly used imaging modality to describe the degree and extent of coronary atherosclerosis during diagnostic cardiac catheterization and percutaneous coronary intervention (PCI). Its accuracy is affected by technical limitations, important interobserver variability, and its poor visualization of the vessel wall. Furthermore, it provides limited information about the functional significance of the lesion. Today, intravascular ultrasound (IVUS), fractional flow reserve (FFR), and optical coherence tomography (OCT) are extensively used to overcome the aforementioned limitations. Despite the increasing published data validating their advantages, IVUS, FFR, and OCT remain largely underutilized.

Imaging technology and diagnostic tools for interventional cardiologists have changed dramatically over the past few years with the introduction of OCT, improvements in IVUS and pressure guide wires used in FFR. Product innovation and integration of these technologies, as well as a growing base of clinical evidence, are transforming the way physicians diagnose, treat and follow-up patients undergoing PCI.

IVUS allows physicians to visualize lumen diameter and vessel walls from within the vessel, providing better guidance for stent placement. Although IVUS came to market more than two decades ago, use in the United States is estimated at approximately 15 percent of PCI procedures, with image quality, time and cost (due to lack of reimbursement) cited as limiting factors to adoption. In Japan however, IVUS has reimbursement and is used in more than 70 percent of PCI procedures.

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Fig. 1: Fractional Flow Guide Wire

What is Fractional Flow Reserve (FFR)? • Fractional Flow Reserve, or FFR, is a guide wire-based procedure that can accurately measure blood pressure and flow through a specific part of the coronary artery. • FFR is done through a catheter at the time of a coronary angiogram (e.g. cardiac catheterization). The measurement of Fractional Flow Reserve has been shown useful in assessing whether or not to perform angioplasty or stenting on "intermediate" blockages.

How Does Fractional Flow Reserve Work? • A very thin guide wire is inserted through a standard 4F or 5F diagnostic catheter during an angiogram. Because of the smaller size catheter, this can be done as an outpatient procedure. • The special guide wire crosses the lesion and is able to measure the flow and pressure of the blood, after infusion of a hyperemic agent, such as adenosine. • Results are displayed on a special monitor (left) along with the "FFR value". • Studies have shown that an FFR value less than 0.75 or 0.80 corresponds to inducible ischemia, and most likely will require interventional treatment. • Blockages that score above this threshold can be safely and adequately treated by medical therapy without the need for angioplasty. • FFR is now a class 1A recommendation in European guidelines, and • class 2A recommendation in U.S. guidelines for assessment of angiographic intermediate coronary lesions (50% to 70% diameter stenosis) and for guiding revascularization decisions in patients with stable ischemic heart disease. • Every CathLab which does PCI should have FFR capabilities to do ethical PCI angioplasty procedures

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FFR wire :

What is OCT? • Optical Coherence Tomography (OCT) is an optical imaging modality that uses near-infrared light to create high-resolution images of tissue microstructure. • Optical of or relating to light (visual) • Coherence a measure of the correlation between phases of a wave or waves • Tomography method of producing images from a series of single planes or slices (Greek “TOMOS=Slice”)

Intravascular OCT : • Flexible fiber-optic catheter used for light delivery • Fiber rotates to create image frames • Fiber pulls back to map vessel segment The more frames per mm, or high frame density, the higher the resolution

Fig. 2: Time for High resolution imaging in CathLab

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Cardiogenic State Is a State of Hypotension and Hypo Dr. Pranav Vaidhya Hackensack University Medical Centre, Heart and Vascular Hospital, Hackensack New Jersey, USA 07601 Corresponding E-mail id: [email protected]

Cardiogenic shock is a state of hypotension and hypo-perfusion of end organs and tissue hypoxia secondary to low cardiac output. Despite recent advances in medical therapy and early reperfusion technique mortality and morbidity of cardiogenic shock remains very high. Newer mechanical circulatory support devices have shown some promising results but large trials are still lacking. The incidence of cardiogenic shock is increasing due to aging population and increasing incidence of coronary artery disease. To improve the odds for patients in cardiogenic shock multiple hemodynamic and biochemical metrics have been used to predict early shock. Most of the patients with ACS and Shock do not present with Shock but develop Shock after the admission in hospital. Though management of Cardiogenic Shock is the Domain of Interventional cardiologist, the newer therapies to improve outcome requires the coordinated efforts of multiple disciplines and specialists Cardiogenic Shock is a time dependent clinical scenario and requires team approach. Goal of team should be 1. Rapid identification of pre-shock and shock condition and determine the cause. 2.Utilization of resources and supportive therapies and development of protocol and algorithm to implement a plan for escalation of mechanical hemodynamic supports by combining centres of excellence in case of refractory shock.

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Can We Declare a Victory Against Cardio-Renal Disease in Diabetes? Dr. Mikhail Kosiborod Saint Luke’s Mid America Heart Institute

The titanic burden of type 2 diabetes-associated complications continues to wreak havoc, reducing life expectancy, subtracting valuable quality years, and posing grave economic challenges for regions of both high and low income. The cardio-renal complications of diabetes remain a source of considerable morbidity, mortality, and economic hardship. And, to top it all, these diabetes-related complications are on the rise. A large number of patients with diabetes exhibit sub-clinical heart failure, With evidence suggesting that these defects are found even in those who do not present with inducible ischemia. Guidelines have emphasized the importance of diabetes as a risk factor in the development and natural history of heart failure (stages A and B) and remind us that once heart failure develops, the presence of diabetes affords poor prognosis irrespective of the type of heart failure (heart failure with preserved or reserved ejection fraction. The vicious cardio renal cycle is often difficult to break, with recalcitrant effects on volume regulation, sodium homeostasis, inflammation, and metabolism that typically result in rapid decline and in early mortality. The unmet need of heart failure and renal disease in diabetes seems to have met its match in SGLT2 inhibitors. The results of the DECLARE - TIMI-58 trial changes the calculus of how we should choose and prioritize antihyperglycemic therapies in type 2 diabetes. No previous class of glucose-lowering agents has shown cardiac benefit in patients in primary prevention, which arguably represents the largest number of people with diabetes worldwide. Whereas the glucagon-like peptide 1 receptor agonists have been associated with reductions in ischemic events, these are largely confined to those with ASCVD. Therefore, the observation that dapagliflozin can reduce heart failure-related hospitalizations and retard progressive renal deterioration in primary prevention individuals represents a new day for people with type 2 diabetes. Although we are cognizant that affordability, as always, will be the Achilles’ heel, we also note that the economic yields of preventing heart failure-associated hospitalization or a transition to dialysis dependency can be quite profound, and in this regard, Formal cost-effective analyses will be very instructive. While the emphasis of the SGLT2 inhibitors has been on the treatment of patients with type 2 diabetes, many ongoing heart failure and renal outcome studies with SGLT2 inhibitors also include people without type 2 diabetes. If positive, the results from these newer trials may expand the breadth of SGLT2 inhibitors even further. For now, however, let us DECLARE an important victory for type 2 diabetes.

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Cardiogenic State Is a State of Hypotension and Hypo Dr. Pranav Vaidhya Hackensack University Medical Centre, Heart and Vascular Hospital, Hackensack New Jersey, USA 07601 Corresponding E-mail id: [email protected]

Cardiogenic shock is a state of hypotension and hypo-perfusion of end organs and tissue hypoxia secondary to low cardiac output. Despite recent advances in medical therapy and early reperfusion technique mortality and morbidity of cardiogenic shock remains very high. Newer mechanical circulatory support devices have shown some promising results but large trials are still lacking. The incidence of cardiogenic shock is increasing due to aging population and increasing incidence of coronary artery disease. To improve the odds for patients in cardiogenic shock multiple hemodynamic and biochemical metrics have been used to predict early shock. Most of the patients with ACS and Shock do not present with Shock but develop Shock after the admission in hospital. Though management of Cardiogenic Shock is the Domain of Interventional cardiologist, the newer therapies to improve outcome requires the coordinated efforts of multiple disciplines and specialists Cardiogenic Shock is a time dependent clinical scenario and requires team approach. Goal of team should be 1. Rapid identification of pre-shock and shock condition and determine the cause. 2.Utilization of resources and supportive therapies and development of protocol and algorithm to implement a plan for escalation of mechanical hemodynamic supports by combining centres of excellence in case of refractory shock.

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Smart Gadgets and Activity Trackers Dr. Neil Mehta Cleveland Clinic Lerner College of Medicine at Case Western Reserve University Corresponding Email Id: [email protected]

There has been an explosion in the use of personal activity trackers, and it has become a huge industry. People are using these devices to track number of steps walked, number of flights climbed, number of miles biked and hours slept. More recently, smart watches have been developed (e.g. Apple Watch series 4) that can track heart rhythms and are approved for detection and notification of atrial fibrillation and arrhythmia. In the USA employers are asking employees to meet fitness goals by submitting such data to get discounts on the premiums of their employer funded health insurance. Is there data that these devices improve health outcomes? Do they provide any lasting benefits? We will review evidence regarding the impact of these devices on health.

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CT Calcium Scoring: Utility and Clinical Implication Dr. Urmil Shah Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

Traditionally the predication of future cardiovascular risk is performed using population based risk algorithm such as Framingham Risk Score (FRS) and Atherosclerotic Cardio-Vascular Disease (ASCVD). These risk algorithms have proven accuracy for risk predication at population level but at individual level not that much helpful. Assessment of subclinical Atherosclerosis has been proposed as emerging risk factor as its shows actual presence of Atherosclerosis rather than probability of development of Atherosclerosis from mere presence of risk factor. One of the promising ways identifying subclinical Atherosclerosis is Coronary Artery Calcium Score (CACS) and other is carotid intima-media thickness (CINT). With wide spread availability of multi detector CT scan Coronary Artery Calcium estimation (CACS) is found to be very useful in knowing presence and extend of atherosclerosis (Figure 1). In absence of conditions like chronic kidney diseases hyper parathyroidism predictive accuracy of CACS is verified in large multi centric prospective study (NESA). CACS = 0 was associated with very low event at the end of 10 year compare to agatston score of more than 300. Recently MESA investigator has developed a risk score (Figure 2) which in-comparison to traditional risk calculator like FRS or ASCVD,MESA score is found to be of better value in starting atherosclerosis progression prevention treatment like Statin and Aspirin. Calcium scores more than 400 without any risk factor has higher rate of event than more than three risk factor with calcium score of zero. Calcium Score is very useful in low or intermediate risk group patient from other risk score. Recent 2018 AHA guideline for cholesterol management have classified CACS along with CRP as emerging risk factor (Figure 3)

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and can be helpful for starting lipid lowering therapy for primary prevention in low and intermediate risk group of patients. In Indian subset of patients, where ASCVD and FRS risk calculator may underestimate the risk of Indian CAD patients as it occurs at very younger age. CAC score is measured by multiscanner CT Scan, within just 15 min., with very low radiation and low cost without contrast agent and may be of great value in especially in finding out Atherosclerotic in young Indian and start preventive measure early.

Infective Endocarditis Update Dr. Anish Chandarana Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Infective endocarditis is defined by a focus of infection within the heart and is a feared disease across the field of cardiology. Despite its being the cardiovascular disease with the highest mortality, there have been relatively less scientific evidences supporting its treatment. It is frequently acquired in the health care setting, and significant proportion now occurs in patients without known heart disease. Despite optimal care, mortality approaches 30% at 1 year. The challenges posed by infective endocarditis are significant. In addition to its being heterogeneous in etiology, clinical manifestations and course; There is a lack of research infrastructure and funding, with few randomized controlled trials to guide practice. Longstanding controversies such as the timing of surgery or the role of antibiotic prophylaxis have not been resolved. This presentation will provide an idea about current guidelines on prophylaxis, diagnosis and treatment of infective endocarditis.

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Novel Heart Failure Therapies / Devices in Heart Failure Dr. Ajay Naik Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Heart failure is a progressively debilitating disease that dramatically decreases the life expectancy and quality of life of affected patients. Heart failure carries a one-year mortality rate of approximately 20 percent, and five-year mortality estimated at 50 percent. Heart failure accounts for nearly 20 percent of total hospital admissions. The incidence of heart failure has not declined within the past 20 years, but the survival after onset has increased in younger patients and men.

HF Drug Therapy Heart failure is characterized by chronic, persistent activation of the renin-angiotensin-aldosterone system as well as the sympathetic nervous system. The neurohormonal blockade of these systems has been the mainstay of HF therapy for more than 20 years. The implementation of angiotensin-converting enzyme (ACE) inhibitors and antiandrenergic therapies has revolutionized the treatment of heart failure to slow the progression of heart failure and improve survival. The current regimen for managing heart failure includes ACE-inhibitors, angiotensin-receptor antagonists, beta-blockers, aldosterone antagonists and diuretics. ARNI is the new drug in the HF drug therapy armamentarium. Certain patients are candidates for cardiac resynchronization therapy (CRT) and others undergo coronary bypass surgery.

Pumps and Transplants HF is a progressive disease. As the disease progresses, existing treatment options for advanced heart failure are limited to left ventricular assist device implantation (LVAD) or cardiac transplant. Patients who have severe heart failure and primary myocardial disease, ischemic cardiomyopathy, or congenital heart disease may be considered for cardiac transplantation, but this is a limited option. Moreover, many patients depend on mechanical cardiac support devices while waiting for a transplant donor organ to become available. Additionally, many patients with end-stage heart failure are not considered for transplantation because of advanced age or other associated morbidities.

Drug and Gene Therapies There is a significant unmet need for novel approaches beyond the standard medical regimens currently used to treat advanced heart failure patients. The majority of current clinical studies are investigations with new approaches to reduce the mortality in acute heart failure. Encouraging results will have to be confirmed in larger clinical trials but may address the unmet need for novel therapeutic approaches to treat advanced HF.

69 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

Stress Cardiomyopathy Diagnosis and Treatment: Case Based State-of-the-Art Review 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 occurs in approximately 1 to 2 percent of patients presenting with troponin-positive suspected acute coronary syndrome (ACS) or suspected ST-elevation myocardial infarction. A prevalence of 1.2 percent was reported from a registry of 3265 patients with troponin-positive ACS. Similarly, stress cardiomyopathy accounted for 1.7 to 2.2 cases presenting with suspected ACS or ST-elevation infarction. Stress cardiomyopathy is an acute reversible heart failure syndrome with serious complications such as ventricular arrhythmias, systemic thromboembolism, and cardiogenic shock. The incidence of stress cardiomyopathy has been rising (15-30 cases per 100,000 per year Stress cardiomyopathy represents a form of neurocardiogenic myocardial stunning. Takotsubo Classic apical ballooning shape is present in the majority of 75% to 80% cases. 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.

Fig. 1: Central Illustration Pathophysiology of Stress Cardiomyopathy

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

Electrocardiogram : • The 12-lead ECG is central in the evaluation of all patients. • The ECG is abnormal in most patients with stress cardiomyopathy (>95%), – showing ischemic ST-segment and T-wave changes. – T-wave inversion, often deep and widespread, and – significant QT prolongation, usually developing 24 to 48 h after the onset of symptoms – ST – segment elevation involving precordial leads is also seen only in about 40% of the cases – QTc prolongation may progress over time to exceed 500 ms, – Polymorphic ventricular tachycardia (torsade de pointes) – ventricular fibrillation

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Biomarkers : • Cardiac troponin T or I, measured by conventional assays are elevated in >90% of patients, • Peak troponin levels are generally <10 ng/ml, which is substantially lower than in classical ACS. • Serum cardiac natriuretic peptides (BNP and proBNP) are almost always elevated, • The peak occurs at 48 h after presentation, and with elevation up to 3 months

Echocardiography : • Transthoracic echocardiography with color and tissue Doppler is the preferred noninvasive imaging • A global LV akinesis/ dyskinesis with a classic circumferential pattern involving the entire apex (most common) the midventricular or basal segments would be suggestive of stress cardiomyopathy. • Diagnosis is generally straightforward in its classic apical ballooning form. • LVOTO due to basal hypercontractility, • MR due to systolic anterior movement of the anterior leaflet of the mitral

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Coronary Angiography : • Coronary angiography is done to rule out ACS many elderly patients will have underlying CAD (bystander disease) • In stress cardiomyopathy, a ventriculography as a supplement to Echocardiography is performed unless contraindicated Cardiac Magnetic Resonance : • Cardiac magnetic resonance (CMR) allows visualization of – myocardial edema- as high-signal intensity in the acute phase – inflammation, and – more complete views of the RV than echocardiography – scarring – The absence of macroscopic fibrosis as documented by the lack of a DGE is a classic hallmark for stress cardiomyopathy with the use of delayed gadolinium enhancement (DGE).

Coronary Computed Tomography Angiography : • The main application is in evaluating epicardial coronary arteries to exclude high-grade stenosis as an alternative to conventional Coronary Angiography

Prevention of Recurrence and Chronic Treatment: • Recurrence rate is reported as 2% to 4% per year • ß-blockers in patients with increased sympathetic tone, • angiotensin-converting enzyme inhibitors or • angiotensin-receptor blockers • Calcium channel blockers 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;

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Risk Factors, Mortality, and Cardiovascular Outcomes in Patients with Type 2 Diabetes. Dr. Milan Chag Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email Id: [email protected]

BACKGROUND : Patients with diabetes are at higher risk for death and cardiovascular outcomes than the general population. We investigated whether the excess risk of death and cardiovascular events among patients with type 2 diabetes could be reduced or eliminated.

METHODS : In a cohort study, we included 271,174 patients with type 2 diabetes who were registered in the Swedish National Diabetes Register and matched them with 1,355,870 controls on the basis of age, sex, and county. We assessed patients with diabetes according to age categories and according to the presence of five risk factors (elevated glycated haemoglobin level, elevated low-density lipoprotein cholesterol level, albuminuria, smoking, and elevated blood pressure). Cox regression was used to study the excess risk of outcomes (death, acute myocardial infarction, stroke, and hospitalization for heart failure) associated with smoking and the number of variables outside target ranges. We also examined the relationship between various risk factors and cardiovascular outcomes.

RESULTS : The median follow-up among all the study participants was 5.7 years, during which 175,345 deaths occurred. Among patients with type 2 diabetes, the excess risk of outcomes decreased stepwise for each risk-factor variable within the target range. Among patients with diabetes who had all five variables within target ranges, the hazard ratio for death from any cause, as compared with controls, was 1.06 (95% confidence interval [CI], 1.00 to 1.12), the hazard ratio for acute myocardial infarction was 0.84 (95% CI, 0.75 to 0.93), and the hazard ratio for stroke was 0.95 (95% CI, 0.84 to 1.07). The risk of hospitalization for heart failure was consistently higher among patients with diabetes than among controls (hazard ratio, 1.45; 95% CI, 1.34 to 1.57). In patients with type 2 diabetes, a glycated haemoglobin level outside the target range was the strongest predictor of stroke and acute myocardial infarction; smoking was the strongest predictor of death.

CONCLUSIONS : Patients with type 2 diabetes who had five risk-factor variables within the target ranges appeared to have little or no excess risk of death, myocardial infarction

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ASCEND: Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus. Dr. Milan Chag Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email Id: [email protected]

BACKGROUND : Diabetes mellitus is associated with an increased risk of cardiovascular events. Aspirin use reduces the risk of occlusive vascular events but increases the risk of bleeding; the balance of benefits and hazards for the prevention of first cardiovascular events in patients with diabetes is unclear.

METHODS : We randomly assigned adults who had diabetes but no evident cardiovascular disease to receive aspirin at a dose of 100 mg daily or matching placebo. The primary efficacy outcome was the first serious vascular event (i.e., myocardial infarction, stroke or transient ischemic attack, or death from any vascular cause, excluding any confirmed intracranial haemorrhage). The primary safety outcome was the first major bleeding event (i.e., intracranial haemorrhage, sight-threatening bleeding event in the eye, gastrointestinal bleeding, or other serious bleeding). Secondary outcomes included gastrointestinal tract cancer.

RESULTS : A total of 15,480 participants underwent randomization. During a mean follow-up of 7.4 years, serious vascular events occurred in a significantly lower percentage of participants in the aspirin group than in the placebo group (658 participants [8.5%] vs. 743 [9.6%]; rate ratio, 0.88; 95% confidence interval [CI], 0.79 to 0.97; P = 0.01). In contrast, major bleeding events occurred in 314 participants (4.1%) in the aspirin group, as compared with 245 (3.2%) in the placebo group (rate ratio, 1.29; 95% CI, 1.09 to 1.52; P = 0.003), with most of the excess being gastrointestinal bleeding and other extracranial bleeding. There was no significant difference between the aspirin group and the placebo group in the incidence of gastrointestinal tract cancer (157 participants [2.0%] and 158 [2.0%], respectively) or all cancers (897 [11.6%] and 887 [11.5%]); long-term follow-up for these outcomes is planned.

CONCLUSIONS :Aspirin use prevented serious vascular events in persons who had diabetes and no evident cardiovascular disease at trial entry, but it also caused major bleeding events. The absolute benefits were largely counterbalanced by the bleeding hazard.

77 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

Heart Failure Imaging Dr. Vipul Kapoor Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email Id: [email protected]

Congestive heart failure (CHF) is a clinical syndrome in which the heart fails to pump blood at the rate required by the metabolizing tissues or in which the heart can do so only with an elevation in filling pressure. A broad spectrum of severity of impairment of cardiac function is ordinarily included in the definition of HF. These impairments range from the mildest forms, which are manifest clinically only during stress, to the most advanced forms, in which cardiac pump function is unable to sustain life without external support Imaging techniques play a main role in heart failure (HF) diagnosis, assessment of aetiology and treatment guidance.

Neuromodulation in Management of Ventricular Arrhythmia Storm Dr. Ajay Naik Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Ventricular arrhythmias are responsible for hundreds of thousands of deaths every year. Catheter ablation of ventricular tachycardia (VT) is an essential component of the management of these life-threatening arrhythmias. However, in many patients, despite medical and interventional therapy, VT recurs. Furthermore, some VT substrates (mid-myocardial, left ventricular summit, and intraseptal) are not easily targeted because of limitations of currently available technology. In certain clinical settings, ventricular fibrillation (VF) episodes that have premature ventricular contraction triggers can also be targeted with catheter ablation. However, in most patients there is no clear VF trigger to target, and therefore polymorphic VT or VF cannot be adequately treated with catheter ablation. The autonomic nervous system plays a crucial role in all aspects of ventricular arrhythmias, yet interventions specific to the cardiac neuronal axis have been largely underutilized. This underutilization has been most pronounced in patients with structural heart disease. However, there is a growing body of literature on the physiology and pathophysiology of cardiac neural control and the benefits of neuromodulation to treat refractory ventricular arrhythmias in these patients. Case-based examples of neuromodulator interventions currently available and a review of the literature supporting their use are being discussed in the presentation.

78 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

My Approach: To A Case of Aortic Stenosis with Chronic Kidney Disease Dr. Keyur Parikh Care Institute of Medical Sciences, Ahmedabad, India Corresponding E-mail id: [email protected]

Use of Contrast in TAVI: AKI is a major concern in TAVI increasing mortality by 2-8 times, more so in patients with CKD. During TAVI Contrast is used for: 1. Preprocedural CTA 2. Procedural Peripheral Aorto-Iliac angiography 3. Aortic Root Angiography 4. Positioning of Valve “check shoots” 5. Post placement Aortic Root Aortography 6. Post procedure Peripheral Aorto-Iliac angiography 7. We present a case of TAVI for severe AS in 78 y/o Diabetic Nephropathic patient using less than 20 cc of contrast 8. Stage 3B Moderate CKD (GFR = 38 mL/min) 9. The risk of AKI is higher due to • Diabetes • Stage 3 B CKD • Elderly Age Case Presentation of TAVI: A 78 years old male, RD Risk Factors: G6PD deficiency, Diabetes mellitus, Chronic kidney disease -Stage 3B Moderate CKD (GFR = 38mL/min), Cr.=1.7, Ischemic heart disease and PVD and Gastritis/Hx of Recent GI Bleed requiring Blood Transfusion Life Style of subject is active. Psychological Status: No abnormalities Prior Clinical History: Coronary Artery Disease, S/P PCI- LCX, RCA (PDA) few years ago with patent Coronaries, S/P Left Femoral PTA with stents 1 month ago with minimal dye and stable Creatinine post procedure Clinical Presentation: Severe aortic valve stenosis and Moderate MV stenosis and MR

79 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

Fig. 1: STS Risk Score

Heart Team discussion*: *3-4 cardiologists, 1-2 cardiac surgeons, 2 Cardiac anesthetists, 1 Imaging Radiologists, 78 year old man with chronic kidney disease and symptomatic severe AS (Class III angina with patent Coronaries), MVA: 2.10 cm2, Grade II MR (possibly aggravated by Aortic Stenosis), If Surgery then do DVR OR TAVI with” low/no contrast”, STS risk score is over 8.0% (for Combined Aortic and Mitral Valve Replacement ) while TAVI Risk Score was 3.8% mortality, MV Not requiring Intervention at this stage and TAVI with low contrast is more appropriate than surgery

Pre-Procedural Strategy: Avoid CTA and do MRA-But were recommended by Valve Company that CTA recommended due to unavailability of “MR based Planning and Analytic Software”, Both CTA (Pre- admitted patient, IV Hydration for 12+ hours, using minimal contrast) and MRA (1.5 Tesla) of Aorta and Aortic Valves done for comparison, Detailed TTE done and People have done “DSA CO2 Angiography” for Infra diaphragmatic Aorto Iliac Arteries in nephropathy

Fig. 2: MRI - Aortic Root

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Non- Invasive Imaging measurement Echocardiography report: • Normal LV size and contractility, Concentric LVH-LVEF: 60% • AV: Thick, calcified, severe AS, • PG/MG: 88/57 mmHg, • Aortic annulus: 21 mm, • AVA: 0.54 cm2, SV: 36 mm ,mild AR • MV: mildly thick, mitral annular calcification +, adequate opening, MVA: 2.10 cm2, Grade II MR, PG/MG: 16/4 mmHg • Mild PAH, RVSP: 44 mmHg

Fig. 3: Non- Invasive Imaging measurement

Fig. 4: Multislice CT angio using low volume of contrast (30cc) and high resolution imaging and “comparative” Non Contrast CT angio also done for Peripheral Aorta

Table 1: ANALYSIS REPORT* CTA vs.MRA

There was 10%-15% VARIABILITY in measurement between the two but still acceptable clinically

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Table 2: Evolut R 29 mm Preferred for it’s recapture ability

Procedural Strategy: Adequate 1 day of hydration with NS and Bicarb (If LV OK), General Anesthesia and TEE with transfemoral approach, All TAVI supplies and Hardware ,with View Box inside the CathLab, Double femoral access- US guided or Cross Over Wire tracking puncture, Use CT Scan done earlier to guide you for anatomical landmarks: Location of artery in relation to Femoral Head and location of SFA/DFA bifurcation, Calcium in the arterial wall, Left Femoral Artery accessed with manual palpation and Fluroscopy (with CTA/MRA on View Box in Cathlab) and 5 Fr. Sheath Placed, Using SIM 1 or 2 catheter or JR -Cross Over contralateral Iliac Artery accessed and Terumo Glide/Radifocus® Guidewire wire from left to right Iliac as a marker during puncture, We may also leave a coronary/0.018 wire also across for potential access from contralateral side in case of post procedure complication, You may also use micro 21 gauge needle for puncture with manual palpation and We preferred to use 18F sheath.

Procedural Strategy: Predilatation of AV optional, Valve crossing easier if predilatation ( Be careful not to use contrast) in critical AV, But many prefer No predilatation, Minimize “Rapid Pacing” (Hypotension) time, Prefer Evolute – R deployment due to recapture capabilities, In CKD patients there is calcification in the cusps/annulus to guide your deployment with NO or MINIMAL contrast, When delivering the valve, do it faster to avoid “Prolong Hypotension”, Use TEE as required, Dye-Less (using Pigtail in NCC and TEE) or Minimum Dye (5 cc) check shoots and post dilation (Only if needed). Preventing contrAst Induced Nephropathy After TranscathEter Aortic Valve Replacement (PANTER) Trial: Current Primary Outcome Measures: Contrast induced nephropathy (CIN) [ Time Frame: Day 3 ], CIN is defined as an increase in Scr >0.5 mg/dL or 25% within 72 hours and Acute heart failure due to volume expansion [ Time Frame: Day 3 ].

Brief Summary: Chronic kidney disease (CKD) and (subsequent) acute kidney injury are frequent in patients undergoing transcatheter aortic valve implantation (TAVI). Moreover, patients are easily hypervolemic and susceptible for cardiac decompensation. Prevention of contrast induced nephropathy

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(CIN) has not yet been studied in patients, and evidence on different strategies is urgently needed. The objective of this study is to evaluate the efficacy of 250ml 1.4% sodium bicarbonate versus hypotone saline (0.65% sodiumchloride) hydration prior to TAVI in patients with CKD to prevent CIN.

TAVR: a Kidney’s Perspective: Based on the data from the Edwards SAPIEN Aortic Bioprosthesis European Outcome (SOURCE) Registry, chronic kidney disease (CKD) is considered one of the strongest independent predictors of 1-year mortality following TAVR. It is well established that patients with CKD carry a higher risk of acute kidney injury (AKI). Elhmidi et al studied 234 patients with severe AS who underwent TAVR between 2007 and 2010 at a single center and found that preoperative serum creatinine level was the only independent predictor of postoperative AKI. Khawaja et al, subsequently demonstrated that higher CKD stage had the strongest independent associations with AKI after TAVR. However, a number of studies did not detect an association between CKD and AKI following TAVR. Voigtländer et al, recently studied the influence of kidney function before TAVR on the AKI incidence in 540 patients. There is a modest increase in GFR in the moderately impaired renal function group and a significant increase in GFR in those with severe decreased renal function. There was no change in GFR after TAVR in patients with normal renal function. Improvement of GFR was also demonstrated at one month following TAVR in patients with preexisting CKD, possibly due to the improvement of cardiac performance following correction of valvular disease. Preprocedural CTA-Replace with Non Cotrast CTA or Ultra Low Contrast CTA or MRA. TAVI preferably performed by transfemoral approach. Procedural Peripheral Aorto-Iliac angiography-AVOID by using manual puncture using CrossOver wire technique and use of CTA/MRA frames inside the Cathlab in a view Box. Use 18 F Sheath preferably in the Groin. Aortic Root Angiography-AVOID with use of TEE. Positioning of Valve “check shoots”-AVOID with use of TEE and proper Pigtail positioned in the NCC as landmark. Post placement Aortic Root Aortography-AVOID with use of TEE. Post procedure Peripheral Aorto-Iliac angiography-AVOID with use of Manual Paplation and USg-Doppler if required. Proper hydration is very important, if tolerated.

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Acute Care of Respiratory Illnesses in Resource Limited Settings Dr. Firoj Ghanchi Department of Respiratory Medicine, M.P. Shah Government Medical College, Jamnagar, India Corresponding Email Id: [email protected]

Acute care planning needs precise diagnosis and standard management plan addressing the issue. Two case scenarios of acute demand symptoms are discussed with emphasis on identifying crucial leads from presenting symptoms and available reports to evolve evaluator strategy cantered around the leads to arrive at a definite diagnosis so as to offer standard treatment for the condition within best of resources. Case one had respiratory progressive dyspnoea and disorders directive chest skiagram facilitating decisive investigation, HRCT chest and ultimately reaching final diagnosis. Case two had enforcing expression of dyspnoea, haemoptysis and extra-pulmonary symptoms necessitating multisystemic exploration and marking out most appropriate investigation thereby, leading to disease specific diagnosis. Identification of clue scenario form available clinical data, lineage and linkage of symptoms and reports, broad enlisting of differentials and multidisciplinary mode at diagnosis and treatment can overcome resource limitation in clinical practice.

Approach to Managing Your Practice Using Social Media Dr. Neil Mehta Cleveland Clinic Lerner College of Medicine at Case Western Reserve University Corresponding Email Id: [email protected]

Many people have adopted social media like Facebook for personal use but doctors have been hesitant to use these sites for professional purposes for various reasons. Recently several healthcare institutions in the USA have been encouraging their doctors to engage on Twitter and Linked In. There are many purposes for this ranging from marketing to activism to consumer education, to staying updated to networking. We will look at use cases for each type of application of social media. Case-based examples of neuromodulator interventions currently available and a review of the literature supporting their use are being discussed in the presentation.

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Accelerated Hypertension Dr. Vipul Kapoor Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email Id: [email protected]

Accelerated hypertension is characterized by markedly elevated blood pressure (diastolic blood pressure usually >120 mmHg) associated with retinal haemorrhage and exudates (grade 3 Kimmelstiel-Wilson retinopathy). If untreated, it commonly progresses to malignant hypertension, which is characterized by papilledema (grade 4 Kimmelstiel-Wilson retinopathy).

Cardiac Patients Based on Recent Cardiovascular Outcome Trials (CVOTs) Dr. Peter Lin Prima Care Initiatives Canadian Heart Research Centre

Diabetes has profound effects on heart (heart failure), vessels (atherosclerosis), and kidney (renal disease). Heart failure and renal disease remain recalcitrant problems in diabetes and are on the rise. SGLT2i have ushered in hope and optimism for cardio renal protection in diabetes, and many biological underpinnings of these benefits have been reported. Given that three large CVOTs focusing on SGLT2i have reported their outcomes, the information can now be synthesised to better understand which patients and clinical outcomes are responsive to this class of antihyperglycaemic therapy. Reductions in hospitalisation for heart failure and renal protection were observed across a broad range of people with atherosclerotic vascular disease and those with multiple risk factors. SGLT2i offered modest but significant reductions in major adverse cardiovascular events observed exclusively in people with type 2 diabetes and atherosclerotic vascular disease but not in those with multiple risk factors. The effectiveness of SGLT2i can also be extracted from real world evidence like CVD-REAL studies, clearly showing the benefits of cardio-renal protection. Now with the available evidence, SGLT2i should be considered as first-line therapy after metformin in most people with type 2 diabetes, irrespective of whether or not they have established atherosclerotic vascular disease, chronic kidney disease, or heart failure.

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Pulmonary Embolism Dr. Urmil Shah Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email ID: [email protected]

If not suspected and managed fast, Pulmonary Embolism (PE) is (especially massive PE) very deadly diseases. D Dimer, BNP/NTproBNP, Troponin I or T, 2D ECHO and CT pulmonary angiography is very helpful in both diagnosis and prognosis. Risk stratifying criteria is very helpful managing patients. Keeping in mind the predisposing factor diagnostic algorithms using wells score is very helpful for primary care physician. (Fig. – 1).

Figure 1 Figure 2

Patients suspected of PE with hypotension or cardiogenic shock CT pulmonary angiography (if available immediately) is first investigation to be carried for quick diagnosis and fast management (Fig -2). Urgent bedside 2 D Echocardiography is to be carried out if immediate CT pulmonary angiography not available. Even in patients without cardiogenic shock / hypotension, patient with high wells score CT Pulmonary angiography / 2 D Echo Figure 3 are recommended not to miss PE and not to delay in starting of the treatment (fig 3). D Dimer is not recommended in this group of patients.

D dimer useful only in low or intermediate group of patients from wells score. (Fig-3) and negative value is more helpful in ruling out of PE. D Dimer is elevated in many conditions as mention below • DIC • Fibrinolytic therapy within 7 days • Malignancies • Aortic aneurysm, MI • Sepsis, severe infection, pneumonia • Age • Hospitalized patients in general • Stress • Excessive exercise • Lipemic samples

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Recent guideline suggests age-adjusted cut-off values (age x 10 mg/L above 50 years) which allowed increasing specificity from 34–46% while retaining sensitivity above 97%.

PE with hypotension / cardiogenic shock if treated timely by starting reperfusion in form of full dose t Pa, will give significant benefits in terms of reducing both mortality and morbidity. Certain imaging / laboratory parameter (fig 4) and PESI / simplified PESI score (fig 5)

Figure 4 Figure 5

Figure 6

is very useful in identifying high risk patients and also will guide treatment especially regarding reperfusion in PE patients without hypotension (Fig 6).

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Critical Issues in Prolonged Use of Steroids Dr. Vivek Patel Care Institute of Medical Sciences, Ahmedabad, India Corresponding Email Id: [email protected]

Patients on long term glucocorticoid therapy are at a risk of acute adrenal crisis from underlying adrenal atrophy secondary to ACTH suppression; especially during critical illness. The extent of glucocorticoid suppression is determined by the potency of the steroid used, the duration of therapy, and the route of administration. In majority of cases, the clinical picture is dominated by profound shock in the most serious form of adrenal crisis and should be considered in any patient with unexplained circulatory collapse. Relatively mild form can present with unexplained hyponatremia. It should be emphasized that the initial diagnosis of adrenal crisis is entirely based on clinical evaluation. Therapy must not be delayed by biochemical confirmation of adrenal insufficiency. Prompt treatment is the key to successful management of acute adrenal crisis.

88 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

ONCOLOGY Parathyroid Tumors- Hyperparathyroidism Dr. Ashok Shaha Professor of Surgery, Memorial Sloan Kettering Cancer Center, New York Corresponding Email Id: [email protected]

Even though parathyroid glands are the smallest endocrine glands functionally, they are extremely important endocrine organs with active function related to calcium and phosphorous metabolism. There appears to be considerable interest in parathyroid diseases related to the surgical management of hyperparathyroidism. Several nuances have occurred in the past decade regarding the management of parathyroid diseases, including molecular biology of the parathyroids, the surgical management of asymptomatic hyperparathyroidism, and preoperative parathyroid localization. Sestamibi scan and intraoperative quick parathormone assay have essentially revolutionized the approach to hyperparathyroidism. Although there appears y be considerable interest worldwide in endoscopic parathyroidectomy, it appears to be performed in very few centres around the globe. The consensus conference organized by NIH in 1991 described the indications for work-up and treatment of asymptomatic hypercalcemia. Since that time, several new studies have indicated early intervention of the asymptomatic hypercalcemia and a variety of differences defined by various endocrinologists in the management of hyperparathyroidism and hypercalcemia. The forthcoming NIH consensus conference will shed more light on the developments in the understanding of parathyroid disease over the last decade. The issue of asymptomatic hyperparathyroidism and its management generates considerable controversy and discussion – mainly related to certain complications of long-standing asymptomatic hypercalcemia, such as cardiac, metabolic and blood pressure related problems. Primary hyperparathyroidism appears to be seen in one out of 400 to 700 individuals and is most common in women above the age of 45. It may also be a part of MEN1 or MEN2 syndromes. Hyperparathyroidism can be divided into primary, secondary and tertiary. Primary hyperparathyroidism refers to the intrinsic derangement of parathyroid tissue – mostly related to parathyroid adenoma or hyperplasia. Secondary hyperparathyroidism is mainly related to renal failure, while tertiary hyperparathyroidism is an autonomous hyper functioning of one parathyroid gland subsequent to secondary hyperparathyroidism. Among the varying causes for hypercalcemia, the most common are metastatic cancer from the lungs, kidney, prostate, breast, or primary hyperparathyroidism. Embryologically, the parathyroid glands develop in the sixth week of gestation. Interestingly, the upper parathyroid glands come from the fourth pharyngeal pouch – along with the thyroid, while the lower parathyroid gland come from the third pharyngeal pouch – along with the thymus. A missing inferior parathyroid gland is generally in the thymic capsule, while a missing upper parathyroid gland may be behind the carotid artery, the esophagus, the superior pole of the thyroid, or in the posterior mediastinum. A superior parathyroid gland may also remain undescended near the hyoid bone. Although there are generally four parathyroid glands, the number can from vary from two to seven. The blood supply to the parathyroid generally comes from the inferior thyroid artery. However, the superior parathyroid gland may get a direct branch from the superior thyroid artery. Occasionally, the parathyroid glands may derive their blood supply from the thyroid gland.

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In the evaluation of primary hyperparathyroidism, the most common pathology is a single gland adenoma (appearing in approximately 85% of the patients); while 13 to 14% of patients may have multiglandular disease or hyperplasia. Though parathyroid cancer is quite rare and is seen in less than 1% of the patients undergoing parathyroid surgery.

LOCALIZATION STUDIES The issues regarding localization studies were summarized in 1986 by John Doppman: “The only localization study required in a patient presenting with primary hyperparathyroidism is to localize a good parathyroid surgeon.” Clearly, this statement was made at a time when localization studies for the parathyroid gland did not have a high accuracy. At present, with sestamibi scan, the localization study has a very high accuracy and specificity rate. In view of the excellent results obtained from non-invasive studies such as ultrasound or sestamibi scan, invasive localization studies such as angiogram, selective venous assay or MRA are rarely required. CT scan and MRI can also be helpful, but there are many false- positive and false-negative results with these investigations. Recently, sestamibi scan has been looked at more from a functional standpoint rather than an anatomical location of the parathyroid gland. The understanding of the functional aspects of sestamibi scan in the enlarged parathyroid gland is addressed in the radio-guided, minimally invasive parathyroid surgery. The question of cost is always raised in the evaluation of hyperparathyroidism and localization studies. In spite of the cost considerations, sestamibi scan (costing approximately $600 to $700) is considered to be appropriate by many endocrine surgeons.

THE SURGICAL TREATMENT OF HYPERPARATHYROIDISM The pathological aspects of hyperparathyroidism may be divided into unique glandular (adenoma) or multiglandular (hyperplastic parathyroid glands.) The treatment of the former is surgical exploration and removal of the abnormal gland. Generally, a majority of surgeons would prefer to biopsy one more gland on the same side to make certain that there is no other abnormal pathology and to compare it with the enlarged parathyroid gland. The average weight of a normal parathyroid gland is approximately 35 milligrams. In the past, before the development of minimally invasive parathyroid surgery, the standard approach included bilateral exploration and removal of all abnormal glands. The patient has multiply enlarged parathyroid glands; the treatment choice would be to remove all enlarged parathyroid glands and to leave at least part of one gland behind (subtotal parathyroidectomy). There appears to be some interest in total parathyroidectomy with auto transplantation, but concern is always raised over whether the transplanted parathyroid surgery will function in each and every case.

MINIMALLY INVASIVE PARATHYROID SURGERY Since the advent of sestamibi scan and its high accuracy, there has been considerable interest in removal of an enlarged parathyroid gland, as seen on a sestamibi scan, with a small incision under local anaesthesia, surgery of 23 hours, or radio-guided parathyroid surgery. Each of these techniques has several pros and cons and the philosophy regarding minimally invasive parathyroid surgery depends upon the individual institution and the operating surgeon. Radio-guided parathyroid surgery has been

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popularized by James Norman, where a sestamibi is injected approximately two hours prior to surgical intervention. At the time of surgical exploration, a small incision is made in the neck and, with a radio- guided gamma probe; the enlarged parathyroid gland may be localized. If the sestamibi scan is obviously positive, the gamma probe is generally not very helpful. However, it will help determine the location of the enlarged parathyroid gland and helps rule out other enlarged parathyroid glands. The intraoperative PTH (quick PTH) is another major advance of recent years. Once the enlarged parathyroid gland is removed, the PTH assay is performed at the 10 minute and 30 minute intervals. If there is more than a 50% drop in the PTH assay, it is generally considered to be a successful surgical procedure. However, every institution may not have the feasibility of performing intraoperative PTH assay. In recent years, endoscopic parathyroidectomy has become very popular in France and Japan. Since a majority of parathyroid surgery can now be performed with a very small incision, it is uncertain whether the endoscopic parathyroidectomy would really materially add much more to the standard surgical exploration. However, the endoscopic view always provides a much larger picture and eases the identification of the recurrent laryngeal nerve. There is always concern raised regarding the possibility of injury to this nerve or bleeding. Larger experience is necessary to make any definitive determinations. However, endoscopic parathyroidectomy of an enlarged parathyroid gland in the mediastinum is a worthwhile consideration – especially in patients at high-risk or those with previous thoracic surgeries.

PARATHYROID RE-EXPLORATION Even though the success of parathyroid surgery is extremely high, approximately 5% of the patients may fail due to multiply enlarged parathyroid glands or a hidden parathyroid gland in either the neck or mediastinum. If the patient had a previous surgical exploration and recurs or persists with hyperparathyroidism, it is vitally important to confirm the diagnosis of primary hyperparathyroidism with appropriate blood and urine studies, as well as to rule out any other causes of persistent hypercalcemia. Once the diagnosis is confirmed, appropriate localization studies are strongly indicated to localize the enlarged parathyroid gland preoperatively. In a majority of the cases, the missing parathyroid gland is generally in the neck behind the esophagus, in the carotid sheet, or undescended thyroid near the hyoid bone. Occasionally, the enlarged parathyroid gland may be in the thyroid gland and may require ipsilateral thyroid lobectomy.

PARATHYROID CARCINOMA Approximately 800 to 900 cases of parathyroid carcinoma are described in the literature. The largest series of 286 cases comes from the NCDB database, published by Scarf-Hundahl, over a ten-year period in the United States. There continues to be considerable controversy in making a diagnosis of parathyroid carcinoma and the clinical features include high calcium, bony disease, and palpable neck mass. The confirmatory diagnosis includes the presence of lymph node metastases, distance metastases or local recurrence after a previous successful surgery. The histopathology shows a rosette formation, severe mitosis, and capsular or vascular invasion. The molecular biological studies and the P53 analysis may be helpful in confirming the diagnosis of parathyroid carcinoma. The treatment for parathyroid carcinoma includes appropriate surgical extirpation of all gross disease, including the thyroid gland and surrounding lymph nodes (if they are enlarged). The role of elective neck dissection remains undefined at this time and the controversy continues regarding the postoperative radiation therapy.

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Thyroid Cancer – The Last Decade Dr. Ashok Shaha Professor of Surgery, Memorial Sloan Kettering Cancer Center, New York Corresponding Email Id: [email protected]

The incidence of thyroid cancer is rapidly rising. Several nuances and paradigm shifts have been noted in the last decade. Even though the story of thyroid surgery goes approximately 150 years when it was thought to be butchery and it was mentioned that no honest and sensible surgeon would ever engage in thyroid surgery. Theodore Kocher’s contributions in the field of thyroid surgery are well known to every surgeon with his major contributions in thyroid physiology and more importantly reducing the mortality from almost 40% reported by Billroth to less than 0.5%. This brought him to receive the Nobel Prize. The thyroid surgery continued to be in the same direction as described by Kocher for the entire 20th century. However over the last 10 years we have seen several innovations in the field of thyroid surgery with contributions from molecular biology, innovative surgical techniques and understanding of the biology of thyroid cancer. This article will discuss the major shifts in thyroid surgery over the last decade.

RISING INCIDENCE OF THYROID CANCER Clearly the incidence of thyroid cancer has been rising enormously over the last 25 years. The incidence of thyroid cancer has almost quadrupled in the United States over the last two decades and approximately 66,000 new patients with thyroid cancer are seen in year 2016. The incidence of thyroid cancer has raised almost 15 fold in South Korea. Clearly this is related to incidental finding of thyroid cancer on a variety of Investigations and the cancers which would have been quiescent for the rest of the Patient’s life have now become apparent with the incidental investigations and imaging studies. If this trend continues approximately 200,000 thyroidectomies will be performed in the United States every year in near future. Clearly this has generated considerable health costs and emotional concerns amongst the patients and the families. It clearly has direct impact on quality of life of patients undergoing total thyroidectomy. Approximately 6% of the American population is known to have microscopic thyroid cancer however what we see in the clinical practice is just the tip of the iceberg. The more we investigate the more we’re likely to find microscopic thyroid cancer. Whether identification and treatment of this microscopic cancer makes a major impact on overall health of the patients remains unclear at this time.

INCIDENTALOMA OF THYROID Most of the thyroid nodules noted today is incidental findings on routine physical examination, by general practitioners, obstetrician or ENT surgeons. The routine imaging studies of the neck such as carotid ultrasound, breast ultrasound with extension into the neck, or imaging studies such as CT scan and MRI have identified high incidence of thyroid nodules. A car accident and cervical trauma leading to MRI has identified higher number of thyroid nodules requiring further investigations to rule out thyroid cancer. In oncologic institutions, PET scan is another common investigation identifying hypermetabolic thyroid nodule. Clearly the incidence of thyroid cancer is approximately 30-40% in patients presenting with unifocal incidental hypermetabolic thyroid nodules seen on PET scan. These nodules should not be neglected and appropriate further investigation should be undertaken including ultrasound and ultrasound guided needle biopsy. We define these lesions as PET associated incidental neoplasms (pain).

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These hypermetabolic lesions do generate considerable anxiety in patients who is already suffering from other tumours. However the incidence Hurthle cell tumours or aggressive thyroid cancer is much higher in this group of patients with PET positive thyroid lesions.

EVALUATION OF THYROID NODULE In the past the classical evaluation of thyroid nodule was clinical examination and appropriate imaging studies. The fine needle aspiration biopsy has become a centrefold investigation in the evaluation of thyroid nodule. The ultrasound has contributed enormously identifying suspicious versus non suspicious nodules with the findings of punctate calcification, irregular margins, and hyper vascularity or presence of suspicious lymph nodes in the neck. Even with the pitfalls of needle biopsy the accuracy is very high and it has become a most important evaluation and follows up of thyroid nodules. Even though the fine needle aspiration biopsy has been the centrefold in the evaluation of the thyroid nodules approximately 30% of the needle biopsy reports are atypical or indeterminate. The Bethesda classification has helped unifying the reporting system however Bethesda III and IV has always generated considerable interest in molecular investigations. Molecular markers and GEC has been commonly used for further evaluation of thyroid nodules reported as Bethesda III and IV. However we need to realize high costs of these investigations and need of individualized and personalized decision making in the management of these thyroid nodules. However the certain molecular markers such as BRAF, RAS, and TERT have shown high incidence of presence of thyroid cancer. Whether these molecular markers will be of help in evaluating the aggressiveness of the thyroid cancer and decision making regarding extent of treatment and follow up remains unclear at this time.

MANAGEMENT OF THYROID CANCER Surgery for Primary Tumour The prognostic factors have been extremely well described in thyroid cancer starting initially from Mayo Clinic, Leahy Clinic and Memorial Sloan Kettering Cancer Centre. The major prognostic factors are age, grade of the tumour, extra thyroidal extension, and size of the tumour. The Mayo clinic defines completeness of resection as a major prognostic factor which essentially defines the need of adequate and appropriate surgery with removal of all gross tumours even in locally invasive thyroid cancers. The Memorial Sloan Kettering Cancer Centre defines the risk group stratifications in well differentiated thyroid cancer leading to low intermediate and high risk groups (good, bad and ugly). The decisions regarding extent of thyroidectomy are best made based on the prognostic factors and risk group stratification. The aim of management of thyroid cancer should be to avoid over treatment and treatment related surgical and medical complications. The debate continues regarding the extent of thyroidectomy between lobectomy versus total thyroidectomy. However the decisions regarding extent of thyroidectomy would be best made on the risk groups. The low risk group patients generally require a lobectomy and will lead essentially normal lives with a survival exceeding 98% with adequate treatment. The preoperative ultrasound now has shown presence of multiple nodules on both sides generally requiring total thyroidectomy. The understanding of the extra thyroidal extension is very critical and the initial surgical decision is extremely important in the long-term control of thyroid cancer. Clearly patients undergoing lobectomy appear to have better quality of life and all of them may not need thyroid medication for the rest of their life. Clearly the issues related to complications of nerve injury and

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temporary and permanent hypopara-thyroidism need to go in the direct equation of management of thyroid cancer and especially extent of thyroidectomy. Clearly patients presenting with aggressive thyroid cancer or high risk group or aggressive histology will definitely require total thyroidectomy.

Management of Neck Nodes The presence of metastatic neck nodes in thyroid cancer is common clinical and surgical finding. The preoperative ultrasound and neck mapping has helped the surgeons to define suspicious lymph nodes with subsequent needle biopsy with cytology and thyroglobulin assay on needle aspirant. However biologically this is one of the unique thyroid cancer where presence of nodal metastasis has not shown major impact on the long-term outcome however recently it has shown the higher incidence of further recurrence in the neck necessitating additional surgeries. If there is clinically apparent lateral neck node one would generally consider a modified neck dissection from level II to level VI. Considerable debate has generated recently on the issue of prophylactic central compartment dissection to avoid or minimize future recurrence in the central compartment. The general philosophy is to evaluate central compartment critically at the time of initial surgery and to remove any suspicious lymph nodes at level VI and VII. It needs to be considered in proper prospective with high incidence of recurrent laryngeal nerve injury and hypoparathyroidism.

AMERICAN THYROID ASSOCIATION (ATA) GUIDELINES Several guidelines have been published around the world in management of thyroid cancer however the ATA guidelines have made a major impact in the last decade in the United States in the management of thyroid cancer. The first guidelines were published in 2006 and subsequent revisions were made in 2009 and 2015. The most recent guidelines published in 2015 reflect the understanding of the biology of thyroid cancer and risk group stratification. The major paradigm shift in these guidelines include minimizing the extent of surgery and limiting lobectomy up to 4cm of well differentiated thyroid cancers, the philosophy of observation of micro carcinomas, avoiding prophylactic central compartment neck dissection, appropriate voice evaluation prior to surgery, use of CT scan with contrast in selected patients with locally aggressive thyroid cancers, and precision decision making in the use of radioactive iodine. There appears to be major paradigm shift in the use of radioactive iodine which was essentially routine practice towards the end of the last century now to use it only in selected patients with well differentiated thyroid cancer. There is a considerable emphasis on the use of external radiation therapy in locally aggressive thyroid cancers especially with poorly differentiated component or aggressive histology. The field of medical oncology has made an enormous impact in the last decade in patients with recurrent and metastatic thyroid cancer with targeted therapies and the FDA has approved certain drugs for treatment of recurrent well differentiated thyroid cancer, medullary thyroid cancer and anaplastic thyroid cancer. The ATA has also published guidelines on medullary thyroid cancer and anaplastic thyroid cancer which have helped physicians streamlining the management of these rare and complex thyroid tumours. Even with our dedication in the management of thyroid cancer I don’t think we have made major progress in the management of anaplastic thyroid cancer even though we understand the biology much better today. The understanding of the grade of papillary cancer is very important with a continuum of progression from well differentiated to anaplastic thyroid cancer with intermediate tall cell, insular and

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poorly differentiated thyroid cancers. The ATA guidelines have also evolved in the management of neck nodes in thyroid cancer shifting from routine prophylactic central compartment dissection to selective use of central compartment dissection.

FOLLOW UP OF PATIENTS WITH WELL DIFFERENTIATED THYROID CANCER Most of the time patients with thyroid cancer are followed by an endocrinologist with special expertise in management of thyroid cancer. Once again the follow up of patients with thyroid cancer is directed by the risk group stratification. Low risk thyroid cancer patients require minimal investigations such as thyroid function tests and thyroglobulin every 6-12 months and ultrasound every year for the initial few years and subsequently at an interval of 3-5 years. The overall survival in the low risk group exceeds 98%. Our current problem still revolves around locally aggressive thyroid cancer in high risk group patients with thyroid cancer where we should involve our resources. The understanding of the quality of life especially of women with thyroid cancer and total thyroidectomy needs to be redefined as some of these patients may not return to their normal life. Clearly most of the patients live very happily with thyroid replacement however some of these patients just don’t feel well and may suffer with lack of energy for a long time.

Clearly we have seen several nuances and paradigm shifts in the management of thyroid cancer. There appears to be considerable interest in developing multi-disciplinary management groups especially for aggressive thyroid cancers with the involvement of expert thyroid surgeon, high volume centres, with the involvement of endocrinologists, medical oncologists and radiation oncologists. With the help of these Multidisciplinary groups I’m sure we’ll be able to serve our patients with high risk thyroid cancer much better.

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“Chota Daana” Campaign for Cancer and Chronic Diseases and Tele Screening Network Premalignant lesions of Oral Cavity Dr. Pawan Gupta Institute of Cancer Care, Jaypee Hospital, Noida Corresponding Email ID: [email protected]

Cancer is curable when diagnosed early. Reaching out to the people with the signs and symptoms of cancer is a challenge. CHOTA DAANA (small lesion) is a populist campaign which is launched to empower the people with the knowledge and self examination and early detection of lesions. To facilitate the program a tele screening online network is being proposed. Oral premalignant lesions, signs and symptoms and therapy will cure most of the patients. Knowledge about the same to the doctors and also to the mass will go a long way to detect the disease early and give a cure. Win over tobacco – a protocol evidenced based approach to help quit tobacco consumption and self and clinical oral examination will help curb cancer and other chronic diseases in the future and create a healthy and a lively Country.

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Tobacco Cessation – Challenges and Solution Online Network Model Mr. Rishabh Agarwal, Dr. Pawan Gupta Innovative Cancer Care and Rehabilitation Pvt Ltd, Vaishali Corresponding Email ID: [email protected]

Tobacco is an epidemic of our time. It cripples a person affecting him mentally, sickening him physically and ultimately killing him, leaving his family handicapped. As per WHO study 69.6% of the tobacco users want to quit and have made at least one attempt during their lifetime. Sadly, most people fail in their attempt because of lack of clinical intervention. Additionally, the major challenge is that the tobacco user would not go to a psychiatrist, but the general doctor with some comorbid condition who would treat the comorbidity but not the tobacco addiction. The latter neither has the expertise nor time for treating tobacco.

Lack of proper training, resources, infrastructure and sensitization abets their disinterest in treating the addiction in patient. Therefore, Cancer Tobacco wellness and oral Screening program has been pioneered as a network of online Telemedicine solution to help both the doctor and patient. This program specifically provides detailed training to doctors and counsellors on both pharmalogical and behavioural intervention, facilitates the setup of tobacco wellness centres for cessation, provides innovative tools for measuring and monitoring health index of individuals and numerous self -help resources, provides e-record maintenance system on the cloud, helps with medication and rehab products with 24x7 online portal and ensures constant online support, follow up and transformation of the tobacco user. Cancer Win over Tobacco (WOT) is a sensitization program for different professionals, corporates, hospitals, schools and colleges that spread awareness on abstaining from tobacco and encouraging existent users to seek help. This

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solution is being integrated and delivered with the existent healthcare system without causing the need to establish a separate channel for treatment of tobacco dependence. We present this solution which attempts to transform the health outcome.

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Tobacco Cessation – Challenges and Solution Online Network Model Mr. Rishabh Agarwal, Mr. Rabindra Mishra, Mrs. Shruti Agarwal, Dr Pawan Gupta Innovative Cancer Care and Rehabilitation Pvt Ltd, Vaishali Corresponding Email ID: [email protected]

Tobacco the most dreaded disease of our time. It cripples a person affecting him mentally, sickens him physically and ultimately kills the person using it. As per WHO study 69.6% of the tobacco user want to quit tobacco and have made atleast one attempt during their lifetime. Most people fail in their attempt. They need a support system to free them from this slavery of tobacco. Government is also looking for solutions to set up tobacco cessation centres. The Challenge is that the tobacco user would not go to a psychiatrist, and the general doctor to whom he goes does not have the expertise nor the time for this disease. Most of the tobacco users would go with some comorbid condition to a doctor, who would treat the comorbid condition but not the most important disease that is tobacco. I CAN CARE Tobacco wellness and Oral Screening program is a network online Telemedicine solution made specifically for the purpose. I CAN CARE – WOT program provides training of doctors and counsellors, setting up of WOT centre, counselling platform, health parameter record, online support, follow up and transformation of a tobacco user. We present this solution which attempts to transform the health outcome.

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Hereditary Breast Cancer Dr. Shalaka Joshi Tata Memorial Centre, Mumbai Corresponding Email ID: [email protected]

Breast cancer is the commonest cancer in women worldwide. As per the current GLOBOCAN data it is also the most common cancer in India. Only 10% of all breast cancers have a familial predisposition. One fourth of the hereditary breast cancer is related to BRCA1 or 2 gene mutation. The general population frequency of mutation of the BRCA gene is 1 in 10,000; except for the Ashkenazic Jewish in whom it is found to be mutated at a frequency of 1 in 40. If a woman diagnosed with breast cancer has significant family history, or is younger than 35-40 years, genetic counselling and testing is recommended. Testing for any known mutation in family is carried out first or multi-gene panel testing can be offered in case of an index case. If genetic mutation is identified in a woman diagnosed with breast cancer, one may discuss options of mastectomy over breast conservation with or without a contralateral prophylactic mastectomy keeping in mind a 20-35% incidence of a second primary over 10 years. However, a genetic predisposition is not a contra-indication to undergo breast conservation surgery with proper case selection and appropriate counselling. For the mutation carriers, options such as surveillance, chemoprevention and prophylactic surgery can be discussed without making a recommendation for one versus the other. There is a lack of data with high level of evidence with respect to superiority of any one strategy over the other. The current NCCN guidelines recommend starting surveillance at the age of 25-40 years or 10 years before the age at diagnosis of the youngest member affected in the family. Surveillance strategy includes a mammography and MRI every year at 6 months’ interval and clinical breast examination every 6-12 months. Prophylactic oophorectomy can be offered between 35 and 40 years of age, after completing family to reduce the risk of breast cancer by 50% and that of ovarian cancer by 80-90%.

Chemo- To Do or Not to Do? Older studies suggested benefit of chemotherapy in almost all patients with node positive disease and also in a significant number of node negative patients, irrespective of ER/PR status. A number of women were over treated with this strategy. With the seminal work of Sorlie and Perou based on gene expression profiling, tumours were classified as Luminal A, Luminal B, HER2 enriched, or basal like. These molecular subtypes also formed clear prognostic subgroups. The Luminal subtype was identified as a biologically better group with excellent cure rates. On this background, genomic tests such as ONCOTYPE DX (21 genes signature), were discovered and validated to determine the extent of benefit of chemotherapy in the luminal subgroup. The patients with low recurrence risk could potentially avoid toxic chemotherapy regimens. Similarly, those with a high genomic Recurrence Score (RS) benefited with the same chemotherapy regimens. A large randomized controlled trial by Sparano et al, proved the non-inferiority of endocrine therapy alone as compared to chemo-endocrine therapy in patients with an intermediate recurrence score (16-25) on genomic testing with a 9 years overall survival rate of 93.9% and 93.8% in the

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two groups. The MINDACT group of European investigators similarly evaluated the non-inferiority of omitting chemotherapy in those patients with clinically high-risk profile but genomic low risk based on the 70-gene signature test (MammaPrint). They found that up to 46% women could avoid chemotherapy based on genomic testing in spite of being clinically high risk. A clinical risk score that helps one to predict the need or benefit of chemotherapy in the absence of expensive genomic testing, is based on commonly known prognostic markers such as age, histological grade of tumour, lymph node status, tumour size, immuno-histochemical analysis of the molecular subtype (IHC4 score comprising of ER, PR, HER2 and Ki67 status). IHC4 status is found to be in concordance with most genomic test results. Based on these strategies, it is clear that a carefully selected subgroup of patients of node negative or positive breast cancer can be exempted from chemotherapy. There is a definite shift of focus on personalized treatment based on tumour biology.

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P-101 Coincidental Occurrence of acute Conversion Reaction after S hot of Mmeasles R ubella Vaccine Vala Jasvin, Gupta Sapna Department of emergency medicine, V.S. Hospital, Ahmedabad Corresponding Email Id: [email protected]

Introduction: A young boy with family history of pschiatric disorder was admitted with acute psychosis after vaccination as a part of community Mr Vaccine campaign

Method: Case report

Conclusion: Mass psychogenic illness is known after community vaccination campaign but in this case background history and progression of illness confirms inheritary psychiatric illness that was precipitates after vaccination

Key words: Measles rubella vaccine and psychiatric Illness

P-102 Anaesthetic Management of a Patient with Permanent Pacemaker on {VVO} Mode with Severe Interstitial Lung Disease Posted for Bipolar Hemiarthroplasty. Jain Bhakti, Wadhwan Reema, Chhanwal Heena Department of Anaesthesia, GCS Medical College, Hospital and Research Centre, Ahmedabad, Gujarat. Corresponding Email Id: [email protected]

86 yr. old Female patient 50 kg weight K/C/O coronary artery disease with Hypertension with permanent pacemaker on VVO mode since 14 yr. and Interstitial lung disease with breath holding time 9 sec (NYHA class III) (SPO2 80 % on room air, SPO2 96% with oxygen on facemask) is posted for Rt. Bipolar Hemiarthroplasty for inter trochanteric fracture Femur. All cardiac drugs were continued till day of surgery except Aspirin. The pacemaker was changed to asynchronised (fixed) mode a day before surgery. Surgery was done under combined spinal epidural anaesthesia. Intrathecally 1.8 ml of 0.5% hyperbaric bupivacaine with 25 mcg fentanyl was given. T8 level achieved. Intraoperative vitals remained stable. Surgery lasted for one and half hr. and remained uneventful. The mode of pacemaker changed to synchronized (demand) mode 6 hr. after surgery. Post operatively epidural infusion of Bupivacaine 0.125% and fentanyl 2mcg/ml was continued for 48 hr. for analgesia. Patient remained pain free post operatively.

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P-103 Diagnosis and Management of a Patient Presented with Lithium Toxicity on Therapeutic Dose Shah Meera, Nayak Bhupendra, Modi Urjita, Jarwani Bhavesh, Thakor Advait EMD Department Smt. NHL Municipal Medical College Ahmedabad Corresponding Email Id: [email protected]

Lithium used as monotherapy or augmentation with other medication to treat acute mania and bipolar disorder with depression. Its toxicity commonly presented with cerebellar symptom at low serum level. It has narrow therapeutic range between 0.6-1.2mmol/lit. Mild toxicity will produce diarrhoea, vomiting, stomach pain, tremor, drowsiness. Severe toxicity produces agitation, convulsion, renal failure, hyperthermia, hypotension, delirium, coma, death. Lithium has adverse effect on kidney, thyroid gland, brain. Periodic monitoring of organ test will prevent its complication. Chronic lithium medication produces progressive renal impairment which can be reverse by discontinuing lithium medication. Lithium carbonate is high alert drug

Case Summary We reported a case of 51 year old female patient who had been admitted to emergency department with complain of altered sensorium since 8 days. Lithium toxicity was not at first recognized. After obtaining history regarding previous medication serum lithium level was investigated, which was 3.51 mmol/liter. As lithium level was elevated with decreased urine output, altered renal function test, altered sensorium which was suggestive of renal insufficiency and neurological symptoms due to lithium toxicity. For that haemodialysis was done.

Conclusion Altered sensorium, tremor, decrease urine output, drowsiness, convulsion with patient on antipsychiatric medication should be considered as lithium toxicity in differential diagnosis

Keyword: Renal failure, Bipolar disorder, Altered sensorium

P-104 Warfarin: The Double Edge Sward: A Case Report Patel Binti, Avaiya Rakesh , Makwana Harsha, Thakor Advait Department of Emergency Medicine, V.S Hospital, Smt. NHL Municipal Medical College, Ahmedabad Corresponding Email- id: [email protected]

Warfarin is a narrow therapeutic index anticoagulant drug, recommended for the prevention and treatment of systemic embolism, stroke (associated with atrial fibrillation and venous thromboembolism). Here we have reported a case of 75 year female hypertensive patient with atrial

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fibrillation since last 6 months and was on antihypertensive drug along with warfarin therapy(5mg/day).She presented with melena, haemoptysis, and abnormal coagulation profile. Inj. Vitamin K, packed cell volume, fresh frozen plasma and platelet rich concentrate was given. Presence of genetic variation in which activity of CYP2C9 is reduced and drugs (fluconazole, miconazole, valproic acid) that inhibit the function of CYP2C9 should be considered in warfarin toxicity. Warfarin toxicity can be prevented by INR testing, patient education, diet modification, drug interaction and dose adjustment in chronic liver disease. Keywords: Anticoagulant, Warfarin, Toxicity, International Normalised Ratio (INR)

P-105 Management of intraoperative arrhythmias Desai Yatharth, Doctor T P, Maheshwari Bharat Department of Anaesthesia, B.J Medical College & Civil Hospital, Ahmedabad Corresponding Email Id: [email protected]

Key Words: Anaesthesia, Cardiac arrhythmias, VPC, Hemodynamic stability Introduction: Arrhythmias is abnormality of cardiac rate, rhythm, or conduction which can be either lethal, or symptomatic or asymptomatic. Incidence of ventricular premature contraction is under 0.5% in 20 year of age to 2.2% in person more than 50 year of age, more common in male than female of same age. Incidence of ventricular premature contraction -15% of observed arrhythmias in anesthetised patients. If left untreated, it may lead to hemodynamic instability, ventricular tachycardia/ventricular fibrillation or arrhythmia associated cardiomyopathy. Aims and objectives: Management of Intraoperative ventricular premature contractions. Method of study: We are presenting our experience managing intraoperative ventricular premature contractions in a patient under spinal anaesthesia for a lower limb surgery. Case: 57 year male patient, operated case of supracondylar femur #, non-union, infection, planned for sequestrectomy + external fixator -past history of fall, known case of hypertension since 8 months, Echo - normal, ECG – normal sinus rhythm, blood investigations -electrolytes normal., induced in spinal anaesthesia – inj. bupivacaine 0.5% heavy 3cc + inj fentanyl 10 microgram, level of T10 achieved, hemodynamic ally stable,1hr into surgery patient, suddenly developed significant ventricular premature contractions(10-12/min). Intraoperative bolus inj. lidocaine 1.5 mg/kg was given. VPC resolved, reappeared. Despite proper hydration and oxygenation VPC did not subside, surgery abandoned. Patient stayed hemodynamic ally stable and conscious. Patient was shifted to ICU for close monitoring and further management. Post operatively VPCs continued with pulse irregularities, medicine reference was done and advised tab. Metoprolol 25mg bd. Patient’s arrhythmias resolved and later discharged. Result: Asymptomatic (<5/min) ventricular premature contractions and those occurring in healthy patients do not need treatment. VPCs which are multiple (>5/min), multifocal or bigeminal require immediate treatment. Underlying causes such as electrolyte imbalance should be corrected immediately. Other causes such as hypoxia, lighter plane of anaesthesia, intraoperative pain, hypovolemic need to be ruled out. Conclusion: Intraoperative arrhythmias need to be treated promptly to prevent further life threatening complications.

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P-106 Anaesthetic Management of a Child with Arthrogryposis Multiplex Congenita: A Case Report Abraham Shyni, Panchal Mona, Bhatia Upasna LG Hospital AMC MET Medical College, Ahmedabad. Corresponding Email Id: [email protected]

Arthrogryposis also known as Arthrogryposis multiplex congenital (AMC) is a rare congenital disorder that causes multiple joint contractures and associated with muscle weakness and fibrosis. It is a non- progressive disease. Anaesthetic issues include difficult Intravenous access, difficult airway and association with anterior horn cell disease and malignant hyperthermia. We report the management of a three year old male child with AMC who underwent Congenital talepes equina varus (CTEV) correction with successful regimen based on an anaesthesia technique using injection Ketamine, Propofol and Non Depolarising muscle relaxant with caudal epidural. The child had an uneventful peri and post-operative course.

Keywords: Arthrogryposis multiplex congenita; Difficult airway; Ketamine; Propofol; NDMR; Caudal Epidural.

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P-107 Anaesthetic Management of Cervical Canal Stenosis Posted for Cervical Laminectomy Turakhia Komal, Doctor T P, Prabhatkuamar Department of Anaesthesia, B.J Medical College & Civil Hospital, Ahmadabad Corresponding Email Id: [email protected]

INTRODUCTION:-Patients with pre-existing cervical canal abnormality are difficult to manage. Better managed with General anaesthesia compare to other mode of anaesthesia as there is a risk of exacerbating pre-existing neurologic deficits affecting respiration or developing new neurologic dysfunction. Difficult airway poses a challenge in cervical spine patients along with any co existing respiratory diseases.

AIMS AND OBJECTIVES: Anaesthetic Management of a Patient with Cervical Canal Stenosis posted for cervical laminectomy.

CASE REPORT: - 55 year male patient with cervical canal Stenosis posted for cervical Laminectomy. History of b/l upper limb weakness since 10 days, heavy built known case of Bronchial Asthma –7 year, on Tab.Deriphylline, MDI. O/E- B/L Crepitation + with occasional ronchi, Airway-Mallampati grade 3 Two finger mouth opening, restricted neck extension. The MRI report- compressive myelopathy at C3 C4 level, changes of myelomalcia at C4-C6-C7 level. Patient induced under general anaesthesia in supine position, airway secured then shifted to prone position with all precautions (proper padding, peripheral pulsation checked). Intraoperative patient developed bronchospasm, diagnosed with increased airway pressure and decreased air entry, managed with Inj.Dexona 8mg, Inj.Deriphylline and aminophylline infusion 5mg/kg/hr., bronchospasm resolved, ABGA normal. On completion Patient shifted to supine position, nebulized, oral, ET suction done, reversed and extubated without any complication, shifted to ward, post op uneventful.

CONCLUSION: The presence of pre-existing deficits in a cervical spine patient theoretically places these patients at increased risk for further neurologic injury. General anaesthesia appears as the best modality. Difficult airway is a common presentation in most cases of cervical spine surgery and needs to manage efficiently. Presence of co morbidities such as bronchial asthma may complicate the post op outcome thus should be promptly treated.

KEYWORDS: - General Anaesthesia, Cervical Canal Stenosis, difficult airway

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P-108 Anaesthetic Management of a New born With Encephalocele Maheshwari Khevana Department of Anaesthesia, B.J. Medical College, Ahmedabad, India Corresponding Email Id: [email protected]

Introduction: A case report of anaesthetic management of 8 day old male neonate weighing 2.63kg having giant occipital encephalocele of approx. 7*5*10 cm born by FTVD in civil hospital, Ahmedabad. Method:8 day old male new-born weighing 2.6kg with encephalocele of approx. 7*5*10cm undergoing excision under general anaesthesia, intubation done in supine position with swelling supported by rings and prone position given to the patient.

Result/Discussion: Difficult airway management, prone position, protection of neural placode, assessment of volume status & prevention of hypothermia are the major challenges encountered by the anaesthesiologist.

Conclusion: Aesthetic management of new-born with large occipital encephalocele is challenging but vigilant evaluation with careful management result in safe and successful result.

Keywords: new-born, encephalocele, difficult airway Management, prone position

P-109 A Case of Snake Bite Uzma Pathan, Sangani Shruti Department of Emergency Medicine, B.J. Medical College, civil Hospital, Ahmedabad Corresponding Email Id: [email protected]

Introduction: Prevalence of snake bites are common in the rural areas. India has about 2.8 million cases of snake bites per year making it the most heavily affected country in the world, reporting the highest deaths. Almost all snakebite deaths in India are attributed to the Russell’s viper, Saw-scaled viper, Indian cobra and the Common Krait. The major families in India are:Elapidae- Common cobra, King cobra and Krait (Neurotoxic) Viperidae- Russell’s viper, Pit viper and Saw scaled viper (Hematotoxic) Hydrophidae (myotoxic)

Case Summary: A 32 year old male patient was referred with a/h/o snake bite at 3 am over right side of chest. On presentation, patient was conscious, oriented, but suddenly collapsed, so CPR was started, monitor showed ventricular fibrillation, so defibrillation done, patient revived, was intubated and treated with antibiotics, fluids, and Anti Snake Venom. Patient was kept in ICU where he regained consciousness, was gradually weaned off the ventilator, extubated, shifted to ward and discharged.

Conclusion: Most of the snake bites are due to non-venomous snakes, but in case of poisonous snakes, with the passage of time, more venom gets bound to the tissues and less is available for neutralization. Most of the deaths are avoidable if the patient is brought to the equipped health centre on time and treatment is started promptly.

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P-110 A Rare Case of Extra-ovarian Granulosa Cell Tumour Pandya Binita , Kapuriya Dharmesh, Bhalodiya Jignasa Department of Pathology, GMERS Medical College and Civil Hospital, Sola, Ahmedabad, Gujarat, India. Corresponding Email id: [email protected]

INTRODUCTION AND BACKGROUND Granulosa Cell Tumour (GCT) is a sex cord-stromal ovarian neoplasm, showing differentiation towards follicular granulosa cells and account for 1.5% of ovarian neoplasms and 6% of ovarian cancers. It is of two types: the more common adult type, usually presenting during the perimenopausal or the menopausal period (50 - 54 years) and juvenile type. Extra-ovarian GCT is a very uncommon tumour, assumed to arise from the ectopic gonadal tissue along the embryonic gonadal ridge and has been reported in sites like retro peritoneum, broad ligament, mesentery, omentum, liver and adrenals.

AIMS AND OBJECTIVES To study the histopathological features of Granulosa Cell Tumour.

MATERIALS AND METHODS The sent specimen was processed, paraffinized and H and E slides were studied.

CASE REPORT We report a case of fifty-one-year-old female who had complain of pain in abdomen and Post-menopausal discharge for 2 months. No abnormality was detected on physical examination. USG abdomen and pelvis indicated possibility of left ovarian cyst measuring 33 x 65 x 58 mm. On gross examination of the sent specimens of uterus, cervix and bilateral adnexae, left sided ovarian cyst and a distal tubal mass was found measuring 5 x 3.4 x 2.5 cm. Microscopic examination of the tubal mass revealed tumour cells arranged in different patterns - micro follicular with Call-Exner bodies, macro follicular, solid and some trabecular. Cells were showing round to oval nuclei with prominent nuclear grooves – folds (coffee bean appearance). Mitotic count is 3-4/10 hpf. The findings suggested Granulosa Cell tumour (adult type) arising from fallopian tube.

CONCLUSION Extra ovarian GCT is extremely rare, in our case it was found in the distal (infundibulum) Portion of fallopian tube.

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P-111 Spinal Anaesthesia in a Case of Kyphoscoliosis Bhikadiya Pinal, shah Vibhuti, Shah Sushmita AMC MET Medical College Corresponding Email Id: [email protected]

Kyphoscoliosis is forward and lateral bending of the spine commonly affecting the dorsal and lumbar spine. It may be idiopathic or associated with other abnormalities like poliomyelitis, cerebral palsy or muscular dystrophy. It results in derangements in cardiac and pulmonary functions and may cause difficulties with both general and regional anaesthesia. We report a case of severe thoracolumbar kyphoscoliosis operated for open inguinal hernia under spinal anaesthesia.

Keywords: Spinal anaesthesia, Kyphoscoliosis, open inguinal hernia repair

P-112 A Case of Pulmonary Langerhans Cell Histiocytosis In A Non-Smoker Female Pandya Darshan, Vyas Chintal, Malhan Smt. N.H.L. Municipal Medical College, Ahmedabad. Corresponding Email ID: [email protected]

Langerhans cell histiocytosis (LCH) is a rare disorder caused by monoclonal Langerhans cells proliferation in bone, skin, and lung, lymph nodes, liver, and spleen, nervous or hematopoietic system. Pulmonary LCH is proliferation of monoclonal Langerhans cells in lung interstitium and airspaces. Etiology is unknown, but cigarette smoking plays an important role. Symptoms are dyspnea, cough, fatigue, and pleuritic chest pain. Diagnosis is based on history and imaging tests and sometimes on Broncho alveolar lavage and biopsy findings. Corticosteroids are given in many cases, but efficacy is unknown. Lung transplantation is usually curative when combined with smoking cessation.

A 20 years old non-smoker female presented to our hospital with chief complaints of non-productive cough and fever with chills since 5 days and dyspnea on exertion since 2 days. Sputum AFB was negative. HRCT findings were suggestive of bilateral diffuse cystic lung disease- changes consistent with Langerhans’ cell Histiocytosis. Patient was treated with symptomatic treatment, antibiotics, corticosteroids and ventilatory support as only definitive treatment is a lung transplant.

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P-113 Local Pattern of infection in Patient of Acute Exacerbation of COPD Admitted in L.G. Hospital Pujara Gaurav, Bhansali Prashant Department of Respiratory Medicine, AMC MET Medical College & LG Hospital, Ahmedabad Corresponding Email ID: [email protected]

Background: Chronic Obstructive Pulmonary Disease (COPD) is a common disease and equally affecting rural population. Majority of COPD exacerbations are infective and facilities of bacterial culture are not available at peripheral health institutions. Acute exacerbations can contribute to irreversible progression of disease.

Objective: To find out the bacteria predominantly causing the AECOPD in our region, its relation with severity of the diseases and antibiotic most effective against these organisms. Material and Methods: Previously diagnosed patients presented with acute exacerbation were investigated for sputum characteristics, culture and drug sensitivity. Study: Prospective observational study

Results: Streptococcus pneumonia was the most common pathogen isolated followed by Streptococcus pyogens and Pseudomonas.

Conclusion: Streptococcus pneumonia is still the most common pathogen in patients with AECOPD of this area. Piperacillin + tazobactum should be the first choice empirical antibiotic. Quinolones should be used cautiously in area where prevalence of tuberculosis is high. However more studies with larger population required which also includes bronchoscopy sampling along with sputum.

P-114 Anaesthetic Management of Patient with Dilated Cardiomyopathy with Low Ejection Fraction and Hepatosplenomegaly Posted for Emergency Right Lower Limb Fasciotomy. Shah Harsh, Shah Vandana, Shah Vibhuti AMC MET Medical College Corresponding Email ID: [email protected]

Idiopathic dilated cardiomyopathy is a primary myocardial disease of unknown etiology characterized by left ventricular or biventricular dilatation and impaired contractility. Patient with dilated cardiomyopathy and hepatosplenomegaly pose many anaesthetic challenges like maintain normovolemia, prevent increase in afterload, avoid myocardial depression, avoid sudden hypotension and avoid tachycardia.

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In case of general anaesthesia, dose dependent myocardial depression may occur with use of induction agents. Patient may also be vulnerable to drug overdose due to slow circulatory time. In case of regional anaesthesia, peripheral nerve block better than central neuraxial block. For central neuraxial block, there will be issues of hemodynamic instability, so more preference towards peripheral regional block. Here, we present a case report on anaesthetic management of patient with dilated cardiomyopathy, low ejection fraction and hepatosplenomegaly who underwent emergency right lower limb fasciotomy under femoral and popliteal block.

Keywords: Dilated cardiomyopathy, low ejection fraction, hepatosplenomegaly, femoral and popliteal block

P-115 Aplastic Anaemia: A Case Report Patel Archita, Dabhi Leena Department of Medicine, AMC MET Medial College And LG Hospital, Ahmedabad, Gujarat, India. Corresponding Email- id - [email protected]

Aplastic anaemia is very rare disorder presenting with pancytopenia with bone marrow hypo cellularity. About 100 thousand cases per year reporting in India. This causes deficiency of all three blood cell types: RBC, WBC and PLATELETS. It may be inherited as haematological as in Franconia anaemia, Telomere syndrome, Shwachman Diamond Syndrome , Familial aplastic anaemia or nonhematological syndrome as in Down, Dubowitz, Seckel syndromes or may be acquired due to radiation, drugs & chemicals, viruses, Immune disease, PNH, Idiopathic cause.

An 18 year younger boy presented in OPD with chief complain of bleeding gums and fever from 6 days, Easy fatigability and weakness from 15-20 days, diarrhoea from 3-4 days. General examination revealed Pallor & Petechial over both arms and chest CBC report revelled Pancytopenia. Bone Marrow Biopsy done and suggested Aplastic Anaemia. Patient was given whole blood & PRCs & antibiotics to prevent infection & then referred to higher centre for further management. Patient went to GCRI and bone marrow transplantation was planned. During treatment pt. developed severe respiratory infection and diarrhoeal disease & pt. died.

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P-116 Diabetic Nephropathy: An Autopsy Case Study Patel Srujalben, Patel Kinara, Bhalodia Jignasa Department of Pathology, GMERS Medical College and Civil Hospital, Sola, Ahmedabad, India. Email id: [email protected]

Introduction And Background : The kidneys are prime targets of diabetes. Diabetic nephropathy is a major underlying cause of morbidity and mortality in both type 1 and type 2 DM, giving rise principally to cardiovascular disease, in particular heart failure, the incidence of which is about 15- fold greater in patients with diabetic kidney disease. 30% of all diabetics die as a result of chronic renal failure. Suboptimal glycaemic control and a higher blood pressure are particularly important risk factors for the development of diabetic nephropathy and most of the time diabetic nephropathy is underdiagnosed.

Aims And Objectives : To study the histopathological features of diabetic nephropathy and identify the cause of death.

Materials And Methods : Sections of the autopsy specimens of kidneys were taken. Paraffin blocks and slides were prepared for the histological study. Case : We report an autopsy case of seventy two year old male came to our department with H/O chest pain before death. Patient was having diabetes mellitus since 25 year. On gross examination, kidneys were small and contracted, outer surface of both the kidneys are granular. On cut section of one kidney: small whitish granules present. Corticomedullar region measuring 2 cm, cortico-medullar junction was lost and calyceal systems were dilated. On cut section of other kidney: small whitish granules and cyst like structure present. The histopathological examination revealed thickening of tubular basement membranes and diffuse and nodular diabetic glomerulosclerosis, confirming the diagnosis.

Conclusion : Mortality in patients with diabetic nephropathy is nearly 20-40 times higher than in patients without nephropathy. Many patients with diabetes, in particular type 2 diabetes and renal impairment die from cardiovascular disease well before they progress to end-stage-renal disease. Since kidney biopsy is usually avoided in critically ill patients, histologic evaluation of autopsy kidneys may be the 1st and only opportunity to better understand their role in morbidity and mortality, so a relatively high proportion of DN was clinically under diagnosed are histologically identified as positive autopsy findings.

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P-117 Anaesthetic Management of Giant Retroperitoneal Mass Shah Krishna, Chadha Indu, Sanghvi Kinjal GCS Medical College, Corresponding Email Id: [email protected]

A 30-year-old man posted for exploratory laparotomy for removal of Retroperitoneal Mass measuring (168x193x228) mm. He had history of Right Nephrectomy 4 year back for non-functioning of kidney. He was chronic tobacco chewer and smoker. His airways examination revealed mouth opening 2.5 fingers with MPG grade 3. SpO2 was 94–96% in a supine position. X-ray revealed elevation of Rt dome of diaphragm. All Lab investigations were within normal limits. Thoraco-abdominal CT shows Right giant retroperitoneal mass (168x193x228) mm extending from Rt. hypochondria to pelvis with mild compression and displacement of IVC and adjacent bowel loop & GB calculus. Patient was given conventional for GA. Intubation was done in semi-recumbent position. Patient was put controlled ventilation (PEEP) set at 3 cmH2O with pressure support set at 17 cmH2O above PEEP which was decreased to 10mm of Hg after the removal of tumour. Intra-arterial & CVP, temperature monitoring was done throughout perioperative period and was kept with in normal range. Tumour is gradually removed along with ileum, caecum and part of ascending colon & anastomosis was done in 3.5 hrs. Incision site is infiltrated with 0.25% bupivacaine 20 ml. and infusion of Fentanyl at 2mic/kg/hr was given for postoperative analgesia. Large retroperitoneal tumour with close proximity to major blood vessels, a relatively long surgery with major blood loss made this procedure challenging for the anaesthesiologist in maintaining euvolemia and haemodynamic stability without causing acidosis, organ damage, coagulopathy and acute kidney injury. A vigilant and proactive anaesthesiologist with good communication with the surgeons is essential for successful management of complex surgeries.

P-118 Traumatic Abdominal Wall Hernia Delayed Repair: Advantageous or Taxing. Bhalla Simran , Dave Bhavesh, Shah Jainam, Parikh Sameer Department of Surgery, V.S. Hospital, Ahmedabad. Email id: [email protected]

Introduction : Traumatic abdominal wall hernia is a rare entity and is caused by blunt trauma to the abdomen. It is defined as the herniation through the disrupted musculature and fascia, associated with adequate trauma, without skin penetration and no evidence of a prior hernia defect at the site of injury. Although surgery is the standard treatment for traumatic abdominal wall hernias, there is no consensus in early or late repair of the defect. Some recommend early surgical intervention in order to avoid the risk of intra-abdominal organ injury, incarceration and strangulation. Elective hernia repair may be feasible and safe in stable patients.

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Methodology : 40 year old patient presented with the chief complain of Swelling in the left lumbar region since 5 months and without any complications. The patient had a past history of RTA 5 months back where Patient suffered from chest trauma blunt abdominal wall trauma and foot injury. Patient had no abdominal complaints at that time and the bruise over the flank region was treated conservatively. Patient was discharged after treating chest and foot injuries. Patient then presented with the huge left lumbar region swelling post 5 months of the RTA and was containing herniating bowel loops and omentum and was treated by hernioplasty by placing a 15*15 ploypropelene mesh after reducing the contents.

Result : The post-operative period was uneventful.

Conclusion : TAWH although rare should be suspected in all cases of high velocity injuries with abdominal wall swellings and CECT should be done for accurate diagnoses. Emergency midline laparotomy with examination of abdominal contents and repair of hernia with non absorbable sutures with or without the use of mesh is favoured. Delayed repair may be considered in selective cases. Thus TAWH are best managed on a case by case basis.

P-119 A Case Report on Anaesthetic Management of the Patient Having Sudden Cardiac Arrhythmia at the End of the Vaginal Hysterectomy, When Position of The Patient Change from Lithotomy to Supine. Pandya Aastha, Shah Vibhuti, Shah Darshana AMC MET Medical College & LG Hospital, Ahmedabad Corresponding Email Id: [email protected]

Cardiac Tachyarrythmia occur commonly during peri-operative period and need to be managed by anaesthetics promptly. It can be due to pharmacological agents or due to some non-pharmacological stimuli. Here, the case showing Tachyarrythmia due to positional changes at the end of surgery from Lithotomy to supine. The lithotomy position is variation of supine position in which hip are flexed, legs are abducted and knees flexed, this leads to various changes in cardiovascular and respiratory system. With sudden change in position from lithotomy to supine leads to decrease in venous return to heart leads to hypotention and tachycardia with irregular heart rhythm. Here we have case report showing management of Cardiac Tachyarrhythmia occur after positional changes (Lithotomy to supine) at the end of surgery in patient posted for vaginal hysterectomy.

Keywords: Positional changes, Lithotomy to supine, Cardiac, Tachyarrythmia, Hypotension.

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118 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

119 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-120 Role of Post Mastectomy Radiotherapy in T1,T2 Lesion with 1-3 Positive Axillary Lymph Nodes - A Retrospective Study of 101 Cases. Sadhwani Manish, Tankshali Rajen Gujarat Cancer and Research Institute, Ahmedabad, India Corresponding Email Id: [email protected]

Introduction: Post mastectomy radiotherapy (PMRT) reduces loco-regional recurrence (LRR) and improves overall survival , There is international consensus to recommend PMRT for patients with tumour size more than 5 cm (T3), tumour invasion of the skin, pectoral muscle or chest wall (T4) and patients with > 4 positive lymph nodes (LN) . However, the role of PMRT for patients with T1, T2 disease with 1–3 positive LN is still controversial. The side effects of radiotherapy and its associated morbidity have to be considered in the risk benefit ratio, thus difficult to arrive at consensus in early breast cancer. In a developing country like India, factors such as patient education, level of awareness, financial aspect, long term follow up, and limitation of resources have to be balanced and tailored according to the indication and need of the patient.

Objectives 1. Empirically explore whether it is advisable to carry out radiation when there are 1-3 nodes 2. Whether Perinodal extention in this subgroup is an important parameter to consider for radiotherapy.

Material and Methods: We collected data after approval from our institutional board review committee and analysed case files of patients who presented and were treated at our governmental tertiary referral centre from a period between 2014-2017.Of the 691 patients who underwent mastectomy, we short listed 101 cases for our study who fulfilled our basic inclusion criteria of T1, 2 N1 on final histopathology. The inclusion criteria for this analysis were: (1) Female patients with unilateral breast cancer and no distant metastasis at initial diagnosis who underwent mastectomy and axillary lymph node dissection; (2) postoperative pathology indicated T1–2 and 1–3 positive axillary lymph nodes (T1–2N1M0) disease, at least 10 lymph nodes removed by axillary dissection; (3) complete surgical resection of the tumour and negative margins; (4) complete estrogen receptor (ER), progesterone receptor (PR) and human epithelial growth factor receptor family 2 (Her2) status; (5) No neoadjuvant chemotherapy was administered before surgery and endocrine therapy was performed based on the hormone receptor status. In order to study the research questions, we formulated hypotheses as follows, 1. Radiotherapy does not have any impact on recurrence post mastectomy.2. There is no influence of Peri nodal extension on recurrence. The above hypotheses were tested using chi-square test.

Results: On applying chi square test we found out the observed and the expected value Radiotherapy was given in 60 patients and 41 were not given .Recurrences were obtained in 9 amongst radiotherapy and without radiotherapy in 16.When chi square was applied with 1 degree of freedom, the value was highly significant at 0.006 with 99% CI. Hence our hypothesis was rejected.

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Also in case of PNE with recurrence and radiotherapy, 8 had PNE with radiotherapy and recurrence and 27 had no recurrence, on computation degree of freedom was 3 and p value was 0.013% hence highly significant.

Conclusions: Radiotherapy should be strongly considered in patients with 1-3 nodes post mastectomy as it decreases the chances of recurrence and also if PNE is present chances of recurrence are increased, hence radiotherapy is considered.

P-121 Evaluation of Adapalene alone Vs Combination Therapy of Adapalene with Clindamycin and Adapalene with Benzoyl Peroxide in Treatment of Acne Vulgaris: A Prospective, Observational study. Parikh Nehal, Sood Shikha, Chaudhary Raju, Rana Devang, Malhotra Supriya Dept. of Pharmacology, Sheth V. S Hospital, Ahmedabad Corresponding Email ID: [email protected]

Introduction: Acne vulgaris is a skin condition majorly affecting adolescent population. It is a multifactorial disorder of pilosebaceous unit. Despite availability of various treatments, it persists as an issue and has a profound negative impact on the Quality of Life (QoL).

Objectives: Evaluation of Adapalene alone Vs combination therapy of Adapalene with Clindamycin and Adapalene with Benzoyl Peroxide in treatment of Acne vulgaris. To analyse health related Quality of Life using the Cardiff Acne Disability Index (CADI).

Methodology: This Prospective, Observational study of 12 weeks duration in patients of acne was approved by the Institutional Review Board. It was carried out in patients visiting the Dermatology OPD at a tertiary care hospital. The informed consent was taken and the data of patients was recorded using the case record form and CADI questionnaire. Patients who were being treated with Adapalene alone and Adapalene combined with either Clindamycin or benzoyl Peroxide in the normal course of treatment were divided into three groups. Effectiveness of drugs was checked by observing improvement in lesions and quality of life was analysed using CADI. Statistical analysis was done using the SPSS 22 software.

Result: A total of 60 patients were enrolled in the study (n=20 in each treatment group). Male: Female ratio was 1:2. Mean age of patients was 19.70 ±3.60 years. Average age of onset of acne was 16.52±2.97 years. Most patients had mild grade of acne (65%) followed by moderate (33%) and almost clear (1.7%). Face was the common site in all the patients, followed by back and chest. 78.3% patients had acne from adolescent age and 15% patients had positive family history. There was a statistically significant reduction in number of lesions in all the three treatment groups (p<0.0001). There was statistical significant improvement in QOL in all the three treatment groups (p<0.0001).

Conclusion: Adapalene is efficacious in the treatment of Acne Vulgaris both alone as well as in combination with clindamycin and benzoyl peroxide. Adapalene also has positive influence on the QOL alone as well as in combination but no superiority of one group over the other was observed.

Key Words: Acne Vulgaris, Adapalene, Benzoyl Peroxide, CADI, Clindamycin

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P-122 A Study Showing Comparison of Hemodynamic Responses of Etomidate and Thiopentone Sodium during Laryngoscopy and Endotracheal Intubation Thaker Ishita, Shah Rupesh Department of Anaesthesia AMC MET medical college, Ahmedabad, India Corresponding Email Id: [email protected]

Introduction: Etomidate and Thiopentone are common anesthetic agents. Previous studies say that Etomidate can be used in patients with limited hemodynamic reserve and Thiopentone can lead to more hemodynamic instabilities. This study was conducted to observe the haemodynamic response during the induction of anesthesia with Etomidate and Thiopentone in elective surgeries.

Materials and Methods: This study was done on patients 18-45 years of age that were admitted for elective surgeries. 50 consenting, ASA I (American Society of Anaesthesiologists), patients were evaluated randomly in two groups, and their cardiovascular responses including: systolic blood pressure (SBP), diastolic blood pressure (DBP),heart rate (HR), and O2saturation (O2 sat) were measured before the laryngoscopy, during the anesthesia induction with Etomidate (0.3 mg/kg) in group A and Thiopentone (5-7 mg/kg) in group B and at 1, 3, 5,10 min after the induction.

Results: There were no statistical differences between both groups regarding gender, age, body mass index, and laryngoscopic grade of patients.Changes of SBP and DBP were significantly lower in group A (Etomidate) than in group B(Thiopentone).There were no significant differences among groups in Heart Rate.

Conclusion: Since, patients receiving Etomidate have more stable hemodynamic condition, if there would be no contraindications, it could be preferred over Thiopentone for general anesthesia

P-123 Are we Allocating Resources as per Need of a Busy Trauma Centre? Gohil Jaldipsinh, Gupta Sapna, Jarvani Bhavesh, Thakor Advait Department of Emergency Medicine, SMT NHL Municipal Medical College, Ahmedabad, Gujarat Corresponding Email Id: [email protected]

Emergency department is the entry point of any multispeciality or tertiary care hospital. This area is core area of any institute where all types of patients are admitted and where critical status of patients ranges and has lots of diversity.Patient may be very critical and haemodynamically unstable or can just present for minor illness but emergency department has to be fully equipped to manage all dire emergency and with skilled persons to handle critical patient. knowing the pattern of admission can be helpful to manage the available resources like drugs,instruments and trained person.Work distribution and availability of various super speciality doctors can also be assessed and that may be helpful in better management of patients. It

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is important to segregate the patient on the basis of severity and to decide which superspeciality branch to be involved for definitive management. A study on collection of demographic data of admission in casualty of trauma centre was conducted over a period of 3 months and data were collected in form of age, sex, provisional diagnosis, average casualty stay and severity of admission was also assessed. These data were collected in retrospective pattern. Results were analysed in terms of age groups, gender and provisional diagnosis of patient at the time ot admission. Immediate course of patient was noted in terms of transfer to multispecialty, high dependence unit or intensive care unit or to medical or surgical wards. Collected data were analysed by appropriate statistical software. These data were able to sort out percentage of medical and surgical admissions; also severity of condition leading to presentation to ED was obtained. Major age groups were identified which can be very helpful for allocation of resources. Observations of this study were useful for distribution of manpower for better management. Surgical patients require more manpower and resources compared to medical patients. Also finding out most frequently presenting medical conditions can help us to make specific drug available for better management and allotment of resources in a busy trauma centre

P-124 A Unique and a Rare Presentation of Ventricular Septal Defect, Septic Brain Abscess and Septic Emboli in a 13 Year Old Adolescent. Dave Rajvi, Patel Rushi, Jarwani Bhavesh, Thakor Advait Department of Emergency Medicine, Sheth V. S Hospital, Ahmedabad Corresponding Email ID: [email protected]

Introduction: The presence of septal defects in congenital heart disease makes way for direct shunting of particulate matter from venous to arterial side of circulation. In one study of 30 children (<15yr of age), 37%children i.e. 11 children with cyanotic heart disease had brain abscess out of which 3 had VSD. Another study says, unoperated cyanotic congenital heart disease is an important predisposing factor or brain abscess accounting for 25 to 46 % of cases.

Case summary: Presenting a case of 13 year old male adolescent having large subtruncal vsd with bidirectional shunt, Truncus arteriosus and severe PAH with absent RPA. The patient presented with fever, vomiting and convulsion. Eventually diagnosed as septic brain abscess in right temporal lobe and septic embolic episode which led to gangrenous changes in upper limb and eventually death of the patient.

Conclusion: Brain abscess and paradoxical septic embolic episode should be suspected in all patients with congenital heart disease and symptoms of central nervous system involvement.

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P-125 Anaesthetic Management of Patient Undergoing Carotid Pseudoaneurysm Repair Tomsy Alukkal, Goswami Shakuntala B.J Medical College & Civil Hospital Corresponding E-mail id: [email protected]

Introduction: Anaesthetic management of a patient who presented with injury to neck and quadriparesis following RTA and was diagnosed with C2-C3 spondylolisthesis and left ICA pseudoaneurysm

Detail: 20 year old male patient, who came with alleged history of RTA presented with weakness of all four limbs and injury to neck. He was investigated and diagnosed with C2-C3 spondylolisthesis and left ICA pseudoaneurysm. Pseudoaneurysm repair was done under GA with difficulty in maintaining haemodynamic stability. The affected artery was clamped during the repair. The case highlights the precautions taken, the detection of strategies to maintain haemodynamic stability and thus present impending cerebral insult during such surgeries when the carotid artery is clamped.

Conclusion: Successful management of such patient is full of challenges in maintaining the haemodynamic stability. It can be accomplished by proper replacement of blood loss and proper planning of management.

Key word: carotid pseudoaneurysm repair, haemodynamic instability

P-126 The Perioperative Management of Patient with Mixed Valvular Lesion for Orthopedic Surgery Solanki Hiral GCS medical college, hospital and research Centre, Ahmedabad Corresponding Email Id: [email protected]

This case report summarises the perioperative management of patient with mixed valvular lesion for orthopedic surgery. A 66year old female patient, weighing 80 KG was posted for fracture IT femur left side for corrective surgery. Patient was known case of hypertension for 3 years taking tablet metoprolol 25 mg twice a day since 3 years with Fair effort tolerance. All routine laboratory investigations RFT, LFT, urine routine and CBC accept haemoglobin 9.8 mg/DL mild anaemia were within normal limits.chest xray normal ECG : T inversion in V1-V5 , RBBB 2D echo LV EF 50% MV- Attached soft tissue on PMLAV- Thick calcific,LA- dilated,RA- Dilated,Severe MR/TR, Mild AR/PR, with severe PAH,Pg Max- 26 mmHG Pg Mean18 mmHG RVSP- 70 mm hg. Risk of general anaesthesia explain to patient and finally general anaesthesia was planned with Asa grade 4 risk. All emergency drugs kept ready on the day of operation. ŸECG BP SP O2 attached Preoperative vitals : ŸBP : 136/84 mm/hg

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Ÿpulse : 86/minute ŸSPO2 : 98% Premeditated by: Ÿ injection midazolam 1 MG IV ŸInjection Rantac 50 MG IV and emset 4 MG IV Ÿ preoxygenation with 100% oxygen for 3 minutes Induction: Ÿinjection Fentanyl 100 MG+ 30 MG IV Ÿ injection propofol 40 MG IV Ÿ injection Cis-Atra 8 mg Iv loading dose Ÿ intubated with portex oral cuffed endotracheal tube size 7.00 mm. Ÿmaintained by sevoflurane at 1.5%, Oxygen 1L/min + N2O 9L/min with cis-Atra 2mg Vitals : BP : 126/82 mm/hg P : 82/minute Spo2 : 100% ŸIV fluid injection RL 500 ml and voluven 500 ml ŸSurgery successfully done without any intraoperative cardiac events. Ÿ reversal by glycopyrrolate 0.08 MG IV Ÿ Injection neostigmine 2.5 MG IV Vitals : P : 86/minute BP : 110/70 MM/HG SPO2 : 100% ŸExtubation was done after spontaneous respiration and good muscle tone, power and all reflex achieved ŸWound infiltration with 7 ml lignocaine, + 5 ml bupivacaine 5% + 2 ML NS Ÿ injection Paracetamol 1 gram Iv given for postoperative analgesia.

P-127 Petroclival Meningioma Gohil Yajurvendra, Patel Mukesh, Shah Kalpesh, Parmar Kirit Department of General Surgery Department, Sheth V. S Hospital, Ahmedabad Corresponding Email ID: [email protected]

Introduction: Meningiomas are the most common primary intracranial tumours. They are usually slow- growing, circumscribed, benign lesions. Meningiomas may occur anywhere that arachnoid cells are found (between brain & skull, within ventricles, along spinal cord). Meningiomas account for 14.3-19% of primary intracranial neoplasms. In this case meningioma was located at the very rare location of junction of clivus and petrous bone.

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Methodology: We present a case of a 60 year old female presented with complaints of Headache, slurring of speech and imbalance while walking for last 2 months. Surgical management was planned for the patient. We removed the tumour doing surgery in 2 stages. In first stage we performed the devascularisation of the tumour and half of the tumour was resected. In the second stage after 3 days of first surgery, we resected the remaining tumour that was abutting 7th and 8th cranial nerves and extending upto brainstem and upto vertebral artery. After surgery patient was relieved off her symptoms and did not have any complications.

Result: The post-operative period was uneventful. Patient was relieved off her symptoms and did not have any complications.

Discussion: Most meningiomas are incidental finding and do not require any treatment. Symptomatic meningiomas are managed with medical treatment. Surgical management is required in cases where symptoms are not relieved by conservative treatment and/or have documented growth on serial imaging (CT scan/MRI). Most of the meningiomas are cured if completely removed but complete surgical removal is not always possible. In incomplete resected tumours radio-therapy is given to remove the residual tumour if needed.

P-128 Pulmonary Echinococcosis Rathod Manoj , Patel Chirag Emergency Medicine Department, B. J. Medical Collage, Civil Hospital, Ahmedabad, Gujarat Corresponding Email Id: [email protected]

Introduction: Echinococcosis or Hydatid disease is caused by larvae, which are the metacestode stage of the tapeworm Echinococcus. The vast majority of infestations in humans are caused by E. granulosus causes cystic echinococcosis, the pastoral form, which has a worldwide distribution and is concentrated in sheep-raising areas. Humans are an accidental host and usually infected by handling an infected dogs and cattle. Pulmonary disease appears to be more common in younger individuals.

Case History: A 12 year old girl patient presented in ER with Chief complains of dry cough & fever with chills since 10 days, breathlessness on exertion since 7 days. On presentation Pulse Rate – 100/MIN,BP – 106/72 mmHg,RR – 30/MIN,SPO2 – 90 % on room air. After primary resuscitation with oxygen supplementation and supportive treatment, she was underwent investigations. Radiological reports X-ray chest (PA) s/o. Consolidation in left lower zone with p/o. left lung abcess? USG Thorax revealed large hydatid cyst. MSCT scan Thorax showed large well defined cavitary lesion with internal collapse, and fluid level with collapsed floating membrane noted within cyst which is 7 * 10 * 9 cm. Maximum wall thickness of the cyst is 5 mm. Patient was advised on antihelmenthic treatment Tab. Albendazole (200 mg) twice a day. Patient was underwent surgical intervention – Left sided thoracotomy and hydatid cyst removal with intercostal drain tube in situ. Patient had smooth post-operative period. She was discharged on 8th day in stable condition.

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Conclusion: Isolated pulmonary cysts are more frequent in children. CT scan can elucidate the cystic nature and its further characteristics of space occupying lesion of lung. CT scan not only revealed diagnosis of hydatid disease but also provide accurate localization for planning of surgical treatment. The current treatment of pulmonary hydatid cyst is complete excision of excision of the cyst with maximum preservation of lung tissue in children.

P129 Paraquat Intoxication- A Fatal Poisoning Case Report and Literature Review Parekh Rohan, Makwana Harsh, Gajjar Mehul, Thakor Advait Department of Emergency Medicine, Sheth V. S Hospital, Ahmedabad Corresponding Email ID: [email protected]

Parquet is among the most dangerous poison which is widely used as herbicide in India. A lethal oral dose of the 20% concentration solution is about 10-20 ml in an adult and 4-5 ml in a child. It causes rapid irreversible damage to the lungs and also leads to renal failure and liver failure and finally death. Can be detected by plasma and urine parquet concentration and also predict the prognosis. Oxygen should be used cautiously and can be treated with Cyclophosphamide and steroids within 2-3 hours as it will not be effective once the cells have been infiltrated.

P-130 Study of The Clinical Profile and Outcomes in Primary CNS Lymphoma Patients at GCRI Pendse Shantanu, Patel Apurva, Tahliani Nahush, Bhargava Vijay, Naseer Mohammed, Philip George Gujarat Cancer & Research Institute, Ahmedabad, Gujarat Corresponding Email Id: [email protected]

Primary Central Nervous System Lymphoma (PCNSL) Is An Aggressive Lymphoma Involving Only The Cns (Brain Parenchyma, Spinal Cord, Eyes, Cranial Nerves, And/Or Meninges). It Is An Unusual Entity Comprising Around 5% Of Extra Nodal Lymphomas With A Dismal Prognosis. Most Of The PCNSL Are Histologically Diffuse Large B-Cell Lymphoma (DLBCL). The Prognosis Of Patients With PCNSL Is Poor And Inferior Compared With Dlbcl Occurring In Other Sites. PCNSL Exhibits Unique Biologic Features And Only Certain Drugs Penetrate The Blood Brain Barrier And Give A Therapeutic Benefit. Moreover, These Petients Generally Have A Poor Performance Status At Presentation. Patients With Histopathologically Proven Primary Cns Lymphoma Presenting To Gcri Were Included In Study. In The Present Population-Based Study The Median Survival Of The Patients Who Were Available For Survival Analysis (N=37) Was 14.8 Months. This Compares Favourably With Other Population Based Studies. Although Treated Patients Are Positively Selected, Survival In Our Study Seemed Greatly Influenced By The Treatment. Patients Receiving Radiotherapy Or Both Chemo And Radiotherapy Had A Significantly Better Survival Than Patients Receiving No Therapy At All. The Heterogeneity Of The

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Chemotherapy And The Radiation Regimens Applied And The Limited Sample Size Makes It Difficult To Compare The Survival Among Patients Receiving The Different Regimens. By Univariate Analysis We Have Demonstrated That Young Age, Good Performance Status, Radiotherapy Either Alone Or In Combination With Chemotherapy, And Lack Of Malignant Cells In Csf Are Associated With Longer Survival.

Key-Words: Lymphoma, CNS, DLBCL, Performance Status, Prognosis, Chemotherapy, Radiotherapy, Survival.

P-131 Global Trigger Tool : A Proficient Adverse Drug Reaction Autodetection Method in Critical Care Patient Units Pandya Amee, Rana Devang, Darji Nishita, Gupta Sapna, Malhotra Supriya, Patel Pankaj Department of Pharmacology, Sheth V. S Hospital, Ahmedabad Corresponding Email ID: [email protected]

Background: Emergency department is the most crucial part of hospital where clinician often misses out adverse drug reaction. Although there are systems for reporting the adverse drug reactions (ADRs), these still remain under reported. Here use of low-cost, low-tech trigger tool method escorts the clinician to identify, determine, treat and prevent ADR. Global trigger tools(GTT) 1 are highly accepted and recommended by global health authorities across the world, but is still never tried in Indian settings.

Aim: To identify and evaluate all the ADRs occurring at Emergency Medicine Department as notified using the Global Trigger Tools.

Methods: A prospective review of all patients’ case files presenting in Emergency Department was conducted over a 12 week period irrespective of ADR presentation or otherwise. The records were assessed after taking written consent. GTT were utilized for the detection, monitoring, reporting and analysis of ADRs. Type of ADR was analysed according to Rawlins & Thompson classification, Causality Assessment using WHO-UMC Criteria and harm categorization of ADRs using NCC MERP. Severity & Preventability was analysed according to Modified Hartwig and Seigel Scale & Modified Schumock and Thornton Scale respectively.

Results: A total of 136 subjects were enrolled in the study. 51 Trigger tools were utilized, where triggers were found in 99 (72.8%) patients and Adverse Drug Reactions (ADRs) were found in 37 (27.2%) patients, with mean of 4.1±2.19 triggers per record with ADRs. Out of which, 78.4% were probable, 59.5% were predictable, 67.6% were moderately severe and 16.2% were definitely preventable. Most common triggers were Abrupt medication stoppage (72.05%), Anti-emetic use (52.94%), Time in Emergency department >6hours (33.08%) and Abnormal blood urea-creatinine (22.79%). Most common systems affected were GIT(22.8%), cardiovascular(16.9%), skin(12.5%) and neurological(10.3%) respectively. Most common drugs causing ADRs were Anti-infectives (48.64%) followed by cardiovascular agents (40.54%). Patients with five or more triggers have statistically significant chances of developing ADR (p<0.01).

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Conclusion: The study results suggest that IHI global trigger tool could be useful to identify ADRs in hospitals twice as more efficiently when compared to traditional ADR identification methods. Close review and analysis with triggers would help in early recognition of ADRs and its associated morbidity and mortality. Information regarding this tool should be disseminated to physicians.

P-132 Anaesthetic Management of Children with Moyamoya Disease Vaidya Nirav, Solanki Rekha, Shah Bhavana Department of anaesthesiology, Gujarat cancer and research institute, BJMC and civil hospital, Asarva, Ahmedabad-380016 Corresponding Email Id: [email protected]

Moyamoya disease is a condition that results from bilateral stenosis or obstruction of the intracranial arteries at the base of the brain that usually present as recurrent strokes in children. Diagnosis is made principally from cerebral angiography, computerized tomography scanning and electroencephalography. Surgical procedure EDAS (ecephalo-duro-arteriosynangiosis) is often complicated by cerebral ischemia. So goal in perioperative period is to maintain the balance between oxygen supply and demand in the brain. This report presents three cases of moyamoya disease aged 7 years old girl(14kg), 3 years old boy(10kg), 4years old girl(12kg) . All three children underwent the EDAS procedure under general anesthesia. Main goals during anesthesia are maintenance of normocapnia, normovolemia and normothermia. All were premedicated with oral Midazolam 0.5mg/kg two hours prior to surgery . Xylocain 2% applied topically on local i.v puncture site. Patient were induced with inj. Glycopparolate 0.01mg/kg, inj. Fentanyl 2mcg/kg, inj. Thiopentone sodium 5mg/kg and inj. Vecuronium bromide 0.1mg/kg. After proper ventilation with Oxygen and Sevoflurane for three minute, patient were intubated with proper size uncuffed flexomatalic endotracheal tube. Patients were maintained with Oxygen, Nitrous and continuous infusion of inj. Vecuronium bromide 0.1mg/kg/hr. For brain relaxation inj. Mannitol 1gm/kg i.v was given 20 minutes before dura opening and inj. Furosemide 1mg/kg i.v was given. All patient were reversed with inj. Glycopparolate 0.02mg/kg and inj. Neostigmine 0.05mg/kg. All children were extubated in operation theatre and they didn’t develop new neurological deficits during initial postoperative period. Keywords: Moyamoya disease, EDAS procedure, Anesthetic management.

P-133 Assessment of End Organ Damage in patients with Resistant Hypertension Dave Nisarg, Bhalia Bhargav Department of Medicine, Smt. NHLMMC and Sheth V.S General Hospital, Ahmedabad, India. Corresponding Email ID: [email protected]

Introduction: Resistant Hypertension (RH) as defined by the guidelines is blood pressure that remains resistant to treatment in spite of a therapeutic strategy that includes appropriate lifestyle measures plus a diuretic and two other antihypertensive drugs belonging to different classes at adequate dosages.

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Aims and Objectives: Aim of the study was to evaluate the prevalence of RH and the presence of associated cardiovascular (CV) risk factors and target organ damage (TOD) in hypertensive patients.

Methodology: A cross sectional study was conducted in V.S Hospital medicine department comprising total of 30 patients, who were on antihypertensive treatment and blood pressure was not controlled. Among all hypertensive patients about 4-5% patients were with RH. The mean age was 59±5 yrs, 60% were males, and they underwent detailed history, routine laboratory examinations and both OPD and 24 hour BP measurement.

Description: (1) Heart: Hypertensive heart disease is due to structural and functional adaptation leading to left ventricular hypertrophy, CHF, abnormality of blood flow due to atherosclerotic coronary artery disease, microvascular disease and cardiac arrhythmia. (2) Kidney: Atherosclerotic hypertension related vascular lesions in kidney primarily affect preglomerular arterioles resulting in ischemic changes in glomeruli and postglomerular structures. Glomerular injury may be a consequence of direct damage to the glomerular capillaries due to glomerular hyperperfusion, hyperfiltration, hypertrophy and eventual focal segmental glomerular sclerosis. (3) Brain: Hypertension is the strongest risk factor for stroke. Hypertension related cognitive impairment and dementia may be a consequence of a single or large vessels multiple lacunar infarcts due to occlusive small vessels diseases resulting in subcortical white matter ischemia.

Results: Patients with RH were predominantly old, had impaired glucose values (118±45 vs. 102±23 mg/dl, p<0.05), the GFR (calculated by MDRD formula) was lower in RH (71±16 ml/min/1.73m2 vs. 83±17, p<0.01). The patients with RH had greater LVH (0.43±0.07 vs. 0.37±0.06 p<0.001).

Conclusion: In our patient group the prevalence of RH was of considerable importance. Patients with RH were older, had impaired glucose values and a higher prevalence of cardiovascular and renal end organ damage.

P-134 A Rare Presentation of Organophosphorus poisoning with Diabetes Insipidus and Machiafava Bignami Syndrome Shivam N. Shah, Patel Shivani Department of Medicine Civil Hospital, Ahmedabad Corresponding Email id – [email protected]

OrganoPhosphorus poisoning is the most common cause of parasuicide in India. Around 39.8% of Organophosphorus poisoning patients complicate with respiratory paralysis requiring mechanical ventilation. Sometimes it can be associated with Multi Organ dysfunction syndrome and acute kidney injury in 15.7% of the patients. Diabetes Insipidus is a rare complication of Organophosphate poisoning possibly due to transient hypoxic damage to hypothalamus. Marchiafava bignami disease is a progressive neurological disease characterised by corpus callosum demylination and necrosis resulting in loss of consciousness, seizure, ataxia, hemiparasis, apraxia, and coma.

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A 20 years old male who occasionally consumes alcohol presented with an alleged history of Organophosphate compound ingestion about 400 ml around 10 days ago. The patient was initially treated at a peripheral centre with atropine and pralidoxime. His serum cholinesterase level was low. Patient was then hemodialysed 3 times for acute kidney injury and was eventually put on mechanical ventilation for respiratory failure and eventually tracheostomised. However following onset of multiorgan dysfunction he was referred to our center. On admission patient had normal temperature with BP 100/70mmHg and pulse 82/min and respiratory rate was 22/min. He was unconscious, responding minimally to deep pain stimulation. Blood investigation revealed Hemoglobin-8.9gm/dl, Total WBC Count- 17,000/cmm,platelets- 284000/cmm, creatinine-6.8mg/dl,urea-116mg/dl, normal electrolyte levels, SGPT was 2400 IU/L, total Bilirubin 5.8mg/dl with markedly elevated serum amylase - 1102 U/L & serum lipase-2062 U/L and INR- 1.5.His urine output was 100ml/day. Ultrasonography abdomen suggested changes of acute pancreatitis with raised bilateral renal cortical echogenicity. He was started on higher antibiotics with balanced fluid and electrolytes and was further Hemodialysed in ICU. Urine output increased after 5 days of Indoor stay reaching up to 7 liters per day on day 7th.When further Investigated his urine osmolality was decreased (196 mOsm/kg), urinary specific gravity was 1.003 while plasma osmolality was 287mOsmol/kg. Hence a suspicion of central Diabetes insipidus was made. Desmopressin nasal spray was given in a dose of 10µg/dose 2-3 times a day for 6 days. After Desmopressin therapy urine output was 3-4 lit/day .Patient regained consciousness. His renal function test improved with Serum Creatinine of 3.7mg/dl and urea of 78 mg/dl. Patient was gradually weaned off mechanical ventilation. MRI Brain scan revealed corpus callosum and bilateral internal capsule necrosis suggestive of Machiafava Bignami disease. Renal biopsy was done later which suggested changes of Mesangioproliferative Glomerulonephritis with acute on chronic tubulointerstitialdisease. Tracheostomy closure was possible after 25 days of treatment. Patient was then followed up with renal function tests which show improvement with Serum creatinine of 1.7mg/dl, urea 34mg/dl and urine output of 2-3 liters/day.

P-135 Sjogren’s Syndrome with Proximal Renal Tubular Acidosis Jha Aastha Department of General Medicine, VS General Hospital, General Medicine Department, Ahmedabad, India Corresponding Email Id: [email protected]

Introduction: Sjogren’s syndrome is a chronic autoimmune disease characterized by glandular involvement causing xerostomia and xerophthalmia. It has a female preponderance. The patient’s sera are positive for anti SSA as well as anti SSB antibodies. About one third of patients also show extra glandular involvement like Raynaud’s phenomenon, vasculitis, glomerulonephritis, lymphomas and other organ involvement. Usually Sjogren’s patients present with distal Renal Tubular Acidosis (RTA) with severe academia due to inability of renal tubules to secrete H+ ions.

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A 45 year old female presented to the casualty of our hospital Ahmedabad, with complain of sudden onset, acute motor quadruparesis gradually increasing in intensity over 2 days. On examination she had 2/5 power in all four limbs. All deep tendon reflexes as well as both plantars were absent. Cranial nerve, sensory and cerebellar examination was normal. Magnetic Resonance Imaging of spine was unremarkable. On investigation, her serum potassium level was 1.8 mmol/L. Arterial Blood Gas analysis showed minimal acidosis with low serum bicarbonate levels (10 mmol/L). Urinary pH was 7.0 and Urinary potassium excretion was found to be high (18.3 mEq/L). An Ultrasound of parotid glands was suggestive of parotitis. ANA analysis was done which was positive and ANA blot showed positive anti SS-A and anti SS-B antibodies specific for Sjogrens syndrome. Urinary picture was suggestive of proximal RTA which is in contrast to its normal picture of distal RTA in a patient of Sjogren’s syndrome. Adding oral bicarbonate supplements and administering potassium intravenously and later orally improved patient’s condition so drastically that she achieved a power of 5/5 in all four limbs within 48 hours.

Conclusion: The given patient is a rare case of Sjogrens syndrome, where, instead of usual glandular involvement, she presented with hypokalemic quadruparesis. This hypokalemia was a result of proximal RTA rather than the usual distal RTA seen in Sjogren’s syndrome. She improved drastically on intravenous and later oral potassium, oral sodium bicarbonate as well as tablet hydrochloroquine which normalized her potassium levels. On these medications she now maintains normal serum K levels and remains asymptomatic.

P-136 Dengue Encephalopathy –A Rare Case Presentation in Adult male Patient. Nakum Umeshkumar, Shah Nilima Department of General Medicine, B.J. Medical College, Civil Hospital, Ahmedabad Corresponding Email ID: [email protected]

The clinical spectrum of dengue fever ranges from asymptomatic infection to dengue shock syndrome. Unlike other adenovirus infections, dengue virus does not usually cause neurological manifestations. However, in recent years, neurological manifestations of dengue have been documented. Dengue encephalitis is an extremely rare and fatal disease in adult.

We reported a case of 23 year old male presented with c/o High grade fever with chills and rigor since 3days and altered sensorium since one day. On cns examination patient had altered sensorium. So our differential diagnosis was pyogenic meningitis, enteric encephalopathy, herpes encephalopathy, tubercular meningitis and cerebral malaria. His routine investigations were hb-13.10g%, total count 3000 /cmm, platelets 16,000/cmm .Peripheral smear showed leucopenia, thrombocytopenia s/o an acute viral infection. Test for malaria (pf/pv) was negative. IgM typhi was negative and Dengue NS1 Antigen test and Dengue IgM were positive. CSF showed no cells with protein 128.51 md/dl and sugar 72.38 mg/dl, CSF ADA was normal. CSF HSV was negative. There was papiloedema on fundus examination. MRI brain was normal. Patient was initially treated by IV fluids, Inj. ceftriaxone, Inj. daxona and inj. Valproate in view of altered sensorium and poor GC.

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Patient gradually improved after 10 days. Patient’s condition had improved and had no residual neurological deficits.

Conclusion: Dengue encephalitis should be considered in the differential diagnosis of fever with altered sensorium, especially in countries like India where dengue is rampant. We must have a high index of suspicion or else this uncommon manifestation of a common disease can be easily missed.

Key Words: Dengue Encephalitis, NS1 Antigen, High grade fever, Neurological manifestation.

P-137 A Rare Case of Marchiafava Bignami Syndrome Jagani Harsh, Rathod Sangita Department of Medicine, AMC MET Medical College and Seth L.G. Hospital, Ahmedabad, Gujarat, India Corresponding email Id: [email protected]

MBD is considered to be a rare and severe complication of chronic alcoholism. It is characterized by necrosis and subsequent atrophy of the corpus callosum, which is the major brain structure connecting corresponding areas of both hemispheres although lesions involving cerebellar hemispheres and peduncles were also reported. MARCHIAFAVA AND BIGNAMI first described the disease in three Italians wine drinkers in 1903. Here we have encountered a 45 years old male patient who is chronic alcoholic having history of lethargy, delirium, giddiness, gait ataxia, tingling and numbness in feet, decreased appetite and memory loss. Patient was vitally stable and on neurological examination speech was normal, planters were flexor, power4/5 , tone slightly increased due to spasticity, in DTR'S knee reflexes were exaggerated on both sides ,ankles were sluggish, and biceps ,triceps and supinator’s were normal. Routine blood investigations showed megaloblastic anaemia with HB-6.4 and MCV-104 and other blood investigations were normal. Further MRI brain with whole spine screening was done and it showed hyperintense area involving splenium of corpus callosum s/o cytotoxic lesion and no abnormality of spinal cord were detected which confirmed the diagnosis Marchiafava Bignami Disorder. Patient was treated with iv thiamine and vitB12 injections for 7 days and the symptoms were improved in form of decreased numbness and tingling sensation, patient became oriented, gait was improved and was discharged on supportive treatment of vitamin B complex, iron and folic acid and advised for follow up.

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P-138 A Case of Paroxysmal Nocturnal Hemoglobinuria Presented with Hemolytic Anemia and Hemolytic Jaundice Patel Ankita, Shah Nilima Department of General Medicine B.J.Medical College, Civil Hospital, Ahmedabad Corresponding Email Id: [email protected]

Introduction: Paroxysmal Nocturnal Heamoglobinuria is an acquired clonal disorder which arise as a consequence of somatic mutation, involving one or more heamopoietic stem cell, of PIGA, a gene located on X chromosome that required for synthesis of GPI moiety that anchor some protein to the cell surface .This defect leads to uncontrolled complement activation that accounts for clinical manifestations. Paroxysmal Nocturnal Heamoglobinuria is a rare disorder with prevalence 5 cases per million. We reported a 33 years Old Female with c/o generalised weakness and yellowish discoloration of sclera since 1 month. Patient had also c/o cola colored urine on off for 10-12 years. Patient had visited various hospitals and had h/o multiple blood transfusions; patient had pallor with hepatosplenomegaly. Laboratory investigations were suggestive of pancytopenia with coomb’s negative intravascular haemolysis, haemolytic jaundice and heamoglobinuria. After ruling out other causes of haemolytic anemia, Flow cytometry was done which was suggestive of Paroxysmal Nocturnal Hemoglobinuria. Patient was started with supportive treatment with iron, folic acid, B12. Patient was gradually improved & referred for Bone Marrow transplant.

Conclusion : Paroxysmal Nocturnal Heamoglobinuria is a rare haematological disorder acquired mutation of X chromosome resulting in deficiency of GPI anchored protein which presents with intravascular hemolysis with hemoglobinuria, which should be treated with humanized monoclonal antibodies (if available) or Bone Marrow transplant and supportive treatment

Key Words: Paroxysmal Nocturnal Heamoglobinuria, Hemolytic Anemia, Hemolytic Jaundice, Glycosylphosphatidylinositol Anchor Protein (GPI-AP)

P-139 Tolosa-Hunt Syndrome- A Case Report Prajapati Payal , Dabhi Leena Department of Medicine, AMC MET Medical College and LG Hospital, Ahmedabad, Gujarat Corresponding E-mail id- [email protected]

Tolosa-hunt syndrome is a rare disorder characterized by External Opthalmoplegia caused by Nonspecific Inflammation (Nongranulomatous) Cavernous sinus or Superior orbital fissure. Tolosa-hunt syndrome is very uncommon before age of 20 years. In people older than 20, it appears to have even distribution between male and female. A patient presented in Emergency Room with 5 months of amenorrhea and breathless. General examination revealed Bilateral ptosis and Opthalmoplegia. MRI brain done and suggestive of cavernous sinus pseudotumour. CSF Routine/micro and ANA by IF was done to rule out other aetiology related to cranial nerve palsy. Corticosteroids are given to this patient as treatment along with symptomatic treatment. Patient's counselling regarding spontaneous remission was done.

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P-140 Stroke as the Sole Manifestation of Takayasu Arteritis in a Young Female. Acharya Pavan, Patel Monila Department of Medicine, NHL Medical College & Sheth V.S. General Hospital, Ahmedabad, India. Corresponding Email ID: [email protected]

Takayasu arteritis is a rare disease affecting the aorta and its main branches, causing arterial claudication and end-organ ischemia, including stroke. The etiology is unknown but is believed to be autoimmune. We describe the case of a 16-year-old-female with no significant medical history who presented with right- sided hemiparesis, bruits over the carotid and subclavian arteries. Stroke was investigated extensively in this young patient. Only nonspecific inflammatory markers such as erythrocyte sedimentation rate and C- reactive protein were elevated. Imaging studies revealed left middle cerebral artery territory infarct with blockage of common carotid arteries, bilateral bifurcation, most parts of left internal carotid artery and proximal part of right internal carotid artery. The diagnosis of Takayasu’s arteritis was made and the patient was started on steroids and immunomodulators with good clinical response. In conclusion, Takayasu's arteritis must be recognized as a potential cause of ischemic stroke in young females.

P-141 Dengue Encephalitis with Akineic Mutism - A Case Report Bhalodiya Chintan, Gadani Zalak Department of General Medicine, AMC MET Medical College & LG Hospital, Ahmedabad Corresponding E-mail Id: [email protected]

Dengue virus neurotropism seen in 0.5%–7.4% of symptomatic cases. Dengue fever is a mosquito-borne Arboviral disease, caused by the dengue virus and transmitted by infected Aedes mosquito. Dengue fever spectrum ranges from classical dengue fever to dengue haemorrhagic fever and dengue shock syndrome. In Classical dengue fever presenting clinical symptoms are high grade fever, headache, joint pain, skin rash. In some cases severe dengue infection lead to liver failure, shock coagulopathy leading to cerebral insult. CNS complications like dengue virus encephalitis, immune-mediated syndromes like acute disseminated encephalomyelitis, myelitis, Guillain–Barré syndrome, neuritis brachialis, acute cerebellitis,Dengue- associated stroke.Neuromuscular complications are hypokalemic paralysis, transient benign muscle dysfunction and myositis.Common neuro-ophthalmic complications are maculopathy and retinal vasculopathy. Dengue fever with CNS complications associated with high morbidity and mortality. Here we encountered a case of 20 year old male patient presenting with high grade fever, altered sensorium and convulsion. On neurological examination, patient was disoriented, irritable, planters were flexor, no neck rigidity, bilateral pupils reactive to light equally, Deep tendon reflexes normal except knee reflex exaggerated, not able to speak nor moving body parts. Patient had sinus tachycardia; other vitals were within normal limits. In blood investigation, thrombocytopenia and high SGPT titer were present. Serum Dengue NS1 and IGM were positive. In MRI brain, heterogeneous hyperintense areas in bilateral thalami, fronto-parietal regions with associated hemorrhagic areas seen, which confirmed Dengue Encephalitis after rulling out Japanese encephalitis. Patient was treated with antiviral, anticonvulsant drugs and dopa agonists. Patient although survived with akinetic mutism as sequel of dengue encephalitis.

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P-142 A Case of Anti Musk Antibody Positive Myasthenia Gravis Parmar Vishal, Vyas Chintal, Patel Bhargav, Patel Khushali Department of General Medicine, Sheth V. S Hospital, Ahmedabad Corresponding Email Id: [email protected]

Myasthenia gravis (MG) is an autoimmune disorder of the skeletal muscles characterized by a decrease in the number of available acetylcholine receptors. Approximately 80-90% of patients have detectable serum anti-AChR antibodies, but there is conclusive evidence that patients without these antibodies also have an antibody mediated disorder. Recently, it was shown that approximately 40-50% of seronegative MG (SNMG) patients have antibodies to a surface membrane enzyme, muscle specific tyrosine kinase (MuSK) which is responsible for Agrin induced AChR clustering at the postsynaptic membrane. A 53 year old male patient presented with slurring of speech and difficulty in swallowing since 1 month, which was insidious in onset and gradually progressive. Renal function test, electrolyte, MRI brain, EMG NCV, RNS studies were normal. Anti Ach receptor antibodies were negative but anti MuSK antibodies were positive. Patient was treated with plasmapheresis and other myasthenia drugs. Patient is improved with treatment.

P-134 A Case of Bardet Biedl Syndrome- A Rare Genetic Disorder Vora Mauli, Patel Shivani Department of medicine, Civil Hospital Ahmedabad Corresponding Email Id: [email protected]

Bardet Biedl Syndrome is a rare autosomal recessive genetic disorder with estimated prevalence of 1/100000 affecting males and females equally. It is caused by specific mutation in BBS ( total 18 genes, gene 10 being the most common) which play critical role in structure and function of cellular cilia.It is classically defined by six features viz truncal obesity, intellectual impairment, renal anomalies, polydactyly, retinal degeneration and hypogenitalism. the most dreaded complication is renal failure which may warrant renal replacement therapy i.e. hemodialysis or renal transplantation. Several other abnormalities associated with this syndrome are – diabetes mellitus, dental abnormalities, hypercholesterolemia, hypertension, cardiac arrhythmias and anosmia. A 20 year male presented to Emergency Ward with generalized oedema and decreased urine output for 15 days with breathlessness at rest for 2 days. He had gradual painless diminution of vision for 5 years which led to complete blindness. On examination the patient had normal temperature with BP-100/60 and RR- 22/min regular with pulse of 98/min. General Examination revealed polydactyly with bradydactyly, wide forehead, pinched nose, small mouth, dental crowding, thin upper lip and everted lower lip with hypernasality of voice. Fundus examination was suggestive of atypical retinitis pigmentosa. He was a school dropout with an Intelligence Quotient (IQ) of 50. Patient had no recent or remote past history of seizure episodes or ataxia or fever. Family history revealed that patient’s paternal male cousin had succumbed to similar illness. The patient had S.creatinine of 8.8 mg/dl and S.urea 125 mg/dl with normal

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electrolytes and urine output of ~100 ml/day. Intact parathyroid hormone level was 800 ng/l. Urine microscopic examination was unremarkable. His hemoglobin was 7.8 gm/dl with normal total and platelet count with S.calcium-6.2 mg/dl, S.cholesterol-121 mg/dl, S.uric acid-5.1 mg/dl and S.phosphate-3 mg/dl. Ultrasonography of abdomen suggested bilateral small kidney size (LK 60 X 62, RK 64 X 58) with mild hydronephrosis in right kidney. 2D ECHOCARDIOGRAPHY was unremarkable. Putting together his clinical history and investigative findings a diagnosis of Bardet Biedl Sundrome was made. Renal functions and urine output improved after 3 cycles of dialysis. He was then followed up after a month in which S.creatinine gradually decreased to 1.6 mg/dl. Genetic testing facility was not available, so patient and relatives were counseled regarding prognosis and follow up. Hence, Baardet Biedl Syndrome is a rare condition in which diagnosis is mainly made clinically, supported by genetic testing.

P-144 Adult-Onset Bartter’s Syndrome: A Case Report Emani Ajay Smt. N.H.L. Municipal Medical College, V.S. General Hospital, Ahmedabad Corresponding Email id: [email protected]

Introduction: Bartter’s Syndrome is characterized by renal potassium wasting with hypokalemia, metabolic alkalosis, increased renin-angiotensin-aldosterone system, normal blood pressure, resistance to the pressor effects of angiotensin II and juxtaglomerular cell hyperplasia. Most of the cases have been noted in the pediatric age group and adult-onset cases are very rare (reportedly less than 20%). Case Report: A 55-year-old woman was admitted to the V.S. General Hospital, with a month history of severe generalized weakness and fatigue. The first episode occurred one year ago and spontaneously remitted from it following bed rest. She denied ingestion of licorice, diuretics, laxative or any other medication, and she had no significant nausea, vomiting or diarrhea. The patient appeared relatively well and had a height of 154 cm and a weight of 52 kg. The pulse rate was 128/min, the blood pressure 70 mmHg systolic pressure, and the respiration rate 18/min. The remainder of her physical examination was within normal limits. Laboratory findings included persistent hypokalemic alkalosis with 1.3mmol/L for serum potassium. Serum sodium averaged 135 mEq/L, total calcium 5.8 mg/dL, ionized calcium 1.02 mEq/L, inorganic phosphorus 3.2 mg/dl, magnesium 1.1 mEq/L, uric acid 2.0mg/dl and serum osmolality 278.7 mosl/kg, and serum creatinine 1.14 mg/dl. There were no proteinuria, hematuria and abnormality of the urinary sediment. Twenty four-hour urinary excretion of sodium, potassium, chloride, calcium, glucose was high and urine amounts 2,800 cc. The constellation of hypokalemia, relative hypotension, increased renin activity, increased aldosterone level and juxtaglomerular hyperplasia substantiated the diagnosis of Bartter’s syndrome. The patient had been treated with potassium chloride, 40 mEq twice a day, spironolactone, 50 mg three times a day, propranolol, 20 mg three times a day, enalapril, 2.5 mg a day and indomethacin, 25 mg three times a day. The administration of medications led to an increase in serum potassium to 3.5 to 4.5 mEg/L. In association with this improvement in the serum potassium concentration, the patient’s muscle strength was rapidly recovered and the patient did well for the following two months.

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Discussion: Bartter’s syndrome consists of hypokalemia due to renal potassium wasting, elevated plasma renin activity and aldosterone secretion, normal blood pressure, hypo responsiveness of blood pressure to infused angiotensin II and hyperplasia of granular cells of the juxtaglomerular apparatus of the kidney. The clinical symptoms of Bartter’s syndrome are dominated by hypokalemia. Treatment is generally focused on the repair of hypokalemia by inhibition of the renin-angiotensin-aldosterone or the prostaglandin-kinin system. Potassium supplementation, magnesium repletion, propranolol, spironolactone, prostaglandin inhibitors and converting enzyme inhibitors all have been advocated, but each has met with limited success.

P-145 Autosomal Dominant Polycystic Kidney Disease - A Case Report. Patel Trupti, Gadani Zalak Department of General Medicine, AMC MET Medical College and LG Hospital, Ahmedabad, Gujarat, India Corresponding Email ID: [email protected]

Autosomal dominant polycyctic kidney disease (ADPKD) is a systemic disease, marked by progressive increase of bilateral renal cysts, resulting in chronic kidney disease (CKD) and often leading to end stage renal disease (ESRD). Apart from renal cysts, patient often have extra renal disease, involving liver, heart and vasculature, other less common but eqully imortant extra renal manifestation of ADPKD include diverticular disease, hernia, male infertility, pain, intracranial anuerysm and liver cyst. Extra renal disease burden is often asymptomatic but may result in increased morbidity and mortality. Here we encountered a case of 30 year old male patient presenting with complain of headache and first time GTCS.O\E patient has bounding pulse with high bloog pressure- 180\100 mmHg. blood investigation shows s.creat 9 mg%, s.urea 88mg% with normal blood indicies and normal urine output. USG KUB suggestive of multipe cortical cysts in poles of both kidneys with loss of CMD p/o ADPKD. MRI Brain plain and MR Angio shows normal appearence.We have managed this patient by giving antiHTN agent and one cycle of Hemodylysis has been done. S.creat level decrease to 7.9 mg% followed by Hemodylysis. Patient dischared with controlled blood pressure and further maintanance Hemodylysis is advised in follow up.

P-146 Post Malarial Medium Vessel Vasculitis with AKI- A Case Report Biswas Saurabh Department of Medicine, B.J. Medical College. Ahmadabad, India Corresponding Email ID: [email protected]

Malaria is a mosquito-borne infectious disease affecting humans and other animals caused by parasite belonging to the Plasmodium group. It causes fever, chills, rigor, tiredness, vomiting, and headaches. In severe cases it can cause yellow skin, seizures, coma, or death. Malaria may complicate to respiratory distress, severe anaemia. Also enlarged spleen, enlarged liver or both, low blood sugar, and haemoglobin in the urine with renal failure may occur. Complications may include spontaneous bleeding, coagulopathy,

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and shock. Vasculitis is a group of disorders that destroy blood vessels by inflammation. Both arteries and veins are affected. Medium vessel Vasculitis include: Buerger's disease, Kawasaki disease, Polyarteritis nodosa. AKI is defined as progressive rise in Serum Creatinine by 0.3mg/dl or >50% rise from baseline from last 24 hours or decrease in urine output <400ml within 24 hours or decrease in urine output 0.5ml/kg/hr. for more than 6 hours. A 40/Male pt. named Jayantibhai presented to us with Chief Complaints Fever with Chills from last 10 days, Pain in Abdomen, Yellowish discoloration of sclera and urine from 3-4days and decrease in urine output from 2-3days. Patient found P.Vivax Positive (trophozoites and rings seen) in Peripheral smear with altered RFT and LFT. Then Pt. put on haemodialysis. After 1 day of admission Patient developed blackening of digits of bilateral lower limbs and upper limbs with mild swelling. USG Doppler was done and reported normal. CT-Angiography was done and S/O Vessel Wall Thickening and Luminal Irregularities. CTVS reference done and it was conservative management from their side. ANA with ANA profile was done and found ANA-2+ (Nuclear Speckled Pattern); ANA Profile S/O PL-12 Antibody, Srp-54 Antibody. Then Rheumatologist Opinion taken and it was medium vessel vasculitis (secondary) and advised for Inj. MPS f/b T. Prednisolone, Inj. LMWH and T. Clopidogrel. After that patient is well improved symptomatically.

P-147 A Rare Case of Disseminated Cysticercosis Patel Ravi, Suthar Nilay Department of General Medicine, AMC MET Medical College & LG Hospital, Ahmedabad Corresponding Email Id: [email protected]

Cysticercosis is caused by the larval stage of the tapeworm Taenia solium; clinical syndromes include Neurocysticercosis and Extraneural cysticercosis. In endemic areas, Neurocysticercosis is an important cause of Adult-onset seizures. Disseminated cysticercosis is a rare form of cysticercosis in which the cysticerci spread out through the whole body, most commonly the subcutaneous tissues, skeletal muscles, lungs, brain, eyes, liver, and occasionally the heart, thyroid, and pancreas. A 32 year old male presented to our hospital with complain of repeated episodes of convulsions. After extensive investigation like MRI Brain, multiple X-ray of different parts of body etc. patient diagnosed with Disseminated Cysticercosis (DCC) with primary lesion in the brain and Extraneural cysticercosis in muscles of lower limb. We treated him with Steroids in tapering doses, Anticonvulsant and Albendazole. Keywords: Neurocysticercosis, Disseminated cysticercosis, Extraneural cysticercosis

P-148 P. Falciparum Malaria Presenting as Acute Pancreatitis Agrawal Gaurav, Solanki Bhagirath Department of General Medicine, B.J Medical College & Civil Hospital Corresponding Email-id: [email protected]

Malaria is one of the most important protozoan infections of human and remains endemic in India. It is one of the common cause of acute febrile illness and can cause a wide spectrum of clinical manifestation ranging from uncomplicated febrile illness to multiorgan failure. However Pancreatitis is rare and potentially fatal complication of malaria. Herein I present a case of Plasmodium Falciparum Malaria in a young male who presented with Pancreatitis which was managed successfully with antimalarial and conservative treatment.

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P-149 Constrictive Pericarditis- A Case Report Modi Kashyap Department of Medicine, AMC MET Medical College and LG Hospital, Ahmedabad, Gujarat, India Corresponding Email ID: [email protected]

Constrictive pericarditis is a rare presentation .we need very high index of clinical suspicion to diagnose the disease. It most commonly presents secondary to tuberculosis(TB) in the developing world and post radiation therapy in the developed world. A 30 year old female presented with complain of abdomen distention, Her USG abdomen suggestive of moderate ascites. ASCITIS fluid examination show 2.59 gm/dl fluid albumin and serum albumin is 5.5 gm/dl, So SAAG is >1.1 (2.91 gm/dl) is suggestive of transudative fluid and her computed tomography scan show infective etiology in form of ground glass opacity with intervening normal parenchyma noted in bilateral lung field, p/o mosaic perfusion, pericardial calcification noted, p/o old healed calcified lesion. Mediastinal lymphadenopathy, p/o Koch’s etiology can’t be ruled out. Which is suggestive of constrictive pericardiatis? treatment consist in case of transient constrictive pericarditis consider medical therapy alone NSAIDs, corticosteroid, treatment of heart failure is ACE inhibiters and diuretics, chemotherapy, if medical treatment failure complete surgical pericardiectomy associated with high operative mortality and chronic constrictive pericarditis consider complete surgical pericardiectomy associated with high operative mortality(>6% ).

P-150 A Rare Congenital Heart Disease – Double Outlet Right Ventricle Chaudhari Dhaval Department of General Medicine, Sheth V. S. Hospital, Ahmedabad. Corresponding Email Id: [email protected]

Double outlet right ventricle (DORV) is a rare cardiac malformation especially in adulthood. We report a man with DORV at the age of 27 years. He has visited many hospitals for growth retardation and complains of breathlessness but diagnosis is not made yet. He visited our hospital for complain of dyspnoea on rest. He was cyanotic and had clubbing of fingers and toes and facial oedema. The S2 is loud and single, mid systolic murmur (ejection) along the left sternal border is present. Chest x-ray shows cardiomegaly. Electrocardiography showed right axis deviation and RVH. Laboratory examination revealed polycythaemia (Hb: 19.4 g/dl), increased levels of hepatic enzymes due to congestive liver and marked hypoxemia (PaO2: 50 mmHg). Diagnosis of DORV was made with echocardiography.

P-151 A Rare Case of Scrub Typhus Complicated by Interstitial Pneumonitis Parmar Poojan, Rathod Sangita Department of medicine, AMC MET Medical College, Maninagar, Ahmedabad Corresponding E-mail Id: [email protected]

Scrub typhus/bush typhus is a form of typhus caused by intracellular obligate gram negative parasite “orientia tsutsugmushi, a obligate gram negative parasite, transmitted by bite of “trombiculid mite “. Scrub typhus is clinically characterized by, after an incubation period of 7-21 days, a vesicular lesion at the site of mite feeding, which later on becomes an eschar with regional lymphadenopathy, after few days,

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scrub typhus presents with fever, severe headache, myalgia, cough, lymphadenopathy and splenomegaly and hepatomegaly. In severe cases disease may get complicated by interstitial pneumonitis, adult respiratory distress syndrome, acute hepatic failure, acute renal failure, disseminated intravascular coagulation, meningitis, myocarditis. Chances of ARDS and interstitial pneumonitis are higher in patients with high WBC count and alter liver profile. Scrub typhus is diagnosed by eschar at the site of bite of mite, elevated WBC counts, altered liver and renal function tests, chest x-ray findings of pneumonitis, usg-showing liver or renal enlargement, Weil Felix test, IFA, IGM by ELISA. We have encountered a 38 year old male, with no history of addiction, complaining of fever with chills (moderate grade, intermittent) for 7 days, with severe headache; gradually over a period of 2 days he developed complain of cough with expectoration, associated with breathlessness, which was even present at rest On examination he had cervical lymphadenopathy, with bilateral crepts present on auscultation over chest (bilateral midzone and lower zone).

Investigations: CBC: leukocytosis, Liver enzymes were elevated, chest x-ray showing inhomogeneous opacities in both lung fields (midzone and lower zone), sputum culture turns out negative Usg abdomen showing: mild hepatomegaly. Pt had tachypnea and breathlessness initially ,with low spo2( 82% on air and 90% on o2), so initially he was kept on bipap support(fio2 60%)- maintaining spo2-98% and started on Inj. Piptaz, Inj. Levoflox, T.Linox, T.Tamiflu, for 3 days , but even after broad spectrum therapy there was no significant improvement in symptoms noted, after 3 days of initial treatment patient was given Cap.Doxycycline for protozoal coverage after starting of it in 3 days there was drastic improvement seen in patient’s symptoms ,patient’s tachypnea gradually went away and gradually patient was weaned off from ventilator support . Retrogradely IGM by ELISA for Scrub typhus came out to be Positive with high titer.(3.25,normal 0-1.25) Patient was advised 7 days course of Cap Doxycycline.Pt was discharged after completion of the course of it.

P-152 Mesentric Vasculitis as an Initial Presentation of Systemic Lupus Erythematosus Nair Dhanya, Acharya Pavan Department of Medicine, NHL Medical College & Sheth V.S. General Hospital, Ahmedabad, India. Email ID: [email protected]

A 28-year-old woman presented, and was admitted, to our hospital with a 2-day history of periumbilical postprandial abdominal pain with nausea and vomiting and abdominal distension. On admission to our hospital, she was afebrile and normotensive, and the physical examination revealed only diffuse abdominal distention and mild rebound pain without rigidity; occult testing of stool for the presence of blood was negative. A laboratory evaluation was unremarkable except for a platelet count of 90,000 per cubic millimetre, hypocomplementemia, and elevated levels of anti–double-stranded DNA antibodies. Xray abdomen standing showed multiple air fluid levels. Computed tomography of the abdomen revealed diffuse circumferential wall thickening with submucosal edema of the entire small bowel, showing the “double halo,” or “target,” sign, there was no evidence of thrombosis, perforation, or infarction. The target

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sign is nonspecific but, in patients with active lupus, suggests the presence of inflammation or edema caused by small-vessel intestinal vasculitis. High-dose methylprednisolone (2 mg per kilogram of body weight per day) was administered, with the dose gradually tapered over a 2-week period; the patient had an excellent clinical response.

P-153 Study of Clinical Profile in Patients with H1N1 Swine Flu in Ahmedabad Doshi Abhi, Suthar Nilay Department of General Medicine, AMC MET Medical college and LG hospital, Ahmedabad Corresponding Email ID: [email protected]

H1N1 flu is a catastrophic viral infection which affects the young & middle aged population which otherwise is healthy causing fatal A.R.D.S. This study was conducted to assess the demographic, clinical & radiological profile and outcomes in patients with H1N1 Swine Flu presenting at a tertiary care hospital of Ahmedabad.

Materials & Methods: A retrospective study was carried out during 2017-2018 period on 50 confirmed cases of H1N1 Flu. Cases were confirmed by their positive respiratory samples assessed by Reverse Transcriptase PCR test.

Results: Present study included 19 (38%) males and 31 (62%) females (including 3 pregnant) with 28 (56%) of them between the age of 25 – 50 years and 46 (92%) belonging to urban society. The most frequent presenting complains was fever (92%) followed by cough (82%), dyspnea (52%), sore throat (40%) & rhinitis (30%) in decreasing order. Hypoxia on presentation (SPO2 <92%) was seen with 20% subjects and a positive Chest X Ray finding was present in 38% subjects. 46% patients of H1N1 Flu had associated other medical comorbidities. Mortality was noted in 6% cases with 33% of pregnant females and 18% of those above the age of 50 years.

Conclusions: The incidence of H1N1 flu is high in female gender, middle age group, urban residents and subjects having other medical illnesses. Clinical Outcome was negatively influenced by the pregnant status, presence of hypoxia on presentation, positive chest X ray findings, old age & presence of other medical co morbidities. Early detection of swine flu through meticulous screening in the community with a high index of suspicion followed by prompt and adequate treatment can prevent disease transmission and mortality in various urban settings.

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P-154 A Rare Case of Neuroleptic Malign Syndrome with Lithium Encephalopathy Patel Ravindra, Parmar Sarita Department of Medicine, B.J. Medical College, Civil Hospital Ahmedabad, Corresponding Email Id : [email protected]

Neuroleptic malignant syndrome is an idiosyncratic reaction to antipsychotic characterised by triad of hyperthermia, altered mental status and acute onset of muscle rigidity .it is associated with autonomic dysfunction like elevated body temperature, tachycardia and labile blood pressure. Marked elevation of creatinine kinase and renal failure can occur by rhabdomyolysis. Lithium is used in bipolar mood disorder extensively but it can cause CNS toxicity and subsequent encephalopathy and renal failure. A 50 year old male k/c/o bipolar disorder since 20 years presented to civil hospital Ahmedabad emergency ward with c/o diarrhea, rigidity involving all four limbs, fever since 2 days followed by convulsion one day back. Patient was on tab trifluperazine, carbamazepine, phenytoin and tab lithium (450)SR 1-1-1 since 15 year for bipolar disorder. O/E temp- elevated, pulse- 102/min, bp 130/82mmhg, RR-18/min CNS- unconscious, DPS positive, DTR were normal with b/l planter extension. Neck rigidity present. So our differential diagnosis were 1-metabolic encephalopathy ,2-meningoencephalitis, 3-neuroleptic malignant syndrome, 4-heat stroke. Our positive Investigation were s.creat- 5.92mg/dl, s.urea-215.6mg/dl, cpk total- 2900.7IU/L, s.lithium-2.3mmol/l, u.myoglobin->1000ng/dl , csf r/m-normal , MRI brain p+c were normal. So our diagnosis was neuroleptic malignant syndrome with lithium encephalopathy. So patient was shifted to ICU for intensive monitoring of vitals. Antipsychotic and lithium were withheld. Hemodialysis was initiated and continues for 6 times in view of rhabdomyolysis as well as lithium induced renal failure. Gradually laboratory parameter became normal. Supportive treatment was given to keep vital stable.

Conclusion : Lithium is mainstay of treatment of bipolar disorder and response rate is 70-80% in acute mania but it has narrow therapeutic range (0.5-1.2Meq/l). so strict monitoring of blood level of lithium is requires to prevent its toxicity and subsequent encephalopathy. Neuroleptic malignant syndrome with lithium encephalopathy is a life threatening emergency particular with renal failure associated with high mortality up to 50%. So omission of 1st generation antipsychotic should be done in bipolar disorder.

Key Word: Neuroleptic malignant syndrome, rhabdomyolysis, hemodialysis, lithium encephalopathy.

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P-155 Autoimmune Hepatits Type-2: A Case Report of Rare Diseases. Patel Gopi, Suthar Nilay Department of Medicine, AMC MET Medical College And LG Hospital, Ahmedabad, Gujarat, India Corresponding Email ID: [email protected]

Introduction: Autoimmune Hepatitis is chronic diseases of unknown cause and is characterized by continuing hepatocellular inflammation and necrosis and has tendency to progress to cirrhosis. 42 year old Nonalcoholic Hindu married male patient presented with abdominal distension, bilateral pitting type of pedal edema and yellowish discoloration of sclera since 15-20 days. There was no past history of blood transfusion or any other significant medical past history. On general examination there was pedal edema and ascites was present and were no any other sign of liver cell failure. On systemic examination there were shifting dullness present. On routine hematological workup Hemoglobin was found to be 8.6, APC- 1.97 lac, TC were normal, SGPT-714 U/L, SGOT-960 U/L, bilirubin-8.4(direct-7.4 & indirect-1.0). There was significant hypoproteinemia. Serum Protein (Total-6.0? Albumin- 2.4 & Globulin- 2.6), Amylase & Lipase was within normal range. All Viral Marker (A, B, C, and E) & HIV were non-reactive. USG abdomen showed altered echotexture of liver s/o cirrhosis. Ascitic tapping was done and ascetic fluid routine/micro was found to be normal and ADA-0.09. CECT was advised & it was suggestive of Cirrhosis of liver, splenomegaly, portal hypertension, and ascites and no any sign suggestive of carcinoma. To rule out other cause of cirrhosis, ANA, LKM-1 was advised and LKM-1 was found to be positive and patient was diagnosed to be have Type -2 hepatitis leading to cirrhosis of liver.

Discussion: Early diagnosis of autoimmune hepatitis is crucial so that immunosuppressive treatment can be begun as early as possible to prevent progression to cirrhosis or to rescue patient with ongoing liver failure.

Conclusion: Non Alcoholic patient in whom all the common cause of cirrhosis is ruled out, needs work up for autoimmune aetiology.

P-156 Pregnancy Induced Acute Fulminant Hepatitis Patel Gayatri, Saiyad N, Vohra Sheetal, Solanki Sunita Department of Medicine, V.S Hospital, Ahmedabad Corresponding Email Id:[email protected]

Acute liver failure (ALF) in pregnancy negatively affects both maternal and foetal outcome. The spectrum of liver disease in pregnancy may range from mild asymptomatic transaminitis to fatal and irreversible deterioration in liver functions leading to significant morbidity and even mortality. Acute liver failure (ALF) is described as the development of coagulopathy, usually with an international normalized ratio of >1.5, and any degree of mental alteration (encephalopathy) in a patient without pre-existing liver disease and with an illness of <26 weeks' duration. Here with we present successful management of a case of pregnant women with obstretic history of G2P1A0L1 with 7 month of pregnancy who develop acute fatty liver of pregnancy with fulminant hepatitis with hepatic encephalopathy.

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P-157 Guillain-Barre Syndrome and Acute Hepatitis E: A Rare Association Raj Vishwajeet Department of Medicine, B.J.M.C. Civil Hospital, Ahmedabad, India Corresponding Email Id: [email protected]

Hepatitis E remains most common cause of acute viral hepatitis in India. Mode of spread is feaco-oral route. Hepatitis E generally affects adults more than children and males more than females. Acute hepatitis is uncommonly associated with neurological conditions like meningitis, encephalitis, myelitis, radiculitis and GBS. The exact pathogenesis of hepatitis causing GBS is not known. Antecedent infection is thought to trigger an immune response causing demyelination and axonal degeneration. There is possibility of molecular mimicry of hepatotropic virus and components of myelin of peripheral nerves. We are presenting case of rare association between GBS and Acute Hepatis E.

P-158 A Case of Polycythemia Vera with Portal Vein Thrombosis Kunpara Janmejay, Parikh Archit Department of General Medicine, V.S General Hospital, Ahmedabad, India Corresponding Email ID: [email protected]

Introduction: Polycythaemia Vera is caused by neoplastic proliferation of erythroid, megakaryocytic and granulocytic elements what is referred to as panmyelosis. It may be an incidental finding in an asymtomatic individual or present as erythromelalgia, headache, dizziness, blurred vision, fever, weight loss and thrombotic manifestation. Without treatment it is life threatening and may progress to myelofibrosis or acute leukemia. A 45 year old female presented to our hospital with complains of right hypochondriac pain and for one month and weight loss and itching for 3 months. On examination she was vitally stable, general examination was normal. On systemic examination abdomen was soft and slightly tender. Ultrasound of abdomen showed 16cm splenomegaly with an enlarged portal vein of 15mm at porta. Following this a Doppler study was done which showed defective colour filling with no flow suggestive of portal vein thrombosis. Her Hb was 10.6, RBC=4.13*10^12, PCV=34.9, MCV=84.5, MCH=25.6%, TOTAL COUNT OF 12740 with neutrophilia and APC= 2,86,000. Peripheral smear showed no abnormal cells. The RFT AND LFT was normal. She was further investigated with B12=250, iron=20, ferritin=35. Homocystiene, erythrocyte sedimentation rate, C reactive protein, factor 5 mutation, protein C and S deficiency, ANA, APLA profile which turned out to be normal. Genetic study showed JAK2 mutation and bone marrow biopsy was done which confirmed the diagnosis of polycythaemia vera. She was treated with aspirin and LMWH overlapped with warfarin. The follow up USG showed partial recanalization of portal vein. Patient was then referred to higher centre. There she was started on hydroxyurea. We have planned to follow up patient after 10 days.

Conclusion: This was a unique case of Polycythaemia Vera with an Hb of 10.6 and normal blood counts presented with Portal vein thrombosis and splenomegaly. The conclusive diagnosis was made by genetic study and bone marrow biopsy.

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P-159 Assessment of End Organ Damage in Patients with Resistant Hypertension Patel Prasanna , Pandya Hiren Department of Medicine, S C L Hospital, NHL Medical College, Ahmedabad Corresponding Email ID: [email protected]

Hypertension resistant to treatment in spite of therapeutic strategy that includes appropriate life style measures plus a diuretic and two other anti-hypertensive drugs of different classes at adequate dosages is associated with cardiovascular risk factors and target organ damage.

P-160 Rare Presentation of Neurofibromatosis with Dyke Davidoff Masson Syndrome. Patel Ramesh, Rana Himanshu Department of Medicine, B. J. Medical College and Hospital, Ahmedabad. Corresponding email id: [email protected]

A 26 years old male patient came to civil hospital Ahmedabad with chief complain of generalised tonic clonic movement about 5 episodes associated with loss of consciousness, frothing from mouth and involuntary loss of urine. From history it was found that patient was known case of seizure disorder and was on tab valproate and tab phenytoin. On general examination it was found that patient had multiple neurofibromas, cafe au lait spots and axillary freckling, however central nervous system examination was normal, also there was facial asymmetry and mild mental retardation. Fundus examination done showed presence of lisch nodules in iris also there was positive family history of this patient and from pedigree chart it showed autosomal dominant inheritance suggesting neurofibromatosis-1

P-161 A Rare presentation of Myxoedema Coma / Crisis in Patient Having History of Complicated Pregnancy Shah Harshil, Sheth Kaushal, Panchal Manisha Department of General Medicine, P.D.U. Medical College, Rajkot Corresponding email id: [email protected]

Myxoedema coma is an uncommon but life-threatening form of untreated hypothyroidism with physiological decompensation. A forty year female Hindu patient with chief complain of fever followed by sudden loss of consciousness last 2 days, treated in private hospital, for hypoglycaemia and after 2 days of admission there, referred to us. She has no past history of any major medical illness or drug history. On clinical examination, patient was afebrile, unconscious, not responding to deep pain stimulus. There was dry skin, puffy face and hypotension refractory to inotropes. RS, CVS system – normal and on CNS examination there was B/L planter absent, pupils normal, all four limbs hypotonia, and neck rigidity absent, DTR absent. CBC, LFT, RFT, Serum electrolytes and CSF within normal limit. CXR (PA), ultrasonography was normal and MRI brain was grossly normal. Patient was treated conservatively for 2 days and steroid was started for refractory hypotension and patient responded. After 3 days of unexplained unconsciousness and due to her clinical features like puffy face and dry skin, her TFT was done and showed severe secondary hypothyroidism. After 2 days of supplementation of thyroxine 500µg, patient was become conscious and normal neurological

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findings can walk after 5 days of admission so discharged after 7 days on tablet thyroxine 100µg. On detailed history she gave history of severe postpartum hemorrhage followed by lactation failure. So, we concluded that it was case of postpartum Sheehan’s syndrome with delayed presentation.

Conclusion: Myxoedema coma is a classic endocrine emergency and represents the most extreme form of hypothyroidism. Because of atypical presentation, its diagnosis in an unconscious patient may be delayed or even missed. Though rare today, it is important to recognise it because of its high mortality and potential reversibility.

P-162 Microscopic Polyangitis (mpa) Presented with Rare Condition as Pulmo-Renal Vasculitis. Makvana Mansukh, Rana Himanshu Department Of Medicine, B.J.Medical College, Ahmedabad Corresponding Email id: [email protected]

Microscopic polyangitis is member of the family of anca positive vasculitis with annual incidence of 3.8 cases per 1 million populations. It was first recognised in a subset of polyarteritis nodosa patients who presented with segmental glomerulonephritis. In our case a 62 year old female patient presented with complains of low grade fever, abdominal pain, nausea for one month, decrease urine output, doe & hemoptysis for 15 day.mpa shows a wide spectrum of organmanifestion. In rare condition it may present as rapidly deteriorating pulmo-renal vsculitis. I present this case as a case of academic interest.

P-163 A Case of Systemic Lupus Erythematosis Presented as Congestive Cardiac Failure Variya Dhruv, Dhangar Vandana ,Kothari Prafful Department of General Medicine, Surat Municipal Institute of Medical Education and Research, Surat Corresponding email id: [email protected]

Introduction:- Systemic lupus erythematosus (SLE) is an autoimmune disease that affects many organ systems. As a cardiac manifestation, overt myocarditis is uncommon and not considered in the standard diagnostic criteria for SLE. Lupus myocarditis may rarely be the initial presentation as a fatal complication of SLE. Therefore, there is little information on clinical manifestations and outcomes of myocarditis in SLE. Case Report: A 18-yr-old female patient was admitted due to low grade fever since 2 months, Breathing difficulty with anasarca for 2 weeks and one episode of convulsion before a day of admission. Clinical examination revealed pallor, facial puffiness, pitting edema in both upper-lower limbs and bilateral pulmonary rales. Chest radiography showed cardiomegaly, interstitial pulmonary edema, and pleural effusion Echocardiogram showed moderate to severe amount of pericardial effusion (1.8 mm thin strip of pericardial effusion) and mild pulmonary hypertension. Hb-6.5, WBC-1.9, PLT 1.15, ESR 19, CRP- 13.14(reactive), ASO-64 , RA-9.4, ANA +4. Antibody to dsDNA, SmD1 and PO(polsku)positive. Serum C3 level 55(reduced). This leads to diagnosis of SLE with acute myocarditis. Intravenous methylprednisolone (1 g/day) for 5 days was given and followed by oral prednisolone (60 mg/day). The symptoms were dramatically improved and pulmonary edema was decreased on chest radiography in 48 hr after corticosteroid therapy. In 2 weeks after corticosteroid therapy, pulmonary edema and pleural effusion disappeared on chest radiography.

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Conclusion:- In clinical studies, myocarditis has been identified in about 9% of patients with SLE. Criteria for classification of SLE such as photosensitivity, serositis (pericarditis), proteinuria, hemolytic anemia, lymphopenia, positive anti-dsDNA, and positive ANA. Most myocarditis in SLE is asymptomatic but may be manifest with fever, dyspnea, palpitation, and nonexertional chest pain. The gold standard of diagnosing myocarditis in SLE remains endomyocardial biopsy. However, endomyocardial biopsy is an invasive procedure and its diagnostic yield is very low at 10-20%. Therefore, the diagnosis of myocarditis in SLE depends largely on the clinical suspicion and echocardiographic findings. In our case pt having similar complain and criteria matching the diagnosis of SLE with myocarditis.

P-164 Tuberous Sclerosis A Rare Genetic Disorder Ganvit Manojkumar, Upadhyay Kamlesh Department of Medicine, B.J.Medical College and Hospital, Ahmedabad Corresponding Email id: [email protected]

Tuberous sclerosis is an autosomal dominant genetic disorder. It is also known as bourne ville's disease. And is characterised by the triad of mental retardation, seizure, and facial angiofibromas. Small benign tumors develop in the brain as wellas in visceral organs like kidney and liver. Neurological manifestation of the disorder are due to involvement of brain. My case presernted with facial angiofibromas , renal angiomyolipomas and subependymal nodule. On considering all this findings my patient was diagnosed as tuberous sclerosis. As such tuberous sclerosis is rare disorder , i present this case as a case of academic interest.

P-165 Pituitary Macro Adenoma : A Case Report Kalyani Maulik, Bhansali Prashant Department of Medicine, AMC MET Medical college & L.G. hospital, Gujarat, India. Corresponding Email Id: [email protected]

Pitutory adenoma are tumors of pitutory gland. 64% of them are benign, 35% invasive asymptomsnd 1% carcinoma. Microadenoma(<10mm) are most common and most of time doesn't cause any called Incidentaloma. Macro adenoma are rare and presents with symptoms of hypopitutarism or due to compression of optic chiasma. Hormon secreting adenomas are very rare. A 35 year old female presented in OPD with chief complaint of headache, low vision, nausea and photophobia since 15 days. There were no complaints of fever, any limb weakness or any focal deficit. On examination pupils were bilateral symmetrical and reactive to light. Horizontal nystagmus seen in both eyes in all four directions. Perimetry revealed Bilateral Temporal Hemianopia. MRI brain with contrast done and it showed 29*19*12 mm sized peripheral enhancing lesion suggestive of pitutory macro adenoma. Patient transfered in neurosurgical unit and Endoscopic Transnasal Transsphenoidal resection done. Biopsy revealed benign adenoma. After surgery patients visual symptoms improved and nystagmus disappeared.

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P-166 Atypical Hemolytic Uremic Syndrome Rathava Umeshbhai, Patel Jagdish Department of Medicine, B.J.Medical College, Ahmedabad. Corresponding Email Id: [email protected]

Atypical hus is an extremely rare disease characterised by low levels of circulating red blood cells, low platlets, due to their consumption and inability of the kidney to process waste products from the blood and excrete them into urine(aki)a condition known as uremia.in my case a30year old male patient presented with decrease urine output and multiple skin lesions since 2 days. And recent h/o diarrhea 15days back. Fever 10days back.in this case, patient having low pc; altered rft; raised indirect bilirubin; raised ldh and anti factor h ab positive, with negative f/h/o is s/o atypical hus. I present this case as a case of academic interest.

P-167 Hirayama Disease: A Case Report with Clinical and Radiological Aspects Satija Jivitesh, Karbhari Aashna, Parmar Mahendra, Mehta Chetan Department of Medicine & Radiolodiagnosis, SSG Hospital, Vadodara, India Corresponding Email Id: [email protected]

Introduction: Hirayama Disease, Sobue disease or Juvenile non-progressive amyotrophy, is a rare non- progressive neurological disorder. Mostly seen in young Asian men (esp Japan and India), in their second and third decade, it is a dynamic compressive, ischemic cervical myelopathy. Clinically characterized by insidious onset of unilateral or bilaterally asymmetrical pure motor LMN type of weakness involving the forearm and hand muscles with a conspicuous lack of symptoms like pain and sensory deficit. On imaging, localized spinal cord atrophy (C5-C7), abnormal curvature, asymmetric cord flattening, loss of attachment of the dural sac in the neutral position, anterior displacement of the dorsal dura on flexion and a prominent posterior epidural space are the cardinal features. Treatment is mostly conservative.

Case Report: We report the case of a 19 year old male who came to us with a history of insidious onset of weakness in both the hands beginning with left side followed by right of 3 years duration. On examination he had clawing of both hands with wasting of forearm muscles and diminished reflexes. Lower limbs had no abnormality with normal deep tendon reflexes. Dynamic MR imaging of cervical spine showed a crescent shaped epidural mass which became more prominent on flexion, appearing hyper intense to cord on T1 and T2 weighted images, showing homogeneous enhancement on post contrast images extending from C5 to C7 vertebral levels. Based on these features a clinical-radiological diagnosis of Hirayama disease was given. A cervical collar was prescribed and patient is on regular follow up with no progression of symptoms.

Conclusion: Hirayama disease, a rare self limiting has pathognomonic signs whose recognition will aid early diagnosis and prevent lasting disability.

Keywords: Hirayama disease, Juvenile non-progressive amyotrophy, Sobue disease, Motor neuron disease

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P-168 Wilson’s Disease and its Neuro-Psychaitric Manifestations Manwar Vipshyana, Upadhyay Kamlesh Department of Medicine, B.J.M.C. Civil Hospital, Ahmedabad, India. Corresponding email id: [email protected]

Wilson's disease (WD) is a relatively rare disease of copper metabolism. Wilson’s disease is an autosomal recessive disorder caused by mutations in the ATP7B gene, which encodes a membrane-bound, copper transporting ATPase, and characterized by inability of the liver to transport and store normally absorbed dietary copper, resulting in abnormal deposition of copper in the basal ganglia, eyes, liver and other tissues. The presentation is usually neurologic or hepatic, seen in 40% of patients. Psychiatric presentation of WD is reported in only 15% of patients. The psychiatric manifestations may precede the neurologic features in the early course of WD.This is case of 38 yrs old male with hepatic and neuro-psychaitric manifestations.

P-169 A Case of Pyogenic Meningitis due to Colonic Perforation by Ventriculoperitoneal Shunt Vengayil Vipin Department of General Medicine, Shree Mahavir Super speciality Hospital Surat Corresponding Email Id: [email protected]

Clinical Case history 50 year male smoker presented to the emergency department with c/o # headache - 3 days (sudden onset, extremely severe) # fever with rigor - 3 days (high grade, continuous) # altered sensorium - 1 day (dengue NS1antigen positive from outside hospital) Past illness; January 2018 – diagnosed subarachnoid haemorrhage with basilar top aneurism & Intraventricular extension with hydrocephalus, evd inserted. He was intubated f/b tracheostomy done & GNB (acinetobactor baumanii) positive On respiratory secretions. Also had vasospasm related multiple cerebral infarcts. February 2018 endovascular coiling & right sided vp shunt done.(ventriculomegaly on Repeat brain ct scan) March 18 ruptured liver abscess left lobe, managed with usg guided aspiration & Antibiotics. Digital substraction angiography showing Basilar top aneurism (ruptured)

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Post coiling status; hydrocephalus post evd insertion

No fignificant personel or family history On examination; conscious, oriented, gcs- E4V4M6 Pulse -94/minute, bp -160/90mmHg, RR- 24/minute, Temp- 100F, spo2- 97% on RA Neuro pupils bilaterally equal & reacting to light, plantar both extensor, mild motor weakness right side & Sensory system normal other systems ; normal October 24th ; LP-csf suggests pyogenic meningitis, started meropenem & vancomycin Csf culture -pseudomonas aeruginosa October 28th ; ct abdomen shows vp shunt end migrated inside transverse colon, Exteriorisation of shunt done on same day. Uneventful postop period Repeat csf culture -klebsiella & serratia marscesens Started inj colistin, intravenous & intrathecally,after 5 days continued prev. antibiotics Ct abdomen showing tip of vp shunt tube inside transverse colon

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November 6th ; blocked right vp shunt, reinserted left sided vp shunt Ncct brain shows both left (new) & right (old) vp shunt cranial end

Continued antibiotic 41 days, he responded well. Discussion # In symptomatic vp shunt adult patients, suspicion of bowel perforation should be kept high, if they develop abdominal symptoms or gram negative or anaerobic meningitis. # In a patient with simple bowel perforation & no other complications, a formal laparotomy is not required while in patients with intraabdominal complications, urgent laparotomy should undertaken. # If detected on time & managed properly, the results are good (as in this case) References • Robert BS, Michael HL, Richard AR. Colonic perforation by ventriculoperitoneal shunt. Surg Neurol. 1986;25:173–7. • John DB, Brodkey JS, Schaefer IK. Colonic Perforation by ventriculoperitoneal shunt tubing: A case of suspected silicone allergy. Surg Neurol. 1998;49:21–4. //// Schulhof LA, Worth RM, Kalsbeck JE. Bowel perforation due to peritoneal shunt – A report of seven cases and review of the literature. Surg Neurol. 1975;3:265–9

154 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-170 A Case Report of Cadasil Syndrome:Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts And Leukoencephalopathy Jain Mayank, Naik Kamalchandra, Patel Dipika Department of General Medicine, Surat Municipal Institute of Medical Education and Research Corresponding Email Id: [email protected]

Introduction:- Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) is a hereditary early-onset vascular disease causing recurrent ischemic subcortical infarcts, generally accompanied by migraine, cognitive impairment,psychiatric symptoms and progressively severe neurologic deficits. It is a rare disease with prevalence of 2/1,00,000, Largely undiagnosed with women less severely impaired cf. to men and presents in mid 20s to age 45.

Case Report:- A 31-yr-old male patient was admitted with convulsion and giddiness since 1 day. Convulsion was gtcs type with history of loss of consciousness, tongue bite and vomit.Patient also had complains of loss of memory on /off since 3years and had a history of irrelevant talks and excess laughters occasionally as said by relatives. MRI brain report suggestive of CADASIL SYNDROME.

Conclusion:- Patient had complain of convulsion and dementia and the blood investigations and MRI report was suggestive of CADASIL SYNDROME.

155 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

171. A Case series of Hashimoto Encephalopathy Vaja Anilkumar, Solanki Sunita NHL medical college & V.S. general hospital Corresponding Email Id: [email protected]

Hashimoto encephalopathy (HE) is a steroid-responsive but relapsing neuropsychiatric disorder associated with high titers of anti-thyroid antibody with or without thyroid dysfunction. Though numerous neurological manifestations are often associated with thyroid disorder, this entity is less documented. We are reporting 3 cases of HE in this case series.

• First is a 63 years old female presenting with sudden onset focal seizure following an attack of mild fever. Other causes of vascular, infective, metabolic, autoimmune and toxic encephalopathy were excluded. MRI of brain revealed oedematous gyri of left medial temporal lobe with diffuse age related brain atrophy. Patient’s thyroid function tests were normal but anti-thyroid peroxidase (anti-TPO) antibody was significantly raised. EEG showed diffuse slow wave pattern. After suspecting diagnosis of HE, Intravenous methylprednisolone (one gram) given for five days. Patient regained consciousness slowly over a period of one week. HE must be kept in mind in comatose patients when other metabolic, infective and structural neurological causes have been excluded. Proper and timely treatment can salvage the patient. • A 65 year old female presenting with sudden onset deep coma following an attack of mild fever and vomiting for two days. Patient was a known diabetic. Hypoglycemic coma, diabetic ketacidosis and hyperosmolar coma were excluded by laboratory investigations. High blood sugar was corrected with insulin. She had hyponatremia and hypokalemia which were corrected withelectrolyte replacement. Liver function tests were normal, but serum ammonia was mildly raised. CSF study was normal. Despite correction of her metabolic derangements patient failed to regain her consciousness. CT scan of brain was normal. MRI of brain revealed diffuse brain atrophy. Patient’s thyroid function tests were normal but anti- thyroid peroxidase (anti-TPO) antibody was highly raised. EEG showed diffuse slow wave pattern. Intravenous dexamethasone (24 mg/d) was started. Patient regained consciousness slowly over a period of one month. To reduce the toxicity of steroid, oral azathiprine 50 mg/day was added later with tapering of steroiddose. • A 78 year old female who developed sudden onset behavioral abnormalities associated with choreiform movement of extremities. All causes of vascular, infective, metabolic, autoimmune, paraneoplastic and toxic encephalopathy were excluded. Anti thyroid peroxidase antibody was found to be raised with very high titre. A diagnosis of HE was made. Prompt treatment with high dose steroid led to dramatic improvement of symptoms including choreiform movement

156 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-201 Factor Affecting Mortality in Ventilated Patient of Opium Poisoning in Tertiary Care Hospital Vora Pratik Govt. Medical College Bhavnagar , Corresponding Email Id: [email protected]

In Gujarat and Maharashtra organ phosphorus, opium, Datura and alcohol poisoning are the commonest. Hence a detailed study of organ phosphorus poisoning was planned. Owing to the cheapest price, high toxicity and easy availability of organ phosphorus compounds, poisonings due to them for suicidal purposes have come as on important issue and growing group in toxicology during last two decades. It is important to known the various prognostic factor of O.P.C. poisoning. Because if we are knowing prognostic factors of O.P.C. poisoning, we can treat cases accordingly. Prognostic factor are like amount of poison, mean time delay, age of patient, severity of presentation, route of poisons etc.

1. The mortality was directly related to severity of O.P. compound poisoning. The mortality was 47% in severe poisoning in comparison to 33% in moderate and 11% in mild poisoning. 2. Mortality was directly proportional to MTD. The shorter the MTD, more the chances of survival. The mortality was66.6% who presented between 13 hours to 24 hours as comparison, to 25% who presented from 5-12 and 31.4% who presented within 4 hrs... 3. The Mortality was higher in patients who had taken large amount of O.P. compound. Mortality was 54.54% in patient consumed >50 ml as compared to 11.1% in patient consumed below 25 ml. 4. O.P.C. poisoning is associated with many complications. The commonest being aspiration 5. Most commonly use op compound is monocrotophos followed by chlorpyriphos and cypermethrin but mortality is higher in dimethiole and Malathion. 6. The mortality is higher (60%) in lower AchE activity (<1000). 7. The mortality rate is higher if duration of ventilation > 14 days. 8. The overall mortality in O.P. compound poisoning was 30%.

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P-202 Rupture liver abscess: Analysis of 10 cases Modh Foram Chandnani Rajesh Department of General Surgery, SMIMER Hospital Surat Corresponding Email- Id:[email protected]

Background: Liver abscess (pyogenic and amoebic) is frequently encountered clinical condition; however, it can result in lethal outcome if there is a delay in diagnosis and treatment. Despite modalities to diagnose the condition early, still ruptured liver abscess presents with a common cause of acute abdomen in surgical emergency. In developing countries, ruptured liver abscess is a common cause of mortality. For contained abscess, nonsurgical options are considered; however, for ruptured liver abscess, surgical intervention is considered necessary. Materials and Methods: This was a retrospective study carried in SMIMER Hospital, Surat from January 2018 to June 2018. All patients with ruptured liver abscess (clear signs of peritonitis) were included in this study, and those patients having other causes of peritonitis were excluded. Results: Out of the 10 patients assessed, 8 male patients were mainly affected (%). The most affected age group was 31-50 years %) followed by 50–60 years (%).Right hypochondrium pain was the most common presenting complaint. 1 patients (%) had presented with signs of toxaemia. Only right lobe of the liver was affected the most in all patients (%). Escherichia coli were the most common organism isolated in our study in 7 patients (%). A total of 4 patients (%) had diabetes in our study and total of 1 patient had mortality in our study. Conclusion: Ruptured liver abscess most commonly involves the right lobe of the liver. Males are affected far higher than the females; probable cause believed to be higher alcohol consumption. Most common affected age group falls between 30 and 50 years of age. If prompt treatment is started in time, mortality involved with it is evitable. Keywords: Laparotomy, liver abscess, rupture

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P-203 Cross Sectional Study of Comparative Analysis of Blood Pressure by Mercury, Digital and LED Sphygmomanometer among Medical Students of a Tertiary Care Teaching Hospital of Baroda. Jain Utpalakshi, Mistry Chirag, Pathak Narendra Department of Pharmacology, Physiology, Medical College Baroda Corresponding E Mail id: [email protected] ; Mobile No: 7016709853

• Study background and Objectives: Globally there is a movement to discard mercury based equipment with safe and reliable alternative considering risk of environmental. On the other hand, various researchers have raised question on validity of blood pressure (BP) report by non-mercury equipment. In India, there is lack of adequate data about young hypertensive (<25 years). So, this study was conducted with an objective to compare BP measured by Digital and LED sphygmomanometer as compared to Mercury sphygmomanometer, and to identify possibility of false diagnosis of Normotensive or Hypertensive. • Methodology: After Ethics Committee permission, a cross-sectional study was conducted by measurement of BP by Mercury, LED and Digital sphygmomanometer after taking consent of medical students. Difference in systolic, diastolic, pulse pressure and mean arterial pressure among same participants with three different instruments was analysed by one-way analysis of variance (ANOVA). • Result: As per “gold standard” mercury sphygmomanometer, out of total 252 student participants, total 221 (87.7%) were normotensive as per staging of Indian Hypertension Guideline-II. On the other hand, total 179 (71.03%) participants were identified as normotensive as per staging of JNC VIII Guideline. ` Overall, 10 (3.96%) participants were diagnosed hypertensive by mercury sphygmomanometer. On the other hand, total 18 (7.14%) and 7(2.78%) participant were diagnosed as hypertensive by Digital and LED Sphygmomanometer respectively as per Indian Hypertension Guideline-II. Overall difference in pulse pressure, mean arterial pressure and diastolic BP was highly significant as per ANOVA test (P < 0.05). • Conclusion: Considering variation in measurement of BP, change in types of sphygmomanometer can be misleading while diagnosis of hypertension or monitoring of drug treatment response. Such change can lead to false high or low blood pressure which can affect further treatment and outcome towards end organ damage prevention goal. In spite of environmental threat of mercury, in absence of comparable equipment, mercury sphygmomanometer is still considered “Gold Standard” instrument. Overall validity of non- mercury equipment is still questionable, which may be solved by meta-analysis of large scale comparative research studies. Key Words: Blood Pressure, Digital, Guideline, LED, Mercury, Sphygmomanometer, Young Hypertensive

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P-204 Solid Pseudo papillary Tumor of Pancreas with Encasement of Splenic Artery - A Rare Case Sonam, Ankit Corresponding Email Id: [email protected]

Introduction: Solid pseudo papillary neoplasm (SPN) is a rare pancreatic tumor. Most patients are female within the second or third decade of life with only a small minority concerning children. Frequently described as low malignant potential tumors, surgical resection remains the main treatment. They are histologically, clinically and prognostic ally quite distinct from the more common pancreatic ductal adenocarcinomas.

Case Presentation: A 26-year female presented with abdominal pain localized to left lower abdomen without any other associated symptom. CT and MRI scan showed a well-defined heterogeneous density lesion with multiple foci of calcification noted abutting tail of pancreas of size 75 x 41 x 51mm. It has large exophytic component at stomach, spleen and splenic flexure. It was encasing the splenic artery. Endoscopic Ultrasound showed tumor tail pancreas with irregular areas of necrosis and extensive internal calcification. The patient underwent Distal Pancreatectomy and total splenectomy. On Histopathological examination diagnosis was confirm of SPN with complete resection and no-evidence of malignancy. In Follow up patient is doing well. Discussion: SPN are usually found incidentally. Hence a high index of suspicion in radiology followed by confirmatory pathological diagnosis is the main stay. Despite advances in imaging pseudo cysts, other cystic neoplasms and neuroendocrine tumor remain a differential diagnosis. Symptoms may be present as abdominal pain and vomiting due to compression. A surgical approach is usually indicated aiming complete resection, with tumor size not predicting resectibility.

Conclusion: SPN of pancreas are extremely rare and usually have excellent long-term prognosis after surgical resection.

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P-205 Comparison of Prescription of Potentially Inappropriate Medications in Residents of Old Age Homes and Patients Receiving Care in a Tertiary Care Hospital Using Beers Criteria. Dave Ruchir Corresponding Email Id: [email protected]

Elderly population is very vulnerable to adverse effects of medications. Certain medications have higher chances of causing adverse effects in geriatric age group. Evidence is against prescribing these medications to the elderly. A list of such medications, Beers criteria, revised by American Geriatrics Society in 2015, is used to categorize these drugs as Potentially Inappropriate Medications. The researchers analysed prescription pattern of 200 subjects with age = 65 years. 100 subjects from old age homes (OAH) and 100 subjects receiving medications from a tertiary care hospital in Ahmedabad were randomly chosen. It was found that subjects from OAH were significantly older than their corresponding subjects from the other group and were also given significantly higher number of PIM. Average number of PIM prescribed to females in OAH was also significantly higher than their counterparts in the other group. 55% of subjects in OAH received at least one PIM, whereas only 26% of subjects receiving care from a tertiary care hospital received at least one PIM. At least 27% of subjects of OAH received 2 or more PIM, whereas just 2% of subjects from OAH received 2 or more PIM. Lorazepam was the most commonly prescribed PIM in OAH, whereas ranitidine was the most commonly prescribed drug in tertiary care hospitals. Ibuprofen was the second most common PIM, with 15% of OAH residents receiving this drug, while none of the patients from tertiary care hospital received ibuprofen. Most of the patients of tertiary care hospital were given aceclofenac instead; a drug not included in Beers criteria. All the results point towards a poor medical care provided to subjects of OAH, which add to the already their meager quality of life.

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P-206 Pulmonary Tuberculosis with Diabetes Mellitus: A Combination for Atypical Radiographic Presentation Vyas Yagnang, Leuva A.T Department of TB & Respiratory Medicine Medical College, SSG Hospital, Vadodara, Corresponding E-mail Id: [email protected]

Background: Pulmonary Tuberculosis (PTB) is one of leading cause of death in developing countries. Diabetes Mellitus (DM) is chronic metabolic disorder with high prevalence in developing country. With rising trend in prevalence of DM and its association with PTB, both conditions together pose daunting challenge to existing PTB control program. PTB in DM patients commonly present with atypical symptoms and radio graphical changes which pose diagnostic challenge for general physicians. Objective: Purpose of study is to identify atypical presentation associated with DM and stratification of these changes with their sugar level and treatment status.

Method: It is Hospital base prospective study carried out for 10 months and studied 165 patients with DM having chest x-ray changes and confirmed PTB.

Results: Out of 165 PTB with DM patients, 61(37%) have Upper Zone and 104(63%) have rest lung zone involvement. Rest zone mainly includes unilateral or bilateral mid zone or lower zone or multiple zone involvement. In uncontrolled DM patients, 26(15.8%) have upper zone and 44(26.7%) have rest lung zone involvement. In controlled DM patients, 5(3%) have upper zone and 6(3.7%) have rest zone involvement. Among newly diagnosed DM patients, 27(16.4%) patients with RBS =155 mg/dl have upper zone and 40(24.1%) have rest zone involvement as well as in patients with RBS<155 mg/dl 3(1.8%) have Upper zone and 14(8.5%) have rest zone involvement. As per ADA guideline for uncontrolled sugar level, 53(32.1%) patients have upper zone and 84(50.9%) patients have rest zone involvement. For controlled sugar level, 8(4.9%) patients have upper zone and 20(12.1%) have rest zone involvement. Out of 61(37%) on treatment, 27(16.4%) have upper zone involvement and 36(21.8%) have rest zone involvement. Out of 104(63%) not on treatment patients, 34(20.6%) have upper zone involvement and 68(41.2%) have rest zone involvement. Single zone involvement found in 91(55.2%) patients and multiple zone involvement found in 74(44.8%) patients.

Conclusion: We concluded that DM patient who have PTB are more likely to have atypical radiological features which may cause confusion among general physician for diagnosis. Patient sugar level and current status of treatment have influence the distribution of PTB lesions on chest x-ray.

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P-207 Pulmonary Embolism, A Quite Frequent Occurrence, Often Missed. Banthia Nilesh Neo Clinic and Echo Centre and Neel Clinic and ICCU Panvel, India. Corresponding Email ID: [email protected]

present a case of a 55yrs/M, a case operated for Inguinal hernia, all ok, discharged on 5 Th post op day. Pt. is a Case of DM on treatment, went for f/u on 7 the post op day, all ok. On the 7 th post op day, pt. complained of dyspnoea, with chest pain at 2 am in the night, admitted to our hospital, Neel Clinic and ICCU, with ECG s/o acute Inf-lat ischaemic changes, P 120/min, Spo2 92%, dyspnoeic, BP 120/80mmhg, was started on O2, with BIPAP support, and standard ACS treatment protocol. By morning pt. was better, with decreased pain, but tachycardia and minimal dyspnoea persisted. ECG was better. Trop I was positive, case discussed with relatives, and planned for coronary Angio, for which the pt. need to be shifted to other tertiary centre. But we did an echo before angio, and it changed the whole scenario. Echo showed Dilated RA and RV with Mc Connells sign, with Moderate PH. There was no RWMA in the LV. All these findings favoured Pulmonary Embolism. Explained to the relative and went and did CT Pul angio, which showed LPA and RPA thrombus occluding 70% of the lumen. As the patient had recent history of surgery whether to thrombolyse or not was a dilemma, but our team with relatives being taken into confidence, thrombolysed the pt, as the pt. had e/o submassive PE. The pt. responde well, and was better in 6-8 hrs. Post thrombolysis, without any bleeding complications. Later he was started on NAOCs which were continued for 3 months. Message—pulmonary embolism is a common disease which usually occurs due to prolonged bed rest, or air travel, or in a post op pt., with risk factors being DM, old age, Ht, Smoking, and Dyslipidaemia. We need to be very vigilant, and look carefully for this illness, diagnose it and treat it, to save pt. lives.

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P-208 A Case of Fahr’s Disease Vishakha Vinod Baroda Medical College Corresponding Email Id: [email protected]

Introduction- Fahr’s disease is a rare cause of convulsion. It is characterized by Bilateral symmetrical, calcium deposition in basal ganglia, thalamus, cerebellum and white matter of cerebral hemisphere. The most common site is basal ganglia. It is seen in radiation, systemic disease, toxins, hypoparathyroidism, pseudohypoparathyroidism, hyperparathyroidism, familial disease. Association of hypoparathyroidism with Fahr’s disease is common. Clinically patient presents with neuropsychiatric, extrapyramidal, cerebellar symptoms or convulsions. Extrapyramidal symptoms are most common.

Case Report- A patient named Sarfaraz Pathan, 23 year old, male, presented with generalized tonic clonic convulsion that was a K/C/O epilepsy taking Phenytoin+ phenobarbitone regularly for last 12 years. He was previously admitted with c/o convulsions (GTCS) once previously. Patients CBC, RBS, Sodium, and S.Potassium were normal. We did CT brain which revealed bilateral symmetrical hyperdensities s/o calcification in B/L putamen, globus pallidus, caudate nuclei, dentate nuclei of cerebellum,thalami, and subcortical white matter of B/L cerebral hemispheres; Suggestive of Fahr’s Disease. His S. ionized Calcium levels were low (3.3meq/l with ECG changes) with increased Parathormone levels (221pg/ml). Thus he was diagnosed as Fahr’s syndrome with secondary Hyperparathyroidism with severe hypocalcaemia.

Conclusion- Fahr’s syndrome should be suspected as a rare cause of Convulsion with Hyperparathyroidism and hypocalcaemia.

164 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-209 Posterior Reversible Encephalopathy Syndrome in a Known Case of Solitary Functioning Kidney with Hypertension Ketan Patel PDU Medical College, Rajkot Corresponding Email Id: [email protected]

Introduction: Posterior reversible encephalopathy syndrome (PRES) is a clinoradiological entity that present with rapid onset of symptoms including headache, seizure, altered consciousness and visual disturbance .it is often but not always associated with acute hypertension ,chronic kidney disease and acute kidney injury both commonly present in PRES and PRES is strongly associated with condition that co-exists in patients with renal disease such as vascular and auto-immune disease ,exposure to autoimmune drugs and organ transplantation. It is therefore important to consider PRES in the differential diagnosis of patient with renal disease and rapidly progressive neurological symptoms. It is an increasingly recognized disorder with a wide clinical spectrum of both symptoms and triggers and yet remains poorly understood.

165 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-210 Intensive Monitoring of Adverse Drug Reactions in Indoor Paediatric Patients at Tertiary Care Teaching Hospital Patel Kandarp, Kanani Neeta Department Of Pharmacology, Government Medical College Baroda, Gujarat, India. Corresponding Email Id: [email protected]

Background: Adverse drug reactions (ADRs) are a major source of concern in paediatric population as they differ from adults in pharmacokinetic and pharmacodynamics responses. ADRs reported in adults do not predict those in children.

Aim: The aim of the study was intensive monitoring of adverse drug reactions in inpatients of paediatric department of tertiary care teaching hospital to asses ADRs in terms of incidence, causality, severity and preventability.

Methods: A prospective observational single centre study was done in the paediatric department of SSG hospital, Vadodara over duration of 8 months. The ADRs were actively monitored and collected reports were analysed for ADR pattern, demographic pro?le, causality, severity, and preventability.

Results: A total of 66 ADRs were documented during the period of 8 months. 53.03% ADRs occurred below the age of 1 year. 89.13% ADRs occurred due to antibiotics. 56.06% ADRs are of Diarrhoea and vomiting. 80.43% ADRs developed after receiving drug intravenously. As per WHO-UMC criteria, 46.96 % ADRs were of probable while 51.51% ADRs were of possible causality while as per Naranjo scale 60.61% ADRs were of probable and 39.39% ADRs were of possible category. As per severity scale 69.70% reactions were mild and 30.30 % reactions were moderate. 57.58% ADRs were probably preventable.

Conclusions: ADRs occurred more among infants and antibiotics were more commonly implicated. Most of the reactions were of mild severity and were probably preventable. Certain Precautionary measures can lead to significant prevention of ADRs in paediatric patients.

Key words: Adverse drug reactions, causality, inpatients, paediatrics, pharmacovigilance

166 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-211 Empirical AKT in Pleural Effusion, How much Reliable? Rajput Sonal, Patel Bhavesh Dept. of TB & Respiratory Medicine Medical College, SSG Hospital, Vadodara, India Corresponding E-mail 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 causes of exudative effusion. Studies have demonstrated that 42-77% of exudative pleural effusions 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.

167 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-212 Epithelioid Sarcoma Misdiagnosed as Non-Small Cell Carcinoma Jose Jince, Sisodia Jitendra Department of TB & Respiratory Medicine Medical College, SSG Hospital, Vadodara, India Corresponding E-mail 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 tumours. 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 tumour was often mistaken for chronic inflammatory processes, necrotizing granulomas, and various fibrohistiocytic tumours.

Case report: A 39yr 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 behaviour, clinicians must be aware of the presenting behaviour of ES in order to avoid misdiagnosis.

168 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-213 A Resolving Lung Abscess on Chest X ray – The Hidden Truth Patel Priyanka, Patel Bhavesh Medical college, SSG Hospital, Department of TB & Respiratory Medicine, Vadodara, India Corresponding E-mail Id: [email protected]

Introduction: A Lung abscess is defined as necrosis of the pulmonary parenchyma caused by microbial infections. The most common organisms are anaerobe bacteria. Local conditions, host resistance and infecting agents all play a role in the formation of Lung abscess. An underlying endobronchial obstructing lung cancer predisposes for the development of a lung abscess.

Case report: A 65 years old farmer male, chronic bidi smoker presented with c/o cough, hemoptysis,chest pain, anorexia,pedal edema and fever since 1month, On examination patient was febrile and tachypneic,maintaing saturation on room air, No clubbing,b/l non pitting pedal edema with discoloration of left foot, cavernous bronchial breath sound on auscultation. Chest xray s/o right upper and midzone consolidation with air fluid level,Sputum culture s/o klebseilla, as abscess was improving on chest xray but patient was not improving clinically .B/L lower limb A/V Doppler s/o left popliteal vein partial thrombosis. We went for CECT chest s/o right lung cavitory mass lesion and CT guided biopsy s/o Adenocarcinoma.

Discussion: Though the most common risk factors for developing a lung abscess are aspiration from nasopharynx,mouth or stomach,bronchiecatsis and alcohol abuse; a endobronchial lung malignancy causing bronchial obstruction and vascular involvement with resulting ischemia lead to tumor necrosis f/b suppurative pneumonia can be the cause lung abscess. Which can be diagnosed well on CT chest and CT or bronchoscopy guided biopsy.In 8-17% of patients lung cancer is the cause of lung abscess which rises to 33% in patients older than 45years.

Conclusion: When A Lung abscess doesn’t improve clinically with appropriate medical management and there is a suspicion of lung cancer results of follow up chest xray can be misleading sodiagnosis could be made with CECT chest or more intensive investigations like CT or bronchoscopy guided biopsy

169 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-214 Constrictive Pericarditis—A Rare Entity, Which Should Be Kept in Mind Banthia Nilesh Neo Clinic and echo centre, Panvel, Navimumbai, Maharashtra, India Corresponding Email ID : [email protected]

Case of a 14 yrs old girl, presenting with abdominal distension, odema feet and occasional dyspnoea. Evaluated with USG abdomen s/o hepatomegaly, ascitis, and GB wall thickening, blood reports all normal, including LFt, CBc, creatinine, and TSH. Pt had no h/o fever, or cough, loose motions, jaundice. Ecg and CXR were also normal. Started on diuretic with some response but odema and abd distension persisted, so admitted to our hospital after 4-5 months of illness for complete work up of her disease. We did echocardiography which showed dilated RA and LA, with septal bounce, and variation in MV Doppler velocities with respiration, also annulus reverses, with Lateral MV tissue Doppler velocity being less than the medial MV annulus , also there was IVC plethora, with dilated hepatic veins, with flow reversal in it with expiration. Also the pericardium was thickened and measured 5mm in a small girl. All these findings went in favour of constrictive pericarditis. We went ahead and did cardiac MRI, which confirmed our findings and showed pericardium being thickened, 5mm, and septal bounce. Also there were e/o mediastinal nodes. All these went in favour of constrictive pericarditis, with Kochs as the cause. This hhas been diagnosed recently on 13 th December only and now we have started the pt on steroids with ATT and waiting for her response. This is being presented for the rarity of the disease, and how we need to keep on doing investigations and keep our eyes open of a rare disorder, to be diagnosed and pt relieved of the symptoms.

170 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-215 Antibacterial Drug Utilization Study in Patient of Sepsis due to Staphylococcus Aureus. Vaidya Dhruti, Trivedi Niyati Department Of Pharmacology, Government Medical College Baroda, Gujarat, India. Corresponding E-mail id : [email protected]

Background: Sepsis is the most common and highly fatal clinical syndrome due to infection. Gram-positive organisms as a cause of sepsis have increased in frequency over time and are now more common than gram-negative infections. Staphylococcus aureus bacteremia (SAB) is one of the most prevalent and difficult to treat infections and is associated with significant morbidity and mortality.

Aim: The aim of the study was to study Antibacterial drug utility, sensitivity and resistance pattern of Antibacterial drugs in Staphylococcal aureus infective septic patient in medicine department.

Method: A prospective Observational study was done in Medicine Department of SSG Hospital, Vadodara over a period of 9 months.

Result: Total 50 Staphylococcus aureus were tested for their sensitivity and resistance pattern towards ten Antibacterial agents in Microbiology department by disc diffusion method over a period of 9 months. The antibiogram of Staphylococcal aureus indicated widespread resistance to various groups of antibacterial agent ranging from a minimum resistant to Vancomycin (4%) to a maximum of 90% against Penicillin G. Resistance to Methicillin, Linezolid and Clindamycin was found to be 36%, 6% and 50% respectively. Total 142 Antibacterial agents were prescribed in 50 patients. Metronidazole, Ceftriaxone and Piptaz were the most frequently prescribed Antibacterial agents with DDD/1000 patient days 2.44, 3.55 and 2.62 respectively. 30 out of 50 patients needed a change in Antibacterial agents during their course of treatment either due to Antibacterial agent failure or after Culture sensitivity report. Mean duration of hospital stay was 10.78± 6 days. 60% of the patients were prescribed = 3 Antibacterial agents at any point of time during treatment. Mean DOT/LOT was 2.22 + 0.84.

171 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-216 Significance of Lymph Node Ratio in Operated Cases of Breast Cancer as Prognostic Indicator Manchaiah Mayur Corresponding Email- id: [email protected]

Aims : The positive LN ratio (LNR, defined as the ratio of the metastatic LNs to the total number of LNs examined) or the percentage of positive axillary LN was recently reported to be a strong predictor of breast cancer survival by several studies. The aim of our study was to compare prognostic value of lymph node ratio to conventional pathological N staging in Breast cancer and to evaluate lymph node ratio as determining factor in disease free survival.

Material & Methods : A prospective study was conducted on 61 patients of early breast cancer who underwent surgery between August 2016 to August 2018 at The Gujarat Cancer and Research Institute. All patients were investigated and then operated either by MRM or BCS , as per standard of care and patient preference. The survival analysis was done for both disease free survival(DFS) and overall survival(OS). In order to stratify the LNR based prognosis, we used a cut-off of Values less than 0.20, 0.20-0.64 and more than or equal to 0.65. Results: In this study BCS was performed in 16 (26.2%) patients and MRM in 45 (73.8%), along with axillary dissection. Mean number of lymph node retrieval was 13.33 + 4.67 while average lymph node positivity was 3.13+2.8. Lymph node ratio (LNR) was less than 0.2 in 33/61 patients with 2 year disease free survival of 100%, LNR was between 0.20-0.64 for 24/61 patients with 2 year disease free survival of 63.3% and only 4 patients had ratio more than 0.65 with no patient having 2 year disease free survival.

Conclusions: Lymph node ratio and its association with DFS and OS was statistically significant and can be reliably used as prognostic indicator.

172 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-217 Lipoid Pneumonitis Ninama Manisha Department of Respiratory Medicine Corresponding Email ID: [email protected]

A male patient 70year old his working as mechanical worker in sheep engine(open sheep engine---check and changing of defected spare parts---fabrication of defected spare part,clean spare parts with machine oil).duration of work 31 year.not work since 2006.addiction was tobacco and masala chewer since 20 year. History; associated history of accidentaly injestion of machine oil on 15/06/2018.after injestion patient complain of coughing with whitish expectoration,shortness of breath,dryness of mouth,retrosternal and epigastric burning sensation ,giddiness,patient induce vomitus , Past history ;k/c/o of ischemic heart disease under regular treatment since 2018 . On examination:at the time indoor he was complaining of short ness of breathing with chest haviness,no associated with orthopnea or gabharaman,oxygen saturation 91% @room air,auscultation revealed bilateral bibasilar crepitation,his blood pressure around 160/86mmhg,his liver enzyme and kidney function in normal range,no any skin lesion,chest x- ray (PA view)showed bilateral lower zone homogenous opicities. P r e a n d p o s t t r e a t m e n t : H R C T CHEST;21/06/2018;confluent areas of ground glass opacities in both lungs with crazy paving ,seen in both lower lobes.

Differential diagnosis; pulmonary alveoular protieniosis ,aspiration pneumonia,bronchoalveolar carcinoma,pulmonary hemorrhage syndrome,Disscution;patient had history of chronic exposure and inhalation of oil gase and injestion of machine oil ,with induce vomiting s/o aspiration of vomitus ,with no hemoptysis. Treatment;injectable dexona 8mg iv od for 3 days after that on oral steroid according to 1mg/kg for 15 days .After treatment resolving in cxr and in ct chest; D i a g n o s i s : , s / o c h e m i c a l pneumonitis with exogenous lipoid pneumonia

173 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-218 A Rare Clinical Association of Papilledema and Hypocalcaemia. Dhamecha Jaysan, Gadhavi SK, Budharani Deepmala PDU Medical College, Rajkot, Gujarat. Corresponding Email ID: [email protected]

We record a case of a female patient,42 year, presented with chief complain of generalised seizure since last 4 to 5 months and paraesthesia and tingling sensation over extremities since before mentioned duration. Injectable antiepileptic was loaded. upon investigation we found exclusively normal hemogram including blood indices,LFT-RFT. Her mri-brain epilepsy protocol was done which came remarkably normal. Her electrolyte s.sodium and s.potassium were normal but there was low s. total calcium(6.2 mg%) and low s.ionised calcium(0.7mg%) . her fundus was showing bilateral papilledema. upon further investigation her s.phosphorous was raised(7.9 mg%) and high s.parathormone level(8.20 pg/ml) found. Her thyroid profile was entirely normal. Her vitamin-D level and s.magnasium was normal. Hence there was a case of idiopathic(primary)hypoparthyroidism and we observe a rare clinical association of hypocalcaemia and papilledema for which upon expert advice oral calcium and calcitriol only was started for lifelong period.

174 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-219 Anaesthetic Management of Severe Morbid Obese Patient for Left Leg debridement. Makwana Devendra, Shah Bipin Department of Anaesthesiology, GCS Medical college and research centre, Ahmedabad ,Gujarat, India Corresponding Email ID: [email protected]

A 38 year old female patient of weight 240 kg posted for debridement of left leg cellulitis. Patient having BMI of 52 and had complained of redness and inflamed skin of left lower limb since 15 days with history of something bite over le ft leg and gradually increase in the size of raw area. Then patient admitted in the ICU before 12 days with diagnosis of respiratory acidosis and left leg cellulitis with 360 gm% RBS and 170/100 blood pressure. On further investigation patient is diagnosed of DM, HTN, h/o IHD, RESPIRATORY ACIDOSIS. Patient had electrolyte imbalance, that has been corrected in the ICU and patient is intubated and kept on BIPAP ventilator mode for last 10 days and then on oxygen mask for 3 days, and patient is shifted to medicine ward just before 1 day for further management. Patinet had economical issues and can not afford further ICU admission. On preanaesthetic checkup , patient is recently diagnosed of DM, HTN and h/o IHD. Her airway examination revealed 2.5 finger mouth opening, short neck, double chin with 5 cm thyromental distance and 69 cm neck circumference. Patient is maintaining a 84-90 % spo2 on air and oxygen saturation has maintained by giving oxygen by mask.On laboratory investigation patient having abnormal electrolyte, raised trop i (0.04) and hba1c 8.6. With 2D echo finding of EF 45%, anteroseptal hypokinesia and mild TR, MR. And with ST - T changes in lead II, avl , and v2-3. On auscultatory finding RS and CVS is normal. As the part of anaesthesia, patient has been induce with analgesic dose of inj.ketamine 50 mg IV, inhalational agent sevoflurane 3% and local infiltration with 2% inj.lignocaine surrounding the raw area. And spo2 level 100% has been maintained by giving 100% oxygen by spontaneous ventilation. And depth of anaesthesia has been maintained by the tappering the concentration of inhalational anaesthetic agent sevoflurane . In this way we have done the anaesthetic management of this high risk patient.

175 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-220 Kartagener's syndrome Dhori Tushar Corresponding Email ID: [email protected]

Kartagener's syndrome is a autosomal recessive genetic disorder, generally patient presentations with recurrent respiratory tract infections due to impaired function of mucosal cilia. diagnosis confirmed by ciliary dysfunction,genetic studies or mucosal biopsy. I'm presenting a case of 15 years old male patient presented with repeated episodes of upper respiratory tract infections. Radiological investigation revealed Bronchiectasis, sinusitis and situs invertus-a triad of Kartagener's syndrome.patient had positive saccharin test that indicates ciliary dysfunction. Patient was managed conservatively.patient also vaccinated with pneumococcal vaccine and hemophilus influenza b. Goal of this case report is to spread awareness about the rare ciliopathis disease to help early diagnosis and treatment to improve prognosis.

176 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-221 Acute Intermittant Porphyria Rutasavaj Corresponding Email ID: [email protected]

Acute intermittant porphyria is a rare autosomal dominant hereditary metabolic disorder resulting from the half normal level of HMB SYNTHASE activity having highly variable clinical expression is often related to environmental or hormonal factors such as drug,diet and steroid hormones. A 18 years old boys was admitted in the new civil hospital,surat with complains of altered level of conciousness,recurrent bouts of abdominal pain with weakness of limbs. Case presented with neurovisceral symptoms at the age of puberty with presence of porphyrin in urine confirm the diagnosis of ACUTE INTERMITTANT PORPHYRIA. AIP can be lifethreatening. so,accurate diagnosis and proper management are highly important.

177 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-222 Study of Usage Pattern of Fixed Dose Combinations (FDCs) and Their Analysis in Patients Attending Out Patient Departments (OPDs) of Medical Specialties at A Tertiary Care Teaching Hospital. Modi Maulik, Bhave Amol Department of Pharmacology, Medical College Baroda, Gujarat, India. Corresponding Email ID: [email protected]

Background: A Fixed Dose Combination (FDC) is a combination of two or more active ingredients in a fixed ratio of doses. FDCs offer advantages over the single entity preparations, such as, increased efficacy, reduced incidence of adverse effects, reduced cost, simpler logistics of distribution, improved patient adherence and reduced development of resistance.

Aim: To study the usage pattern of FDCs in OPDs of medical specialties and to analyze them using WHO indicators.

Methods: A Cross Sectional-Observational study was done in the OPDs of medical specialties viz. Medicine, Pediatrics, Pulmonary Medicine, Psychiatry & Skin in rotation for 12 months. To cover up seasonal variations, study duration was divided in three parts corresponding to three seasons of year. Data was collected in pre formed Case Record Form & was analysed.

Results: A total 808 prescriptions, having minimum of one FDC, were collected and analysed which included 3638 formulations of which 1472 (40.46%) were FDCs. Maximum 1534 (42.17%) formulations were prescribed in the OPD of Medicine, out of which 609 formulations were FDCs, followed by OPD of Skin which prescribed 268 FDCs in 641(17.62%) formulations. FDCs were more frequently prescribed for males (55.89%) and in age group of 51 to 60 (19.68%). Number of FDCs per prescription ranged from 1 to 4 of which maximum prescriptions were with 1 (45.54%) FDC followed by 2 (34.90%) FDCs. Average number of FDC per prescription (mean ± SD) was 1.81 ± 0.97. Majority of FDCs were prescribed by oral route (80.50%) and in tablet form (63.25%). Among all FDCs, Nutritional supplements (34.92%) were the most commonly prescribed. Looking at seasonal variation, more number of Rota capsules and Powder formulations were prescribed in Winter and Monsoon respectively. Only 20.31%, 20.85% and 28.53% FDCs prescribed were included in WHO (2017), National (2015) and Gujarat State (2018) Essential Medicines List (EML), respectively. 40.82% FDCs were prescribed by Brand Name.

Conclusion: FDCs are widely prescribed with seasonal influence. More FDCs were prescribed by oral route and in tablet forms. More number of FDCs were prescribed from Gujarat State EML than WHO EML.

Keywords: Fixed Dose Combinations, Medical Specialties, WHO core indicators.

178 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-223 Respiratory Complications in Down's Syndrome Gundrasiya Asha, Patel Department of Respiratory Medicine, Government Medical College, Surat Corresponding Email ID: [email protected]

Background: Down syndrome is associated with a significant health burden, which is particularly apparent in young children who will frequently present with cardiac and respiratory problems. Respiratory presentations include problems related to structural abnormalities of the airways and lungs, glue ears, recurrent lower respiratory tract infections and obstructive sleep apnoea. These conditions are readily identifiable and able to be treated. An awareness of the breadth of respiratory problems and a plan to monitor patients with Down syndrome for their development has the potential to improve outcomes.

Case : A 20 year old male, k/c/o Down's syndrome was presented with complaints of cough with expectation since 2 months and breathlessness since 20 days. Patient's CBC, RFT, LFT are normal. Patient's sputum for AFB and CBNAAT are negative for MTB. Patient's S.HIV is non reactive. Patient is giving history of recurrent LRTI infection. Patient's chest X ray s/o . Patient's USG abdomen and pelvis is NAD. Patient's CT scan throax report is suggestive of changes of subacute hypersensitive pneumonitis versus cystic lung diasease. So we had done bronchoscopy of this patient and patient's BAL fluid for differential count are normal. Hence we would able to rule out subacute hypersensitivity pneumonitis. So it is most likely cystic lung disease.

Discussion: Down syndrome can be organised into conditions affecting the upper airways, the lower airways and the pulmonary vasculature. The upper respiratory tract in persons with Down syndrome is often narrow due to congenital and associated conditions. The trachea is often smaller in children with Down syndrome and tracheal bronchus contributes to recurrent pneumonia. Airway malacia cause obstruction in >50% of children with Down syndrome, with other causes more prevalent in adults. These structural factors combine with hypotonia and obesity to increase the likelihood of proxima lairway obstruction.

Conclusion: Respiratory complications are more common in Down's syndrome in childern like cystic lung disease, subacute hypersensitivity pneumonitis etc.

179 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-224 Iieal Ureter for Pan-urteral Stricture of Tubercular Origin Sathwara Kunal, Rajyaguru ,Nathwani Parth Department of Urology, V.S Hospital, Ahmedabad Corresponding Email- id:

Background: Genitourinary tuberculosis (GUTB) is a devasting disease with dreaded complications because of both disease & treatment. It is the third most common extrapulmonary tuberculosis(TB) after tubercular lymphadenitis & bone1.

Case report: A 24 year old male patient residing at Dholka presented with c/o haematuria, dysuria, anorexia & repeated UTI since s2 years & with left PCN in situ since 1 year. Patient was a diagnosed case of GUTB on bladder biopsy and had completed 9 months of AKT. No past h/o pulmonary Koch’s. On investigations- Hb- 12.8, TLC- 11,800, ESR- 67, creat-1.3, Urine routine – 20-25 pus cells & 2-3 rbc's. Urine for AFB was negative & Mantoux test was positive. Chest X-ray - normal, USG s/o left side moderate hydroureteronephrosis with thickened bladder. CT-IVU was s/o beaded appearance of left ureter p/o pan ureteral stricture with delayed excretion from left kidney with hydronephrosis. PCNO gram - complete cut off at PUJ. DIURETIC DTPA renal scan showed moderately impaired function of 36% & GFR of 23 in left kidney & obstructed drainage pattern. URODYNAMIC STUDY- normal compliance & capacity of bladder. So, in view of salvageable kidney and pan ureteral stricture, ileal ureter was done. Post-operatively patient was symptom free along with good renal function & excretion on IVU.

Discussion: Commonest age of presentation GUTB is 4th decade and commonest organ involved is kidney. Ureteric stricture resulting in obstructive uropathy can lead to renal function loss. Review literature states that management of ureteral stricture of tubercular origin poses both a diagnostic dilemma as well as taxes the surgical skills of the reconstructive surgeon2.

180 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-225 Anaesthetic Management of A Patient with Large ASD with Severe Pulmonary Hypertension Posted for Whipple’s Surgery Kisku Anupama , Patel Leena, Shah Bhavna Department of Anesthesia, GCS medical college, hospital and research Centre, Ahmedabad Corresponding Email ID: [email protected]

ASD is the most common congenital acynotic heart disease in adults and accounts 10% of congenital cardiac defects in adults.ASD occur more frequently in females. Pulmonary hypertension is a major reason for elevated peri-operative morbidity and mortality, even in non-cardiac surgical procedures. We report a case of 45yrs old female patient diagnosed peri-ampullary Carcinoma and posted for Whipple’s surgery. She has large ostium secundum ASD with moderate TR and severe pulmonary hypertension. We had done the successful management of the case using combined general anesthesia with epidural analgesia. Preoperatively, she was managed with torsemide plus spiranolactone. In Intra operative management we focused on avoiding all circumstances that could contribute to exacerbating the pulmonary hypertension (hypoxemia, hypercapnia, acidosis, hypothermia, hypovolemia, fluid overload). During Post-operative phase patient was monitored continuously and pain was managed by epidural analgesia. The patient had an uneventful peri-operative course and discharged from the hospital on 15th post –operative day in good physical condition.

Keywords: ASD, Pulmonary arterial hypertension and epidural analgesia.

181 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-226 Anaesthetic Management of Rachipagus Parasitic Twin Kashi Annapurna Department of Anaesthesiology, B. J. Medical College, Civil hospital, Ahmedabad, India. Corresponding Email ID: [email protected]

Introduction: Conjoined twins is a rare challenging condition,of which,parasitic type are rarer. The rarest of rare,is the Rachipagus type. In this case it was limb attached to thoraco-lumbar region.The importance of thorough pre operative evaluation and planning for organized management of long hours of anesthesia,vigilant monitoring and anticipation of complications such as difficult airway and positioning,blood loss and fluid loss,hemodynamic instability,hypothermia and post operative care emphasized.

Case report: The child was 28 days old and 2.5kg when the surgery was performed, after taking written informed consent for anaesthesia. Baby was given supine position with accessory limb supported by ring during intubation.Monitoring was conducted by ECG, Non Invasive Blood Pressure (NIBP),Etco2, oxygen saturation and temperature monitoring through a skin probe.Prone positioning and controlled ventilation done. Trachea was extubated and baby was hemodynamically stable post operative. Discharged 2weeks after surgery, moving his lower limbs without any neurological deficit.

Conclusion: Perioperative morbidity in patients can be greatly reduced by proper preoperative preparation, optimization of physiological status, preparation for any anticipated airway difficulty and intra operatively close monitoring.

182 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-227 Ileal Pouch Anal Anastomosis and Diverting Loop Ileostomy In Intractable Case of Ulcerative Colitis Gwalani Pooja, Andharia Department of General Surgery, V.S. Hospital, Ahmedabad, Gujarat Corresponding Email ID:

Introduction Ulcerative colitis is a chronic inflammatory bowel disease involving mucosa and submucosa of rectum and extending in continuous fashion in the large intestine and rarely involve small intestine. In condition like intractable, dysplasia, massive colonic bleeding and toxic megacolon surgical management total proctocolectomy + ilealpouch anal anastomosis is needed.

Methodology 50 year old male known case of ulcerative colitis from 10 years on oral corticosteroids mesamine, azathioprine and cyclosporine with complaint of abdominal discomfort, diarrhea and mucus discharge and blood in stool from last 3 years even after increasing the dose of steroids Blood reports revealed anemia and hypokalemia and USG showed mild edematous wall of descending colon with width 5-6 mm Colonoscopy revealed mucosal erythema, edema and loss of vasculature and biopsy showing crypt abscess, crypt branching and loss of goblet cell. Patient underwent exploratory laparotomy and total colectomy with ileal pouch anal anastomosis and diverting proximal ileostomy followed by stomy closure after 6 weeks.

Result Postoperative period was uneventful followed by closure of ileostomy loop after 6 weeks after which altered bowel symptoms gradually resolved.

Discussion Ulcerative colitis is chronic inflammatory disease of large intestine involving mucosa and submucosa characterized in severe cases all the layers get involved and toxic megacolon occurs. Symptoms are mainly weight loss, diarrhea, mucus in stool, urgency, rectal bleeding, hematochezia Treatment is mainly medical for mild to moderate ulcerative colitis –5aminosalicylic acid – mesamine, oral corticosteroids, immunomodulators- azathioprine, cyclosporine, tacrolimus and biologic anti TNF antibodies – infliximab, adalimumab, certolizumab Surgical management – total proctocolectomy+ ilealpouch anal anastomosis is reserved for intractable cases, dysplasia, toxic megacolon and massive colonic bleeding

183 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-228 Idiopathic Spontaneous Pneumomediatinum-A Unique Presentation Muneera , Patel Bhoomika Department of Respiratory Medicine, Government Medical College, Surat Corresponding Email ID: [email protected]

Introduction: Pneumomediastinum is the presence of free air in the mediastinum, other wise known as Mediastinal emphysema. Pneumomediastinum can be divided into spontaneous and traumatic Traumatic pneumomediastinum is caused by blunt or penetrating trauma to chest or iatrogenic injuries such as that produced by mechanical ventilation,thoracic surgery or shoulder arthroscopies. Oesophageal rupture may also lead to pneumomediastinum which is of poor prognosis. When all secondary causes are ruled out then idiopathic spontaneous pneumomediastinum should be labeled.

Case: A 20 year old male patient presented in emergency department with sudden onset of breathlessness and swelling in the neck with no history of trauma or surgery. Patient gives history of weight lifting one hour prior to incident.On examination patient was conscious and vitally stable. Crepitations was present on palpation all over neck. Digital Chest xray was done which showed excessive subcutaneous emphysema all over neck,lung parenchyma was normal and there was no evidence of penumothorax. USG neck also showed subcutaneous emphysema.CECT thorax was done and diagnosis of pneumomediastinum with no evidence of secondary lung diseases was made.Barium swallow was done and showed intact oesophagus.Patientwas labeled as idiopathic spontaneous pneumomediastinum.Patient was treated with high flow oxygen and supportive care.Repeat CECT was done after 48 hours and showed no evidence of pneumomediastinum with complete resolution.Patient was discharged after 72 hour of admission.

Discussion: Idiopathic spontaneous pneumomediastinum is common in young adults .It is due to increase in airway pressure which leads to alveolar rupture or increase in strain against closed glottis during vomiting/ coughing or increase in lung volume after cocaine inhalation or convulsions.Patient presents mostly with subcutaneous emphysema.CECT Thorax confirms the diagnosis.All secondary causes of pneumomediastinum should be ruled out before labeling the patient as idiopathic spontaneous mediastinum.Treatment is supposrtive with oxygen therapy and observation.

Conclusion: Idiopathic spontaneous pneumomediastinum is being a rare entity shouid be suspected in young adults presenting with subcutaneous emphysema with no secondary causes for pneumomediastinum .Treatment consists of displacing the trigger ,rest and administration of oxygen .Antibiotics or chest tube are reserved for specific etiologies and complications,

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P-229 A Case of Viral Pneumonia in a PLWH Patient Nair Arathi , Shamaliya Khyati Department of Respiratory Medicine, Government Medical College, Surat Corresponding Email ID: [email protected]

Introduction: Cytomegalovirus (CMV) pneumonia is an infection of the lungs that can occur in people who have a suppressed immune system.CMV pneumonia is caused by a member of a group of herpes-type viruses. Infection with CMV is very common. Most people are exposed to CMV in their lifetime, but typically only those with weakened immune systems become ill from CMV infection.Serious CMV infections can occur in people with weakened immune systems as a result of:HIV/AIDS,Bone marrow transplant,Chemotherapy or other treatments that suppress the immune system,Organ transplant Case Study: 50 year old female patient presented on 6/12/18 with history of breathlessness for 15 days ,chest pain for 3 days and fever for one day .Patient was already having breathing difficulty for past three months which was increased for past 15 days. She was admitted in another hospital for few days and was referred to civil hospital for further management. On examination patient was concious and oriented, temperature and pulse was normal, respiratory rate was increased and bp was normal. Respiratory system examination showed bilateral equal air entry with bilateral crepitations Patient was diagnosed to have HIV in routine investigations and her cd4 count was 11. Other routine blood investigations showed low haemoglobin and high wbc count with leukocytosis. Peripheral smear examination showed microcytic hypochromic anemia and serum iron was low and total iron binding capacity levels were high which supported iron defeciency anemia. X Ray was done which showed bilateral lower zone opacity and CT thorax showed ground glass appearance with air trapping mainly in lower lobes which was suspicious of pneumonia especially Cmv as patient was severely immunocompromised. Blood culture was done which isolated Ecoli and sputum culture and sensitivity showed klebsiella bacteria . Cmv viral load and igm levels were done which came to be positive,hence the diagnosis of Cmv and klebsiella pneumonia was made. 2d echo of patient was done which came to be normal hence cardiac cause of breathlessness was ruled out. Discussion: Cytomegalovirus (CMV) pneumonia is a major cause of morbidity and mortality in allogeneic bone marrow transplant and lung transplant recipients. However, its role as a cause of lung disease in patients with the human immunodeficiency virus (HIV) is controversial. Although CMV can be isolated from lung specimens in patients with HIV-associated respiratory illness, it is rarely the causative pathogen. Most adults with HIV infection have latent CMV infection of many tissues including the lung, and most cases of CMV pneumonia are believed to be caused by reactivation secondary to severe immunocompromise. The clinical presentation of pneumonia caused by CMV pneumonia is similar to that of Pneumocystis carinii, with fever, cough, hypoxemia, and diffuse radiographic opacities. Conclusion: CMV pneumonia is a rare disease which is seen in severely immunocompromised patients. Although approximately 60% of cases respond initially to anti-CMV therapy, the disease is associated with progression and high early mortality, probably related to severe underlying immunosuppression.

185 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-230 A Rare Case of Bilateral Medical Medullary Syndrome. Shah Arth, Basu Abhijit Department of General Medicine, Geetanjali Medical College and Hospital, Udaipur, India. Corresponding Email id: [email protected]

Bilateral medial medullary syndrome is a very rare type of stroke with catastrophic consequences. Early diagnosis is crucial. Here I present a case of 50 year old male with complaints of Gabharahat and burning all over the body. Then he suddenly developed quadriplegia, difficulty in swallowing, weakness in tongue muscle and difficulty in breathing. He had prior history of HTN and DM type 2. MRI brain with MRA brain and neck vessels was advised. MRI brain showed characteristic ‘’heart shaped’’ infarct on diffusion weighted (DWI) image and bilateral medial medullary stroke was confirmed. MRA of brain and neck vessels was normal. Lumbar puncture was performed which showed normal cells, protein, and glucose. Blood and CSF culture was normal. NCV of all four limbs was performed and was normal. Bilateral medial medullary stroke is missed sometime because of symmetric and midline pattern of abnormal signal and similarity to artefact.

186 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-231 Organ phosphorus Induced Haemolysis in a Case of Haemoglobin D Iran Trait. Patil Chandrakant, Panjwani Sunil, Kamdar Panna Department of General Medicine, Government Medical College, Bhavnagar, Gujarat, Corresponding Email Id: [email protected]

Background: Organ phosphorus poisoning is one of the most common suicidal poisoning and accounts around 300000 deaths annually worldwide. Mode of poisoning by occupational, accidental or suicidal. Dizziness, restlessness, vomiting, diarrhoea, sweating, bradycardia, respiratory paralysis, convulsion, loss of consciousness and coma are usual manifestations of poisoning. • Haemoglobin D iran is rare variant of Haemoglobin and is found in Punjab, Rajasthan and Gujarat region of India and Pakistan. It is derived from a point mutation in the beta globin chain, where glutamic acid is replaced by glutamine at 22 positions. Haemoglobin D iran is usually present in heterozygous form, associated with normal Haemoglobin and clinically insignificant. • Case presentation: We report a case of 23 year old female admitted with history of accidental organ phosphorus poisoning. She was presented with vomiting, loss of consciousness and bradycardia. Patient was intubated and managed accordingly, later she was extubated and improved well and discharged. After 8 days she came with complaints of yellowish discolouration sclera and urine and decreased appetite. Her lab investigations suggestive of anaemia with haemolytic picture, elevated total and indirect bilirubin and lactate dehydrogenase. Normal prothrombin and activated partial thromboplastin time. Bleeding and clotting time were normal. Ultrasonography of abdomen was normal. Haemoglobin electrophoresis was positive for heterozygous Haemoglobin D iran. Patient was managed symptomatically with blood transfusion. She was cured well. • Conclusion: Organ phosphorus poisoning is very rarely cause haemolysis. Organ phosphorus acts on acetyl cholinesterase enzyme on myoneuronal junction and RBC’s membrane. It concludes that Haemoglobin D iran variants were susceptible for haemolysis as delayed complication in Organ phosphorus poisoning, so physicians to be aware of this unusual presentation.

187 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-232 Intestinal Obstruction: Lipoma of Large Intestine Tinwala Montu Corresponding Email Id: [email protected]

Intussuception as a cause of intestinal obstruction in adults in a rare occurrence. There invariably has to have an underlying pathology which needs to be ruled out. A case of intussuception in adult due to large intestinal lipoma is presented here in context to that assoction. Imaging studies (usg cect abdomen) may be of diagnostic help; but ultimately it's always what you see by your bare eyes as u explore. As such for diagnosis histopathological examination (mainstay diagnosis of any lump/swelling) stays so as to avoid misdiagnosis of underlying cancer (most often diagnosed at this age)

188 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-233 Organophosphate induced delayed polyneuropathy (OPIDP) Trivedi Vyoma, Vora Alpesh Department of General Medicine, Government Medical College, Bhavnagar, Gujarat, Corresponding Email Id: [email protected]

Background: organophosphates are used as insecticides, medication and nerve agents.one of the most common causes of poisoning worldwide causing more than 2lakh death per year. . Dizziness, restlessness, vomiting, diarrhoea, sweating, bradycardia, respiratory paralysis, convulsion, loss of consciousness and coma are usual manifestations of poisoning. Organophosphate induced delayed polyneuropathy is a rare delayed neurotoxic effect which occurs 1-5 weeks after severe toxicity from some cholinesterase inhibitors. The cause of this condition is unknown while some have associated this condition with inhibition of an enzyme called neurotarget esterase Case presentation: we report a case of 28 year old male with h/o suicidal op poisoning presented with stool urine incontinence and breathlessness patient was intubated and managed accordingly later extubated improved and discharged with no residual deficit. After one and half months presented with b/l lower limb tingling and numbness with difficulty in standing and walking without support with loss of ankle and plantar reflex. NCV test suggestive of distal motor sensory axonal degeneration

Conclusion: Any patient presenting with peripheral neuropathy with a history of OP ingestion OPIDP has to be included in the differential diagnosis.

189 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-234 A Rare Case of Haemorrhagic CNS Manifestation in Sickle Cell Disease Patient Kaklotar Sandip , Vasava Ashvin, Sharma Arvind, Borse Paras Department of General Medicine Government Medical College, New Civil Hospital, Surat Corresponding Email: [email protected]

Sickle cell disease is inherited as autosomal recessive disease caused by mutation in beta-globin chain at 6th position where glutamic acid is replaced by valine. Sickle cell disease is common in tribal community of South Gujarat. Sickle cell disease patient usually present with complications like haemolytic crisis, painful crisis, acute chest syndrome, sequestration crisis and aplastic crisis but spontaneous haemorrhagic manifestation like intraparenchymal and intraventricular hemorrhage is rare in sickle cell disease. We report a case of 26 year old male who was a known case of sickle cell disease and presented with sudden loss of consciousness with GCS 3/15. Patient was resuscitated and intubated and was urgently shifted for CT brain which was suggestive of intraparenchymal and intraventricular hemorrhage with subarachnoid hemorrhage. Patient was treated conservatively but patient expired in some hours. Although it is rare but as a physician we should be aware of this rare complication as a part of spectum of neurological complication in sickle cell disease patients. This life threatening complication can be preventable in sickle cell disease patients by keeping HBS<30% by chronic blood transfusion/apharesis or hydroxyurea.

190 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-235 Hemiparesis As Presenting Manifestation In A Case Of Sub acute Sclerosing Panencephalitis Bhagat Piyush, Kamdar Panna Department of General Medicine, Government Medical College, Bhavnagar, Gujarat, India Corresponding Email Id: [email protected]

Background : SSPE is a rare chronic progressive demyelinating disease of the CNS associated with a chronic nonpermissive infection of brain tissue with measles virus. The frequency has been estimated at 1 in 100000 to 500000 measles cases. The incidence has declined since introduction of measles vaccine. Most patients give a history primary measles infection at an early age followed by latent interval of 6-8 year develops progressive neurologic disorder SSPE. Common clinical features of SSPE are focal and or generalised seizures, progressive intellectual disturbances, visual disturbances, ataxia and later death.

Case presentation: We report a case of 18 year old female presented with left sided hemiparesis and extensor planter response since 1 day. Past history of fever with convulsion at the age 10.MRI brain shows ill-defined areas of subtle T2W and flair hyper intensity are noted at bilateral frontal temporal parietal periventricular regions could be periventricular leukoencephalopathy/encephalitis/demyelination. CSF examination shows elevated proteins with positive for measles IgG (>300AU/ML) antibodies and serology test positive for measles antibody. All these are consistent with SSPE.

Conclusion: The presenting symptoms in patients with SSPE are multiple and variable, most patients present with subtle personality and mental changes, decreased visual acuity, focal and or generalised seizures. Hemiparesis which was initial presenting symptom in our patient is rarely seen in SSPE. So it concludes that one of the rare cause of hemiparesis in young patients is SSPE and management accordingly.

191 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-236 Tenofovir Induced Fanconi Syndrome: A Rare Cause of Hypokalemic Paralysis Manju Yadav, P. Dudhrejia Department of General Medicine, PDU Medical College, Rajkot. Corresponding Email ID:[email protected]

Introduction: Tenofovir disoproxil fumarate (TDF), an oral prodrug of tenofovir, was the first NRTI to be approved for the treatment of (HIV) infection. Acute renal failure, Fanconi's syndrome (FS), dysregulation of divalent ion metabolism and diabetes insipidus have been reported with its use. Here, we describe an uncommon complication of TDF induced FS presenting as hypokalemic paralysis.

Case history: A 45-year-old male presented with acute onset weakness of all four limbs of one day duration. There was no past history of diarrhoea or URTI in the recent past or any past history of neurological or renal disorders. He was diagnosed HIV infection 9 years back and was started in 2015 with tenofovir, lamivudine and atazanavir. Physical examination revealed muscle power of 2/5 in all four limbs. Deep tendon reflexes were sluggish and pin prick sensation was normal. There was no respiratory distress and no bowel bladder involvement . His potassium was 1.8 meq/l. FS leading to hypokalemic paralysis was suspected given the presence of a hyperchloremic metabolic acidosis,hypokalemia, hypophosphatemia, glucosuria and proteinuria. He required replacement with intravenous potassium chloride for 2 days to keep potassium above 3 meq/l. Patients muscle power dramatically improved within 36 h of hospital admission with potassium correction.Tenofovir was stopped as we suspected it to be the cause for FS.

Discussion: Tenofovir is a nucleotide reverse transcriptase inhibitor approved for the treatment of HIV in combination with other antiretrovirals. FS results from generalized dysfunction of the proximal renal tubule leading to impaired reabsorption of aminoacids, glucose, urate, bicarbonate and phosphate and increased excretion of these solutes into the urine. The classic clinical features of FS include polyuria, dehydration, hypokalemia, hypophosphatemia, metabolic acidosis and rickets in children or osteomalacia in adults. FS may be heritable or acquired.

192 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-237 A Case of a Protein C and S Deficiency Presented With Cerebral Infarct Patel Manoj, Hadiyel Ila Department of Medicine, Govt. Medical College, Bhavnagar, Gujarat Corresponding Email: [email protected]

? Globally, stroke is a second commonest cause of mortality. Especially, Stroke in young is a major health problem worldwide. Disorders of coagulation leading to thrombotic event are approximately 1% of all ischemic strokes and 4-8 % of young stroke. As Protein C and S deficiency can lead to hypercoagulable state and rarely present as cerebrovascular accidents. ? We are reporting a case of 14 year old male presented with left middle cerebral artery territory infact due to combined protein C and S deficiency. He presented with complaints of acute onset of slurring of speech and left sided hemiparesis, after detailed investigations and as there were no precipitating factors for stroke, the cause for ischemic event was found to be combined protein C and S deficiency. ? As a physician, while dealing with a case of cerebral infaction in young patient, screening for protein C and S deficiency should be kept in mind so that early initiation of anticoagulant therapy can decrease recurrence of such events in future.

193 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-238 Poster on Skeletal Fluorosis Shah Aalap, Lakhani Jitendra Department of General Medicine, Smt. B. K. Shah Medical Institute & Research Center, Vadodara, India. Corresponding Email Id: [email protected]

Introduction: Consumption of water containing excess fluoride will lead to Skeletal Fluorosis which leads to crippling effects. This might be in the form of bone pain, effect on teeth and neurological complications which may lead to radiculopathy and compressive myelopathy.

A Case Report: A 45 year old lady presented with severe bone pains and stooped and stiff posture to orthopedic OPD. Patient was admitted in orthopedic ward for presumptive diagnosis of ankylosing spondylitis. As patient developed bladder incontinence, patient was referred to us for neurological evaluation. On neurological examination, patient was depressed, had a lot of anxiety and was having agony as she had restricted movement of joints with positive Straight Leg Raise test. Her cranial nerve examination was normal. She had 4+ motor power in all four extremities with brisk reflexes and bilateral extensor plantars. Patient was from Dhar district of Madhya Pradesh. Our earlier experiences and reported cases from Dhar district of skeletal fluorosis with neurological manifestation, we presumed of the same in this patient. She was investigated further. Her X-ray of cervical as well as dorsolumbar vertebrae showed increased bone density with osteophyte formation and narrowing of spinal canal. X-ray of forearm was ordered which showed calcification of interosseus membrane. Patient was initially treated with steroids which may have led to decrease in spinal cord edema and relieved her bladder incontinence. Patient also was given Pregabalin and other Non-steroidal anti- inflammatory dugs which decreased her morbidity.

Discussion: Etiology of fluorosis in India is from water derived from Bore-wells. Over half of ground water sources in India have fluoride above recommended levels (1mg/L). In 57 water samples tested in 10 villages within Dhar district, fluoride concentration was found to be in range of 0.11-13.4mg/L. Our patient hails from Dhar district and was consuming bore-well water.

Conclusion: Fluorosis is common at places where there is water scarcity and patients drink water from bore-wells. They can present with bone pains, dental fluorosis and skeletal abnormalities.

194 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-239 Posterior Reversible Encephalopathy Syndrome in a Patient of Eclampsia with Concomitant HELLP Syndrome Dudhatra Ashutosh, Paliwal Sanjay Department Of General Medicine, Geetanjali Medical College and Hospital, ,Udaipur,India Corresponding Email Id: [email protected]

Posterior reversible encephalopathy syndrome(PRES) occurs due to cerebral hyperperfusion likely due to endothelial dysfunction in a variety of conditions which include hypertensive encephalopathy,eclampsia, postcarotid endarterectomy syndrome, and toxicity from calcineurin-inhibitor and other medications.HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome is a dangerous complication of pregnancy associated with microvascular injury.A 26 year old female with 31 weeks of pregnancy with no significant past history presented with altered sensorium and history of 2 episodes of tonic clonic seizures on the same day for which she had received treatment in other hospital .Patient had to be intubated,blood pressure was controlled and emergency vaginal delivery was performed.Patient was diagnosed with HELLP syndrome and subsequently with PRES after a brain MRI.HELLP syndrome was further complicated by renal failure for which multiple sessions of hemodialysis were done.Subsequently her GCS(Glasgow Coma Scale) score improved and was extubated.She had a complete neurological recovery.Eclampsia complicated by PRES is relatively common,however concomitant occurrence of HELLP syndrome and coma is relatively rare.Our case of HELLP syndrome accompanied by PRES recovered completely after prompt management and emergent delivery.PRES is almost always reversible.Thus physicians should remain alert for patients with HELLP accompanied by neurological signs and symptoms.

195 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-240 A Case Report of Thyroid Storm in Known Case of Graves’ Disease, Diabetes Mellitus and Hypertension Tiwari Annu, Budharani Deepmala Dept. of Medicine, Civil Hospital, Rajkot, Gujarat, India Corresponding Email ID: [email protected]

We report a case of thyroid storm in a known case of graves’ disease, diabetes mellitus and hypertension. A 70-year-old female, admitted in our emergency ward, presented with complaints of fever, palpitation, abdominal pain, vomiting and shortness of breath for one day. Patient was a known case of diabetes mellitus, hypertension and graves’ disease since 10 years and was on metformin and enalapril for diabetes mellitus and hypertension respectively. Patient was on carbimazole for graves’ disease but was taking carbimazole irregularly since last 3 years. On examination patient was conscious, oriented but agitated and irritable. Temperature was 101 degrees Fahrenheit, pulse rate was 182 per minute, blood pressure was 160/90 mm Hg and bilateral exophthalmos was noted. Blood investigations revealed hyperglycemia, leucocytosis, and low serum TSH (<0.008 microIU/ml), high serum free T4 (3.08 ng/dl), high serum free T3 (12.06 pg/dl) levels. TSH Receptor Antibody, anti-Tg antibody, and anti-TPO antibody were strongly positive. All other investigations (including serum urea, serum creatinine, serum sodium and potassium levels) were within normal limits. ECG revealed sinus tachycardia. She was diagnosed with thyroid storm with a score of 85 points as per Burch-Wartofsky Point Scale (BWPS). She was managed with oral Prophylthiouracil with a loading dose of 600mg, then 200 mg every six hours, along with beta blockers, Dexamethasone (8 mg) iv was administered every 12 hours. Since lugol solution was not available in our facility, patient was managed with PTU, dexamethasone and beta blockers only. Hyperglycemia was controlled with insulin therapy. Enalapril was continued for hypertension. Patient improved clinically and symptomatically within 12 hours and heart rate decreased from 182 to 124 per minute within 24 hours and gradually decreased further with continued treatment and stabilised to 86 per minute within 5 days. Patient was then switched to carbimazole after stabilisation and discharged in vitally stable condition.

196 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-241 Guillain-Barre Syndrome Associated with Plasmodium falciparum Malaria Haideri S, Basu Department of General Medicine, Geetanjali Medical College and Hospital Corresponding Email Id: [email protected]

Malaria is one of the most important parasitic disease transmitted by the bite of infected female anopheles mosquito, causing 1200 deaths each day in tropical communities. Several neurological complications such as cerebral malaria, cranial nerve lesions, extrapyramidal symptoms, frontal lobe syndrome, periodic type of muscular paralysis, subarachnoid haemorrhage and bulbar paralysis have been reported. A 50 years old male patient was admitted with history of fever with chills, multiple episodes of loose stools and vomiting for 10 days and gradual onset and progressive bilateral lower limb weakness for 5 days causing difficulty in doing daily activities. Previously, patient suffered from falciparum malaria 1 month back and was treated with intravenous artesunate after which he completely recovered. On examination, there was bilateral LMN type facial weakness, decreased power in bilateral lower limbs and sensory ataxia and decreased touch and pain sensation in both lower limbs. His peripheral blood film showed plasmodium falciparum ring forms. MRI brain was insignificant. Cerebrospinal fluid was acellular with high protein suggestive of albumin-cytological dissociation. Electroneuromyography (ENMG) showed bilateral sensory motor demyelination peripheral polyneuropathy. He gradually improved with IV Quinine, Doxycycline and physiotherapy. This case shows the manifestation of Guillain-Barre syndrome following a parasitic infection leading to temporary demyelination and recovery after disappearance of parasitemia. Hence, early and specific treatment can reduce morbidity and mortality in such cases.

197 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-242 Varicella Zoster Encephalitis Complicated with Thrombocytopenia, ARDS, and Pericardial Effusion with Impending Cardiac Tamponade Shah Bhavik, Teli Brij Department of General Medicine, PDU Medical College, Rajkot Corresponding Email ID: [email protected]

Primary infection with Varicella Zoster Virus (VZV) results in varicella or chickenpox, which is characterized by vesicular lesions on an erythematous base in different stages of development. It may be associated with pneumonia, intestinal obstruction, or myopericarditis, and its capacity for multiple neurologic sequalae is of major clinical importance. The authors here present a similar case of VZV encephalitis complicated with thrombocytopenia, ARDS, and pericardial effusion with impending cardiac tamponade. A 15 years old female patient presented with complaint of fever for 3 days which was associated with multiple fluid filled lesions on face and both lower limbs for 4-5 days. Her past history was significant for Atrial Septal Defect (ASD) closure 8 years back. The patient’s saturation (sPO2) was 88% on room air and over the span of few hours following admission, she developed altered sensorium. Her initial blood count was suggestive thrombocytopenia with leukocytosis associated with shift to left. After ruling out papilledema, CSF (Cerebrospinal Fluid) examination was carried out post-lumbar puncture, which was suggestive of reactive pleocytosis. She had tested negative for Dengue IgM and HIV antibodies. Her MRI (brain) with contrast came out to be normal and she was started on intravenous acyclovir. However, due to decreased sPO2 and tachypnea along with fluffy opacities on Chest X-Ray which were suggestive of Acute Respiratory Distress Syndrome (ARDS), she was put on BiPAP ventilation for 3 days once her sensorium started improving, along with supportive antibiotics to prevent Ventilator Associated Pneumonia (VAP). She was also transfused 3 units of Platelet Concentrates (PC) and two units of Red Cell Concentrates (RCC). She was given intravenous Acyclovir for 14 days along with supportive antibiotics like Piperacillin-Tazobactam and Amikacin. Once her sPO2 started improving and CXR became evident for cleared lung fields, her cardiomegaly was more pronounced on repeated CXRs. 2D Echocardiography was suggestive of moderate pericardial effusion with impending tamponade. Cardiologist opined to tap the pericardial effusion in Cath Lab under expert observation to prevent tamponade. So, the patient was referred to U.N. Mehta ICRC for further management.

198 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-243 Atypical Manifestation of Plasmodium vivax Malaria: Intracerebral Bleed, Right Hemiparesis and Seizures. Desai Yash, Basu Dept. of General Medicine, Geetanjali medical college and hospital, Udaipur, India Corresponding Email ID: [email protected]

Malaria is one of the most common parasitic infections in our country. It presents with high grade, intermittent fever associated with chills and rigors. It may complicate into severe form of malaria such as cerebral malaria, pulmonary edema and severe metabolic acidosis. Atypical manifestations may involve multiple systems like cardiac, hepatic, renal and central nervous system. Cerebral form of malaria is the most common and potentially life threatening neurological complication. An 18 year old male with P. vivax malaria presented with complaints of fever, decreased appetite, and abdominal discomfort for 1 month. On 7 th day of admission, patient suddenly had an episode of vomiting after which the patient became unconscious, not responding to deep pain stimulus, with uprolling of eyes and signs of aspiration were present. NCCT brain was done which showed large intraparenchymal haemorrhage in left fronto-parietal lobe extending into the ventricles with intra-ventricular extension. Patient was immediately managed with ventilatory support and vasopressor support for hypotension and was then taken for decompression surgery. Patient succumbed to the disease two days later. This case emphasizes on the severity of P. vivax induced cerebral malaria associated with intracerebral bleed. Rapid diagnosis and readiness to combat any complication such as severe anemia, severe thrombocytopenia, acute renal failure, acute respiratory distress or intracerebral bleeding.

199 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-244 Gitelman’s Syndrome Kotiya Janki, Solanki Bhagirath Dept. of General Medicine, B.J. Medical College, Civil Hospital , Ahmedabad , India Corresponding Email ID: [email protected]

Gitelman syndrome (GS) also referred to as familial hypokalemia-hypomagnesemia, is an autosomal recessive salt-losing renal tubulopathy that is characterized by hypomagnesemia, hypocalciuria and secondary aldosteronism, which is responsible for hypokalemia and metabolic alkalosis caused by mutation of SLC12A3 gene.The prevalence is estimated at ~25 per million. Transient periods of muscle weakness and tetany, sometimes accompanied by abdominal pain, vomiting and fever are often seen in GS patients. The diagnosis of GS is based on clinical symptoms and biochemical abnormalities. Herein I present a case of 26 year old male presented with recurrent bilateral lower limb weakness treated successfully with potassium, spironolactone and magnesium supplements.

200 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-245 Dieulafoy's Lesion of Terminal Ileum Shukla Mayank, Syed Javed Dept. of General Medicine, Geetanjali Medical College and Hospital, Udaipur,India Corresponding Email ID: [email protected]

Dieulafoy's lesion also called persistent caliber artery, is a large caliber arteriole that runs immediately beneath the gastrointestinal mucosa and bleeds through a pinpoint mucosal erosion. Dieulafoy's lesion is an uncommon but important cause of recurrent upper gastrointestinal bleeding. Extragastric location of Dieulafoy's lesion is very rare. We report a case of Dieulafoy's lesion of the Terminal ileum in a 47-year old man with history of recurrent lower gastrointestinal bleeding who came to the emergency department because of intermittent bleeding per rectum for three days. Colonoscopy showed the whole colon and terminal ileum was bloody stained up to 20-30 cm in the terminal ileum where there was a superficial , aberrant , pulsating actively oozing vessel was noted with no underlying ulceration compatible with Dieulafoy's lesion , two clips were applied after which hemostasis was secured. small bowel bleeding continues to be difficult to visualize directly on routine endoscopy.Therefore, diagnosis of bleeding in the small bowel is often delayed.To localize a source of small bowel bleeding, multidisciplinary approaches such as abdominal CT, angiography, radionuclide scan, and capsule endoscopy is needed.With the development of endoscopy, push enteroscopy is performed to diagnose and treat a bleeding source. endoscopic treatment will replace surgery in a significant portion of small bowel Dieulafoy lesion cases. The application of clips is one of the important endoscopic modalities for control of bleeding.

201 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-246 Systemic Lupus Erythematous with Psychoses Chaudhary Minesh, Gupta Nidhi, Parikh Jitendra Dept. of Medicine, B J Medical College, Ahmedabad, Gujarat Corresponding Email ID: [email protected]

Systemic lupus erythematosus (SLE) is a chronic disease that is characterized by an autoantibody response to nuclear and cytoplasmic antigens. SLE has protean manifestation and follows a relapsing and remitting course. More than 90% of cases of SLE occur in women, frequently starting at child bearing age. SLE is a chronic inflammatory disease that can affect almost any organ system, although it mainly involves the skin ,joints ,kidneys ,blood cells and nervous system. the classic presentation of a triad of fever ,joint pain and rash in a woman of child bearing age should prompt investigation into diagnosis of SLE. Patients may present with any of the following presentations - constitutional ,mucoskeletal, dermatologic, renal, neuropsychiatric, pulmonary, gastrointestinal, cardiac, hematologic. neuropsychiatric manifestations in SLE are common, however presentation with psychosis is a rare manifestation .incidence of psychosis is 12%.there may be cognitive deficit ,lupus headache , psychoses ,seizure ,peripheral neuropathy and cerebrovascular events.. it can be due to drugs, steroids used for SLE or secondary to SLE because of its brain involvement which is termed as neuro psychiatric systemic lupus erythematosus(NPSLE)no single clinical, laboratory ,neuropsychological and imaging tests can be used to differentiate NPSLE from non- NPSLE patient with similar neuropsychiatric manifestation. we present a case of 18 year old female patient with SLE who presented with psychosis due to SLE with other changes of SLE and managed successfully with steroid, cyclosporin and plasmapheresis. we recommend high index of suspicious of SLE in young female patient with neuropsychiatric manifestation with other stigmata of SLE and aggressive management with steroids ,immunosuppressive like cyclosporin and plasmapheresis.

202 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-247 A Case of Chronic Progressive External Ophthalmoplegia Patel Rootik Department of General Medicine, Geetanjali Medical College and Hospital Corresponding Email ID : [email protected]

Chronic Progressive External Ophthalmoplegia (CPEO) is a type of eye disorder characterized by slowly progressive inability to move the eyes and eyebrows. We report a case of 70 year old male presented with complaint of B/L ptosis and dysphagia along with hoarseness of voice. His ACH receptor antibody value are positive hence, Neostigmine and oral Steroid therapy are given. However in view of no therapeutic response to these drugs and later supplementation of significant positive family history of similar complaints in mother and all brothers of the patient indicating maternal pattern of inheritance was suggestive of Mitochondrial Disorder most likely CPEO. Diagnosis was confirmed by muscle biopsy which showed ragged red fibres suggestive of mitochondrial myopathy.

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P-248 Spinal Muscular Atrophy, Hypothyroidism and Polycythemia: A rare presentation of Sickle Cell Trait and Thalassemia Minor.\ Shah Meera, Muley Arti, Kantharia Rajan, Bhuta Palak, Patel Vipul, Patel Gaurang Department of General Medicine, Hospital Piparia, Waghodiya, Vadodara, India Corresponding Email ID: [email protected]

Sickle cell hemoglobinopathy is seen in scattered populations all over the world, more so in tribal areas. Endocrine and metabolic dysfunctions have been reported in patients with sickle cell anemia (SCA), but may be more common in β-thalassemia major (β-TM)1 and are believed to be due to release of inflammatory mediators. These dysfunctions may present as hypoadrenal, hypothyroid, hypogonadal dysfunctions and polycythemia which are mostly seen in second and third decades of life.Reports of development of weakness due to neuropathy have also been there. However, development of endocrinal dysfunctions and polycythemia are rarely seen in Sickle cell trait (SCT) or thalassemia minor. We present a case of 27 year old male patient of sickle cell trait with thalassemia minor who developed hypothyroidism, polycythemia and spinal muscular atrophy. The sequence of events in this case may suggest development of hypothyroidism and polycythemia secondary to sickle cell trait and thalassemia minor, which have been reported previously in cases with SCA and thalassemia major. This case presented with Spinal Muscular Atrophy type of myopathy which has not been reported previously with either SCA, thalassemia or hypothyroidism. Even with polycythemia, there have been few reports of neuropathy but to our knowledge there has been no report of polycythemia with SMA. Complications like hypothyroidism and polycythemia developed in case of SCT and thalassemia minor may suggest that presence of both might be contributory to a more severe presentation and for development of complications.

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P-249 A Rare Case of Rasmussen Aneurysm Abhaykumar, Parikh Damodar Department of General Medicine, Geetanjali medical college and Hospital, Udaipur,India Corresponding Email ID :[email protected]

Rasmussen's aneurysm is a pulmonary artery aneurysm associated with a cavitatory lung lesion.It was originally described by Fritz Valdemar Rasmussen in association with cavitary lung lesions of tuberculosis.As with any aneurysm, a Rasmussen's aneurysm is at increased risk of rupture and bleeding into the lungs.Haemoptysis is the usual presenting symptom and may be life-threatening when it is massive. Its Locationis Usually distributed peripherally and beyond the branches of the main pulmonary arteries.we report a case of Rasmussen aneurysm in a 47 year old male patient came to General medicine department of our hospital.He presented with Chest pain , Shortness of breath & Haemoptysis. Patient had a past history of tuberculosis. Chest X ray shows an cavitatory lesion in right lower lobe with consolidation in bilateral lower zones.CECT thorax shows a cavity in posterior basal segment of right lower lobe along with well defined enhancing area seen in the cavity communicating with lower segmental branch of right pulmonary artery. Digital angiography demonstrating a large aneurysm. Coil packing was done. Life threatening massive hemoptysis can arise from a pseudoaneurysm of pulmonary artery or its branches contiguous to a tuberculous cavity. Such pathology, also known as Rasmussen's aneurysm can be differentiated from a bronchial or systemic source of bleeding by an urgent MDCTA, which localizes the lesion and guides therapy. Emergency endovascular management techniques like arterial trans-catheter embolization are the preferred therapeutic modality for massive hemoptysis arising from a Rasmussen's aneurysm.

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P-250 Poster on Multinodular Goiter with CKD Moradiya Kalpesh, Lakhani Jitendra Department of General Medicine, Smt. B. K. Shah Medical Institute & Research Center, Vadodara, India. Corresponding Email ID: [email protected]

Introduction: The incidence of goiter, diffuse and nodular, is very much dependent on the status of iodine intake of the population. In general, in iodine sufficient countries the prevalence of multinodular goiter is not higher than 4%. Thyroid hormones play a very important role regulating metabolism, development, protein synthesis, and influencing other hormone functions. Thyroid hormones (T3 & T4) can have significant impact on kidney disease.

A Case Report: A 52 year old female nonHypertensive and nondiabetic presented with swelling in neck since 4 years and bilateral lower limb edema associated with dyspnea on exertion since last 1 month. Initially swelling was small then it gradually progressed to present size. She is a known case of Hypothyroidism since 4 year. She was admitted in medicine ward for further management. Her physical examination was normal except for neck swelling and pedal edema. Routine hematological profile shows Anemia and biochemical parameters suggests raised serum Creatinine level. USG Thyroid gland showed grossly enlarged thyroid with multiple nodules noted in entire thyroid, suggestive of multinodular goiter. USG abdomen shows Loss of CMD suggestive of Chronic Kidney Disease. Thyroid function tests showed the patient to be subclinical Hyperthyroidism. Her Anti-TPO antibody was Negative. No bruit heard on auscultation. Her FNAC (Fine Needle Aspiration Cytology) was suggestive of Benign Thyroid Lesion with Hurthle cell changes.

Discussion: Patient has a Multinodular Goiter with CKD. This may be due to the decreased clearance of the inorganic Iodides, causing a hypertrophic effect on the thyroid gland tissue leading to goiter. A decreased clearance of Goitrogenic substances like aryl acid due to CKD may also be a factor. Research has shown that increased serum Iodine levels can result in prolongation of the Wolff-Chaikoff effect.

Conclusion: Thyroid disorders and CKD are independently prominent medical conditions.so it is important to consider the physiological association of thyroid Dysfunction in relation to Kidney Disease.

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P-251 Rare Presentation of Takayasu Arteritis as SAH Patel Mantavya, Paliwal Department Of General Medicine, Geetanjali Medical College and Hospital Corresponding Email ID: [email protected]

Takayasu arteritis is a rare, systemic, inflammatory and stenotic disease of medium and large sized arteries characterized by strong predilection for the aortic arch and its branches. It most commonly affects women of childbearing age. It has an estimated annual incidence rate of 1.2 - 2.6 cases per million. SAH is a rare complication of Takayasu arteritis, with a total of 26 cases reported worldwide till date. A 15 year old female patient presented with sudden onset of severe episodic headache for 1 day which was pulsatile, maximum in parieto-occipital region, not associated with vomiting and usually lasting for 2-3 minutes, associated with sweating, with bouts of crying during the episode. Blood investigations showed raised ESR and CRP. MRI brain showed left high frontal sulcal hyperintensities suggestive of sub-arachnoid hemorrhage with mild meningeal enhancement with normal MRV study. CSF showed high RBC count and lymphocytic predominance with normal protein and sugar. She was treated as SAH with Mannitol but did not show any improvement so DSA was done which revealed stenosis of right proximal CCA and right ECA ostium occlusion. She fit in 5 out of 6 ACR criteria for Takayasu arteritis and was started on steroids after which she showed marked improvement within few days. Repeat CT Brain showed significant resolution of SAH. The diagnosis of Takayasu arteritis should be strongly suspected in a young woman who developes asymmetric pulses, unexplained fever and headache with raised inflammatory markers.

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P-252 A Case of Sheehan Syndrome Presented with Bilateral Lower Limb Contractures Chauhan Vishal, Vora Chitralekha, Gupta Nidhi Department Of Medicine,BJ Medical College, Civil Hospital Ahmedabad. Corresponding Email ID : [email protected]

Sheehan's syndrome (SS) is postpartum hypopituitarism caused by 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 SS have varying degrees of anterior pituitary hormone deficiency. Its frequency is decreasing worldwide and it is a rare cause of hypopituitarism in developed countries owing to advances in obstetric care. However, it is still frequent in underdeveloped and developing countries. SS often evolves slowly and hence is diagnosed late. History of postpartum hemorrhage, failure to lactate and cessation of menses are important clues to the diagnosis. Early diagnosis and appropriate treatment are important to reduce morbidity and mortality of the patients . I am presenting a case of a patient with SS who was presented with bilateral lower limb contractures since 1 year which got relieved by intravenous Hydrocortisone.

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P-253 Aortic Dissection Presenting with Hemiparesis- A Case Report Sanandia Sweta, Dabhi Leena Department of General Medicine, AMC MET Medical College & LG Hospital, Ahmedabad Corresponding Email ID: [email protected]

Aortic dissection is Potentially life-threatening condition in which disruption or aortic intima allows dissection of blood into vessel wall; Classification of aortic dissections are A)Stanford classification: Type A dissections that involve the ascending aorta independent of site of tear and distal extension; type B dissections involve transverse and/or descending aorta without involvement of the ascending aorta. B)DeBakey classification: Type I dissection involves ascending to descending aorta; type II dissection is limited to ascending or transverse aorta, without descending aorta; type III dissection involves descending aorta only. Incidence in India is approximately 1 million per year.About 20% of people who have an aortic dissection die before they reach the hospital.Risk of death in untreated type A aortic dissection is 25% in first 24 hours,50% in first 72 hours, 80% in two weeks, 90% in first month.

A 55 years old female presented with left sided hemiparesis (left sided upper & lower Limb weakness), giddiness, vomiting & chest pain since one day in emergency room. On CNS examination patient’s left sided power was 2/5 on both upper & lower limbs & the tone was decreased on left sided body. On general examination patient’s BP on left sided arm was 250/150mmHg and on right sided arm BP was non- recordable. On MRI brain there were acute subacute infarcts involving Rt. Fronto-parieto-occipital temporal & Rt. cerebellar hemisphere with hemorrhagic areas. On MDCT angiography of Head, neck & aorta there was thin hypodense line(dissecting intimal flap)noted in lumen of ascending ,arch ,descending & abdominal aorta up to its bifurcation dividing aortic lumen into 2 cavities & that was suggestive of aortic dissection(DeBakey class type 1 & Standfort class type A). Patient was transferred to higher center for CTVS.

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P-254 A Random Glitch : A Rare Case Of Generalised Tonic Clonic Seizure Presented As Fahr’s Syndrome Shukla Harshil Department of Medicine, SMT. NHL Municipal Medical College, Ahmedabad, India Corresponding Email ID: [email protected]

Fahr’s Syndrome includes both Fahr’s disease(Idiopathic Basal Ganglia Calcification) and secondary causes of striopalladodentate calcinosis. Fahr’s Syndrome is a rare, autosomal dominant neurodegenerative disorder characterised by bilateral symmetrical non-atherosclerotic vascular intracranial calcification mainly in basal ganglia, thalami, subcortical white matter, cerebellar deep neuclie. Fahr’s syndrome although encountered rarely, should also be taken in to account in the differential diagnosis of a case with abnormal intracranial calcification along with other familial congenital metabolic syndromes.

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P-255 A Rare Case of Autoimmune Hepatitis-Primary Biliary Cholangitis Overlap – Defying the Age and Gender Norms Batra Swansu, Singel , Gupta Nidhi , Parikh Jitendra Department of Internal Medicine, B.J. Medical College, Civil Hospital, Ahmedabad, India Corresponding Email ID: [email protected]

Introduction : Primary Biliary Cholangitis is an autoimmune liver disease characterized by clinical features of cholestasis, destruction of intralobular bile ducts on histology and positive AMA . PBC more commonly affects middle aged women. The sex ratio of female : male is 9:1. Autoimmune Hepatitis also has a female preponderance and sex ratio of female: male is 3.6:1. AIH has bimodal distribution with first peak between 10 to 20 years and second one between 40 to 70 years . Autoimmune liver disease accounts for 1.7 % to 5.7% of all chronic liver disease in India. Prevalence of AIH PBC overlap varies from 2% in patients initially diagnosed as AIH to 19% in patients initially diagnosed as PBC.

Case Report : A 13 year old boy presented with history of gradually progressive fatigue and jaundice over one year, abdominal distension and pedal edema since six months. Patient had associated complains of night blindness and off-on episodes of fever. Family history revealed death of an elder sibling (female ) at the age of six years owing to jaundice .Routine investigations done were suggestive of Hb-4.5, TLC-5800, platelet-1.35L. RFT was within normal limits. LFTs were deranged. TOTAL BILIRUBIN -3.5. DIRECT BILIRUBIN -1.96. ALT-61 (< 1.5 times ULN) AST-80 ( > 2 times ULN), ALP 1430 ( >3 times ULN) INR-3.36 and ALBUMIN-3.45 .Patient had no history of consumption of any drugs and patient was non alcoholic. Viral markers of patient were negative. Mildly deranged ALT and AST alongwith grossly high values of ALP aroused suspicion of some immunological phenomenon overlaying the primary cholestatic process. Concordance of night blindness , hypocalcemia and altered INR – pointed to deficiency of fat soluble vitamins further strengthening the suspicion of cholestasis. ULTRASOUND of the abdomen was suggestive of liver parenchymal disease with portal hypertension and splenomegaly. Wilsons disease was ruled out by seum ceruloplasmin , 24 hr urinary copper estimation and KF ring examination- all of which turned out to be normal. Serum AFP was normal. Ascitic fluid R/M was transudative and suggestive of changes of spontaneous bacterial peritonitis. To rule out possibility of primary sclerosing cholangitis as a cause of cholestasis, MRCP was done, which was normal . Further serological work up undertaken showed ANA 3+ , IgG – 23.7(nearly 1.5 times ULN) AMA-2+ while ASMA and Anti LKM -1 were negative. To further confirm the serological parameters pointing towards the possibility of overlap syndrome, a liver biopsy was undertaken which was suggestive of Interface hepatitis, Portal tract infiltrates with lymphoid aggregates and plasma cells, portal to portal bridging fibrosis alongwith focal proliferation and injury to bile ductules . The patient thus fulfills the Paris criteria and the Revised Original Scoring System of International AIH group- establishing the definite AIH-PBC Overlap Syndrome Diagnosis. Patient was given supportive treatment in the form of blood products, antibiotics, diuretics, beta blockers and replenishment of all fat soluble vitamins . As per the recommended protocols, definitive treatment of patient was started with concomitant steroids and ursodeoxycholic acid. But owing to patient 's intolerance to steroids, they were discontinued . The last assessed MELD score of the patient being 22, the patient has been listed for liver transplant. Meanwhile patient is being treated with ursodeoxycholic acid and is under regular follow up.

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P-256 Case Report: Pulmonary Lymphangioleiomyomatosis in a Post-Menopausal Female Patient Patel Jaimin, Pandey A, Daxini Arvind Department of Respiratory Medicine, SMIMER, Surat Corresponding Email ID: [email protected]

Introduction: Lymphangioleiomyomatosis (LAM) is a rare systemic disease of unknown aetiology which results from the proliferation in various organs of neoplastic-acting smooth muscle-like cells and occurs primarily in pre- meno-pausal women, leading to the hypothesis of female hormones being involved in its pathogenesis. The disorder is typically characterised by the formation of thin-walled pulmonary cysts resulting in destruction of pulmonary tissue with progressive lung dysfunction. Its key clinical features include dyspnoea, haemoptysis, recurrent pneumothorax, chylothorax, and chylous ascites.

Case Presentation: A Report the case of a post-menopausal female patient aged 54 years came to our hospital with complaint of non-productive cough predominantly during early morning hours and dyspnea on exertion since 2 years. Her past medical history noted menopause around 44 years, and included 10 years of passive smoking. Physical examination revealed inspiratory crackles over both lungs. Her oxygen saturation was 95% in ambient air. Pulmonary Function Test revealed decreased diffusion capacity. 6 Minute Test revealed a fall in O2 saturation post exercise to 89% from 97% at room air. Chest Radiograph findings indicated bilateral perihilar ground glass opacities. High Resolution Computerised Tomography (CT) Scan of Chest revealed multiple symmetrical rounds to oval shaped lucent areas in both lung fields representing thin walled cysts suggestive of Lympangiioleiomyomatosis (LAM). Based on Eurppean Respiratory Guidelines, the diagnosis of “Probable LAM” was established. The patient was prescribed low dose oral cortico-steroid regimem and mucolytic, rendering the patient symptom free as of now.

Discussion : Pulmonary Function Test usually depicts obstructive pattern in majority of case with restrictive pattern displayed in a minority of cases. Clinical course and symptomatology is highly variable which complicates this multi-systemic disease entity. Diagnosis of LAM hinges on radiological (CT) findings and tissue biopsy whenever it is permissible. Treatment options vary from utility of beta-agonists, hormonal derivatives, cytotoxic agents, surgical intervention, and management of complications. Evidence based treatment approach should be devised based on research trials.

Conclusion : LAM is necessarily a diagnosis of exclusion. National registry and forum should be created for rare diseases like LAM to promote research and devise strategies.

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P-257 Thyrotoxic Periodic Paralysis (TPP) - A Rare Disorder Nagre Somesh, Gamit Amit Department of General Medicine, Government Medical College, Surat Corresponding Email Id - [email protected]

We describe a 35 year old male with sudden onset weakness involving all four limbs. Hypokalemia was documented and initially misdiagnosed as hypokalemic periodic paralysis. Patient was treated with intravenous potassium chloride with mild improvement in symptoms. Patients thyroid profile was done in which hyperthyroidism was diagnosed. Patient was subsequently diagnosed as having thyrotoxic periodic paralysis associated with grave’s disease. Tratment with propranolol and methimazole was started and potassium supplements was given with strict monitoring of serum potassium level. Patient becomes symptom free after one week with no weakness in limbs and becomes euthyroid over six months. Thyrotoxic periodic paralysis (TPP) is rare disorder, but it should be considered in patients with acute paralysis and hypokalemia ,and thyroid function should be evaluated.

Keywords: Hyperthyroidism, Hypokalemia, Thyrotoxic periodic paralysis

P-258 Rhinomaxillary Mucormycosis Presenting As Painful Opthalmoplegia Mimics as Tolosa Hunt syndrome In DM- Case Report. Ajapuje Preeti, Rathod Chirag , Shah Meenakshi Department of General Medicine, Gmers hospital ,Vadodara Corresponding Email ID : [email protected]

INTRODUCTION : Mucormycosis is an invasive and fatal infection caused by fungi of the order mucorales. Because of its rapid progression and high mortality,early recognition and aggressive treatment are of paramount importance .The main risk factors are immunocompromised states mainly diabetic mellitus.Tolosa Hunt like syndrome is hallmarked by painful opthalmoplegia .It may pose a diagnostic dilemma and treatment modality in diabetes mellitus..We present a case of patient with features of tolosa hunt syndrome turned out to be rhinomaxillary mucormycosis in a patient with diabetes mellitus who saved by early diagnosis and medical treatment.

CASE REPORT : A 21 year old female diagnosed case of type 1 DM came to emergency department with complaint of right sided eye swelling ,drooping of eyelid ,loss of sensation over right side of face associated with severe headache and vomiting since 2 days.On examination, Patient was oriented, afebrile with normal vitals. There was no neck rigidity. She had right periorbital edema with ptosis (fig.1). Right eye movement in all diections were lost. Intraoral examination revealed caries tooth with whitish patchy lesion over right basal palate and small growth in right nasal cavity .Tissue collected from palate & nose as biopsy sample and sent for histopathological examination showed the characteristic broad, aseptate branched hyphae, which confirmed the diagnosis of mucormycosis..Her investigation on admission revealed

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septicemia with total count of 18000. Her random blood sugar was 361,urine sample were positive for acetone and blood gas analysis confirmed metabolic acidosis. Magnetic resonance imaging (MRI) of brain with venogram reveals mucosal edema and thickening in right ethmoidal sinus and sphenoidal sinus with edema of the right optic nerve.Apart from fluid and insulin therapy for diabetic ketoacidosis, Patient was put on Inj.Amphotericin B,Inj.Meropenam, Inj.Vancomycin and to be started on syrup posaconazole. Her general condition is improving under monitoring.

CONCLUSION : We emphasize that any immunosuppressed or diabetic patient with painful opthalmoplegia(orbitalapex syndrome,cavernous sinus syndrome,tolosa hunt syndrome) should be evaluated for mucormycosis.The neurologist may see patient with painfulful opthalmoplegia in its earliest stages masquerading as other lessserios disease.The present case also highlight the importance of early intitation of amphotericin B and syrup posaconazole therapy ,resolution of predisposing condition would be benefit the suvival rate.

P-259 Stakayasu Arteritis : Early Diagnosis Leading to Better Quality of Life Gill Rooppreet, Pandya Hetal , Barot Hiral, Patel Dipesh, Kotecha Dhruv , Shah Sidharth Deparment of Medicine, Smt.B.K Shah Medical Institute & Research Centre,Sumandeep Vidyapeeth,Pipariya,Vadodara. Corressponding authors: [email protected]

Takayasu arteritis is an inflammatory and stenotic disease of medium and large-sized arteries characterized by a strong predilection for the aortic arch and its branches. It is an uncommon disease with an incidence rate of 1.2 -2.6 cases per million.It has complex clinical presentation and 3 stage scheme is used for simplification with most patients presenting late delaying the diagnosis.We are reporting a case of 40 years old female patient presenting in second stage (vasculitic) of this rare disease. This patient presented with left arm claudication, absent pulses of left upper limb arteries and difference of systolic blood pressure of more than 10 mmHg between arms. The diagnosis was done on basis of classification criteria developed by The American college of Rheumatology, confirmed by color doppler,CT angiography and PET scan. The disease activity is assessed using NIH Prospective study criteria on follow up visit of the patient and was found to have no new or worsening of old symptoms so corticosteroids therapy was tapered off .This report highlights the fact that diagnosing this rare type of vasculitis in early stages is critical to management and prevention of dreadful complications like large arteries aneurysm, Pulmonary Hypertension, Renal artery stenosis etc. and leading to better quality of life with less episodes of active disease. 214 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

P-260 Uncommon Presentation of Neuromyelitis Optica Spectrum Disorders. Dave Manan, Mehta Vinod Corresponding Email Id : [email protected]

Neuromyelitis Optica spectrum disorders are a set of demyelinating disorder that primarily target the optic nerve and spinal cord. Primarily thought to be a subtype of Multiple Sclerosis, now is recognized as a distinct entity. We present a 22y female patient who was admitted for acute onset upper and lower extremity weakness with progression for one week. MRI showed possibility of ADEM which recovered on giving IV followed by oral steroids and azathioprine. After 6 months after withdrawal of steroids she was again admitted with bilateral proximal lower limb weakness. MRI showed now demyelinating lesions in cervical and lower dorsal segments along with left medulla and periventricular region. CSF was positive for anti-aquaporin 4 antibodies and oligoclonal bands. Patient was started on steroids and mycophenolate mofetil. Patient became better symptomatically on follow-up. Optic neuritis and acute myelitis remain the core clinical characteristics of NMOSD but are not essential diagnostic criteria. The clinical manifestations are often very similar, but there are important differences in treatment modalities, clinical course and overall prognosis. Hence, it is important to make an early distinction between NMOSD and multiple sclerosis.

P-261 Multiple Nodular Chest X-ray; Diagnostic challenge Chakravarti Chirag Corresponding Email- id: [email protected]

There are several cause for multiple nodular opacities on chest xray like tuberculosis, abscess, nocardia, aspergillosis, maligancy, pulmonary metastasis from primary in other body part like breast, Gastrointestinal tract, gall bladder,sarcoma,and systemic disease(rheumatoid nodules, sarcoidosis, granulomatosis with polyangitis).

CASE : A 55yr old male,chronic bidi smoker working as a farmer since last 25yr having complain of cough with yellowish expectoration on&off episode,low grade fever,loss of appetite,and significant weight loss and dull aching abdominal pain since last few month.No complains of dyspnea,nausea,vomiting.No complain of joint pain,skin rash,and any bowel/bladder dysfunction. Examination : Grade 1 clubbing present Bilateral normal breath sound present. Well maintaind oxygen saturation at room air.

INVESTIGATION- Blood counts were in normal range. Liver function test shows high in range S. Bilirubin ( total, direct, indirect) remains high.. S. LDH was high.. Sputum for acid fast bacilli was negative. Sputum for genexpert/MTB was negative.

CHEST XRAY shows bilateral diffuse nodular opacity.

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P-262 Acute Acquired Methemoglobinemia with Conjugated Hyperbilirubinemia-A Rare Case Patwardhan Nitish, Akholkar Pankaj Shri M P Shah Medical College and Guru Gobindsingh Civil Hospital, Jamnagar, India Corresponding author email id:[email protected]

Methemoglobinemia is a disorder of hemoglobin which alters its oxygen carrying capacity.It can occur as a congenital defect of hemoglobin or may have an acquired cause.Acquired causes of methemoglobinemia are mostly due to exposure or ingestion of nitrates, nitrites, aniline compounds, drugs like dapsone, phenacetin, phenytoin, anesthetics.Acquired methemoglobinemia due to organic compounds used for agricultural purposes is rare.Here, we report a case of a 35 year old male with acquired methemoglobinemia due ingestion of a bio-organic compound (plant larvicide and plant wormicide).Treatment with methylene blue(cumulative dose of 6 mg/kg) and Vitamin C was given along with supportive treatment which involved invasive mechanical ventilation. Pulse oxymetry showed 80% oxygen saturation at presentation which normalized on day 7. The patient developed conjugated hyperbilirubinemia during the treatment, which peaked to 18 mg/dl on day 7 and gradually decreased to normal levels after about two months.The patient was discharged successfully on day 20 without any residual sequele.Hemolysis due to methylene blue treatment in methemoglobinemia is documented in some case reports, but a long course of conjugated hyperbilirubinemia as an effect of organic compound toxicity or in treatment of methemoglobinemia is a very rare finding.

P-263 Pectoralis Major Myocutaneous Flap for Reconstruction after Oral Cancer Surgery in Indian Scenario: Our Experience in 200 Patients Chaudhary Mukesh, Harish L Corresponding Email- id: [email protected]

Background : Pectoralis major myocutaneous (PMMC) flap, however, owing to its robust vascularity and easy learning curve for surgeons, is still a workhorse at centres with limited resources and heavy patient load. At our center, head and neck malignancies constitute a major proportion of cancers in the adult population,with most patients presenting in advanced stages. PMMC flap is the principal mode of reconstruction following composite resections. It provides the required bulk for a composite defect with acceptable cosmetic outcomes.

MATERIALS AND METHOD : Study Design: Single institute retrospective study Duration of study: August 2016 — December 2017 No: of patients: 200 oral cancer patients undergoing PMMC flap reconstruction . Patient demographics, site of lesion, duration for reconstruction, occurrence of complications, etc were studied. Standard technique for harvesting the PMMC flap was implemented. Follow up period of one year was analysed.

OBSERVATION AND RESULTS : Majority of cases were Stage IV – 110 patients (55%).Most common site of Primary was Buccal mucosa – 76 patients (31%). Overall flap related complications were recorded in 41% patients. Major complications were orocutaneous fistula(10%), partial flap loss(10%), and infection (10%).

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CONCLUSION : Owing to its versatility, easy learning curve, and a constant vascular pedicle, PMMC flap is still one of the most favoured approaches for the head and neck reconstruction with acceptable cosmetic and functional outcomes. Our experience in 200 cases has shown low flap related complications. Thus, in limited resource settings with heavy patient load, PMMC flap is still a workhorse flap for head and neck reconstruction.

P-264 Myeloid Sarcoma: Case Series and Literature Review Pareek Ananya, Patel Apurva, Tahiliani Nahush, Naseer Mohammed Gujarat Cancer & research institute, Ahmedabad, Gujarat

Myeloid sarcoma (MS) is a malignant extramedullary tumour consisting of immature cells of myeloid origin. It may precede, present concurrently or follow Acute Myeloid Leukemia (AML) in de novo case or may also be present and might be the only manifestation of recurrent AML, Myelodysplastic syndrome (MDS) or Chronic Myeloid Leukemia (CML). It frequently involves skin, orbit, bone, periosteum, lymph nodes, gastrointestinal tract, soft tissue, central nervous system and testis. Because of its different localization and symptoms, and the lack of diagnostic algorithm, MS is a real diagnostic challenge particularly in patients without initial bone marrow involvement. The correct diagnosis of MS is important for optimum therapy, which is often delayed because of a high misdiagnosis rate. Certain cytogenetic abnormalities are associated with increased risk of extramedullary involvement, potentially through altering tissue-homing pathways. The prognostic significance of extramedullary involvement is not fully understood. Therefore, it has been difficult to define the optimal treatment of patients with MS. Owing to the rarity of this disorder, large series are seldom reported, and the literature is mainly composed of case reports. We at our institute reviewed a series of 5 cases of MS with respect to Clinicopathologic and Immunohistochemical features and compared with available literature.

P-265 Management of a Case of Raw Area with Vacuum Dressing over Abdomen Post Wound Infection and Necrosis with Exposed Mesh of Anterior Abdominal Wall Muscles in a Operated Case of Incisional Herniomeshplasty. Shah Veer, Andharia, Kushwaha, Suthar Kaushal, Parikh Samir Department Of General Surgery, V.S. General Hospital Corresponding Email Id: [email protected]

A 50 year old male patient with a large ( 20 x 10 cm ) midline incisional hernia after being operated for ileoileal RA in 2016 was planned for incisional herniomeshplasty. Incisional herniomeshplasty with component seperation was done but skin and anterior abdominal wall necrosis occured and so the wound was debrided to create a raw area of 20 x 25 cm in the centre of the abdomen with even exposure of the mesh that had been placed between posterior rectus sheath and rectus abdominis muscles. Later sequential debridement was done and 9 cycles of vacuum dressing were done. Later as granulation tissue appeared we shifted to saline soaked dressings and granulation tissue covered the entire raw area even the mesh. There was no other alternative to which laparotomy closure could be done so vacuum dressing was a boon in the case. After 3 months of dressings STG was kept over the area and it was taken up. Patient has quit smoking in the post operative period and is living a rouitne life with no significant comorbidities related to the surgery.

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P-266 Clinical Profile of Diffuse Large B-Cell Lymphoma Annadanam Harshavardhan, Patel Apurva, Nahush Tahiliani,Mukesh Kumar, Sushant Gujarat Cancer & Research Institute, Ahmedabad, Gujarat Corresponding Email Id: [email protected]

The most common type of Non Hodgkin lymphoma (NHL) which accounts for 55% of all NHL in Indian population. About one half of DLBCL patients can be cured with current therapies, but most of the remaining half eventually die of the disease. Two main gene patterns have been characterized according to the germinal center (GC) or post-GC (activated B-cell) origin. Our aim was to study the demographic profile, clinical presentation, staging, prognostic factors and management of patients with diagnosis of DLBCL. All newly diagnosed histologically confirmed primary DLBCL presenting to GCRI were included in the study. DLBCL was presented mostly in middle age of patients with median age at presentation was 52 years, which is relatively a decade earlier as compared to Western populations. Male dominant gender ratio was observed with male to female ratio of 1.36:1. Majority of patients (69%) had good ECOG performance status at the time of presentation. Superficial lymphadenopathy was the commonest sign (87%) and bone marrow involvement was the most common extranodal site at the time of presentation, which occurred in 15% patients. The final evaluation was done in 70 patients who had received complete treatment at this institute. It was observed that after the completion of treatment, CR was attained in 61% (43/70) of patients, whereas in 39% (27/70) of patients, disease was residual or progressive at the end of follow up, 61/70 (87.1%) patients alive at end of follow up and remaining 09/70(12.9%) of patients lost to follow up (6) & died. 1 year PFS and OS rate was 40% and 48% respectively. The most frequent adverse event during treatment was myelosuppression seen in 32(35.5%) patients. GCB type was most commonly observed subtype of DLBCL. Subtype of DLBCL had no effect on treatment outcome and CR rate similar in both subtype of DLBCL. In limited stage of DLBCL, CR rate achieved in more than three fourth of patients whereas in advanced stage DLBCL, CR rate declined to one half of patients. Majority of patients (62%) had low risk group disease with IPI score low to intermediate low and higher CR rate (56%) detected in same group of patients whereas CR rate in intermediate high to high risk of group of patients were detected in only 20% of patients. Currently at last follow up, majority of patients (87%) are alive while remaining 13% patients either lost to follow up or died. Near half of patients (44%) are in continuous clinical remission while 15% patients relapsed and 11% patients have progressive disease at last follow up. Median follow up duration is 8.2 months. The median PFS was 9 months and median OS was 11.1 months. 1year PFS and OS rate was 40% and 48% respectively.

P-267 Median Arcuate Ligament Syndrome Jariwala Jigar, Kuswaha Manoranjan Deptartment of General Surgery, Smt. N.H.L Municipal Medical College, Ellis Bridge, Ahmedabad Corresponding email id: [email protected]

Background: Median arcuate ligament syndrome (MALS), also known as celiac artery compression syndrome and Dunbar’s syndrome is an extremely rare condition with chronic abdominal pain and radiological evidence of celiac artery compression.

Objective : our primary objective here is to understand how to diagnose such a rare condition and how to manage these patients. Method : A series of 4 patients presented at V.S. General Hospital, Ahmedabad from September 2017 to September 2018 with chronic long standing vague abdominal pain and were diagnosed with median

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arcuate ligament syndrome and underwent laparoscopic median arcuate ligament release. We have a 6 months follow-up of all patients.

Results : In our study, out of the 4 patients diagnosed with MALS, two were females and two were males. Most common presenting complain was chronic post-prandial epigastric pain. All the 4 patients experienced immediate relief after surgery. Mean operating time was 146 minutes.Time to return to daily activity was 1 day. Post operative ultrasound with colour Doppler of abdomen showed no compression of celiac artery with normal blood flow. No recurrence of symptoms at the 6 months follow-up. Rate of conversion from laparoscopic to open surgery was zero.

Conclusions : MALS is often missed at diagnosis due to its nonspecific symptoms. Although MALS is a diagnosis of exclusion, when evaluating patients, especially young females, who present with abdominal pain of unclear etiology, MALS should be considered. Abdominal Doppler and CECT abdomen plays a crucial role in diagnosing it. Laparoscopic ligament release is a minimally invasive approach having advantages such as decreased intraoperative blood losses, small risk of cardiopulmonary complications, fewer adhesions, cosmetic benefits and a shorter hospital stay. In conclusion, waiting for additional cases or larger series, we promote this novel approach as avalid alternative to traditional open surgery.

Keywords: median arcuate ligament syndrome, laparoscopic ligament release.

P-268 Clinico-Pathological Profile and Treatment Outcomes in Patients of Prostate Cancer from a Regional Cancer Center of Western India Philip George , Patel Apurva, Tahiliani Nahush, Mukesh Kumar, Santhanu Pendse Gujarat Cancer & Research Institute, Ahmedabad, Gujarat Corresponding Email Id: [email protected]

Prostate cancer is the second most frequently diagnosed cancer and the sixth leading cause of cancer deaths in males worldwide. Rates of prostate cancer vary widely across the world. It is a bigger health concern in developed countries. Risk factors of prostate cancer are increasing age, ethnic origin and hereditary. In India, majority of cases are diagnosed at the advanced stage, hence morbidity remains high. Besides this, cancer mortality rates are under reported due to poor recording of cause of death. This study reviewed the demographic profile, clinical features, stage and treatment outcome of carcinoma prostate patients. It is a prospective observational study in a regional cancer center over a period of one year.

KEYWORDS : prostate cancer, clinical profile, treatment outcome

P-269 Unusual Presentation of Pheochromocytoma as a Visual Symptoms Harsh Pathak Corresponding Email Id: [email protected]

Pheochromocytoma has long proven to be a diagnostic challenge for clinicians. This challenge is expanded when symptoms of this disease manifest as unusual presentation. Here we report the case of a 20 year male patient with complain of sudden onset painless blurring of vision in both eye since 12 days. No other symptoms like headache, redness of eye, watering from eye is there. At the time of admission Patient’s blood pressure was 190/120mm of HG .Fundus examination reveals hypertensive haemorrhagic spots. Vacuities work up was normal. 24 Urinary VMA was high. USG abdomen showed hypo echoic lesion with

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few cystic areas within it near hilum of left kidney suggestive of pheochromocytoma which was confirmed by CECT abdomen. Pheochromocytoma is a rare catecholamine producing tumour that requires a high index of suspicion by the clinician. This case emphasizes about pheochromocytoma as a differential diagnosis in young hypertensive patient presented with visual symptoms.

P-270 Anaesthetic Management of a Patient with an Ovarian Mass Adherent to Sigmoid Colon with Excessive Bleeding - A Case Report Khokhar Sanobar, Solanki Rekha, Shah Bhavna Dep. Of Oncology B J medical college & Civil Hospital, Ahmedabad, Gujarat cancer and research institute, BJMC and civil hospital, Asarva, Ahmedabad Corresponding Email Id: [email protected]

A 50 yrs. old, 50 kg female patient having Ca Ovary with sigmoid colon involvement presented with abdominal pain and abdominal swelling. Patient had H/o Hypertension since 3 yrs. Important role of anaesthesiologist begins with preoperative optimization, proper intra-operative and postoperative management. Mass was adherent to sigmoid colon, sigmoid resection was done. Left common iliac vein and internal iliac artery were ligated. Blood loss was 3000 ml and replaced with 5 ? PCV, 3 ? FFP, 3 ? Platelet consentration, 5 ? RL, 1 ? NS . Inj.Heparin 5000 IU IV given and reversed with Protamine sulphate IV. Patient was extubated. Post operatively, Patient had loss of movement of left lower limb and cold limb. Doppler showed left popliteal artery, proximal part of anterior and posterior femoral artery thrombosis. Left femoral thromboembolectomy was done. Inj Heparin 5000 IU given. Patient was shifted with ET tube and put on CPAP mode of mechanical ventilation and extubated in the next morning. Tab. Warfarin 2mg and Tab. Aspirin 75 mg was started, Warfarin was stopped after 2 days. For perforative peritonitis emergency explorative laprotomy with sigmoid colostomy was done and put on CPAP mode of mechanical ventilation and extubated in the next morning. Higher S.bilirubin(2.30) and S.K+(6.31) were managed successfully. During dressing by the surgeon, patient became unconscious and was gasping so patient was immediately intubated and put on SIMV mode. Shifted to CPAP mode on next day and extubated on next day. Patient was shifted to ward on 17th postoperative day with normal investigation.

Key word: Ovarian mass, Sigmoid colon,Excessive bleeding and Embolectomy.

P-271 The Navicular Bone Chondrosarcoma a Rare Case Patel Dhruv, Elroy , Nikhil, Aamar, Zeeshan, Desai Sanjay Dept of Surgical Oncology, SAIMS, Indore Corresponding Email ID: [email protected]

Introduction: Chondrosarcoma is the second most common primary malignant tumor of the bone (20-27% of all primary bone sarcomas). Although very rare in foot and hand bone (<5%), it most commonly affect Pelvis & Ribs(45%), Ileum(20%), Femur(15%), Humerus(10%) & Others (10%).

Case summary: In our case, 55 yr old female patient presented with left foot swelling with pain & difficulty in walking. On examination, 5*4 cm swelling present over left foot. Ankle joint movement is restricted without any sensory-neural deficit. Pre-Op MRI s/o lytic expansile lesion size of 5.8*3.8*3.7 cm in navicular

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bone with moderate associated soft tissue components & Tru-cut Biopsy s/o chondrosarcoma grade-1 . Patient had underwent wide local excision with removal of soft tissues and navicular bone completely. Plating done between first metatarsal and talus. In follow-up, patient can walk comfertabely without any support. HPE s/o chondrosarcoma of navicular bone (intermediate grade) with extention into soft tissues. Discussion: According to the literature, foot bone chondrosarcoma has very low incidence. Conventional central chondrosarcomas account for nearly 80-90% of all chondrosarcomas. Incidences differ according to the sex and age but do not differ among ethnic groups. The prognosis is correlated with the grade and stage of the lesion at the time of diagnosis. The location of the lesion is also important because tumors in areas where complete wide resection is possible are associated with better prognoses. Recurrence and distant metastasis may develop. The metastasis rate for primary chondrosarcoma is higher than that for secondary chondrosarcoma, and the rate of distant metastasis is higher in patients with local recurrence than in those without local recurrence.

Conclusion: Surgery is mainstay of treatment in bony chondrosarcoma. The role of chemotherapy and radiation therapy is not well established.

P-272 Acute lung Injury due to Low dose Methotrexate in a Case of Acute Lymphoblastic Leukaemia Srivastava , Parikh Sonia Department of Medical and Paediatric Oncology, The Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India Corresponding Email id: [email protected]

Lung injury is a rare adverse effect of methotrexate toxicity, an antimetabolite chemotherapeutic agent. Published literature suggests that it usually occurs in patients of connective tissue disorder who already may have components of interstitial lung disease. This is a case report of a 6 year old male child with acute lymphoblastic leukaemia who developed acute lung injury after 6 months of weekly maintenance methotrexate despite receiving four cycles of high dose methotrexate in the past without any similar complications. This is a diagnosis of exclusion and is conventionally made by combining clinical and laboratory criteria.

P-273 A Rare Presentation of Organophosphorus poisoning with Diabetes Insipidus and Machiafava Bignami Syndrome Shivam N. Shah, Patel Shivani Department of Medicine Civil Hospital, Ahmedabad Corresponding Email id – [email protected]

OrganoPhosphorus poisoning is the most common cause of parasuicide in India. Around 39.8% of Organophosphorus poisoning patients complicate with respiratory paralysis requiring mechanical ventilation. Sometimes it can be associated with Multi Organ dysfunction syndrome and acute kidney injury in 15.7% of the patients. Diabetes Insipidus is a rare complication of Organophosphate poisoning possibly due to transient hypoxic damage to hypothalamus. Marchiafava bignami disease is a progressive neurological disease characterised by corpus callosum demylination and necrosis resulting in loss of

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consciousness, seizure, ataxia, hemiparasis, apraxia, and coma. A 20 years old male who occasionally consumes alcohol presented with an alleged history of Organophosphate compound ingestion about 400 ml around 10 days ago. The patient was initially treated at a peripheral centre with atropine and pralidoxime. His serum cholinesterase level was low. Patient was then hemodialysed 3 times for acute kidney injury and was eventually put on mechanical ventilation for respiratory failure and eventually tracheostomised. However following onset of multiorgan dysfunction he was referred to our center. On admission patient had normal temperature with BP 100/70mmHg and pulse 82/min and respiratory rate was 22/min. He was unconscious, responding minimally to deep pain stimulation. Blood investigation revealed Hemoglobin-8.9gm/dl, Total WBC Count- 17,000/cmm,platelets- 284000/cmm, creatinine-6.8mg/dl,urea-116mg/dl, normal electrolyte levels, SGPT was 2400 IU/L, total Bilirubin 5.8mg/dl with markedly elevated serum amylase - 1102 U/L & serum lipase-2062 U/L and INR- 1.5.His urine output was 100ml/day. Ultrasonography abdomen suggested changes of acute pancreatitis with raised bilateral renal cortical echogenicity. He was started on higher antibiotics with balanced fluid and electrolytes and was further Hemodialysed in ICU. Urine output increased after 5 days of Indoor stay reaching up to 7 liters per day on day 7th.When further Investigated his urine osmolality was decreased (196 mOsm/kg), urinary specific gravity was 1.003 while plasma osmolality was 287mOsmol/kg. Hence a suspicion of central Diabetes insipidus was made. Desmopressin nasal spray was given in a dose of 10µg/dose 2-3 times a day for 6 days. After Desmopressin therapy urine output was 3-4 lit/day .Patient regained consciousness. His renal function test improved with Serum Creatinine of 3.7mg/dl and urea of 78 mg/dl. Patient was gradually weaned off mechanical ventilation. MRI Brain scan revealed corpus callosum and bilateral internal capsule necrosis suggestive of Machiafava Bignami disease. Renal biopsy was done later which suggested changes of Mesangioproliferative Glomerulonephritis with acute on chronic tubulointerstitialdisease. Tracheostomy closure was possible after 25 days of treatment. Patient was then followed up with renal function tests which show improvement with Serum creatinine of 1.7mg/dl, urea 34mg/dl and urine output of 2-3 liters/day.

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ONCOLOGY

1. Chondrosarcoma of Root of Zygoma Prajapati Mayur, Patel Vatsal, Patel Alpesh, Patel Nehal Department of E.N.T, Shardaben General Hospital, Smt Nhl Municipal Medical College, Corresponding Email Id: [email protected]

Chondrosarcomas are malignant cartilaginous neoplasm rarely seen in Head and Neck region accounting for 5.76% of all cases with most common sites like maxilla, nasal cavity, nasal septum, and mandible with male to female preponderance of 2:1. Chondrosarcoma is uncommon in first 2 decades of life with most patients in the 4th and 6th decades. These lesions range from low grade tumour with low metastatic potential to high grade aggressive tumour characterized by early metastasis. 5 years survival rate of chondrosarcoma of the facial bones has been reported to 67.6%. As it is a radio resistant tumour, radical resection is the most effective treatment modality. Chemoradiation is usually advised for locally recurrent or residual tumour. But lifelong treatment is essential since this lesion shows a high incidence of local recurrence as well as regional and distant metastasis more than 2 decades later. INCIDENCE: 4.2 TO 6.7 %. Keywords: Chondrosarcoma, Chondromyxoid matrix, Root of Zygoma.

2. A Rare Case Report: Primary Squamous Cell Carcinoma Thyroid Palod Sahaj, Bhandari Virendra, Khan Aafreen, Ali Tauseef, Gupta Sumit and Verma shalu Department of Radiation Oncology, Sri Aurobindo Medical College and PG Institute Indore, India Corresponding Email Id: [email protected]

Introduction : Primary squamous cell carcinoma is a rare entity in all of thyroid malignancies due to lack of squamous origin cells in the gland. The overall prevalence is less than 1% and very few cases have been reported in literature worldwide. This case report is our experience with this rare histology tumor. Case report : A 65 year old female presented to us with complaints of difficulty in swallowing and pain along with small swelling in the neck. Physical examination revealed a 2 x 2 cm mass in midline of neck extending to left side. Metastatic workup was inconclusive. Computed tomography scan (CT) neck revealed 3 x 3.8 x 4 cm mass in left lobe of thyroid along with left side neck nodes and magnetic resonance imaging (MRI) revealed its retrosternal and perithyroid extension. She was subjected to hemithyroidectomy of right lobe of which post operative histopathology revealed well differentiated squamous cell carcinoma thyroid. Then she was subjected to post operative radiation 60 Gray (Gy) in 30 fractions (#) at dose of 2 Gy per # 5 days a week over a period of 6 weeks. She responded well to treatment is currently on follow up with controlled disease.

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Conclusion: Despite no standard guidelines on the management of this rare entity in our experience, treatment line consist of surgery then followed by radiation postoperatively. Any long term survival in such patients have not been reported yet. Such cases with rare presentation pose a challenge to managing team due to lack of standard care guidelines and it needs thorough evaluation.

3. Neuroendocrine Carcinoma at an Unusual site Mathew, Sherin P; Parikh, Sonia, Anand, Asha S, Shivchhand, Akshay Department of Medical and Paediatric Oncology, The Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India. Corresponding Email Id: [email protected]

Primary Neuroendocrine carcinomas of the orbit are extremely rare and exact incidence has not been reported. The histology of these high grade, aggressive tumours maybe small cell or poorly differentiated (often large cell) and the diagnosis is usually established by immunohistochemistry. The treatment is multimodality approach and data is limited. As most of the patients present with multiple sites of metastases, the first line is chemotherapy which includes platinum based combination chemotherapy as used for small cell lung carcinoma. Patients presenting with a single site of disease is rare and in such cases, radiation therapy with or without resection should be added to the combination chemotherapy. Herein a case of neuroendocrine carcinoma of the orbit, locally advanced without any distant metastases, who has been treated with combination chemotherapy and radiation therapy is reported, along with review of literature regarding clinical presentation and management options and outcome.

4. Significance of level V lymph node dissection in clinically node positive SCC oral cavity Harish N L, Sharma Mohit, Pandya Shashank Department of Surgical Oncology, Gujarat Cancer & Research Institute, Ahmedabad. Corresponding Email Id : [email protected]

Objectives: To determine the role of level V lymph node dissection in N+ SCC oral cavity cancer. Study Design: prospective Methods: 200 cases of SCC oral caivty who underwent surgical treatment of primary lesion with comprehensive neck dissection were evaluated. Level V lymph nodes were dissected separately from Level I-IV neck dissection specimen and sent for histopathological analysis. We studied the risk factors for Level V nodal metastasis and incidence of histopathologic metastasis to level V nodes in cN0, cN1 and cN2 groups. Results : 45 cases were cN0 and 155 were cN+. None of cN0 (45) patients had level V metastases. Out of 155 cN+ cases 107 were cN1 and 48 cN2. Amongst cN1 cases, cN1 with palpable level lb node(94), none had level V involvement but cN1 with palpable ll/lll node(13) 1 patient had level V metastasis. 8 patients from cN2(48) group had level V involvement(Prevalence-16%). The incidence of Level V lymph node metastasis was 4.5%. Tongue is the most common site to give rise to level V metastases and ECS was present in 100% and LVI in 89% patient with level V metastases.

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Conclusion : By stringent selection not only patients with cN0 but patinets with cN1 oral cavity SCC with level lb as only site can safely undergo SND. Potential risk factors for level V lymph node metastasis are: clinically evident ECS, multiple lymph node involvement and cN1 with deep jugular chain of lymph node involvement.

5. Nasopharyngeal type poorly differentiated squamous cell carcinoma (Lymphoepithelial carcinoma) in parotid gland presenting as a metastatic cervical lymphadenopathy: A case report Vadodariya Bhavin, Shah Harshit, Vaja Zuber, Choksi Vishal Department of Head Neck surgery and Oncology, Apollo CBCC Cancer Care, Apollo Hospital, Ahmedabad Corresponding Email Id- [email protected]

Introduction : Nasopharyngeal type poorly differentiated squamous cell carcinoma (squamous cell carcinoma with associated lymphoid stroma) commonly occurs at the nasopharynx and rarely occurs at other sites in the head and neck region.

Case Report : The patient is 50 years old, non smoker gentleman. His chief complaint was swelling in left upper neck and parotid region . There were no notable facts in his past history and family history. The patient noticed his painless swelling of his upper neck in March 2018, and then he went to the government hospital, where FNAC from neck swelling done which was suggestive of undifferentiated carcinoma. In July 2018 he consulted a private doctor where he was advised CT scan of the neck. CT Neck revealed 2.8*2.3*3.5 cm sized heterogeneous lesion in upper pole and 3.2 * 2*4.3 cm sized lesion in lower pole of parotid with 3*2 cm sized heterogeneously lymph nodal mass in level Ib,III and IV region. Excision biopsy of left neck node done by private doctor in July 2018 which revealed Metastatic poorly differentiated carcinoma and Immunohistochemistry positive for CK,EMA,P63,CK 5,6 and negative for LCA. Patient then consulted us on October 2018 with local examination two separate firm ,non tender and mobile swelling in parotid region with non tender, hard and mobile nodal mass in left level I,II and III and level V and normal oral cavity examination. We got done review of histopathology slides of excisional neck node biopsy which revealed undifferentiated nasopharyngeal type carcinoma with negative EMA and P63 and EBC RNA was positive in the In situ hybridisation. We performed nasopharyngoscopy and biopsy on two separate occasion in October 2018 which revealed no abnormality and biopsy suggestive of benign respiratory epithelium..We advised patient to undergone whole body PET CT scan in November 2018 which revealed heterogeneously enhancing FDG avid enlarged lymph node in superficial lobe of parotid gland and discrete multiple FDG avid enlarged necrotic nodes in left level I to V. We performed Total Parotidectomy(Facial nerve sparing ) and modified radical neck dissection type 3 in November 2018. The histopathology revealed nasopharyngeal type poorly differentiated carcinoma of left parotid gland with 18 out of 39 lymph nodes positive for malignancy. The tumour was multinodular and size was 2.5*2 cm . The level I to V and parotid nodes were positive for malignancy.

Discussion : Lymphoepithelial carcinoma is defined undifferentiated carcinoma consists of large cell type with remarkable infiltration of non-tumour cells like lymphocyte or plasma cell [1]. This tumour became

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independent of the previous category with large cell carcinoma according to the WHO classification in 2005 [1]. In respect of treatment, it is thought to need complete dissection and additional irradiation in many reports. A Case series by Ma et al. suggests Salivary gland lymphoepithelial carcinoma has a better prognosis that partially attributes to surgery with neck dissection and postoperative radiotherapy. [2].

Conclusion : There is a strong relationship between lymphoepithelial carcinoma and EBV infection. In our case of parotid gland tumour, existence of EBV was indicated by way of in situ hybridization. We acquired satisfactory prognosis by performing The Facial nerve sparing total parotidectomy and modified radical neck dissection type 3 regard to lymphoepithelial carcinoma of parotid gland.

6. Factors Affecting Lymph Node Positivity in Early N0 Buccal Mucosal Cancers Gangopadhyay Abhishek Gujrat Cancer & Research Institute, Ahmedabad Corresponding Email Id: [email protected]

Background: Cervical lymph node metastasis has a great impact on long term, disease free and overall survival of head and neck cancers. A good number of buccal mucosa cancers have pathologically positive nodes after neck dissection, which was clinically and radiologically negative for nodes pre-operatively. There is also a sequential pattern of involvement in different levels of neck nodes, which is usually maintained in buccal mucosal cancers. Newer evidences focus on shifting to conservative neck approach aimed at achieving good functional outcome without compromising oncological safety. The aim of the study is to predict cases, which may have positivity lymph nodes and modify surgical planning for neck accordingly.

Material & Methods: This is a retrospective study of 122 patients of squamous cell cancer-buccal mucosa (T1 – T3) who were clinically and radiologically negative for neck nodes pre-operatively. Patients were analysed for pathological lymph node positivity in respect to T stage, tobacco addiction, depth of invasion, perineural invasion, lympho-vascular invasion, degree of differentiation, mentioned in the diagnostic biopsy.

Results: Among total patients 36 were pathologically positive for lymph node. All the factors were studied with Pearson’s Chi-square test. Among all, depth of invasion > 0.5 cm (p = 0.006) and lympho-vascular invasion (p = 0.011) were found significant.

Conclusion: A good informative diagnostic biopsy and proper pre-operative clinical and radiological examination can help in changing surgical planning in N0 early buccal mucosal carcinomas.

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7. Sentinel lymphnode biopsy in a morbidly obese patient with breast mass with clinically no axilla: case report sharath kumar Surgical oncology gcri Ahmedabad Corresponding Email Id: [email protected]

Introduction : Obesity is common in a breast malignancy patient , and its a risk factor for breast cancer in postmenopausal individuals, here we are reporting the feausibility of sentinel lymph node biopsy in a morbidly obese patient weighing 130kg and to avoid axillary dissection if sentinel lymph node is negative .

Case Detail : A severly morbid obese 62 year female patient (130kg) with BMI of 53, presents with history of breast lump in her right breast since 1 and half month, on examination a 2cm *2cm lump noted in outer upper quadrant of right breast, firm to hard in consistency , with clinically no palpable axillary lymph nodes. Mammography showed multicentric mass measuring 15*11mm ,13*9mm, 20*10mm at 5, 6, and 9 o, clock position on right breast , with right axillary lymph node measuring 15*4 mm. Birads category 4b. Patient was prepared and underwent wide local excision and sentinel lymph node biopsy using radio colloid and methylene blue(dual method). on table we identified 2 sentinel lymph nodes which were radioactive by gamma probe but only one node was radioactive and blue as well. Both nodes were sent for frozen section . Both nodes were negative for malignancy. Breast cancer and breast surgeries though commonly performed sentinel lymph node biopsy is not routinely used in all centers even till now, and doing sentinel lymph node biopsy in a severly morbid patient with a BMI of 53 was challenging . Our team performed a successful SLN biopsy on this patient avoiding an unneccessery axillary dissection and its related complications.

8. Retropharyngeal Lipoma A Case Report Sadangi Sudam, Pandya Shashank, Sharma Mohit Department of Surgical Oncology, Gujarat Cancer & Research Institute Ahmadabad, India. Corresponding Email Id: [email protected]

Lipomas are most common benign tumours of mesenchymal origin. Only 13% of these tumours arise in head and neck. Lipomas of retropharyngeal region are rare, slow growing tumours. They do not cause symptoms until they reach large size. It is a rare entity few reports appear in literature. Treatment is surgical excision. Surgical approach for excision is based on location of tumour. We present a case of lipoma in retropharyngeal space causing respiratory distress in a 70 years old female. The radiological findings and surgical management will be discussed.

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9. Meibomian Gland Carcinoma of Eyelid involving Orbit requiring complex resection and reconstruction: A case report. Shah Harshit, Vadodariya Bhavin, Vaja Zuber, Rathod Priyanka, Patel Mrudul, Choksi Vishal Department of Head and Neck Oncosurgery, Apollo CBCC Cancer Care, Ahmedabad Corresponding Email Id- [email protected]

Introduction: The Meibomian gland carcinoma(MGC) is a rare malignant tumor of the eyelid with an incidence of 1-5.5% of eyelid malignancies arising from sebaceous glands. Some studies show an increased incidence of sebaceous gland carcinoma(SGC) in the Asian population. The tumor is more commonly seen in elderly individuals and in the upper eyelid where the meibomian glands are numerous.

Case Report : A 56 years old, male presented with ulceration at left eye noticed in January 2018, and then underwent a biopsy in February 2018 which was suggestive of moderately differentiated squamous cell carcinoma. On examination, the patient had an exophytic growth involving left upper eyelid, lower eyelid, eyeball, conjunctiva and extraocular muscles. There was loss of vision in left eye with no perception of light. There was an enlarged, firm, mobile 1*1 cm sized Right level II node palpable. MRI of the orbits showed well-defined soft tissue lesion in superolateral part of conal-intraconal compartment of left orbit with no definite bone erosion, orbital apex involvement or intracranial extension. We performed Anterior craniofacial resection, orbital exenteration, partial (supra-structure) maxillectomy, superficial parotidectomy, type 3 modified radical neck dissection and reconstruction with microvasular anterolateral thigh flap, local flap and skin graft in March 2018. Histopathology report was suggestive of MGC carcinoma of left eyelid sized 5*4*3.5 cm involving periorbital soft tissue with lymphovascular and perineural invasion with positive parotid lymphnodes. The patient has completed adjuvant radiotherapy. The patient has been regularly followed up. Patient is currently doing well and no evidence of disease.

Discussion MGC is a slow-growing tumor of the eyelid having a poor prognosis when compared to other eyelid malignancies because of delayed diagnosis, as it is frequently mistaken for benign conditions. Treatment of SGC is primarily surgical. Surgical treatment may range from a local excision to orbital exenteration. If there is evidence of regional lymph node involvement radical neck dissection along with partial parotidectomy should be performed. The mortality rate is 5-10% because of delay in making diagnosis and delay in the treatment.

Conclusion : Surgical treatment extend the survival rate of such patients. Our experience revealed its unusual aggressive behavior and role of radiation in it.

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10. Vascular malformation of buccal mucosa : A case report. Shah Parth, Shah Navin K. M. Shah Dental College & Hospital Corresponding Email Id: [email protected]

Vascular lesions are among the most common congenital and neonatal abnormalities. Most of the congenital vascular malformations were often misdiagnosed and left untreated. These lesions are the result of an embryonic abnormality of the vascular system. This is a case report of 22 year male patient who reported in the department of Oral and Maxillofacial Surgery, K. M. Shah Dental College & Hospital ,Vadodara with a chief complaint of swelling and discoloration of the right side of hard patale . It was diagnosed as vascular malformations of hard palatal of right side.

11. Central Giant Cell Granuloma: A Case Report . Abhani Viren, Shah Navin K. M. Shah Dental College & Hospital Corresponding Email Id: [email protected]

Giant cell lesions (GCLs), previously referred to as giant cell granulomas, are benign tumors of the jaws of unknown etiology. Surgical management of aggressive GCLs is challenging, as these lesions demonstrate a tendency to recur following surgical removal. In addition, surgical treatment can be associated with significant morbidity. In an attempt to reduce both the extent of morbidity and the recurrence rate following surgery, a number of pharmacologic therapies have been advocated on the basis of assumptions about the predominant cell types and receptors, for the management of these lesions. Reporting A case of 24 year old female patient came with the complain of swelling in the lower right side of the mandibular region and diagnosed of GIANT CELL LESION of the jaw and as per the scientific literature the patient is being treated with intralesional steroids injections to prevent surgical morbidity and resection of the lesion has been planned at a later stage of the treatment.

12. Winged nasolabial flap for reconstruction of buccal mucosa Ananth Kumar, Trada Jeegisha Department of Oral & Maxillofacial Surgery K.M. shah Dental college & hospital Corresponding Email id: [email protected]

The use of nasolabial flap in reconstruction of head and neck defects has proved to be efficacious and reliable. The versatility of this flap has been attributed to the fact that there is often abundant non-hair bearing skin in this well vascularised region. Flap elevation is quick and simple, with minimal donor site deformity and rapid post-operative rehabilitation. Also, the proximity to the defect and achievement of good cosmetic result with preservation of function and least distortion of anatomy makes it the flap of

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choice. The purpose of this study is to evaluate the role of modified single-stage winged nasolabial island flaps for reconstruction of buccal mucosal defects after surgical excision of fibrous bands in patients with oral submucous fibrosis. Here is a case series of 3 patients who presented with oral submucous fibrosis and underwent surgical excision of fibrous bands and reconstruction of the defect with bilateral single-stage winged nasolabial island flaps.

13. Versatility of Local Flaps in Intraoral Defects Monika Surana, Shah Navin Department of Oral & Maxillofacial Surgery, K. M. Shah Dental College & Hospital, Sumandeep Vidyapeeth, Waghodia, Vadodara. Corresponding Email id: [email protected]

The human face reflects ones identity and appearance to the outside world. When this part of the body is damaged due to uncertain circumstances, it leaves behind scars, defects and disfigurement of one’s personality which is directly reflected upon by the world. Intraoral defects cause some kind of disfigurement in terms of functionality just like the extraoral defects leads to poor aesthetic personality. Intraoral defects leads to hindrance in one’s routine oral functions such as mastication, swallowing deglutition and speech. Thus to reconstruct such defects becomes important in terms of maintaining a healthy lifestyle. One of the undisputed concepts in head and neck reconstruction is that whenever possible, one should strive to reconstruct the defects with tissues that more closely resemble the missing tissue not only in color but also in thickness and texture. This can be achieved in case of intra oral defects by the use of Local Flaps. Local flaps are flaps that are located adjacent to the defect site. They may be contiguous to the defect or a small amount of tissue may separate the flap from the defect. The surrounding tissue is transferred to repair the defect and therefore the flap tends to be similar in color and texture, and the thickness can often be tailored to the needs of the defect. This paper presentation is on the various series of few cases of local flaps such as nasolabial, buccal fat pad, buccal advancement and FAMM flaps that have been used to reconstruct the various kinds of intraoral defects at our center performed and its various clinical implications.

14. Antibiotic Prophylaxis in Thyroid and Parathyroid Surgeries: An Overkill? Malekar Priyanka, Vaja Zuber, Vadodariya Bhavin, Chokshi Vishal Department of Surgical Oncology (Head & Neck Unit), Apollo CBCC Cancer Care, 1A, Bhat, GIDC Estate, Gandhinagar Corresponding Email Id: [email protected]

Background: Prophylactic antibiotic use in thyroid and parathyroid surgeries is not recommended according to international guidelines.

Methods: We did a retrospective analysis of the prophylactic antibiotic use in thyroid and parathyroid surgeries at our institute between January 2014 to December 2018. We did a cost-effective analysis of

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antibiotic use in a setting of low economic resources. A total 90 patients underwent thyroid and parathyroid surgeries. Sixty-eight patients did not receive antibiotic prophylaxis while 22 patients received antibiotics (Cefuroxime, 1.5 gm). Eight patients had diabetes mellitus all of whom received prophylaxis. The average duration of stay was 3 days (minimum 1 day and maximum 18 days). Forty three out of 90 patients (47%) had a neck drain. The average age of patient was 46. None of our patients with or without prophylaxis developed clinical infection except one in the prophylaxis group who developed surgical site erythema. The average cost per injection (drug, disposables, nursing charge) was Indian Rupees 520 (US dollars 7. Or Euros 6.5). out of 22 patients who received prophylaxis, in 10 patients (hemithyroidectomy & total thyroidectomy) antibiotics could have been avoided.

Conclusion: We reiterate that antibiotic prophylaxis in clean surgeries like thyroid and parathyroid have no role, except in some selected cases. Drains did not increase the rate of infection, even in the group of patients received prophylaxis. In a limited resource setting antibiotic add to the cost of treatment and chances of developing secondary resistance. Due to our economic situation the international guidelines of antibiotic prophylaxis need not be adhered to if proper antiseptic precautions are followed.

15. Challenges in the management of Oral Submucous Fibrosis Arora Sonal, Shah Navin Department of Oral and Maxillofacial Surgery, K. M. Shah Dental College and Hospital, Corresponding Email Id: [email protected]

Oral submucous fibrosis is defined as the chronic, insidious disease affecting the oral cavity and sometimes pharynx, although occasionally preceded and/or associated with vesicle formation and is always associated with juxtaepithelial inflammatory reaction followed by fibro elastic changes in the lamina propria with epithelial atrophy leading to stiffness of oral cavity leading to trismus and inability to eat. Oral submucous fibrosis is a chronic debilitating and a well recognised potentially malignant condition associated with areca nut chewing, an ingredient of betel quid and is prevalent in South Asian population. Pathogenesis is not yet established but is believed to be due to multifactorial causes; hence the treatment of oral submucous fibrosis postulates a major challenge for oral physicians and surgeons. Management of this condition is of either medical or surgical means. Various grafts in surgical method are palatal island flaps, temporalis muscle flap graft, split-thickness skin graft, buccal fat pad graft, bilateral nasolabial flap, and tongue flap are used but the treatment remains controversial because of the challenges faced by the surgeons in treatment and the complications.

231 Annual Scientific th 15 Symposium JIC 2019 24th Year of Academics January 4-6, 2019

16. Role of Post Mastectomy Radiotherapy in T1,T2 Lesions With 1-3 Positive Axillary Lymph Nodes - A Retrospective Study of 101 Cases Sadhwani Manish , Tankshali Rajen Gujarat Cancer and Research Institute , Ahmedabad, India Corresponding Email Id: [email protected]

Introduction: Post mastectomy radiotherapy (PMRT) reduces loco-regional recurrence (LRR) and improves overall survival , There is international consensus to recommend PMRT for patients with tumour size more than 5 cm (T3), tumour invasion of the skin, pectoral muscle or chest wall (T4) and patients with > 4 positive lymph nodes (LN) . However, the role of PMRT for patients with T1 , T2 disease with 1–3 positive LN is still controversial. The side effects of radiotherapy and its associated morbidity have to be considered in the risk benefit ratio , thus difficult to arrive at consensus in early breast cancer.In a developing country like India, factors such as patient education, level of awareness, financial aspect, long term follow up, limitation of resources have to be balanced and tailored according to the indication and need of the patient.

Objectives 1.Empirically explore whether it is advisable to carry out radiation when there are 1-3 nodes 2..Whether Perinodal extention in this subgroup is an important parameter to consider for radiotherapy.

Material and Methods: We collected data after approval from our institutional board review committee and analysed case files of patients who presented and were treated at our governmental tertiary referral centre from a period between 2014-2017.Of the 691 patients who underwent mastectomy, we short listed 101 cases for our study who fulfilled our basic inclusion criteria of T1,2 N1 on final histopathology. The inclusion criteria for this analysis were: (1) Female patients with unilateral breast cancer and no distant metastasis at initial diagnosis who underwent mastectomy and axillary lymph node dissection; (2) postoperative pathology indicated T1–2 and 1–3 positive axillary lymph nodes (T1–2N1M0) disease, at least 10 lymph nodes removed by axillary dissection; (3) complete surgical resection of the tumor and negative margins; (4) complete estrogen receptor (ER), progesterone receptor (PR) and human epithelial growth factor receptor family 2 (Her2) status; (5) No neoadjuvant chemotherapy was administered before surgery and endocrine therapy was performed based on the hormone receptor status. In order to study the research questions, we formulated hypotheses as follows,1. Radiotherapy does not have any impact on recurrence post mastectomy.2. There is no influence of Peri nodal extention on recurrence. The above hypotheses were tested using chi-square test.

Results: On applying chi square test we found out the observed and the expected value Radiotherapy was given in 60 patients and 41 were not given .Recurrences were obtained in 9 amongst radiotherapy and without radiotherapy in 16.When chi square was appliedwith 1 degree of freedom , the value was highly significant at 0.006 with 99% CI.Hence our hypothesis was rejected. Also in case of PNE with recurrence and radiotherapy,8 had PNE with radiotherapy and recurrence and 27 had no recurrence,on computation degree of freedom was 3 and p value was 0.013% hence highly significant.

Conclusions: Radiotherapy should be strongly considered in patients with 1-3 nodes post mastectomy as it decreases the chances of recurrence and also if PNE is present chances of recurrence are increased , hence radiotherapy be considered.

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