Objectives: The purpose of this study was to diagnose obstructive hydronephrosis in symptomatic patients of horseshoe kidney with Technetium-99m (Tc-99m) diethylenetriamine pentaacetic acid (DTPA) diuretic renal scintigraphy. Patients and Methods: We retrospectively reviewed 30 symptomatic patients with horseshoe kidney who were referred to our department for Tc99m-DTPA/Tc99m L, L EC scan to look for subrenal drainage pattern from January 2011 to May 2016. Tc99m DTPA scan was done in all 30 patients. Tc99m dimercaptosuccinic acid III (DMSA-III) scan was done in 12 of these patients. Results: 30 symptomatic patients (21 adults and 9 children) with mean age 32.47 yrs and 5.55 years respectively with a known diagnosis of horse shoe kidney on ultrasonography (USG) were analysed with respect to patient symptoms, drainage pattern and consequences of stasis due to renal anomaly. Out of 30 patients (60 renal moieties), 24 were hydronephrotic as reported on USG by a competent radiologist. Out of these 24 moieties, 10 showed obstructed clearance pattern/slow sub-renal drainage and rest were normal. Other outcomes like asymmetrical cortical function, urolithiasis, Urinary tract infection (UTI) and scarring have also been described. Conclusion: DTPA renal scintigraphy is a non-invasive and sensitive investigation for the diagnosis of obstructive hydronephrosis in horseshoe kidney. It can very well be used in very young patients for an early diagnosis and management. Long term follow up would be advisable in these patients especially to monitor development of complications. Its importance along with USG cannot be downplayed as the added advantages like functional information, drainage pattern, differential function are necessary for a justified management protocol.

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Objective: We compared the efficacy of Semont's maneuver with Epley's maneuver in the management of benign paroxysmal positional vertigo (BPPV).We conducted a randomized and prospective double-blind study. Materials and Methods: We included 60 diagnosed cases of BPPV. These patients were categorized into Group 1 and Group 2. Epley's maneuver was performed in 30 patients of Group 1. Semont's maneuver was performed in the rest of the 30 patients of Group 2. We included diagnosed patients of BPPV above 20 years of age of both genders. Patients having peripheral and central causes of vertigo and cervical spondylosis were excluded from the study. Results: The mean age in Group 1 and Group 2 were 50.07 and 44.87 years, respectively. Sixty five percent of the patients were females and 35% of the patients were males. A total of 26 out of 30 Group 1 (87%) patients and 17 out of 30 Group 2 (57%) patients showed improvement. Comparing the two groups on the basis of improvement after maneuver showed that Group 1had greater improvement (54%) compared to Group 2 (46%). Statistical tests such as Chi-square test and t-test were applied. Conclusions: Epley's maneuver is more effective in the treatment of BPPV than Semont's maneuver.

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Objectives: To analyze the results of diverse surgical approaches performed for reversal of female sterilization and to understand the possible impact of primary host factors which may contribute to a successful outcome. Method: A retrospective analysis was performed on all patients who submitted themselves for a surgical reversal of female sterilization in a tertiary care teaching hospital over a 10-year period from 2002 to 2012. Setting: Department of Obstetrics and Gynecology, Government Medical College Hospital Kottayam, Kerala, South India. Results: A total of 69 surgical procedures were carried out for reversal of female sterilization. Of them, following surgery, 29 (42%) had intrauterine pregnancies. Of these, 3 (4%) aborted, 9 (13%) suffered an ectopic pregnancy, while the "successful take home baby rate" was 37%. A total of 31 women were lost to follow up. Conclusions: Reversal surgeries have a fair rate of success in women who have had sterilization, though the success rate varies with the surgical approach, the age of the woman, and the technique adopted during the course of female sterilization. It may be best if female sterilization procedures were to be restricted to the isthmus with minimal damage to the fallopian tubes.

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Introduction: Predicting a difficult airway is one of the necessities in anesthetic practice. Multiple tests used singly and in combination have been used to predict it, with varied results. We conducted a study to compare the exactitude of various airway assessment tests individually and in combination with parameters suited to the Indian population for the prediction of difficult laryngoscopy. Aims: The aim of this study was to compare various airway assessment tests individually and to statistically analyze the three best tests from our analysis in combination with the Modified Mallampati Test (MMT) for their efficiency in predicting a difficult laryngoscopy in apparently normal individuals undergoing endotracheal intubation. Materials and Methods: This was a prospective, single-blinded, observational study, where 250 patients of American Society of Anesthesiologists Physical Status Grade I and II, without predictors for difficult airway undergoing elective surgeries, were assessed and graded for thyromental distance (TMD), ratio of height-to-TMD (RHTMD), inter-incisor gap, head and neck movement (HNM), MMT and upper lip bite test (ULBT), and correlated intraoperatively with Cormack and Lehane score, and combinations of the best three tests with MMT were then statistically analyzed using standard formulae and the IBM SPSS version 20 statistics software. Results: Analysis of tests for difficult laryngoscopy showed that RHTMD and TMD had the highest sensitivity (90.0% and 70%). ULBT and HNM had the highest specificity of 99.0% and 91.4%. ULBT and TMD were highest in positive predictive value (PPV) (90% and 58.3%) and RHTMD and TMD in negative predictive value (NPV) (97.8% and 94.1%). Of the combinations, MMT + RHTMD had the highest sensitivity (95.0%), NPV (98.4%), odds ratio (23.5), and relative risk, but MMT + ULBT had higher specificity (65.7%), PPV (32.1%), and likelihood ratio (2.5). The combination of MMT + ULBT + RHTMD had 100% sensitivity and  100% NPV and 57% specificity and 30.8% PPV. Conclusion: Ratio of height to TMD is the single best test for difficult laryngoscopy. A combination of MMT + RHTMD + ULBT would be the best option for the prediction of difficult laryngoscopy in apparently normal patients.

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Introduction: Invasive aspergillosis (IA) is the most frequent invasive fungal infection occurring in high risk patients with haematological disorders and also an important cause of morbidity and mortality in them. Lungs comprise the primary site of IA in the vast majority of cases, and the most frequently occurring form of IA. Early diagnosis followed by early initiation of therapy improves outcome. The current culture based diagnostic methods are insensitive and slow. Detection of Aspergillus galactomannan (GM) in serum using the platelia Aspergillus enzyme immunoassay (GM EIA) represents sensitive, non-culture-based tool for the early diagnosis of IA. Recent studies have shown that during IPA, GM is released earlier and in higher concentration in the BAL fluid than in serum. Thus, an early and accurate diagnosis of IPA can be reached by detecting antigen in BAL samples. Materials and Methods: Thirty consecutive high risk patients with haematological disorders satisfying the inclusion and exclusion criteria according to EORTC-MSG diagnostic criteria and undergoing indoor treatment were recruited between November 2013 and December 2014 into the study. In all the patients, bronchoalveolar lavage (BAL) fluid GM and serum GM assays were assayed. Results: The diagnostic accuracy of the two tests was measured by calculating the sensitivity, specificity, predictive values and receiver operating characteristic curve (ROC). The optimal BAL GM index for diagnosing probable and possible IPA was >1.00 OD, resulting in a sensitivity and specificity of 93.75% and 78.57% respectively. As per ROC curve, when the optimal BAL GM index for the diagnosis of probable and possible invasive pulmonary aspergillosis (IPA) was OD >0.5, it resulted in sensitivity and specificity of 50% and 71.43% respectively. BAL GM was thus found to have a significantly higher sensitivity as compared to serum GM. Conclusion: In all high-risk patients with haematological disorders where the clinical and radiological findings favour the possibility of invasive pulmonary aspergillosis, conducting a GM assay in BAL fluid sample is far more rewarding than carrying out the traditional serum GM assay. BAL GM has a high diagnostic accuracy when correlated with the EORTC/MSG diagnostic criteria, and this high diagnostic yield is useful in obviating the unnecessary widespread use and abuse of empirical antifungal therapy in patients with IPA.

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Goldenhar syndrome is a rare condition with multiple anomalies involving craniofacial structures including the eyes, ears, and vertebrae. The etiology of this usually unilateral syndrome is unclear. We report a case of Goldenhar syndrome who presented with a limbal dermoid in the left eye and left pre-auricular skin tags. The multisystem aspects of this rare disease have been discussed with emphasis on early diagnosis and multispeciality approach necessary to manage it.

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Persistent urogenital sinus (PUGS) is a common cloacal anomaly, which has a social stigma attached to it. The characterization and definition of the extent can be a challenging task for an imaging consultant. Herein, we describe a case of a 6-month infant with cloacal defect along with review of embryogenesis.

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Introduction: A wide variety of chemotherapeutic agents are currently in use for the treatment of hematological malignancies in children. A spectrum of mucocutaneous adverse effects has been attributed to these agents, however, the data largely consists of case reports and case series. Material and Methods: Proforma of all pediatric patients up to 18 years of age, with confirmed hematological malignancies (lymphoma and leukemia), undergoing chemotherapy, and attending the pediatric hemato-oncology clinic of a tertiary care hospital over a period of 2 years were analyzed. A detailed history, mucocutaneous examination and investigations were recorded as per  the proforma. The results are presented as mean ± standard deviation. The prevalence of various side effects of chemotherapy is presented as percentages. Results: The age of the patients ranged from 1.2 to 14 years (mean age: 6.6 ± 3.2 years). The duration of the disease ranged from 2 to 122 weeks. Mean duration of chemotherapy was 23.9 ± 24.7 weeks. The analysis consisted of 38 (76%) males and 12 (24%) females (M: F: 3.2:1). Seventy-four percent of the patients had B-cell acute lymphoblastic leukemia (ALL), 6 patients had T-cell ALL, 3 patients had Philadelphia chromosome (+) T-cell ALL, 3 patients had non-Hodgkins lymphoma (NHL) and one patient had hemophagocytic lymphohistiocytosis (HLH). Methotrexate (72%) was the most common agent used followed by vincristine (68%), 6-mercaptopurine (58%), daunomycin (48%), and asparaginase (30%). Hyper-pigmentation was the most common cutaneous side effect noticed in 6 patients. Three patients developed abscess. Two patients each developed tinea corporis, petechie, and thrombophlebitis. One patient each had scabies, pityriasis versicolor, miliaria rubra, allergic contact dermatitis, lip lick cheilitis, ear discharge, and conjunctivitis. One patient developed acute methotrexate toxicity. A total of 24 patients developed mucosal lesions, with aphthous ulcer (20%) being the most common, followed by oral candidiasis (12%) and herpes labialis (12%). Seventeen (34%) patients had diffuse anagen effluvium. Most common change affecting the nails among the study patients was Beau's lines for both fingernails (26%) and toenails (36%). Other less common changes included melanonychia, leuconychia, Mees lines, Muehrcke's nails, half and half nails, etc. Conclusion: The mucocutaneous manifestations associated with chemotherapy cause significant morbidity and possibly mortality in children. A proper knowledge of these manifestations can help in early identification and withdrawal of the offending agents and preventing the morbidity with appropriate and timely management.

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Familial adenomatous polyposis (FAP) is the most common adenomatous polyposis syndrome. It affects all age groups and all races. Almost all patients with FAP develop colorectal cancers in the absence of surgery. A number of variants of FAP have been described, out of which Gardner syndrome is one subtype. Indian data on FAP or its rarer variants is scarce and limited to isolated case reports due to its low incidence. ^[1] We herein report five cases of FAP treated in our hospital and illustrate challenges in the management. The case series also highlights the interesting case of the fifth female who presented with synchronous duodenal adenocarcinoma and colonic adenocarcinoma in the background of multiple polyps in the entire colon. The case amply highlights the need of increased awareness of the syndrome and its variants while treating patients with polyposis-related conditions along with a center of referral where facilities for screening, counseling, genetic tests, surgery, and tumor banking and multidisciplinary facilities are available.

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Emphysematous pyelonephritis (EPN) is a life threatening infection of the renal parenchyma with gas formation, usually caused by the organism Escherichia coli and carries significantly high mortality rates. This study is a retrospective analysis of all cases of EPN admitted to our institute over a two year period. The clinical details, demographics, associations with co-morbid illnesses and urinary tract obstruction have been considered. The outcomes to treatment were assessed. Twelve patients of EPN were studied during the period of January 2013 to December 2014. The majority of them were females (male:female = 3:9) with a mean age of 51 years. Left sided EPN was more common than the right side. Three cases (25%) had bilateral EPN. Eleven patients were diabetics and ten cases had renal dysfunction. E. coli was the most common organism detected in urine culture and blood culture was sterile in most of the cases. Mean duration of hospital stay was 13 ± 4.86 days. The majority of patients responded to medical management and only one patient required unilateral nephrectomy. The literatures on EPN management suggest vigorous resuscitation and appropriate medical treatment, followed by immediate nephrectomy. However, with advancement of critical care nephrology, we conclude that aggressive management with appropriate antibiotics, strict diabetic control along with other supportive measures like renal replacement therapies will yield satisfactory results. Surgical intervention is required for urinary obstruction and nephrectomy should be reserved for the few patients who continue to deteriorate despite medical management and correction of obstruction.

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Background and Objectives: Adverse postoperative airway events are a significant problem in infants following primary cheiloplasty. This study aims to describe a simple inexpensive tool which, used prophylactically, can minimize postoperative airway obstruction (POAO). A retrospective cohort analysis was conducted among 314 infants who underwent primary cheiloplasty under general anesthesia at a hospital in Kanyakumari District in Tamil Nadu, India. Materials and Methods: The infants were divided into two cohorts, the first prior to introduction of the modified nasal airway (termed locally as "Rocket" due to its appearance once fixed in position), and the second after its use began in July 2007. The Rocket, consisting of an uncuffed endotracheal tube, 0.5 mm smaller in diameter than that used for intubation, was placed prophylactically prior to extubation in the nasal space of infants considered at risk. The incidence of POAO was compared between the two cohorts. Results: The incidence of POAO in cohort I (N = 86) was 8.1%, which reduced significantly to 0.44% in cohort II (N = 228) where the Rocket was used prophylactically prior to extubation. Interpretations and Conclusions: The prophylactic use of the Rocket minimized the occurrence of POAO following primary cheiloplasty in infants with cleft lip ± cleft palate ± cleft alveolus. The Rocket may be a costeffective solution to prevent POAO in infants undergoing these procedures, particularly in challenging and rural circumstances, where access to short-acting agents and customized airways may be limited.

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Tuberculosis often manifests as pleural effusion which generally shows clinical and radiological response to antitubercular therapy. However, it is not common to find a paradoxical contralateral effusion to develop despite successful therapy, especially in immuno competent treatment responsive patients with no other etiology of the same. We report such a rare case in which the patient presented with left-sided pleural effusion, which resolved with treatment, only to follow-up with massive right-sided pleural effusion which resolved spontaneously on continuation of antitubercular therapy.

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Leiomyosarcoma is rarely encountered in the sinus and skull base. The common location of this tumor is the female genital tract and the limbs because of the preponderance of smooth muscle at these sites. Clinically, these tumors are very aggressive, and the prognosis is poor. Here, a report of a bilateral frontoethmoidal leiomyosarcoma with review of literature is presented. A 28 year-old male presented with a gradually progressive painful frontal swelling with episodes of headache. The patient underwent a frontal craniotomy and the tissue was sent for histopathological examination. Histopathological diagnosis of leiomyosarcoma was made with the routine hematoxylin and eosin stain and immunohistochemical markers. Although there have been case reports in the literature describing the primary intracranial leiomyosarcoma involving the frontal and ethmoidal sinuses, this lesion continues to cause difficulty in preoperative diagnosis. The case is reported for the rarity of its location and the diagnostic challenge it poses.

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A 49-year-old female with complaints of dyspnea on exertion and palpitations was admitted to our hospital for further care. Clinically, the patient was found to have severe mitral stenosis with severe pulmonary arterial hypertension. Cardiac color Doppler was suggestive of severe rheumatic mitral stenosis not amenable to balloon mitral valvuloplasty with severe pulmonary arterial hypertension and incidentally detected nonrestrictive cor triatriatum sinister. Patient was advised open mitral valvotomy/mitral valve replacement with repair of cor triatriatum

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