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MADURAI MEDICAL JOURNAL ISSN. No. 0972-3056
RNI. No. 55383/92
Official Jour nal of IMA Madurai Meenakshi Branch Volume - 18
MMJ
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Dr. Ramesh Ardhanari M.S., M.Ch. (GE) Dr. K. Sampath Kumar M.D., DNB., DM (Nephro) Dr. A.R. Raghuram M.S., M.Ch. (CTS), D.N.B., FIACS. Dr. M. Krishnan M.D., D.A. Dr. P. Krishnamoorthi M.D., FIAMS., FCGP. Dr. Indira Athappan M.D., DGO. Dr. T. Mukuntharajan M.B.B.S., DMRD. Dr. N. Panchavarnam M.S., M.Ch. (Plastic) Dr. N. Maharajan M.D., D.A. Dr. K.S. Anand M.D., (Anaes) Dr. V. Sathya Narayana M.S., D.Ortho., DNB. Dr. S. Balasubramanian M.S., (Ortho) Dr. S. Padma M.D., DNB. (O&G) Dr. R. Sivakumar M.D., DNB., (Cardio) Dr. S. Selvamani DNB.(GM), DNB. (Cardio) Dr. M. Sampathkumar M.D., D.M. (Cardio) Dr. S. Kumar M.D. (Anaes) Dr. K.S. Kirushnakumar M.D. (RT) Dr. A. Kannan M.D. (Paed), Dr. K. Selva Muthu Kumaran M.Ch. (Neuro) Dr. S. Senthil Prabahar M.D. (Derm) Dr. M.S. Senthilnathan M.D. (Nuc.Med) Dr. Narendra Nath Jena M.B.B.S., DFM., PG., Diab., FAEM. Dr. R. Vijaya Bhaskar M.S., M.Ch. (Surg. Onco) CO-ORDINATION & COMPILATION
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MEDICAL RESEARCH IN INDIA Venkatraman Ramakrishnan – Nobel prize for chemistry 2009!. My heart thumped with joy when the news of an Indian scientist winning the Nobel spread like a forest fire. This 59year old genius born in the temple town of chidambaram made a billion people back home proud, by his achievement for his pioneering work on ribosome, a cellular machine that makes protein. I just took my news paper and retired to my resting room sipping a cup of coffee, wondering if Venkatraman would have achieved this, if he had been in his motherland. A country with vast unwieldy population, a plethora of diseases, largest pool of patients suffering from cancer, diabetes and other maladies, would definitely make us the global hub of out sourcing of medical research. The word ‘Research‘ came from two syllables a prefix ‘Re‘ and ‘Search‘. ‘Re’ means again or a new and ‘Search’ means to examine closely, to probe, to test and to try to bring out the facts or principles. Research needs lot of dedication, persistence, perseverance, sacrifice, sincerity and definitely a good monitory and a moral support. Medical research in India is a controversial issue. Some feel in a developing country like us, we have much more to worry, than doing high quality research. Some feel that high quality research can be done even in poor countries. The value of medical research has to be clearly understood and it should cater to the needs of the society. It has to be learned that proper understanding of a pathology and different ways of approaching it, if well studied should definitely help the ailing population and cut down on medical expenses. Societies governing research like Indian society of Medical Research and Indian Society of clinical research, should give a better leadership to medical research. There should be frequent meetings of the editors of Indian medical science journals to improve their quality. If the above mentioned thoughts are in vogue I am sure we would also be able to achieve great laurels working inland. Indian medical science research is at its take off stage. It needs honest efforts, financial support and encouragement to catch up with international standards and hopefully it is not too far ……………..
Dr. N. Karunakaran Editor in Chief - MMJ, Consultant - Radiologist Mobile : 98431 50688 E-mail : mathivathani07@gmail.com
Spotter - 4 All Medical practitioners, PG’s & CRRI can answer this quiz.
MMJ
G Adult female presented with abdominal pain and abdominal gurading. G Send your answer with in 20th of November.
Corner
G Write your full name, qualifications and place of practice. G Answers can be sent through SMS - 99431 97495 or 98431 50688 / E-mail : mmjquizcorner@gmail.co G For enquiries you can contact above phone numbers.
Cardiogenic pulmonary edema. The classical Butterfly shadow or Bat’s wing appearance is one of the radiological manifestation of cardiogenic pulmonary edema. This appearance is seen in minority of patients.
Last month
Quiz Answer...... Spotter - 3
Cardiogenic pulmonary edema.
The other appearances include peribronchovascular thickening, subpleural pulmonary edema, thickened septal lines, hilar haze and generalized increase in density of lung parenchyma. Whatever the pattern, a stricking feature of cardiogenic pulmonary edema is rapid change on film taken over short intervals. Rapid clearing is particularly suggestive of diagnosis.
R
MMHRC congratulates the following Doctors who correctly answered the last month quiz (Spotter - 3) Chennai Dr. Akash (SRM Hospital) Dindugul Dr. Anitha Dr. Hallilur Rahman (Vedasanthur) Dr. Jason (Oddanchatram) Dr. Kesavamoorthy Dr. P.D. Nelson (Vedasanthur) Dr. Sindhu Balasubramanian Dr. Ubaidu Rahman Kanyakaumari Dr. Edward Ruban Dr. G. Radha Madurai Dr. Ashiq Dr. Hema Malini (Tirumangalam) Dr. M. Muthukumar (MIOT) Dr. C. Ramesh Dr. Sangamithra Swaminathan Dr. K.R. Santharam Dr. T. Sharmila (T. Vadipatti) Dr. Shenbaga Priya Dr. A. Swaminathan
Manipal - Karnataka Dr. K.S. Ravichandran Namakkal Dr. Vidhya Thangam Pudukkottai Dr. P. Elamaran (Manalmelgudi) Ramnad Dr. Fathima Chinnadurai Dr. S.R. Raja (Paramakudi) Sivagangai Dr. Jayanthi (Karaikudi) Dr. Kaliappan (Karaikudi) Dr. K. Senthil Kumar (Davakottai) Trichy Dr. Brindha Dr. Harirama Krishnan Dr. G. Venkatesh (Thuraiyur) Theni Dr. Ethiraj Tirunelveli Dr. Akilandabharathi (Sankoran Kovil) Dr. Chandrasekaran (Veeravanallur) Dr. Gomathi Annapoorani
Upcoming Event Date : 08-11-2009 (Sunday) Time : 9-00 a.m to 3-00 p.m
Dr. Jaganathan (Valliyoor) Dr. Mathan Dr. Padmanabhan (Kallidaikurichy) Dr. L.N. Radha Dr. N. Sankaran Dr. R. Srinivasan Dr. Thanga Vinayagam (Puliyangudi) Thanjavur Dr. Manimaran (Pattukottai) Dr. J. Suresh Kumar (Kumbakonam) Thiruvarur Dr. M. Chandrasekaran Dr. A.K.M. Vinoth Tuticorin Dr. K. Arumugam (Thiruchendur) Dr. K. Balaganesh (Nazareth) Dr. R. Balamurugan (Kovilpatti) Dr. C.K. Chidambaram (Kovilpatti) Virudhunagar Dr. Arulprakash (Aruppukottai) Dr. Ravisankar (Aruppukottai)
Neurocon 2009 Symposium on Headache
Venue : MMHRC Conference Hall I
Registration Free
Time Topic 9-30 a.m Trigeminal Cephalalgia 10-00 a.m Headache in raised Intra cranial Pressure 10-30 a.m Primary Headache
Speakers
Sr. Consultant Neurologist Apollo Hospitals, Chennai
Paediatric Neurologist, Chennai
11-00 a.m 11-30 a.m
Headache in childhood
Dr. T.C. Vijay Anand M.D., DNB (Neuro) Consultant Neurologist, MMHRC
Dr. K. Selvamuthukumaran M.Ch., (Neuro) Sr. Consultant Neuro Surgeon, MMHRC
Dr. R. Sreedharan M.D., D.M. (Neuro) Dr. G. Kumaresan M.D., DCH., DM. (Neuro)
Subarachnoid Dr. A. Raja M.Ch., (Neuro) Haemorrhage Recent Concepts HOD and Sr. Consultant Neuro Surgeon
Kasturba Medical College, Mangalore
Dr. M. Rajaguru M.D., D.M. (Neuro)
12-00 a.m 12-30 a.m
Idiopathic Intracranial Hypertension Paediatric Headache Neuro Surgeon’s - Perceptive
2-00 p.m
Interesting Case Discussion & Quiz
Sr. Consultant Neurologist, MMHRC
Dr. K.V. Karthikeyan M.Ch., (Neuro) Consultant Neuro Surgeon, MMHRC
1-00 p.m - 2-00 p.m Lunch
MMJ OCTOBER 2009
Single Stage correction of Coarctation of Aorta with Aneurysm of Aorta and Rheumatic Mitral Regurgitation with Endocarditis CASE REPORT
Dr. K. Balamurugan M.B.B.S., D.A., DNB. Jr. Consultant, Dept. of Cardiac Anaesthesiology MMHRC, Madurai
Dr. S. Kumar M.D. (Anaes) Sr. Consultant, Dept. of Cardiac Anaesthesiology MMHRC, Madurai
Dr. Rm. Krishnan M.S., M.Ch. (CTS), DNB Dr. A.R. Raghu Ram M.S., M.Ch. (CTS), DNB., FIACS Consultant, Dept. of Cardio Thoracic Surgery MMHRC, Madurai
Head & Sr. Consultant, Dept. of Cardio Thoracic Surgery MMHRC, Madurai
ABSTRACT R h e umatic Heart disease is common in o u r p o p u l a t i o n w i t h p o o r s o c i o - e co n o m i c sta t u s . L a te p r e sentation of Coarctation of Aorta in a d u l t h o o d i s n o t u n co m m o n i n d ev el o p i n g co u nt r i es . We en countered a patient with a combinat i o n o f t h es e t w o p r o b l em s co m p l i ca te d by en d o ca r d i t i s a n d aneur ysm of aorta. This is a rare pr es enta t i o n a n d w e d es c r i b e o u r s u cces s f u l m a n a g e m ent o f t hi s dif ficult problem. The available l i ter a t u r e o n t h i s r a r e p r o b l e m h a s b een r ev i ew ed .
K E Y W O R D S : Aorta, Valves, Rheumati c H ea r t D i s ea s e , C o n g e n i ta l l e s i o n s . INTRODUCTION Rheumatic Heart disease is common in our population. Coarctation of Aorta presenting in adulthood is not uncommon in developing countries. We encountered a patient with a combination of these two problems complicated by endocarditis and aneurysm of aorta. This is a rare presentation and we describe our successful management of this difficult problem. CASE REPORT A 34 yr lady presented to our institution initially 7 yrs back for investigations for infertility. During routine workup it was found that she was hypertensive with severe coarctation of aorta and moderate mitral regurgitation. She CORRESPONDING AUTHOR
Dr. A.R. Raghuram M.S., M.Ch.(CTS), DNB., FIACS.,
was put on anti-hypertensive medications and advised surgery for coarctation. She became pregnant and desired to postpone further interventions. She had a normal delivery with good control of blood pressure with drugs. One year later she presented with class II dyspnoea and echocardiogram revealed a tight coarctation and severe mitral regurgitation. She was advised surgery but refused. 5 yrs later she presented with history of prolonged fever, class II-III dyspnoea and interscapular pain. Echocardiogram revealed vegetations in anterior mitral leaflets with severe mitral regurgitation and preserved left ventricular function. Her blood cultures were negative. She was put on empirical antibiotic therapy for culture negative endocarditis. CT Aortogram revealed severe coarctation and a saccular aneurysm in the post-coarct segment (Fig.1). After 3 weeks of antibiotic therapy her fever subsided and she was willing for surgery.
Head & Sr. Consultant, Department of Cardiothoracic Surgery Meenakshi Mission Hospital and Research Centre, Madurai - 625 107 Phone : 94 452 2588741 Mobile : 94422 48333 E-mail : arraghuram@hotmail.com
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MMJ OCTOBER 2009
Fig 1: CT Aortogram She was put on left lateral position after general anesthesia with double lumen endotracheal tube and the left femoral vessels were exposed. Left posterolateral thoracotomy was done and pleural cavity entered through fourth intercostal space. Mediastinal dissection revealed a tight postductal coarctation and a saccular aneurysm of left fourth intercostal artery at its junction with aorta distal to coarctation (and not a saccular aneurysm of aorta as initially suspected in CT) (Fig 2).
Dacron graft was interposed between the transected ends. FFB was weaned uneventfully. Hemostasis was secured and thoracotomy closed with a drain. She was turned over to supine position and midline sternotomy done. Aorto-caval cardiopulmonary bypass (CPB) was initiated and mitral valve exposed through transseptal approach. The anterior leaflet was destroyed with vegetations and posterior leaflet was scarred and retracted due to rheumatic disease. The valve was excised and replaced with a 27 mm mechanical valve. CPB was weaned uneventfully. The postoperative period was uneventful and patient was discharged on tenth postoperative day with oral anticoagulation. Culture of the excised leaflet tissue was negative. However, the empirically chosen antibiotic was continued for a total period of eight weeks. She was followed up at six months and maintains a normal prosthetic valve function and no significant gradient across the descending thoracic aorta and is afebrile. DISCUSSION Coarctation of Aorta presenting in adulthood is not uncommon in developing countries. Rheumatic heart diseases are rampant in populations with poor socio-economic conditions. A presentation with these two problems complicated by endocarditis and aneurysm of aorta is quite rare and we could not find a similar case history in published English literature.
Fig 2: Operative Photograph She was heparinised and partial femorofemoral bypass (FFB) was instituted to maintain lower body perfusion. The aorta was cross-clamped across the base of left subclavian artery and adjacent arch and distal to the aneurysmal segment of descending aorta. The intervening diseased segment was excised and brisk back-bleeding from the large intercostal arteries controlled with sutures. An eighteen millimeter albumen impregnated woven 5
The management options are single-stage correction of both lesions and two-stage approach with either of the two lesions tackled in the first stage. When a patient presents with such combined problems, there are no predetermined guidelines to manage them. The dilemma was to decide which lesion to tackle first if it is a staged procedure. Tackling the coarctation first may relieve the afterload and reduce the mitral regurgitation. However we were not sure preoperatively whether the saccular aneurysm in aorta is due to intercostals blow-out or is it a mycotic aneurysm of endocarditis origin. Leaving the mitral lesion
MMJ OCTOBER 2009
for a second stage was fraught with the risk of infection of the interposed aortic graft from endocarditic vegetations. So, we thought the mitral lesion should be tackled as soon as possible after the aortic surgery. Clamping the aorta at the level of subclavian artery interrupting its flow will further increase the afterload and severely compromise the heart increasing the regurgitation. So, we elected to use femoro-femoral bypass support during the aortic surgery. However, there are other possible options also. Mulay et al [1] have reported successful management of three patients in two stages with initial intra cardiac correction and delayed surgery for coarctation. The concern in this approach is the high afterload during weaning from bypass. Their argument is that afterload is not high because of large collaterals in adult patients and their successful outcome supports this. In patients with aortic regurgitation, there is a fear of reduction in coronary blood flow if the coarctation is dealt with first resulting in afterload reduction[2] . This is not a problem in mitral insufficiency. Musumeci[3] has reported two patients treated with correction of coarctation in first stage without adverse effects on coronary perfusion. One of the patients had aortic regurgitation, severe left ventricular dysfunction with renal and hepatic dysfunction which improved promptly after relief of coarctation. The other patient had severe mitral insufficiency due to endocarditis and severe coarctation. They controlled the infection and dealt with coarctation by percutaneous dilatation and repaired the mitral valve after a week. They recommend that in the presence of severe mitral regurgitation or impaired left ventricular function, the coarctation should be dealt with first. Clark et al[4] have reported successful single stage correction of aortic valve disease and coarctation of aorta through a clamshell incision and left nephrectomy for
carcinoma kidney. Successful single stage repair has been reported by others also[5] .The advantage of single stage approach apart from cost and length of stay is the avoidance of interruption in anticoagulation regimen in patients with prosthetic valves implanted in the first stage in cardiac-first approach. If infection is not an issue, the same patient could have been treated by endovascular approach to dilate the coarcted segment and exclude the aneurysm by a stent-graft either after or before the mitral valve surgery. What makes this patient unique is the occurrence of intercostal aneurysm along with coarctation and valvular lesion. Intercostal aneurysms are quite rare in patients with coarctation of aorta. Barrat–Boyce [6] has reported only eleven cases in his large experience over 30 years. The incidence seems to rise with increasing age at presentation. REFERENCES 1.
Mulay AV, Ashraf S, Watterson KG. Two-Stage repair of adult corctation of the aorta with congenmital valvular lesions. Ann Thorac Surg 1997;64:1309-1311.
2.
Rufilanchas JJ, Villagra F, Maronas JM, Tellez G, Agosti J, Juffe A, Figuera D. Coarctation of the Aorta and severe aortic insufficiency: what to repair first? Am J Surg 1977; 134:428-30.
3.
Musumeci F, Penny WJ. Aortic coarctation associated with aortic or mitral valve disease: which lesion to correct first? Ann Thorac Surg 1998; 66: 603-604.
4.
Clark SC, Zacharias J, Hamilton JRL, Asif Hasan. Coarctation with valvular lesions in adults Ann Thorac Surg 1998;66:600-601.
5.
Ohuchi H, Kawazoe K, Kosakai Y, Kitoh Y, Kawashima Y . One-staged repair for coarctation of the aorta and annuloaortic ectasia with severe aortic regurgitation in a patient with Turner syndrome ( Article in Japanese) Nippon Kyobu Geka Gakkai Zasshi. 1992; 0(12):2247-51.
6.
Barrat-Boyes B. Surgical correction of the coarctation of aorta: a review of 30 years experience. Trans Coll Med South Africa 1985;1:25.
Source of support-Nil Conflict of Interest - None declared
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MMJ OCTOBER 2009
Minoxidil - Should Physicians take it back from the Dermatologists? CASE REPORT
Dr. Arun Kumar Sah M.D., DNB., Resident, Department of Nephrology MMHRC, Madurai
Dr. K. Sampathkumar M.D., DNB., D.M. (Nephro) Head & Sr. Consultant, Department of Nephrology MMHRC, Madurai
ABSTRACT M i n oxidil is one of the forgotten antihyp er ten s i v e d r u g s w i d e l y u s ed to p i ca l l y i n t h e t r e a t m e nt o f b a l dness. As renal failure patients freq u ent l y h a v e, d i f f i c u l t to co nt r o l hy p er te n s i o n , M i n ox i d i l ca n be used in combination therapy. Recent st u d i e s h a v e s h ow n fa vo u r a b l e o u tco m es i n p a t i e nt s o f c hronic kidney disease.
K E Y W O R D S : Hypertension, Anti-hyper te n s i v e d r u g s , B a l d n es s , Va s o d i l a ta t i o n , H em o d i a l y s i s , D i a lysis, Potassium channel agonist, Hy p er t r i c h o s i s
INTRODUCTION Minoxidil, first used as Loniten to treat high blood pressure was found to have an interesting side-effect, the ability to reverse or slow down the balding process. It is predominantly being prescribed for topical use for baldness by dermatologists. Again its potency and efficacy in difficult to control blood- pressure has resurfaced following various studies including in renal failure patients. HYPERTENSION IN HEMODIALYSIS PATIENTS More than 80 percent patients on hemodialysis have difficult to treat hypertension. Three mechanisms are involved in producing hypertension in them: 1. High Renin 2. Salt and water retention 3. Heightened Sympathetic activity CORRESPONDING AUTHOR
Dr. K. Sampathkumar M.D., DNB., DM. (Nephro)
Head & Sr. Consultant, Department of Nephrology Meenakshi Mission Hospital and Research Centre, Madurai - 625 107 Phone : 94 452 2588741 Mobile : 99948 72250 E-mail : drksampath@gmail.com
7
Various groups of anti-hypertensive drugs are used to treat hypertension. These include: 1. 2. 3. 4. 5. 6.
Calcium channel blockers - widespread use, but Amlodipine has adverse effect of causing pedal edema in some patients. Beta blockers - dose reduction needs to be done for Atenolol as duration of action increases. Also in combination with Clonidine it may cause bradycardia. ACE inhibitors and ARBs - are contraindicated in bilateral renal artery stenosis and known to cause hyperkalemia more so in patients of renal failure. Diuretics - notorious to cause dyselectrolytemia and muscle cramps. Also they are less useful in anuric patients. Clonidine - Potent but skipping a single dose leads to rebound hypertension. Alfa- Methyldopa - is a weak antihypertensive.
MMJ OCTOBER 2009
THE CHANGE OF HANDS Initially discovered as an anti-hypertensive, was soon taken up by dermatologists the world over for treating baldness.Usually a 5% concentration solution of Minoxidil is used for men and a 2% solution for women for treating baldness. Its mechanism of action is due to it being a potassium channel agonist, causing hyperpolarization of smooth muscle in arterioles leading to decreased peripheral vascular resistance, vasodilatation and a decrease in blood pressure. It is predominantly an arterial dilator where there is abundance of smooth muscle in their tunica media. This vasodilatation increases the blood supply to the scalp when applied locally promoting hair growth over a period of 2 to 3 months. Use of the drug as an anti-hypertensive has again resurfaced following numerous evidences, and now increasingly being used for control of blood pressure. DOSAGE Initial dosage 2.5 to 5 mg as a single daily dose co administered with a diuretic (usually loop) and a β - blocker or combined α & β blocker. Effective dosage range is 10 to 40 mg/day in single or 2 – 3 divided doses (max. dosage 100 mg/day), with dose escalation every 3 – 4 days. Divided doses are used in case of difficult to control tachycardia In patients intolerant to β – blocker, Clonidine or CCBs may be combined to reduce HR. PHARMACOKINETICS
Plasma half-life in humans is 4.2 hours
Excreted principally in the urine
Renal clearance corresponds to the GFR
VARIOUS STUDIES’ OUTCOMES IN RENAL FAILURE PATIENTS 1.
In patients not requiring dialysis prior to therapy, renal function was preserved, and in patients on dialysis, bilateral nephrectomy was avoided[1].
2.
Effective control of blood pressure prevents or reverses impairment of renal function in patients with refractory hypertension not associated with primary renal disease [2].
3. Impressive renal functional improvement may occur with Minoxidil use in some patients with malignant hypertension [3]. CONTRAINDICATIONS/WARNINGS 1.
Pheochromocytoma - because it may stimulate secretion of catecholamines from the tumor through its antihypertensive action.
2. Acute myocardial infarction 3. Dissecting aneurysm of the aorta. ITS VARIOUS SIDE-EFFECTS INCLUDE 1.
Swelling of the face and extremities due to salt & water retention –Concomitant use of an adequate diuretic is almost always required and to prevent possible congestive heart failure. Mechanism involved is activation of K channel in thick ascending loop of Henle increasing Na/K/Cl activity →↑Na & Cl reabsorption Temporarily Minoxidil may be discontinued and may be restarted later with a diuretic.
2.
Cardiac Arrhthmias - Angina may worsen or appear for the first time because of increased heart rate and cardiac output. Concomitant administration of a beta adrenergic blocking drug is done to avoid this Transient ST-T changes occur in upto 90% of patients that resolve during long term therapy.Minoxidil associated LVH may be attenuated by coadministration of ACEI/ARBs. 8
MMJ OCTOBER 2009
3.
Focal necrosis of the papillary muscle & subendocardial areas of the ventricles in animals is reported. Mechanism involved is ischaemia provoked by increased oxygen demand (tachycardia, increased cardiac output) and relative decrease in coronary flow (decreased diastolic pressure and decreased time in diastole) caused by the vasodilator effects of these agents coupled with reflex or directly induced tachycardia.
4.
Hypertrichosis- about 80% due to increased cutaneous blood flow to affected areas. It occurs 3 to 6 weeks after starting therapy with Minoxidil. It is first noticed on the temples, between the eyebrows, between the hairline and the eyebrows, or in the side-burn area of the upper lateral cheek, later extending to the back, arms, legs, and scalp.
5. 6.
Alkaline phosphatase increase varyingly without other evidence of liver or bone abnormality. Serum creatinine increase by an average of 6% and BUN slightly more, but decline to pretreatment levels soon. Renal failure or dialysis patients require smaller doses of minoxidil
7. Reports of pericarditis, effusion in 3%, occasionally with tamponade in association with the use of minoxidil 8.
Hazards of rapid control of blood pressure i.e. precipitation of syncope, cerebrovascular accidents, myocardial infarction and decrease or loss of vision or hearing can sometimes occur.
Any patient with malignant hypertension should have initial treatment with Minoxidil carried out in a hospital setting, both to assure that blood pressure is falling and to assure that it is not falling more rapidly than intended.
9
CONCLUSION Minoxidil offers a potent weapon for difficult to control hypertension in CKD. The physician should be well versed with its side effect profile, before they start using it in their patients.
Pic. 1 – Hypertrichosis pattern in a patient on Minoxidil REFERENCES 1.
Domenic A. Sica.An Underused Vasodilator for Resistant or Severe Hypertension. J Clin Hypertens. 2004; 6:283–287
2.
W M Bennett, T A Golper, R S Muther, D A McCarron. Efficacy of Minoxidil in the treatment of severe hypertension in systemic disorders. Journal of Cardiovascular Pharmacology. 1980; 2 Suppl 2:142-8.
3.
D Taverner, R F Bing, A Heagerty, G I Russell, J E Pohl, J D Swales, H Thurston. Improvement of renal function during long-term treatment of severe hypertension with Minoxidil. The Quarterly journal of medicine. 1983; 52(206): 280-7.
Source of support-Nil Conflict of Interest - None declared
Condolence MMHRC expresses its deepest condolence for the demise of
Mrs. Sharadha Sripad M/o. Dr. H.S. Sudhakar Rao Periyakulam, Theni Dist.
c
Mr. R. Srivasan
F/o. Dr. S. Mani Mohan Cumbum, Theni Dist.
2 Decades at MMHRC - Urology Department The first to do so!
Dr. T.R. Murali M.S., M.Ch. (Uro) Sr. Consultant & HOD Dept. of Urology Mobile : 98942 48778 E-mail : golde2003@gmail.com
Dr. R. Ravichandran M.S., DNB. (Uro) Sr. Consultant - Dept. of Urology Mobile : 94426 48266 E-mail : drravi99@rediffmail.com
On this historic occasion nostalgia floods me. Memories of our step by step growth over a decade and a half, into a renowned department in the country, flood me. Today, we practice, “State of the Art. Urology”, with the latest advances across all its subspecialties. I must take this opportunity of thanking all my colleagues who helped in the phenomenal growth of the department in the first decade, especially N.S. Raja. Also, were involved many post M.Ch Senior Residents, PGs in Urology and medical officers. I was the first Consultant in MMHRC to join forces with the Founder Chairman in his monumental vision of changing the health practice of Madurai. It was to make advanced medical care available to everyone at an affordable cost. Under his guidance MMHRC was the first to introduces new services not only in Urology but also in related fields like Nephrology, Surgical Gastroenterology. The Urology department handles Andrology as a separate division to respect the privacy that such clients need. The Andrology department is the best in this part of the country doing yeoman service to the sexually challenged men and the infertile couple. Based on the strength of the Andrology department a high quality seminology lab was established, and later a female infertility department with all the ART services including IVF/ICSI. Many thousand couples have been guided and helped by the various ART procedures done. The Andrology department remains the referral base of many urologists within the state as well as outside.
Dr. K. Venugopal M.S., DNB. (Uro) Consultant - Dept. of Urology Mobile : 94426 48266 E-mail : konanki9@rediffmail.com
Over the years Urology has developed subspecialties like Uroradiology – Diagnostic and Inverventional, Endourology and ESWL, Uro-oncology, Pediatric Urology, Gynaecurology, Andrology, Neurourology and Urodynamics, Reconstructive Urology and Renal Transplantation. Laparoscopic Urology is the latest addition to the ever growing specialties which includes Laser Urology. 2. Second, I thank the management for the support though one would have expected with the Founder Chairman himself being a Urologist, a large UroNephrological Institute should have been established by now. It may yet be! Nevertheless, as Individual departments both Urology & Nephrology have developed quality in delivery of advanced therapy. 3. Third and in my opinion vital is the help of the referral doctors and well wishers who have sent us cases of all sorts in all conditions. We have been able to help the vast majority of them even the sick and diseased. In a few we have failed despite our efforts. The presence of a team approach in MMHRC has been always our forte and has been a prime factor in our success. 4. Fourth and finally I must thank all our patients who submitted themselves to our care with implicit trust. We have not failed them. In whatever shape they came, they went home better. In no case were we found wanting in not trying our best.
Over the years there has been a lot of confusion about the referral pattern of strictly urological cases to our centre. It is generally believed that the Nephrologist so named, is the saviour of the nephron. But the nephrologist see cases in ARF where there is complete recovery or in ESRD/CKD where the potential for recovery is nil and permanent dialysis is the end result. It is the urologist who see more cases of renal failure that can be salvaged by appropriate urological treatment. What cases are Best Referred to A urologist? A Urologist is a surgeon well trained in Nephron Sparing and has as much concern for the Nephron as the Nephrologist. Similarity, a urologist has all the skills to manage pediatric urological problems. 1. All cases of Urinary Stones with or without Renal Failure. It is the Urologist who treats urinary stones and stabilizes renal function, occasionally with the help of the nephrologist. Finally, in recurrent stone formers a metabolic stone screen of the blood and urine is performed to prevent stone recurrence. Follow up for stone recurrence is the surgeon’s prerogative. 2. Any complicated Urinary Infection involving the kidney such as Emphysematous pyelonephritis, Renal Abscess, Para-nephric Abscess, Papillary Necrosis, Anuria, Oliguria in Renal failure, but stable are all surgeon’s disease. This is because in most, drainage will be required such as internal, by DJ Stent, external by aspiration or open drainage, to salvage the kidney. In some cases nephrectomy is necessitated. In our large experience it is not the S. Creat that determines the need for dialysis but the general condition of the patient in addition to Acute Indications for HD such as fluid overload, pulmonary edema, severe hyperpotassemia, very high urea / creatinine with encephalopathy / pericarditis / effusion and the like. The important point to note in each is as that infection is still locked up, the kidneys are still obstructed. Hemodialysis only makes the patient tolerate the subsequent urological procedure but does not correct the disease.
3. Renal masses like carcinoma with or without renal failure, ‘UPJO’ unilateral or bilateral, obstruction to solitary kidneys, VURs, Infections in childhood – mostly due to VUR in girls, obstruction in boys – PU valve, Phimosis and dysfunctional voiding in both can be diagnosed by application of urological methods. In fact the follow up of PU valve child even though the valve is well ablated depends on the behavior of the thick walled, dysfunctional, high pressure, low compliance bladder. These children have to be followed beyond puberty to check if S.Creatinine is stable or rises progressively.This is because of the high demands on the kidneys by the increased metabolism associated with the pubertal growth spurt. Such children can develop hypertension which has to be evaluated and treated in consultation with a nephrologist. Growth retardation should be looked for specifically. Cases with congenital deformities like hypospadias, epispadias, undescended testis, micropenis, endocrinal abnormalities affecting the sexual organs should be referred straightaway to the andrologist /urologist for quick decision and rational treatment. Frankly neurological disorders after treatment by the neurophysician or neurosurgeon and who have bladder dysfunctions can be diagnosed by complex urodynamics tests done by trained urologists. Correction of such dysfunctions is achieved with a combination of drugs over a prolonged period carefully checking the upper urinary tracts, for signs of deterioration. Surgery of the neurogenic bladder is a difficult exercise and is done by urologists with several years of experience in handling such disorders. Sub Specialties of Urology The Urology team which I am heading is proud to reach the 20 year milestone in service to the public. Putting service before self, with the help of able colleagues the department of urology is rendering sterling uro care to the people of Madurai and the surrounding districts. In Uro-oncology we have reached a new acme with the standardization of laparoscopic radical nephrectomy , partial open nephrectomy (to
salvage kidney), Radical open prostatectomy, transurethral surgery for superficial bladder cancers, radical cystectomy for invasive carcinoma bladder, creation of the neobladder , the ideal solution in urinary diversion, preservation of the bladder neck in female urological cancers and radical operations for cancers of the testes, penis and the urethra. Laparoscopic adrenelectomy is already the gold standard for removal of the diseased adrenal gland.
are emerging and are being added to armamentarium.
Paediatric Urology is best handled by urologists because of their vast endoscopy and laparoscopy skills. Also, it makes sense that follow up beyond 12 years required in most childhood urological conditions like PU valves, congenital deformities, can be done only by a dedicated urologist. Children get a life time of care with the urologist specifically addressing the problem of adolescence, sexual changes and male fertility. Neuro-urology and urodynamics has taken a new turn with the acquisition of Triton the “new kid on the block”, urodynamic equipment from “ Laborie “. Many cases of neuro vesical dysfunction have been detected early with excellent treatment solutions. The therapeutic goal is preservation of upper tracts, restoration of the bladder storage function and freedom from any sort of Incontinence. In cases where the outcome of TURP is less than ideal, UDE has been able to predict it remarkably well even before the procedure. PCNL has emerged as the mainstay for clearance of renal stones more than 1.5cm in size. ESWL is offered in selected situations enhancing its success rate. Ureteroscopy both rigid and flexible have made stone clearance, without an operation anywhere in the urinary system possible. These along with a stone prevention program, in compliant patients, gives life long freedom from urinary stones.
New procedures for stress Incontinence like TOT insertion, for Urge Incontinence – Botox Injections, Laparoscopic Bursch suspensions, Sacrocolpopexy are being standardized .
Laparoscopy done at our centre for over a decade now has ushered in new changes in the practice of urology. Several laparoscopic procedures are standard- Lap. Adrenalectomy simple nephrectomy, radical nephrectomy, donor nephrectomy, pyeloplasty, V V F repair and so on. New indications for laparoscopy
Renal Transplant work including salvage of Cadaveric kidneys shows our expertise in this area. We have crossed 400 live related renal transplants. All vascular work is done by the urologist with excellent results. Our team is specialized also in insertion of CAPDs – open, percutaenous , laparoscopic and also creation of AV accesses.
Holmium laser prostate enucleation is a daring new field in the therapy of BPH, capable of being used, even in anticoagulated patients. Buccal graft urethoplasty has changed the management of urethral strictures. Along with a back up team of excellent anaesthesiologists dedicated OR, post OP, Intensive care and the urology ward nurses, ancillary services like Nephrology, Pain care, Medical, Radiation Oncology and Respiratory care Physicians the patients cannot opt for a safer place to experience surgery. The availability of excellent imaging facilities enhances our diagnostic skills. The Cardiology dept. monitors the performance of surgery in the cardiac risk patients while diabetics are monitored round the clock by on line diabetologists. “Surgery cannot get safer yet” Welcome to the New World of Urology at MMHRC where technology transfer is rapid and the latest is already here. This is the “ one stop shop” for all urological problems. Of course in MMHRC wherever a case is sent the treatment is delivered by the right person but a time delay could be avoided by direct referral. Also the patient comes to know who the primary treating doctor is and is more amenable to treatment by the urologist. I hope the referring doctors take note of this and help us to serve their patients diligently. Thank You Uro Team
MMJ OCTOBER 2009
ARTICLE
Spinal Injury Series-Part I Thoraco-Lumbar fractureManagement principles & outcome
Dr. S. Balasubramanian M.S. (Ortho) Sr. Consultant & Chief Spine Surgeon MMHRC, Madurai
ABSTRACT I n j u r y to t h e spine is increasing in incidence to an alarming ex tent. Thoraco - l u m b a r s p i n a l i n j u r y tops the list of spinal injuries. Surgical decompression of injured s p i n a l co r d a n d r i g i d stabilization of the spine are crucial for rapid rehabilitation. Agg r es s i v e , a p pr o p r i a te , planned rehabilitation is crucial to augument the surgical result s . I n t h i s a r t ic l e, w e w i ll discuss the management principles and common problems enco u nter ed i n t h o r a co - l u mbar fractures. KEY WORDS : Thoraco - lumbar fractures, Conus medullaris, paraplegi a te a m , r eh a b i l i ta t i o n of paraplegics. Spinal injuries are always associated with a high incidence of devastating consequences. Spinal injury is unique in that the resulting consequences are experienced not only by the patient but by the whole family.
sudden transition of the rigid thoracic spine (rib cage gives rigidity to thoracic spine) to the very flexible lumbar spine leads to concentration of forces at TL junction (Fig 1) leading on to the high incidence of fractures at this region.
Thoraco-lumbar (TL) junctional injury is dealt with in the first part of this ‘Spinal Injury Series’ because it is the most common type. Thoracolumbar spinal injury implies fracture of D11, D12, L1 and L2. Most common mode of TL injury in India is due to fall from height. Fall from building construction site or from tree tops are the most common types seen in our setup. Thoraco-lumbar junction is peculiarly prone for injury due to the following reason. The CORRESPONDING AUTHOR
Dr. S. Balasubramanian M.S. (Ortho)
Sr. Consultant & Chief Spine Surgeon Meenakshi Mission Hospital and Research Centre, Madurai - 625 107 Phone : 91 452 2588741 Mobile : 98431 49953 E-mail : ortho_drbala@yahoo.com
13
Fig. 1
MMJ OCTOBER 2009
IMPORTANCE OF TL JUNCTION The spinal cord ends at the level of L1-2 disc space. The lower end of the spinal cord is a bulbous structure known as ‘conus medullaris’ which controls the function of lower limb and bladder and distal colon. Hence injury to the TL junction can lead to ‘profound neurological deficit’ in the form of paraplegia with bladder and bowel dysfunction (Fig 2).
D11 D12
Conus medullaris
TLJ
L1 L2
Fig. 2 Thoraco-lumbar junction (T L J) Thoraco-lumbar junction also harbours equally important vital structures. These include the solid abdominal organs namely kidneys, liver and spleen. These organs are also frequently injured in association with TL spinal injury, further adding complexity to the injury. MANAGEMENT PRINCIPLES
Fig 3 a,b,c: Showing the retropulsed posterior fragment completely occluding the spinal canal (arrow). The circle in fig3c should be the position of the cord. Radiographs revealed a burst fracture of L1. High dose methyl predniosolone sodium succinate was started (NASCISS III protocol) considering injury to the conus medullaris. Appropriate imaging studies revealed a retropulsed bone fragment completely occluding the canal (Fig3a,b,c). He also had associated renal injury and lung contusions which were managed conservatively by respective speciality. The patient was taken up for surgery as soon as the patient’s vitals were stabilized. Firstly, the spine was approached posteriorly and pedicle screw fixation done two levels above and below the injured segment (Fig. 4a). Wide laminectomy was done at L1 level and the retropulsed bony fragments occupying the spinal canal were punched forwards to decompress the spinal cord. Dural lacerations were repaired to contain CSF leak.
Let us consider this 24 years old male patient as an example to outline the management principles. He sustained a L1 burst fracture following a fall from height while doing electrical work in a factory. He reached the hospital within six hours following the injury. He was immediately immobilized on a spinal board at the ‘accident and emergency’ department and vitals stabilized. He was found to be completely paralysed below the waist and a distended bladder which was catheterized.
Fig 4 (a):posterior stabilization with pedicle screw fixation (b):patient positioned for anterior retroperitoneal transpleural approach for L1 body reconstruction, (c) :Titanium mesh cage filled with local autograft (d) : final anterior reconstruction of L1 body with cage.
14
MMJ OCTOBER 2009
Three days later, through ‘anterior retroperitoneal and trans- pleural approach’ the fractured L1 vertebral body was removed and reconstructed with a titanium mesh cage filled with bone grafts (Fig 4b,c,d; Fig5a,b).
Fig 5: (a): Radiograph of final reconstruction (b):CT 2D reconstruction image Following all around (3600) decompression of the spinal cord and rigid stabilization of the spine, it was made possible to rapidly rehabilitate the patient. The patient started recovering neurological functions steadily and was rehabilitated to the level of independent walking with callipers over a period of several months. He recovered good bladder and bowel control. Though he could not return to his electrician work, he was productively employed in a nearby shop. EXPECTATIONS FOLLOWING SURGERY IN TL INJURIES The chances of neurological recovery in TL spinal injuries are favourable (as in the case illustrated above) if the spinal cord is decompressed and the spine stabilized at the earliest. However, at the present state of medical development, it is important to realize that no spine surgeon can give a guarantee for ‘complete’ return of functions to pre-injury level in spinal cord injured patients. It is important to realize that even sensory recovery will go a long way in helping these patients, for example to avoid pressure sores etc. 15
Timing of surgery is a topic of great discussion these days. Dispute still continues among the spine surgeons about the allowable time delay from the time of injury to surgical decompression, but there is a general agreement that ‘the earlier the better’. The use of high dose methyl prednisolone sodium succinate (NASCIS III protocol) is followed in our centre in all spinal cord injury patients with few exceptions. We believe that it does contribute to neurological recovery. REHABILITATION Post surgical rehabilitation is the key to successful outcome. The degree of spinal stability achieved by surgery dictates the aggressiveness of the rehabilitation protocol apart from the patient’s general condition (associated injuries). Round the clock, specifically trained rehabilitation team should be available in any centre managing spinal cord injury. Detailed description of the rehabilitation protocol is beyond the scope of this article. The patient’s relatives should be involved in the care of the patient from the beginning. This boosts the confidence of the patient and goes a long way in the rehabilitation process. From our experience we found that the patient’s relative need not be literate to carry on with the rehabilitation protocol. It is the total commitment which is more important. Common problems encountered by these patients can be grouped roughly into three broad categories: EARLY PHASE This period lasts for 4-6 weeks from the time of injury. Respiratory distress, atelectasis, pneumonia, urinary tract infection, paralytic ileus, impacted faecal matter and pressure sores are frequently encountered. ‘Paraplegic team’ of nurses and physiotherapist are crucial to overcome these problems during this phase. INTERMEDIATE PHASE It starts from the end of early phase and extends variably from 4-6 months, dictated principally
MMJ OCTOBER 2009
by the neurological recovery and patient cooperation. There is a very high incidence of psychological issues during this period (eg., depression, mood fluctuations, aggressiveness towards family members etc,.) which should be handled by a psychiatrist. The incidence of respiratory, urinary and pressure sore problems decreases significantly during this phase with better understanding. LATE PHASE The problem during this phase is unique and should be dealt by appropriate specialists for satisfactory outcome. Frequent problems encountered are andrological (sexual satisfaction of the partner), child bearing, urological (ways to gain bladder control), adaptation for returning to previous job or finding a new suitable occupation (dictated by the neurological recovery) and psychological (feeling as a burden to the family) etc,. The medical field has advanced innumerably to address these problems and it is best to involve the appropriate specialist to take care of these issues.
CONCLUSION Thoraco-lumbar fractures are the most common spinal injury. Though the TL junction is located much lower down in the spine, due to the clustering of the neurons at this level (conus and epiconus) the neurological consequences are profound. There is also a high incidence of abdominal and chest injuries associated with this fracture. Thorough decompression of the spinal cord and rigid stabilization of the spine is the best treatment approach that can be recommended in these patients which can yield fruitful results. Rehabilitation remains the corner stone for successful outcome. These patients are prone to develop multisystem problems and a dedicated team of urologist, andrologist, psychiatrist and gastroenterologist are indispensible. Last but not the least, it is essential to involve the family members during every step of rehabilitation. Source of support-Nil Conflict of Interest - None declared
Contact The Editor Madurai Medical Journal Meenakshi Mission Hospital Madurai - 625 107
MMHRC Wishes the following Couples a Happy and Prosperous wedded life Dr. S. Niranjana M.B.B.S., DMRD.,
D/o. Dr. R.V.S. Surendran & Dr. Devaki Surendran Karaikudi, Sivagangai Dist. and
Dr. Ajaykumar Anandan M.D., (Anaes)
Dr. Ramanathan Moorthy M.D. (Anaes), IDCC., S/o. Dr. L.V.K. Moorthy, Imm. Past President, IMA TNSB and
R. Divya M.B.A.,
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Dr. C. Keerthana Victoria
D/o. Dr. A. Charles Stephen Rajasingh & Dr. Jansi Charles, Madurai
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Dr. A. Benedict Daniel Abraham Dr. D. Dhiviya Raj M.B.B.S., D. Ortho., DNB (Ortho) and
St. Joseph Hospital, Dindigul and
Dr. M. Selva Meena M.B.B.S.,
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M. Ajitha M.B.A.,
D/o. Dr. K. Manivannan, Sivagangai and
J. Abilash B.E., M.B.A.
25-10-2009
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MMJ OCTOBER 2009
AN INTERESTING CASE OF HYPOKALEMIC PERIODIC PARALYSIS CASE REPORT
Dr. S. Ramu M.D. (Gen) Registrar, Dept. of Neurology MMHRC, Madurai
Dr. T.C. Vijay Anand M.D., DNB. (Neuro) Consultant, Dept. of Neurology MMHRC, Madurai
Dr. M. Rajaguru M.D., D.M. (Neuro) Sr. Consultant, Dept. of Neurology MMHRC, Madurai
ABSTRACT Per i odic paralyses (PP) are a heterogeneo u s g r o u p o f m u s c l e d i s e a s es c h a r a c te r i zed by ep i s o d es o f f laccid muscle weakness occurring at i r r e g u l a r i nter v a l s . M o st o f t h e co n d i t i o n s a r e h e r e d i ta r y a n d are more ep isodic than periodic. They ca n b e d i v i d e d co nv e n i e nt l y i nto p r i m a r y a n d s eco n d a r y d i s o rders. Here we present an interestin g ca s e o f hy p o ka l a em i c p er i o d i c p a r a l y s i s o f s eco n d a r y ca u se
K E Y W O R D S : Hypokalemia, thyrotoxico s i s CASE REPORT A 48 years old male presented in the emergency department with complaints of difficulty in walking since evening with the history of weakness of both lower limbs and history of severe exceptional work one day back. Patient had similar episodes before (2 episodes with in past 3 years). There was no history of backache, sensory disturbances, respiratory difficulty, neck muscle weakness, drug intake or heavy carbohydrate meal intake. On examination, patient was conscious, oriented, afebrile.Vitals were stable, cardiac and respiratory systems were normal on examination. On neurological examination higher mental functions and cranial nerves were normal. Motor examination revealed reduced tone and power(1/5) in both lower CORRESPONDING AUTHOR
Dr. T.C. Vijay Anand M.D., DNB. (Neuro) Consultant, Department of Neurology
Meenakshi Mission Hospital and Research Centre, Madurai - 625 107 Phone : 94 452 2588741 Mobile : 99433 32329 E-mail : tcvijayanand@yahoo.co.in
17
limbs. Patient was bedridden.DTR were depressed bilaterally. Sensory & cerebellar examinations were normal. On investigation, serum potassium was low (2 meq/l).serum sodium, blood urea,serum creatinine,blood sugar and ABG were normal. thyroid functions done showed elevated T4(8.38microg/dl) with normal TSH(0.54 iu/ml). ECG showed prolonged QT interval. Patient was thus diagnosed as a case of hypokalaemic periodic paralysis secondary to thyrotoxicosis. Patient was treated with intravenous potassium chloride and betablockers. Patient improved dramatically. Patient was put on antithyroid drugs and advised follow up. DISCUSSION Thyrotoxic periodic paralysis (TPP) is a well known complication of thyrotoxicosis especially in asian population. All patients with HypoKPP require screening for hyperthyroidism. Episodes of weakness occur after activity or after meals
MMJ OCTOBER 2009
with high carbohydrate content. Potassium administraton treats the acute attacks, and nonselective betablockers may both alleviate the acute attack and prevent recurrence of paralytic attacks. Correction of the thyroid disorder cures the periodic paralysis. Transient hypophosphatemia and hypomagnesemia have been documented along with elevation in creatine phosphokinase in patients with TPP. These disturbances correct as the acute thyrotoxicosis resolves.
c. CKD
d. Adrenal insufficiency
e. Excessive diuretics and laxative abuse
The pathophysiology of TPP remains unclear. Hypokalaemia is the consequence of a rapid and massive shift of potassium from extracellular in to the intracellular compartment, mainly in to the muscles. This is believed to be related to increased sodum-potassium-AT Pase activity. Ther is increased number as well as activity of the Na/K-ATPase pump in patients with thyrotoxicosis. Patient with TPP had significantly higher pump activity than thyrotoxic patients without TPP.The enhanced beta adrenergic activity in thyrotoxicosis further increases Na/K-ATPase activity and may explain why nonselective betablockers can abort or prevent further attacks. Management of TPP includes correction of hypokalaemia and treatment of the underlying hyperthyroid state. The definitive therapy for TPP includes treatment of hyperthyroidism with antithyroid medications, surgical thyroidectomy, or radioiodine therapy. After initiation of definitive therapy, patients should avoid precipitating factors and continue propranolol until a euthyroid state is achieved to prevent recurrence . TPP is curable once a euthyroid state is achieved. POINTS TO BE LEARNED 1) Conditions that cause secondary kalaemic paralysis includes the following
a. Thyrotoxicosis
b. 17alpha hydroxylase deficiency
2)Treatment of TPP
a. Emergency therapy
KCL 10meq/h i.v.,and /or KCL 2g every 2 hr,orally
Monitor serum potassium,to avoid rebound hyperkalaemia
Propanolol 3-4 mg/kg orally
b. Prevention of recurrent attacks
Avoid precipitating factors
Propanolol 20 to 80 mg every 8h orally
c. Definite therapy of hyperthyroidism with antithyroid
Drugs/thyroidectomy/radiotherapy
REFERENCES 1. Salifu MO, Otah K, Carroll HJ et al. Thyrotoxic hypokalemic paralysis in Black man. Quart J Med 2001; 94: 659-60. 2. Miller D, del Castillo J, Tsang TK. Severe hypokalaemia in thyrotoxic periodic paralysis. Am J Emerg Med 1989; 7 (6): 584-7. 3. Fisher J. Thyrotoxic periodic paralysis with ventricular fibrillation. Arch Intern Med 1982; 142 (9): 1362-4. 4. Ober KP. Thyrotoxic periodic paralysis: report of 7 cases, a review of literature. Medicine 1992; 71: 109-20. 5. Schulze-Bonhage A, Fiedler M, Ferbert A. Periodic paralysis as the first manifestation of hyperthyroidism. Dtsch Med Wochenschr 1996; 121: 1498-1500.
Source of support-Nil Conflict of Interest - None declared
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Contact : 98942 26036 18
MMJ OCTOBER 2009
CLOT BUSTER IN BRAIN ATTACK Brief Communication
The traditional definition of stroke, devised by WHO in 1970 is “ a Neurological deficit of cerebrovascular cause that persists beyond 24hrs or is interrupted by death within 24hrs ‘. The 24hr limit divides stroke from transient ischemic attack which is a related syndrome of stroke symptoms that completely resolves within 24hrs. With the availability of treatments that when given early can reduce stroke severity many now prefer alternative concepts such as “ Brain attack “ and “Acute ischemic cerebrovascular syndrome“ that reflect the urgency of stroke symptoms and the need to act swiftly. The treatment of stroke starts with an early diagnosis with a proper and dedicated Imaging suite. The target of thrombolysis is the ‘ zone of ischemic penumbra’, which is defined as the ischemic tissue potentially destined for infarction but not yet irreversibly injured. Various imaging modalities like CT, CTperfusion MRI with diffusion and perfusion studies, PET, SPECT can help us achieve an accurate diagnoses and localization. Patients chosen for thrombolysis should be within 18-80 years of age with a clinical diagnosis of ischemic stroke, with onset of symptoms not more than 3hours. CT Brain which is easily available and quickly performed helps us rule out heamorrhage as the cause for stroke. Thrombolysis can be performed by administration of thrombolytic agents either by intravenous route or through a catheter placed close to the clot causing obstruction in the cerebral vessels and release of clot buster by intra arterial route. This procedure is contra indicated for those who are more than 80years of age, patients receiving oral anticoagulants, bleeding diathesis, known history of or suspected intra
19
cerebral or subarachnoid haemorrhage, active structural lesion of brain and neoplasms. Those patients who are good candidates for thrombolysis, satisfy the NIHSS scoring but are received more than 3hours of onset of symptoms are ideal candidates for intra arterial thrombolysis. A coin has two sides and so does any procedure. Though the rate of complications are less, we still need to be aware of bleeding tendencies and conversion of ischaemic stroke to haemorrhagic stroke, anaphylactic reaction and seizures. Recombinant tissue plasminogen activator is the magic bullet and this procedure to be popularized and well utilized. Both patients as well as general practitioners should be educated, regarding the need to diagnose stroke as early as possible and quick referral to the stroke unit and thrombolysis team who can reduce the morbidity associated with stroke. Thus penumbra in any stroke is the life saving vital area of tissue that needs to be approached pharmacologically “Saving penumbra is saving brain” and time is brain. Thrombolysis centre for stroke in Meenakshi Mission THROMBOLYSIS TEAM 1. Dr. T.C. Vijay Anand MD., DNB ( Neuro ).
Consultant Neurologist
2. Dr. M. Raja Guru MD., DM ( Neuro ).
Sr. Consulant Neurologist
3. Dr. T. Mukuntharajan M.B.B.S., DMRD.
Sr.Consultant Interventional Radiologist.,
4. Dr. K. Selva Muthu Kumaran MCh.,
Sr. Consultant Neurosurgeon,
5. Dr. K.V. Karthikeyan MCh.,
Consultant Neurosurgeon,
6. Dr. Narendra Nath Jena M.B.B.S., DFM., PG. Diab, FAEM.
Consultant Accident & Emergency Medicine Department.
Senior Doctors Award Function, Ramzan and Deepavali Celebrations at Ramnad on 04-10-2009 (with IMA TNSB, Ramnad and Paramakudi)
There was a Doctor’s family get together and Senior Doctor Award Function as a Part of Ramzan & Deepavali Celebrations Organised by MMHRC in Collaboration with IMA TNSB, Ramnad, Paramakudi & Madurai Meenakshi Branches. Dr. R. Gunasekaran, State President, IMA Tamilnadu was the Chief Guest and Honoured the Senior Doctors.
Our Consultants in International Forum
Dr. T.R. Murali Attended 2nd Advanced Genito-Urinary Reconstruction, Live Workshop at Belgrade, Serbia, 9-10 Sep. 2009
Dr.N. Panchavarnam
Attended Cleft 2009 11th International Congress on Cleft Lip and Palate and Related Craniofacial Anomalies & Paper Presentation on Primary Repair of Lip and Nose Aesthetically Fortaleza / Brazil - September 10th to 13th, 2009
Dr. R. Sivakumar, Dr. S. Selvamani & Dr. N. Ganesan attended Transcatheter Cardiovascular Therapeutics (TCT 2009) Interventional Cardiology Conference held at San Francisco USA Sep 21-25, 2009 Dr. N. Ganesan Presented a case in Challenging case forum
28-10-09
2nd
Dr.
V.K. Nair
Memorial
Oration
on
03-10-2009
at
MMHRC
In Remembrance of Lt. Col. Dr. V.K.Nair HOD & Chief Anaesthetist who passed away in service on 30 th November 2008. 2nd Memorial Oration was held on Saturday, 3rd October, 2009. The Orator was Dr. M. Ambareesha, Prof. of Anaesthesiology Kasturba Medical College, Mangalore. The Topic was “Nerve Blocks in Palliative Care, Current and Future Perspectives”
Deepavali Celebrations
on 15-10-2009 at MMHRC
MMHRC Doctor’s Family get together and Deepavali Celebration Organised by IMA Meenakshi Branch Dr. S. Gurushankar - Vice Chairman, Dr. V.N. Rajasekaran - Medical Director, Dr. T. Mukuntharajan - President IMA Madurai Meenakshi Branch, Dr. Ramesh Ardhanari - HOD & Sr. Consultant Prizes were distributed to the Winners.
National Blood Donation Day 2009
National Blood Donation Day 2009 was Celebrated on 1.10.2009, Thursday by Regional Blood Transfusion Centre, Meenakshi Mission Hospital & Research Centre & Indian Red Cross Society in Collaboration with IMA Madurai Meenakshi Branch. Thiru. R. Karpagakumaravel Vice Chancellor Madurai Kamaraj University, Mrs. C. Periyathai - Joint Director of Collegiate Education Madurai Region and Thiru. R.V. Udhayakumar - Film Director were the Special Guests and presented the awards. Bharathidasan University of Trichy who donated 553 Units was given The first prize and all other blood donors were honoured .
Postage paid in cash at Madurai HPO & Posted at Madurai BPC
(Run by S.R. Trust)
Lake Area, Melur Road, Madurai - 625 107
Printed by N. Jayakarthikeyan at Thee Classic Printers, 27, Kakathope street, Madurai - 625 001 Phone : 0452 - 2624466, 2323819, 4381603 E-mail : theeclassicprinters@gmail.com