Medi Magazine kauvery A quarterly magazine from VOLUME - 22 | ISSUE - 01 | JANUARY 2018 - 22 | ISSUE 01 JANUARY VOLUME

Congenital Abdominoplasty kyphoscoliosis correction (Tummy Tuck Surgery)

Bentall Management Of Difficult Procedure Airway Using Awake Fibreoptic Intubation

A case of aplastic anemia presenting with bleeding Boopp manifestations Successfully Treated with ATG.

An unusual case of rapidly progressive Dethethering by renal failure and deformity correction: pulmonary hemorrhage.

World Spine Day Celebration 2017

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CAPSULE MAGAZINE Capsule Magazine is published 01 02 by Kauvery Hospital MANAGING JOINT MANAGING Copyright 2016 © Kauvery Hospital DIRECTOR’S MESSAGE DIRECTOR’S MESSAGE Dr. S. Chandrakumar Dr. S. Manivannan 03 EXECUTIVE DIRECTOR’S PATRONS MESSAGE Dr. S. Chandrakumar Dr. D. Senguttuvan Dr. S. Manivannan 04 06 ADVISORY BOARD Dr. D. Senguttuvan ABDOMINOPLASTY MANAGEMENT OF Dr. Aravindan Selvaraj (TUMMY TUCK DIFFICULT AIRWAY Dr. T. Senthil Kumar SURGERY) USING AWAKE FIBREOPTIC INTUBATION EDITOR Dr. S. Senthil Kumar 07 11 EDITORIAL TEAM BOOPP CONGENITAL Dr. S. Velmurugan Dr. S. Aravinda Kumar KYPHOSCOLIOSIS Dr. Iyyappan Ponnuswamy 13 15 CORRECTION BENTALL A CASE OF APLASTIC PROCEDURE ANEMIA PRESENTING TECHNICAL TEAM WITH BLEEDING Dr. Ve. Senthil Vel Murugan MANIFESTATIONS Dr. A. Subramanian SUCCESSFULLY TREATED WITH ATG. 17 18 ADMIN TEAM Mrs. JPJ. Bindhu BREAKING AN UNUSUAL CASE OF FRONTIERS RAPIDLY PROGRESSIVE ENDOSCOPICALLY RENAL FAILURE AND CO-ORDINATORS PULMONARY HEMORRHAGE. Mrs. G. Percy Mr. Delip Rajkumar S

DESIGN & LAYOUT Editor’s desk Mr. Vahid Ali N. Dear Readers,

It gives immense pleasure to present you the 22nd edition of CAPSULE. On behalf of the editorial team and our hospital consultants, I wish you all a very Happy New Year 2018. The New Year is all about new things. Every New Year is a bundle of New opportunities to perform and grow. Let us Aim for higher goals in 2018 and work hard to achieve them. I thank each and every author of this Edition for their wonderful articles. EDITORIAL OFFICE Kauvery Hospital VI Floor, Administrative Office, #6, Royal Road, Cantonment, Dr. S. Senthil Kumar, Ms., DNB., (Uro) -620001. Call us at (431) 40 77 777 HOD & Senior consultant Urologist and Andrologist Transplant Surgeon, Laparoscopic surgeon E: [email protected] Kauvery Kidney Centre, Tennur, Trichy W: www. kauveryhospital.com My Dear fellow Clinicians,

I wish new beginnings and new hopes for you Kauvery’s journey continues to expand in few and your family in the coming year. 2017 was more locations and doubling the bed capacity a momentous year in which we embarked on in the next couple of years will become a our ambitious journey to become a major reality with all your continuous support. 2018 player in . The year was indeed will be the year of growth, efficiency and another milestone in Kauvery’s journey. We patient safety which will dawn a new era to have started our 7th unit a 175 bed multi become the most respected and affordable speciality hospital at Salem and we have been healthcare provider in the country. implementing various organizational development programs in quest towards become a professionally managed organisation. We have made innovations in our continual Improvement as an integral part of our progress. Our focus on key initiatives like induction of CXO’s across functions, assessment of our talent pool across levels , May this 2018 be a great strengthening the mid management, year and bring happiness Leadership development programs, and many other OD initiatives are in a nascent stage and and good health to all set to yield the desired results.The ultimate you and your family objective of all these efforts has been towards creating and building a hallmark enterprise that would stand the test of time Warm regards Dr. S. Chandrakumar, MD As we commence the New Year, I would like to express my utmost gratitude to all fellow Founder & Managing Director members of the clinical fraternity and family Kauvery Group of Hospitals members for supporting us throughout our journey.

JANUARY 2018 • CAPSULE MAGAZINE • 01 In this turbulent time when the trans deficit among the public is very high, Let us stay united to increase the brand value of doctor’s community. Let’s improve our communications and media visibility and ensure that doctors get the glory which they deserve. Wish you and your family a great year ahead.

Warm regards Dr. S. Manivannan, MD, DNB Joint Managing Director

02 • CAPSULE MAGAZINE • JANUARY 2018 Dear Colleagues,

I wish you and your family a happy and Kauvery assure to give affordable great successful new year 2018. healthcare as per our core values like Continual Improvement, Heartfelt Personal The start of a new calendar year 2018 seems Touch, Ethical, Empathetic Care, Real like an obvious time to talk about new accountability and Service Excellence. I thank beginnings. Each New Year brings new hopes one and all for your continuous support. and aspirations, new goals, targets and new challenges for us to explore new ideas. Let’s Once again I wish you all a very successful work towards our goals and find ourselves year ahead!! serving as the ideal for this year.

Change is inevitable. Nowadays lot of criticism about doctors and hospitals are happening in Social Media. It is the time to think about the Regards same. The challenges are to be met with Dr. D. Senguttuvan courage to bring positive change in the field. Executive Secretary We will equip ourselves with good Kauvery Hospital – Cantonment, Trichy communication skill and proper documentation to see success.

JANUARY 2018 • CAPSULE MAGAZINE • 03 ABDOMINOPLASTY(TUMMY TUCK SURGERY)

Dr A Arul MozhiMangai,MBBS, MS (General Surgery), Abdominoplasty M Ch () Consultant Plastic and Aesthetic Surgeon, (Tummy Tuck Kauvery Hospital,. Surgery)

The common perception of Abdominoplasty or tummy excess skin and sufficient Female patients must plan beauty in the human body tuck procedure reduction of subcutaneous abdominoplasty after has undergone a dramatic encompasses not only adipose tissue volume can completing family. It is not change in the past three aesthetic body contouring be achieved. Additionally necessary to achieve a decades, culminating in a but also reconstruction closure of specific weight for this pre-occupation not only ofstructural integrity. The musculoaponeurotic laxity procedure but need to fulfill with body weight but also aesthetic goals of improve overall contour few conditions. with body contour. abdominoplasty are to and restore the structural improve the contour, integrity of abdominal wall. The emphasis made by minimize scarring and to modern society on a lean maintain a natural looking The patients’ skin type and PRESENTATION youthful appearance is umbilicus. Both age play an important part Weight is the first important largely responsible for the reconstructive and aesthetic in this surgery. In many factor that affects increased demand for goals should be patients it is not possible to presentation of patients. BMI surgical procedures incorporated in any remove all striae and folds which relates weight to designed to produce an abdominoplasty procedure. and this will be explained to height is most ideal aesthetic contour. Ideally maximal resection of the patients before surgery. commonly used parameter.

04 • CAPSULE MAGAZINE • JANUARY 2018 ABDOMINOPLASTY(TUMMY TUCK SURGERY)

BMI = weight in kg/height in which skin is over expanded Drains are placed to prevent deleterious effect in wound m2. Upper limit of normal leading to a loose inelastic hematoma and seroma. healing. BMI is 25. 26-30 is skin fat envelope. Compression garment is considered overweight, 30 used in the post operative Abdominoplasty is and above is obese. PATIENT SELECTION AND period. performed by a qualified TECHNIQUE Plastic Surgeon after A variety of surgical Patient who have minimal to Patients who present with complete evaluation of the procedures is required to moderate subcutaneous fat laxity of skin below and patient. treat patients in different excess and no abdominal above the umbilicus are BMI ranges. wall laxity are good good candidates for full POST OPERATIVE CARE candidates for liposuction abdominoplasty. In this After surgery, the patient is Second factor that affect the alone. In this surgery, surgery, rectal fascia advised analgesics and presentation is fat through small incisions in plication above and below antibiotics for a few days. deposition pattern which is abdomen, fat is sucked out the umbilicus, along with They are also encouraged to genetically controlled. using cannulas. excision of excess skin and wear a tight jacket called Women typically deposit fat creation of new umbilicus is compression garment to in infraumbilical abdomen, Patients who present with done. Liposuction can be reduce the swelling. Light thighs and hip. Men in abdominal wall laxity with combined with work can be resumed after flanks, below umbilicus and minimal abdominal skin abdominoplasty to get good 2-3 days. Complete inside abdomen. excess below the umbilicus aesthetic results. Drains are recovery is expected in two are good candidates for placed and compression weeks. Like all surgeries, Quality of skin fat envelope mini abdominoplasty. These garments are used in post there are some is a third factor to evaluate. patients are usually young operative period. complications that can Women who have had one women who have had one happen which include or more pregnancies tend or two pregnancies, have PRE-OPERATIVE seromas, the most common to have abdominal skin good skin elasticity and are REQUIREMENT complication, wound laxity and stretch marks. A not overweight. Infra Heart disease, diabetes, healing problems, bleeding, similar process occurs with umbilical rectus fascia lung disorders must be infection, thrombosis and massive weight gain and plication with removal of under control before contour deformities, but subsequent weight loss in excess skin and fat is done. surgery. Smoking has they are not very common.

Organ Donation Awarness Program

Program Name : Seminar on Organ Donation

Month : Dec’17

Cause : To Spread and create awareness about Organ donation.

Venue : Conference Hall, Kauvery Hospital

JANUARY 2018 • CAPSULE MAGAZINE • 05 MANAGEMENT OF DIFFICULT AIRWAY USING AWAKE FIBREOPTIC INTUBATION

Management Of Difficult Difficult airway is the clinical situation in which an anesthetist experiences difficulty Airway Using Awake with facemask ventilation, difficulty in supraglottic device ventilation, difficulty in Fibreoptic Intubation tracheal intubation or all three. Awake fibreoptic bronchoscope (FOB) intubation is an essential skill in the management of a patient with a known difficult airway or who has an anticipated difficult airway as found during the airway assessment preoperatively. This is a technique which allows a flexible oral or nasal route to Dr. Velmurugan Deisingh., MD(Aneasthesiology)., provide a clear visualization of the vocal Consultant, cords and subsequent passage of an Dr. Karishma Puthanpura., endotracheal tube into the trachea under Resident Dept. of Anaesthesia direct vision. Kauvery Hospital, Chennai

WHEN DO WE USE application of 2% lignocaine nasal passage and vocal FIBREOPTIC INTUBATION? jelly, sometimes accompanied cords into the trachea. After Reduced neck mobility: with use of decongestants like the insertion of endotracheal Rheumatoid arthritis, oxymetazoline drops. The tube the patient is completely Ankylosing spondilitis, oropharynx is anaesthetized anaesthetized with osteoarthritis & surgical by using 10% lignocaine intravenous or inhalational fixation of cervical spine spray. This passage can also agents. be anaesthetized my using Fibreoptic bronchoscope Reduced mouth opening: nebulization with 2% Reduced mobility of TM joint, lignocaine mixed with normal CONCLUSION trismus, scarring, contractures saline. Cricothyroid Awake FOB intubation is the and fibrosis, local lesions and (transtracheal) block and gold standard of swelling superior laryngeal nerve management of the predicted block with 2% lignocaine with difficult airway. With the use Lesions of the larynx, pharynx adrenaline anaesthetizes of this technique the need for and tongue – tumors, fibrosis trachea and larynx invasive procedure like Anaesthetists performing FOB intubation (previous radiation of neck) respectively tracheostomy in patients with and swelling. difficult airway has come The FOB with the down. As the patient remains Congenital syndromes and endotracheal tube is inserted awake and maintains a patent conditions: with facial through the nostril and airway during the procedure, deformities, cystic hygromas, advanced inward to enter the the chances of desaturation achondroplasia nasopharynx. Steer the FOB and hypoxic injuries have into the oropharynx, to see been minimal. HOW IS AWAKE the epiglottis. It is then A view through the FOB FIBREOPTIC INTUBATION advanced further into the The anaesthesia team of PERFORMED? laryngeal opening until it Kauvery hospital,Chennai has As the name implies, FOB enters the subglottic space, used this technique in more intubation is performed in an enters the trachea and carina than 50 patients with difficult awake patient under mild is identified. The FOB and tip airway over the last 3 years sedation and local of the ETT is lubricated, so as for surgeries in various anaesthesia of the airway to ease the passage of the department like oncosurgery, passages. The nasal mucosa ETT over the FOB and the plastic surgery and Patient with perioral burns is anaesthetized by local ETT is inserted through the oro-facio-maxillary surgery. contracture– case of difficult airway

06 • CAPSULE MAGAZINE • JANUARY 2018 BOOPP

Boopp Organising pneumonia is defined histopathologically by intra-alveolar buds of granulation tissue, consisting of intermixed myofibroblasts and connective tissue. Although nonspecific, this histopathological pattern, together with characteristic clinical and imaging features, defines cryptogenic organising pneumonia when no cause or peculiar underlying context is found. Rapid clinical and imaging improvement is Dr. Raghav Raj obtained with corticosteroid treatment, but relapses Resident, Internal Medicine are common after stopping treatment. Kauvery Hospital, Chennai

Case report: AND C,ANTI DS 75 year old female came to DNA,APL,LUPUS ANTI medicine opd with chief COAGULANT which were complaints of high grade all negative. and continuous fever for the A diagnoses of past two days and cough Cryptogenic organising for the past two months not pneumonia was made and associated with sputum. She patient was started on iv was a known hypothyroid A provisional diagnosis of community Ct chest was done on third day of methylprednisolone. Patient on Tab. thyronorm 0.75mg acquired pneumonia / atypical admission improved symptomatically pneumonia was made. with no other comorbids. and radigrapically after two days of iv steroids. She was febrile (101F),with And patient was started on saturation of 98% on room antibiotics Xray chest after two days of air. She had bilateral lower (piperacillin+tazobactam steroid therapy-shows lobe crepts R>L. Other and c.doxy). decrease in patchy Systemic examinations was consolidation. uneventful. On the second day of admission patient On blood complained of difficulty in investigations,patient had breathing with a saturation neutrophilia and elevated of 84% on room air and ESR and CRP d-dimer-1.15, increase in b/l crepts .She TROP-I negative.2d echo was under non invasive showed-Ejection fraction of ventilator support and later 62% shifted to venture mask.Her Ct chest revealed multiple throat swab for h1n1 was patchy consolidation in sub Chest xray on the day of negative. A repeat xray pleural and peri She improved symptomatically and admission showed multiple -showed increase in bronchovascular location was discharged with tapering dose patchy air space opacity in multiple patchy air space of oral steroids. predominantly in the right bilateral lung fields(r>L) opacity in bilateral lung side . Blood investigations fields(r>L). was done for ANA, ANCA-P

JANUARY 2018 • CAPSULE MAGAZINE • 07 BOOPP

DISCUSSION progressively mild Histology too old to undergo lung Cryptogenic organizing dyspnoea, anorexia and Patchy fibroblastic plugs in biopsy, or refusing lung pneumonia (COP) is a form weight loss. Dyspnoea may bronchioles and alveolar biopsy, corticosteroid of organizing pneumonia occasionally be severe, ducts (bronchiolitis treatment can be started (OP) for which no specific especially in the eventuality obliterans) and alveoli provided patients have cause is known.There are of rapidly progressive (organizing pneumonia) been informed that many theories for COP,one disease. Physical Plugs formed by spindled diagnosis is only probable nbotable theory proposed examination usually fibroblasts in pale-staining and that a careful follow-up by Milne described a type discloses focal sparse matrix with serpiginous or is programmed. of pneumonia “where the crackles, but may be almost elongated shape. usual process of resolution normal. There is no finger TREATMENT has failed and organisation clubbing.which was very Diagnosis Corticosteroid treatment in of the inflammatory similar to our patient. Clinical features imaging COP results in rapid clinical exudate in the air alveoli of studies and histopatholgy improvement and clearing the lung by fibrous tissue Imaging features combines to give adiagnosis of the opacities on chest has resulted” (resolution was Multiple alveolar opacities of COP. imaging without significant the third stage in the course on imaging represent the But generally COP is a sequelae. However, relapses of pneumonia as described most frequent and typical diagnosis of exclusion,after are common upon stopping by Laennec, which followed imaging features of COP . ruling out all causes of or reduction of the stages of congestion These are usually bilateral organising pneumonia. corticosteroids, thus often and hepatisation) and peripheral, and are Whether a diagnosis of leading to prolonged often migratory. organising pneumonia may treatment. Although the Clinical features On high-resolution be accepted or not without efficiency of corticosteroid Males and females are computed tomography histopathology and based treatment has long been equally affected by COP, (HRCT) scan, the density of only on clinical and imaging established, as is usual in with mean age of onset opacities ranges from findings requires such so-called orphan 50–60 yrs. Clinical ground glass to consideration, especially diseases the precise dose manifestations begin with a consolidation and more because it is increasingly and duration of treatment mild flu-like illness with opacities are detected than frequent in clinical practice. have not been established. fever, cough, malaise and on chest radiographs. In patients too frail and/or

BLS Awareness Program Program Name : BLS Awareness Month: Dec’17 Cause : To Educate do’s & don’ts of first Aid. Venue : Cauvery Global school & College, Trichy

08 • CAPSULE MAGAZINE • JANUARY 2018 We extend a hearty welcome to our Kauvery family

DR. SWAMINATHAN K, DR. GOKULA KRISHNAN, DR. S. MUBARAKALI, MD., MD., MBBS, MEM, CANTONMENT, TRICHY CANTONMENT, TRICHY HOSUR

DR. SANJEEV PRATAP, DR. SRIHARI, DR. VARUN PRASANNA, MBBS., FAEM., MCEM., FRCEM., MS., MCH(PURSUING)., MD., HEARTCITY, TRICHY TRICHY TRICHY

DR. JOHN EDMUND BENNY, DR. R. VILLALAN, DR. P. VIJAY SHEKHAR, M.S. FASM (ISAKOS)., FIJR(ARTHROPLASTY)., MBBS., MS., M.CH., MD., DM(CARDIO)., TENNUR, TRICHY TENNUR, TRICHY HEART CITY, TRICHY

DR. MANOOJ KUMAR, DR. SASI KUMAR, DR. FAZAL, MS (ORTHO)., MS., M.CH., MD., DM., CANTONMENT, TRICHY CANTONMENT, TRICHY CANTONMENT, TRICHY

JANUARY 2018 • CAPSULE MAGAZINE • 09 We extend a hearty welcome to our Kauvery family

DR. ARIVARASAN, DR.G.VIVEKANANDAN DR.A.SENTHILRAJAN MD., DM., MS.,M.CH(URO)., MS(ORTHO)., CANTONMENT, TRICHY SALEM SALEM

DR.S.SATHISH KUMAR DR.P.SARANYA DR. PARTHASARATHY M. MD(ANAES & CRITI CARE).,DNB.,MNAMS MD(PAED)., MD(ANAES & CRITI CARE) SALEM SALEM SALEM

DR.S.KAVITHA DR.B.KARTHIKUMAR DR.A.JAGADEESAN MD(INT. MED.).,DNB(CARDIO)., DMRD,DNB(RD)., MBBS.,DLO.,MD(GEN. MED.)., SALEM SALEM SALEM

DR.R.ASHOK DR.P.ARUN PALANI DR.A.VIGNESH MD(A & E).,FICM.,FIAEM., M.CH(NEURO SURGERY)., MD.,DM() SALEM SALEM SALEM

10 • CAPSULE MAGAZINE • JANUARY 2018 CONGENITAL KYPHOSCOLIOSIS CORRECTION

Congenital complex spinal surgeries and spinal deformity correction kyphoscoliosis cases such as this case are always done under correction intra-operative monitoring. Thus Neurosurgeons, spinal surgeons, anesthetists and neurologists work as a complete team.

Dr. Vignesh Pushparaj Consultant Spine Surgery Dept. of Spine & Neurosurgery Kauvery Hospital, ChennaiNAI

Case report: Management: A 14-year-old Under intraoperative neural detecting changes which female patient monitoring, through posterior will alert if any surgically presented to only approach. After placing induced insults occur. us with hunch adequate anchors above and back/ below the hemi vertebra in It is becoming a part of Congenital kyphoscoliosis deformity the form of pedicle screws, standard medical practice results from developmental over the spine we performedhemi vertebral and has been utilized in vertebral anomalies. Even which was resection initially followed by attempts to minimize after skeletal maturity, it can noticed 3 years multiple osteotomies at 6 neurological morbidity from progress. In addition to prior to levels to achieve correction operative manipulations. cosmetic problems, many presentation and in a step by step fashion The goal of such monitoring patients have significant back her deformity was to get acceptable is to identify the changes in pain and functional disability. gradually position with rods over brain, spinal cord and Others present with progressing with the screws. peripheral nerve function neurological symptoms as a associated back pain. prior to irreversible damage. result of both direct The child was unable Intra-operative compression and traction of to lie supine over his neurophysiological Incidence of iatrogenic the spinal cord over the back for the past 3 years monitoring (IOM) paraplegia despite best deformed curve. Surgical due to the deformity. On is used to assess practice in spinal deformity correction is the only clinical examination the function of corrective surgeries is 0.6 to treatment for significant patient had a spinal cord 3.5 %. With IOM, there is an spinal deformity which kyphoscoliosis at estimated 80- 90 % progress. The important goal thoracolumbar spine reduction in morbidity. Type of surgery is to allow the without any transmission of anesthesia matters very spine and chest to grow neurological deficit and function much during surgeries with appropriately. Radiological investigations during an IOM for optimal results and showed crowding of ribs with operation. As we in kauvery hospital, have a D11 hemi vertebra, which part of IOM, we devised a specific protocol was found to be the major use to ensure best results. reason for the thoracolumbar neurophysiological kyphoscoliosis. parameters for In kauvery hospital,

JANUARY 2018 • CAPSULE MAGAZINE • 11 CONGENITAL KYPHOSCOLIOSIS CORRECTION

complex spinal surgeries and spinal deformity correction cases such as this case are always done under intra-operative monitoring. Thus Neurosurgeons, spinal surgeons, anesthetists and neurologists work as a complete team.

Case report: Management: A 14-year-old Under intraoperative neural detecting changes which female patient monitoring, through posterior will alert if any surgically presented to only approach. After placing induced insults occur. us with hunch adequate anchors above and back/ below the hemi vertebra in It is becoming a part of deformity the form of pedicle screws, standard medical practice over the spine we performedhemi vertebral and has been utilized in which was resection initially followed by attempts to minimize noticed 3 years multiple osteotomies at 6 neurological morbidity from prior to levels to achieve correction operative manipulations. presentation and in a step by step fashion The goal of such monitoring her deformity was to get acceptable is to identify the changes in gradually position with rods over brain, spinal cord and MOST ADVANCED progressing with the screws. peripheral nerve function associated back pain. prior to irreversible damage. IMAGING TECHNOLOGY The child was unable Intra-operative to lie supine over his neurophysiological Incidence of iatrogenic MRI – MAGNETIC back for the past 3 years monitoring (IOM) paraplegia despite best due to the deformity. On is used to assess practice in spinal deformity RESONANCE IMAGING clinical examination the function of corrective surgeries is 0.6 to patient had a spinal cord 3.5 %. With IOM, there is an -3T IMAGING. kyphoscoliosis at estimated 80- 90 % thoracolumbar spine reduction in morbidity. Type without any transmission of anesthesia matters very • Tim Technology for faster exano and better neurological deficit and function much during surgeries with image quality Radiological investigations during an IOM for optimal results and showed crowding of ribs with operation. As we in kauvery hospital, have • Comprehensive Neuro and Cardiac imaging with a D11 hemi vertebra, which part of IOM, we devised a specific protocol spectroscopy and Fibre tracking enabled was found to be the major use to ensure best results. reason for the thoracolumbar neurophysiological • Quite suite – silent MRI (First of its kind in Trichy) kyphoscoliosis. parameters for In kauvery hospital, • Conducive ambience to overcome claustrophobia

12 • CAPSULE MAGAZINE • JANUARY 2018 BENTALL PROCEDURE

proximity to aortic arch. normal value of 24-36 mm, Bentall Aortic root Replacement and its dilation for a with 27mm mechanical St diameter >40 mm is called Procedure Jude Aortic valved conduit. aneurysm). In this case the The right and left coronary ascending aorta was dilated buttons were anastomosed to 7.8 cm. Ascending aortic to aortic root in a aneurysms are exposed to continuous fashion. The the risk of rupture with patient was cooled to 20oC sudden death from cardiac and total circulatory arrest tamponade, or dissection. initiated and distal end of The pathologic changes in Dr. K. Raghavan., M.D. (Internal Medicine) the root graft was the ascending aorta can Consultant, Internal Medicine Dept. of General Medicine & Diabetology Kauvery Hospital, Chennai

A 40 years old regurgitation with severe anastomosed to the aorta cause aneurysmal dilation hypertensive gentle man left ventricular dysfunction. just proximal to take off of of the aortic root, which can presented with complaints A decision for surgical Innominate artery (open affect the ability of the of severe breathlessness on correction was taken. Risk distal anastomoses) .Post aortic valve cusps to close, exertion and recently at rest evaluation by the new procedure patient leading to valve (NYHA III-IV) for one week. EUROSCORE(2011) hemodynamically stable incompetence and aortic He was evaluated elsewhere predicted a peri-operative and showed gradual regurgitation. When the for his symptoms and his mortality risk of 31.5%. The improvement and aortic valve is incompetent, Echocardiogram showed patient was taken for discharged in a week. the valve fails to close aneurysmal dilatation of surgery after explaining the completely, causing a ascending aorta, severe high risk of peri operative Repeat CT scan showed no backflow of blood into the aortic regurgitation, dilated morbidity and mortality. perigraft leak and normally heart from the aorta and left ventricle ( LV EDD- 8.1 functioning valve. increasing the workload of cm & LV ESD – 6.3 cm ) Bentall procedure was done the left ventricle. Left with severe left ventricular which involves replacement Discussion: ventricular hypertrophy may dysfunction (EF – 24%). The of ascending aorta and Aortic aneurysm is defined result from the increased patient was referred here aortic valve with coronary as a permanent dilation of workload and progress to for further management. implantation with a valve the aortic wall that exceeds left heart failure if the aortic Further evaluation by CT conduit. Establishment of 1.5 times the normal regurgitation is not treated. angiogram confirmed the cardiopulmonary bypass diameter of the aorta. (i.e., The Bentall’s procedure is a diagnosis of severe annulo- was difficult as Arterial the segment of the surgical repair of an aortic ectasia, severe aortic cannulation was in close ascending aorta has a ascending aortic or aortic

JANUARY 2018 • CAPSULE MAGAZINE • 13 BENTALL PROCEDURE

root aneurysm in procedure, a composite full-thickness "button" of Post-operative: combination with aortic aortic valve graft is used to aorta surrounding the valve disease. Less replace the proximal coronary ostia, making it commonly, it is used to ascending aorta and aortic easier to implant the repair aortic dissection valve. The procedure is proximal end of the affecting the aortic root and performed through a coronary arteries into valve. During the median sternotomy during openings made in the aortic cardiopulmonary bypass. In vascular graft. this modification of the Ascending aortic aneurysm original procedure, is a lethal disease. Elective coronary artery circulation surgical repair remains the is maintained by removing a gold standard for the management of symptomatic aneurysm or asymptomatic aneurysm with a diameter ≥ 5.5 cm, Lower threshold of aortic diameter for surgery should be considered for patients with aortopathy related to congenital disorders (i.e., Marfan syndrome, bicuspid aortic valve), and Bentall operation can be considered the gold standard surgical therapy in this subset of patient population.

Pre-operative:

14 • CAPSULE MAGAZINE • JANUARY 2018 A CASE OF APLASTIC ANEMIA PRESENTING WITH BLEEDING MANIFESTATIONS SUCCESSFULLY TREATED WITH ATG.

A case of aplastic anemia presenting with bleeding

manifestations Dr. K. Raghavan., M.D. (Internal Medicine) Consultant, Internal Medicine Successfully Treated Dr. Dulam Deepika., MBBS., DNB (MCH) with ATG. Resident Consultant, Internal Medicine Dept. of General Medicine & Diabetology Kauvery Hospital, Chennai

The article describes a case The congenital type (25%) transfusions / exposure to The peripheral smears of aplastic anemia in a usually associated with radiation / intake of any revealed normocytic 35-year-old male patient Fanconi’s anemia and anticancer drugs. normochromic anemia with which presented with dyskeratosis The patient was a known marked reduction in the generalized weakness, rash congenita.Acquired type case of type 2 diabetes number of white blood cells and epistaxis (75%). The causes for half of mellitus and was on T. and platelets with normal Introduction the acquired type is Metformin and T. morphology. Aplastic anemia is a serious idiopathic. Potential triggers Glimepiride since 4 years. Bone marrow aspiration and often fatal hematologic for the onset of aplastic On examination, severe cytology was advised to the disorder characterized by anemia include cytotoxic pallor was seen in lower patient which was hypoplastic bone marrow drugs, T-cell mediated palpebral conjunctiva. inadequate. Bone marrow and peripheral auto-immune disease, Petechial rash was present biopsy was done which pancytopenia. Aplastic iatrogenic agents, viral on the bilateral upper and showed marked hypo anemia is a rare, non infection and pregnancy. lower limbs. Bruises present cellular marrow with contagious, non infectious over left lower limb. No trilineage suppression, and potentially life Case report lymphadenopathy, No absent megakaryocytes and threatening disorder caused 35-year-old male patient pedal edema. Abdominal patchy by destruction of admitted in general examination revealed no lymphoplasmocytosis. pluripotent stem cells in the medicine department in organomegaly. Other The diagnosis of aplastic bone marrow kauvery hospital with systems examination was anemia was established and Clinically it presents with generalized weakness for unremarkable. the patient was referred to bleeding manifestations the past 2 months. Complete Hemogram of a higher center for further most commonly due to Epistaxsis spontaneous in the patient revealed investigation and thrombocytopenia but also onset, 2 episodes in the last pancytopenia with management. can present with fatigue, 4 months. History of hemoglobin of 5.6 gm%. FISH(fluorescence in situ lethargy due to anemia and bleeding gums since 2 days. Total leukocyte count was hybridization) was done in recurrent infections due to History of rash over 1350 cells/mm3 (P–49%, higher centre which was neutropenia. Equal forearms, thighs since 1 day. L–54%, M–02%, E–01%, 100% negative for incidence in both males and History of recurrent fever B–0%). ESR was raised to 99 monosomy 7, contributing females with biphasic low grade, intermittent, mm in the 1st hour. to good prognostic distribution with major peak subsided with medications. Bleeding time and Clotting outcome. in teens and a second rise The patient reported a time was normal. Platelet Due to lack of compatible in elderly. The diagnosis negative history of count was only 14,000 donar, bone marrow ‘aplastic anemia’ is hemoptysis / hematemesis / cells/mm3. Serum iron was transplantation was not confirmed by hypocellularity hematuria / rectal bleeding/ 112mg/l, Serum B12 – 217 done. He was treated with of the bone marrow. jaundice / joint pains / p/ml, Serum Folic acid – PRBC and Platelets, Inj. ATG Aplastic anemia is classified swelling of gums. No 16.12 ng/ml. Coombs test 40mg/kg/day for 4 days (16 as congenital or acquired. history of blood and HAM test – negative. vials in 1 lit NS over 8 hours

JANUARY 2018 • CAPSULE MAGAZINE • 15 A CASE OF APLASTIC ANEMIA PRESENTING WITH BLEEDING MANIFESTATIONS SUCCESSFULLY TREATED WITH ATG.

for 4 days), Inj. Dexa 8mg IV OD for 4 days. Following symptomatic improvement he was discharged Bone with tapering dose of oral steroids and T. cyclosporin 5mg/kg BD after stopping steroid. Currently he is doing well and his blood counts are fairly within normal limits. Residual marrow tissue Discussion: Aplastic anemia is a rare hematologic disease characterized Fat cell deposition by a hypoplastic bone marrow and peripheral pancytopenia. Most common presentation of aplastic Bone marrow trephine biopsy o a case of aplastic anemia showing marked anemia is bleeding tendencies. A decrease in hematopoietic marrow cells with replacement by of fat cells. diagnosis of aplastic anemia should be suspected when there is pancytopenia and no lymphadenopathy or organomegaly. Apalstic anemia and hypoplastic myelodysplastic syndrome are difficult to differentiate even with bone marrow biopsy. The definitive treatment for both aplastic anemia and hypoplastic MDS is Allogenic bone marrow transplantation. Anti Thymocyte Globulin and immunosuppressive drugs are to be considered when BMT cannot be done. The 4 year survival rate with ATG an immnosuppressive drugs is Bone marrow biopsy specimens of Bone marrow biopsy specimens of upto 89%. aplastic anemia. normal marrow

Petechiae

Bruise

Bleeding manifestations in a patient of aplastic anemia

16 • CAPSULE MAGAZINE • JANUARY 2018 DETHETHERING BY DEFORMITY CORRECTION:

Breaking Frontiers Endoscopically Dr. G. Jos Jasper., MBBS., M.Ch (Neuro Surgery)., HOD & Sr. Consultant Dr. MadhuSuthan Dr Srihari (Registrar)

Kauvery Brain & Spine Centre, Trichy

The Neuro Endoscope has For the first time in , causing obstructive curve is very steep as the changed the way the world’s most advanced Hydrocephalus. light source is 30 degrees Neurosurgery is being endoscopy unit , “Aesculap Normally either a needing very precise practised. From simple Min Invent” the only 4 port microscopic transcortical manipulation and the need Endoscopic Third system in the world was trans ventricular approach to reorient one’s Zero Ventriculostomy to 4 introduced into our or the use of the routine degree learning. Handed Extended department. It has got 4 endoscope is done. In Endoscopic Skull Base ports, with the main routine endoscopy if the procedure it has indeed elliptical instrument port cyst wall is very adherent or taken the world by storm. taking in two instruments, if its contents too thick then The usual Neuro endoscope so that the surgeon can only a fenestration is done. has 3 ports – for the light grasp and cut or grasp and We used Neuro Navigation source, suction and one for dissect, which is the more (Nav I3) to guide our the main surgical working anatomical way of doing trajectory. Once inside the instrument. So irrespective things. Aesculap Min Invent was a of however good the boon. The adherent cyst surgical skills were, it was 37 year old lady presented was held and dissected always limited by the fact with sudden onset of very using the special forceps that only one working severe headache with and dissectors and the cyst instrument could be used associated vomiting. She removed totally. –either a dissector or a also had a syncopal It has proved its worth in forceps but never both episode. Work up showed a many other procedures together .. that is till now. third ventricular Colloid Cyst since then. The learning

JANUARY 2018 • CAPSULE MAGAZINE • 17 AN UNUSUAL CASE OF RAPIDLY PROGRESSIVE RENAL FAILURE AND PULMONARY HEMORRHAGE.

An unusual case of rapidly progressive renal failure and Dr. B.Balaji Kirushnan., MBBS., MD (General Medicine)., PGDHSc Diabetology., DNB () pulmonary hemorrhage. Consultant Nephrology Department of Nephrology

Rapidly progressive renal had history of left leg deep admission. On examination In view of sudden onset of failure encompasses a vein thrombosis in he was tachypnoeic with a renal failure with spectrum of diseases which 2011following history of respiratory rate of 33/min, hemoptysis a provisional show a significant decline in long haul air travel for tachycardic with a pulse diagnosis of Rapidly renal function over days to which he received rate of 110/min and progressive weeks with azotaemia, subcutaneous heparin for a hypertensive with a blood glomerulonephritis with proteinuria and hematuria. few days and was stopped pressure of 190/100mm of pulmonary hemorrhage Pulmonary hemorrhage is a later. No further Hg. He had dry gangrene was made. Vasculitic common extra renal investigations were done at of the left 2nd toe and markers were sent. He was manifestation of the that point of time. He had peripheral pulses were commenced on plasma disease. Good pasture’s history of left parotid feeble on the left leg. He exchange 4L with FFP and disease, Microscopic swelling with fever and had bilateral coarse albumin, IV Methyl polyangitis, Granulomatosis underwent left crepitations. polyangitis are a few of the parapharyngeal abscess pulmonary renal syndromes drainage in year 2013. He Urea 95mg% which a nephrologist had gangrene of the left Creatinine 6.5mg% commonly encounters. 3rd toe which was Hemoglobin 6.2gm% Diffuse alveolar amputated in a nearby hemorrhage in anti hospital 1month ago. Total count 13,200 cells/cumm phospholipid antibody Routine blood tests done Platelet count 2.30 lakhs/cumm syndrome is very rare and is one month ago showed associated with poor normal renal functions, no PT INR 1.30 prognosis. Acute kidney proteinuria and normal Sodium 133 injury can occur because of hemoglobin. He was Potassium 4.8 diffuse vascular thrombosis having impending involving the renal arcuate gangrene of the left 2nd Bicarbonate 19 arteries. We report a rare toe and was on dual T.Bilirubin 0.9 case of APLA syndrome antiplatelets. . He has no D.Bilirubin 0.7 with diffuse alveolar history of diabetic hemorrhage and acute retinopathy. He also denies Total Protein 5 kidney injury. history of non steroidal anti S.Albumin 3.2 inflammatory drugs and Case report: native medicines Urine albumin +++ Mr G aged 43 years, non He presented with history of Urine RBC Plenty smoker and non alcoholic, pedal edema, Urine WBC Plenty is a known diabetic since 10 breathlessness and oliguria years on oral anti from 5 days. He had CT chest showed bilateral ground glass opacities involving both lung fields with hyperglycemic drugs. He hemoptysis at the time of interstitial thickening and reticular shadows.

18 • CAPSULE MAGAZINE • JANUARY 2018 AN UNUSUAL CASE OF RAPIDLY PROGRESSIVE RENAL FAILURE AND PULMONARY HEMORRHAGE.

prednisolone 500mg and Renal biopsy showed only made. Patient received reported by mayo clinic tablet mycophenolate IgA in the mesangium and 1mg/kg of steroids, study in 2012. Renal moeftil 500mg twice a day there were no glomeruli in Cyclophosphamide 2mg/kg involvement in primary APS as a life saving measure. He the light microscopy per oral daily and Rituximab is typically caused by underwent 3 plasma specimen. Plasma exchange 375mg/m2 weekly for 2 thrombosis occurring at any exchanges and was was stopped and patient doses. location within the renal symptomatically better with was continued on steroids He was discharge with vasculature, leading to no hemoptysis, o.5mg/kg per day. Patient home BiPAP therapy . He diverse effects, depending breathlessness improved deteriorated after 1 week of developed respiratory on the size, type and site of and was on low flow oxygen hospital stay, he had failure and succumbed to the vessel involved. The inhalation. worsening breathlessness his illness. renal manifestations of APS and cough. Repeat CT scan thus may include renal Anuric state continued and showed features of Discussion: artery stenosis (RAS) and/or he was on hemodialysis worsening of alveolar The frequency of APS in the renovascular hypertension, every alternate day. Anti opacities suggesting general population is renal infarction, renal vein GBM antibodies were worsening pulmonary unknown. One to 5% of thrombosis, and increased negative. ANA was positive hemorrhage. healthy individuals have aPL allograft vascular 1 in 100 dilution with Anticardiolipin antibody IgG antibodies. It is estimated thrombosis. It is important dsDNA, ANCA being was positive in 69.70 IU/ml that the incidence of APS is to rule out secondary negative. Anti Scl 70 and (>20IU/ml). Lupus approximately 5 cases per causes of APLA syndrome Anti mitochondrial anticoagulant was positive. 100,000 persons per year, like SLE or other connective antibodies were positive. All Anti beta2glycoprotein IgG and the prevalence is tissue diseases as secondary other extractable nuclear was positive in 169.4 IU/ml approximately 40-50 cases APLA syndrome is more antigens were negative. He (>20 is positive). Hence per 100,000 persons. common than primary underwent renal biopsy diagnosis of Diffuse alveolar APLA syndrome although from the lower pole of the Antiphospholipid antibody hemorrhage is a very rare the treatment maybe on left kidney. Only one sample syndrome with diffuse manifestation of APLA similar lines. core was obtained as alveolar hemorrhage and syndrome with 18 cases patient was tachypnoeic. acute kidney injury was over a 15 year period being

JANUARY 2018 • CAPSULE MAGAZINE • 19 WORLD SPINE DAY CELEBRATION 2017

World Spine Day celebration 2017

“Every year on October 16th people from around the world join together on World Spine Day to raise awareness about spinal disorders as part of the Bone and Joint Decade’s Action Week. This year, we have organized on 15th October 2017 by inviting Mr.James Vasanthan - Film maker & Music composer as a chief guest and the entire program was lead by Dr.Jos Jasper MBBS.,M.Ch(Neuro Surgeon),Trichy Around 180 people with their families participated and made this awareness program as a memorable day. Entire program was completely interactive and informative to all participants”

“Your health is an investment, not an expense”.

20 • CAPSULE MAGAZINE • JANUARY 2018 APRIL 2017 • CAPSULE MAGAZINE • 14 HEALTH RECIPE - OATS PONGAL - OATS BREAKFAST RECIPES

HEALTH RECIPE Oats Pongal - Oats Breakfast Recipes

Ingredients needed Preparation: Oats - 1/2 cup Soak moong dal (split green gram dal) in hot water for 10 Split yellow moong dal/pasi paruppu - 1/4 cup minutes and cook until soft. Cashew nuts - 3 (break it into 2-3 pieces) Fry cashew nuts in 1/2 tsp of ghee until golden brown. Salt as needed Fry oats in 1/2 tsp of ghee for 2 minutes in low flame. Ghee for frying cashew nuts and oats -1 tsp Method: For the seasoning Cook oats in half a cup of water adding salt. Then add cooked moong dal to oats and cook for some more time until well Ghee/ clarified butter - 2 tsp blended. Check for salt. Ginger finely chopped - 1 tsp Heat 2 tsp of ghee, add pepper and jeera seeds, when jeera Whole black pepper -1 tsp sizzles, add ginger, curry leaves, saute for a second and pour it Cumins seeds/ jeera -1 tsp over the cooked oats + dal mix. Mix well. Garnish with cashew Curry leaves -few nuts and serve hot with coconut chutney or pongal sambar.

About This Recipe:

Calories 147 Sodium 1 mg Vitamin A 0% Calcium 0% Total Fat 2 g Potassium 0 mg Vitamin C 0% Iron 0% Saturated 1 g Total Carbs 27 g Polyunsaturated 0 g Dietary Fiber 4 g Monounsaturated 0 g Sugars 0 g Trans 0 g Protein 5 g Cholesterol 0 mg

JANUARY 2018 • CAPSULE MAGAZINE • 21 Kauvery Hospital Kauvery Hospital Now @ Salem

TRICHY | CHENNAI | KARAIKUDI | HOSUR | SALEM

#9/50, Trichy Main Road, Opp. to Chandra Mahal, Seelanaickenpatti, Salem- 636201 | Ph : 0427- 2465555 W: www.kauveryhospital.com | E: [email protected]