1. Split Cord Malformations
   Rakeshkumar Luhana, Chandrashekhar E Deopujari, Rajan Shah, Uday Andar, Chinmay Bhalke
   Split cord malformations (SCM) are anomalies in which the spinal cord is split over a portion of its length to form double neural tubes. It is of two types: SCM type - I; which contains two hemi-cords, each lying within its own dural sac and separated from its counterpart by bony or cartilaginous spur, while SCM type - II contains both the hemi-cords lying within a single dural sheath and separated by intradural fibrous septum or strands.
   
   We would present a retrospective study of 19 patients with split cord malformations operated in last 15 years.
   
   Their clinical presentation, radiological picture, operative procedure, results and complications are studied, data analyzed and presented. There were unique cases i.e. neurenteric cyst in between the 2 hemicords, dermoid cyst in 1 hemicord at the site of lesion and intradural lipoma at the level of the split.
   
   Untethering procedure in many cases was combined with septum excision.
   
   
2. “Intraventricular” Arachnoid Cysts
   Chinmay Bhalke, CE Deopujari, R Shah, R Luhana, V Karmarkar
   Intraventricular arachnoid cyst is a rare but well defined entity. These usually present with a hydrocephalic syndrome. Shunt insertion may be difficult and is usually unsatisfactory. In the last 5 years, we have treated 5 children with anterior 3rd ventricular, 2 children with posterior 3rd ventricular and 3 children with lateral ventricular arachnoid cysts. Endoscopic fenestration has been performed in all these cases. Previous attempts at shunt insertion were unsuccessful in 3 cases.
   
   In intraventricular arachnoid cyst, both cyst walls need to be perforated in view of communicating the cyst to the ventricle; while a suprasellar arachnoid cyst needs to be communicated with the basal cisterns as well. The suprasellar arachnoid cysts can also be tackled trans-sphenoidale. Contrary to children, they typically present in adults with visual symptoms and are not associated with hydrocephalus. We have treated 2 such patients by endoscopic endonasal trans-sphenoidal approach.
   
   All these patients had a good outcome. As the cyst takes time to collapse, radiology may not show complete resolution for a long time, though patients recover clinically much earlier.
   
   
3. Role of Surgery in Intracranial “Granulomas”
   Rakeshkumar Luhana, Chandrashekhar E Deopujari, BS Singhal, Rajan Shah
   A series of 23 cases who presented to us in last 4 years being treated as “tuberculoma” for over 3 months is presented. Non-responders, patients with progressive symptoms or unchanged characteristics of the lesion on MRI were considered for biopsy/excision of the lesion. Surgical excision was performed in 20 cases through a craniotomy (5 stereotactic) while 3 cases had a stereotactic biopsy. Out of these 23 cases, 5 (21.75%) cases turned out to be non-tuberculous lesions; 4 had pyogenic abscess and one had cysticercosis. One patient had mixed lesion of tuberculosis with superadded fungal infection.
   
   Surgical intervention has been therefore helpful by providing definitive histopathological diagnosis, provided tissue for AFB culture/sensitivity and in many cases helped in disease eradication. Surgery has a definite role in the management of “granulomas” and should be considered early; whenever there is doubt about diagnosis or inadequate response to medical treatment.
   
   
4. Outcome of Cervical Spondylotic Myelopathy with Special Reference to Myelomalacia
   Joy Varghese, Keki E Turel, Nootan Kumar Sharma, Shashank Joshi
   Cervical spondylotic myelopathy is the most common spinal cord disorder after 55 years of age. It presents most frequently with central cord syndrome. The pathogenesis of myelopathy has been incompletely understood but predisposing factors are: 1) congenital narrow canal, 2) projecting posterior osteophyte, 3) OPLL, 4) Compression during extension by infolding of thickened inelastic ligamentum flavum, and 5) Antero/retro luxation of vertebral body. Vascular factors come into play at the end stage of the disease and produce devastating irreversible damage of spinal cord if not decompressed earlier. The changes within the cord are shown in the MRI as oedema and/or myelomalacia. Myelomalacia can be seen in the form of fried egg/snake eyes or pencil-shaped artefact at the grey-white matter junction, are hypointense on T1W and hyperintense on T2W, and can be differentiated from oedema and gliosis by using fast spin echo (FSE) MRI. Improvement of spondylotic myelopathy can be measured by using serial MRI that may show decrease in the lesional size. Factors bearing relevance to the outcome of patients with myelomalacia are: speed of development and duration of symptoms, extent of disease, degree of canal narrowing, level(s) of involvement, history of injury, and SSEP findings.
   
   In the last 200 consecutive cases of cervical spine degenerative disease operated by us, 82 patients presented clinically with myelopathy. Of these 52 showed abnormal cord signals of mild to moderate myelomalacia. Follow up of 32 of these patients is available. After anterior cervical discectomy and osteophytectomy, 8 of these patients were relieved completely from myelopathy in a duration of 4 years and 20 patients improved satisfactorily. Only 4 patients did not improve at all, and that was confirmed on follow up serial MRI scans. This sounds quite encouraging and most importantly conveys that despite myelomalacia over 90% of patients do have a fair chance of recovery.

Abstracts of Papers Presented at the 131st Research Meeting of the Medical Research Centre of Bombay Hospital Trust on Monday 12th September 2005

1. Review of Role of B12 in Diabetes
   Maithali Bhagat, Niyati Chawhan, Anand Gokani
   The indoor practice at Bombay Hospital sees a wide variety of patients, most of them chronically ill. One of the commonest symptoms encountered is fatigue, tiredness with meakers. Whilst working in the diabetic clinic, we tested 20 patients with diabetes who also had fatigue as a predominant symptom for vitamin B₁₂ levels in the blood, 45% were deficient in vitamin B₁₂ and not all were uncontrolled. We went further to look at the vitaminB₁₂ levels in 115 members of general population, where we found 1/3rd of the population suffering from B₁₂ deficiency. This prompted a study of basic function of B₁₂ in human body. Vitamin B₁₂'s significant role in carbohydrate metabolism was localized and its role in repair and degeneration in DNA via the homocysteine pathway was noted. In retrospect, it could be postulated that vit B₁₂ deficiency may play a significant role in pathogenesis of diabetes in otherwise healthy individuals by directly stating the carbohydrate metabolism as in the krefs cycle on the impaired repair with regeneration of the pancreatic tissue leading to the slow degeneration of the pancreas. Also the role of vitamin B₁₂ in immunity may contribute to postireal autoimmune destruction of pancreas heading to IDDM.
   
   
2. Review of 4 Terminally Ill Cases - The DNR Order and Its Implications
   Swati Patil, A Gokani
   In hospital practice, we frequently are faced with patients with incurable illness. Whether it be the terminal stages of Cancer, Terminal Renal, hepatic or heart failure or a burnt out case of diabetes. These patients always raise the dilemma in the doctor’s mind....to do not to do. This dilemma crops up at every stage of the illness. Every decision evokes a mixed response. On the one hand the doctor is fully aware that the condition is terminal, the situation is hopeless and effort futile....and on the other hand he has several gadgets and drugs which can be used to further prolong life and postpone death. With medico-legal litigations becoming commoner by the day and doctors being dragged to court for apparent neglect there is naturally a fear amongst the physician community that if a patient were to die in their care there could be dire consequences. It is this feat that prompts doctors to use every facility at hand to save/prolong life regardless of the cost to the patient comfort and dignity of the patient, or the final outcome of the therapy. Sometimes these decisions can prolong a patient’s life to point beyond endurance. The discussion was around four such cases in terminally ill condition and the implications of the do not resuscitate (DNR) order were highlighted.
   
   
3. Hyperglycaemia and Severity of patients with pneumonia
   SR Pandloskar, SV Joshi, HL Dhar
   Aim : To study association between hyperglycaemia and severity of pneumonia.
   
   Methods and Subjects : Retrospectively 100 consecutive cases of pneumonia admitted to Bombay Hospital were studied (Jan 2004 to Dec 2005). Demograhic and clinical data were collected. Attempts have been made to correlate complications and mortality with glycaemic status.
   
   Results : Average of the patients 46.81 years. Maximum cases (64%) were in the age group of 41 to 80 years. Infection was prevalent in both the lobes (69%) compared to right lobe (16%) and left (15%). Severity of pneumonia was age related. Involvement of both lobes was prevalent in higher age group (68.11%). One or more co-morbid conditions were recorded which include hpertension (32%), diabetes, mellitus (25%), heart disease (11%), asthma (6%) and TB (3%). Out of 100 patients, 7% had undergone surgery and 6% were on ventilator. Altered biochemical parameters : low Hb (50%), low calcium (34%) and low total protein (32%).
   
   Overall mortality was 26%. It was highest in 61-80 years age group followed by in the age group 41-60 years (34.38%) compared to younger subjects (26.32%). Associated diseases in the younger group were : pyogenic meningitis, sepsis, acute leukaemia, mental retardation and Gaucher’s disease against diabetes mellitus was predominant (47.62%) followed by Hypertension (33.33%), septicaemia (31.25%), renal failure (25%) and Hodgkin’s disease (6.25%) in higher age groups. There was no correlation between hospital stay and mortality.
   
   Conclusion : Hyperglycaemia is associated with adverse outcomes in patients with pneumonia.
   
   
4. Sublingual - Swallow Immunotherapy - Newer Approach in Allergic Asthma
   SV Joshi, DM Tripathi, HL Dhar
   The rationale of sublingual immunotherapy is a newer approach with controversial results.
   
   Aim : The aim of the study was to evaluate the tolerability, safety and effectiveness of sublingual immunotherapy in IgE mediated allergic disorders.
   
   Methods : Sixty consecutive allergic adults were included in the study. Allergic status was confirmed with modified skin prick test.
   
   Results show that in asthmatics sensitivity to house dust mite (91.3%) was predominant compared to house dust (82.60%), pollen (82.60%), and fungi (78.26%). However, sensitivity to insects was lowest. Initial therapy consisted of incremental doses of glycerinated aqueous allergen extract (60.87% with 6 allergens and 39.13% with 5 allergens) were placed below the tongue and kept for few seconds and then swallowed with ½ cup of water and taken every alternate day till top tolerable dose was achieved. Weekly dose was continued for 3 years as a maintenance dose. Side effects were noted. At the end of three years, with therapy 65.22% showed 70-80% and 34.78% showed 50-60% improvement (av 67.82 ± 11.26%). Half of the subjects did not require any medication and remaining used them occasionally. Only 4 patients in asthma group had mild side effects (itching on palate, throat irritation, vomiting and gastro-oesophageal reflux).
   
   Conclusion : Results of present study suggest that sublingual allergen specific immunotherapy is equally efficacious as subcutaneous immunotherapy in IgE mediated asthma. It is well tolerated and safe probably due to better compliance.
   
   
5. EIB and Respiratory Tract Diseases
   Mansi, HL Dhar
   The present study is aimed at analyzing the lung function in patients with asthma, rhinitis and both asthma and rhinitis and to correlate between exercise induced bronchospasm (EIB) and respiratory tract diseases.
   
   Thirty patients were prospectively included in the present study. These patients were selected from the out patient department from a tertiary care hospital in Mumbai between the period of April 2005 to August 2005 - a period of 4 months. A detailed history was taken and lung function tests (PFT) was conducted in all these patients thrice:- pre and post exercise and post bronchodilator. The lung function was carried out on Medspiror Spirometer and exercise tests was conducted by asking the patients to cycle on a static ergometer bicycle at fixed speed and resistance for a period of 8 minutes.
   
   Out of the Thirty patients; 8 (26.67%) suffered from asthma, 19 (63.33%) suffered from rhinitis and 3 (10%) suffered from both asthma and rhinitis. Out of these 10 (33.33%) patients were females and 20 (66.66%) patients were males. 2 (6.66%) patients were smokers while 28 (93.33%) patients were non-smokers. EIB was seen in all 8 asthmatics, in 8 (42.11%) patients with rhinitis and 2 (66.67%) patients with both asthma and rhinitis.
   
   Base-line mean FEV1 in asthmatics: in males: 72.75 ± 16.85972 L/min; in females: 71.75 ± 44.24459 L/min. In rhinitis: in males: 74.35714 ± 16.70379 L/min; in females: 85.4 ± 32.98939 L/min. In both asthma and rhinitis: in males: 47.5 ± 54.44722 L/min and in one female patient it was 115 L/min.
   
   Base-line mean PEFR in asthmatics: in males: 335 ± 104.7129 L/min; in females: 319.75 ± 101.6018 L/min. In rhinitis: in males: 400 ± 56.56854 L/min; in females: 391 ± 53.54126 L/min. In both asthma and rhinitis: in males : 400 ± 56.56854 L/min and in one female patient it was 340 L/min.
   
   Base-line mean FVC in asthmatics: in males: 78.25 ± 16.13227 L/min; in females: 319.25 ± 18.19112 L/min. In rhinitis: in males: 91.07143 ± 14.50445 L/min; in females 789.8 ± 19.81666 L/min. In both asthma and rhinitis: in males: 97.5 ± 12.02082 L/min and in one female patient it was 102 L/min.
   This study shows that baseline PFT values are lower in asthmatics as compared to patients with both asthma and rhinitis. The highest baseline PFT was seen in patients with only rhinitis. EIB is known to be a predisposing factor in patients with asthma. However, in our study quite a large number of patients with rhinitis (42.11%) also experienced EIB thereby showing that EIB is a predisposing factor in not only patients with asthma- a disease of the lower respiratory tract but also in patients with rhinitis - a disease of the upper respiratory tract.

Abstracts of Papers Presented at the 132nd Research Meeting of the Medical Research Centre of Bombay Hospital Trust on Monday 10th October 2005

1. Nasal Polyps : Is There a Cure?
   Anamika Rathore
   Nasal polyps is a common condition of the nose resulting from prolapsed lining of the ethmoid sinuses due to allergy and hence causing nasal obstruction. In our paper we are presenting a study of 25 cases of nasal polyps with follow up where our objective is to prevent recurrence. Here we have insisted on the importance of proper pre and post operative medical management, a regular follow up and the role of endoscopic sinus surgery in the treatment of the disease. Since most of the patients have an allergic component, a proper history is taken and symptomatic treatment including antihistamines and antibiotics are given. If indicated, a course of systemic steroids is given starting with a dose of about 40 mg OD tapering it over 10 days and stopping it prior to the surgery. We also use local steroid sprays in order to reduce the size of polyps. A CT scan is then done to assess the disease. With this we had an approximate recurrence of 50% but it could be dealt with steroid sprays and medical treatment. Only 3 patients needed revision surgery. Thus with advent of newer and better medical and surgical facilities we have endeavoured to prevent recurrence in these cases to a large extent.
   
   
2. Epistaxis - Endoscopic Management
   Seemab Khan
   Epistaxis is an acute haemorrhage from the nostril, nasal cavity or nasopharynx. It is one of the commonest emergencies in ENT. It affects children, adolescents and elderly equally. Although very often it is managed with the traditional methods in the accidental and emergency departments, an accurate diagnosis of the cause requires much more than this.
   
   With the advent of sino-nasal endoscopes, not only the diagnosis but the management of epistaxis has also become quick, accurate and precise, with much less morbidity and mortality.
   
   Besides trauma and bleeding from Little’s area, there are various other causes of epistaxis and here in this paper, we present a few of them which we have diagnosed and managed endoscopically recently. These include a bleeding spheno-palatine artery, juvenile nasopharyngeal angiofibroma and rhinosporidiosis.
   
   To conclude, epistaxis may be a horrifying clinical condition at the presentation, but with an appropriate and sensible integration of conventional and modern techniques, things can be made easier and smoother for both, the patient and surgeon.
   
   
3. Anaerobic Endophthalmitis
   Shreyas Palav, Karobi Lahiri Coutinho
   A Retrospective study of 11 cases of anaerobic endophthalmitis was done with respect to the onset, clinical appearance and presentation, clinical course, effect on visual acuity, complications, management with its outcome and role of antibiotics used. Anaerobic endophthalmitis is a type of chronic endophthalmitis with delayed onset after surgery. Organisms responsible are propionibacterium acnes and staph epidermidis. It is usually painless and indolent. It presents with gradually increasing vitreitis and granulomatous anterior uveitis. With the symptoms being reduction in visual acuity. On slit lamp examination, creamy white or crumb like white plaque is seen in the capsular bag. Aqueous and vitreous tap along with PCR techniques help in identification. The improvement in visual acuity after treatment with intravitreal antibiotics, steroids and vitrectomy was studied. Few complications like retinal detachment increase in intraocular pressure and recurrence occurred which were managed appropriately.
   
   It was found that timely diagnosis and institution of appropriate therapeutic measures result in a good visual outcome, better prognosis and decreased incidence of complications.