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Kamath M.S.,Christian Medical College Hospital | George K.,Christian Medical College Hospital
Reproductive Biology and Endocrinology | Year: 2011

Clomiphene citrate has been traditionally used as the drug of choice in treating women with anovulatory infertility. In the last decade letrozole, an aromatase inhibitor has emerged as alternative ovulation induction agent. Literature confirms that letrozole has a definitive role in anovulatory women who have not responded to the clomiphene therapy. However its role as an alternative to clomiphene as first line therapy continues to be debated. Although it is probable that the overall benefits of letrozole surpass clomiphene citrate, currently available data does not confirm this view. There is need for large well-designed trials. © 2011 Kamath and George; licensee BioMed Central Ltd.


Rajshekhar V.,Christian Medical College Hospital
Neurology India | Year: 2016

The Department of Neurological Sciences at Christian Medical College (CMC), Vellore was the first department to start neurosurgical and neurological services in India. Jacob Chandy started the department in 1949 against several odds. He started a formal training program in neurosurgery in 1958, for the first time in India, and went on to qualify several neurosurgeons, who in turn pioneered neurosurgical departments all over India. After 1970, K V Mathai and Jacob Abraham guided the department through some difficult times when there was a severe shortage of personnel and no faculty in the neurology section. Through their commitment and hard work, they continued not only the neurosurgery service but also looked after patients with neurological disorders. Mathew J Chandy, son of Jacob Chandy, joined them in 1980 and introduced micro-neurosurgery and several other neurosurgical techniques. Training of residents in micro-neurosurgery began in the early 1980s. The last quarter of a century has been a period of rapid progress for neurosurgery at CMC. There has been an exponential rise in the number of surgeries, number of residents and number of publications. Research has always been an integral part of the activities of the department and several high impact articles have been published by the faculty and residents. The neurosurgical faculty at CMC has also contributed significantly to organized neurosurgery in India and internationally, with five of them serving as President of the Neurological Society of India, a society which had Jacob Chandy as its founder President. With this heritage, the neurosurgery section at CMC, Vellore is likely to continue to provide high quality ethical neurosurgical care to patients from all over India and overseas. © 2016 Neurology India | Published by Wolters Kluwer - Medknow.


Rupa V.,Christian Medical College Hospital | Agarwal I.,Christian Medical College | Rajshekhar V.,Christian Medical College
Otolaryngology - Head and Neck Surgery (United States) | Year: 2014

Objective. To study the steps involved in definitive evaluation and successful management of patients with congenital perilymph fistula presenting with recurrent meningitis. Study Design. Case series with chart review. Setting. Tertiary care center. Subjects and Methods. The case records of 11 patients (12 ears) treated for congenital perilymph fistula presenting with recurrent meningitis were reviewed to ascertain their clinical, radiological, and intraoperative features and outcome following surgery. Results. Most patients presented after at least 3 episodes of meningitis (range, 2-10 episodes). Ipsilateral hearing loss was present in 9 of 12 ears, with normal hearing in 3 patients. Highresolution computed tomography and/or magnetic resonance imaging scanning of the temporal bone contributed to the diagnosis in 75% of cases but was normal in 3 cases (25%). Oval window and round window defects were the most common (66.7% and 63.6%, respectively). Four ears (33.3%) had more than 1 defect. The unusual presentations included 2 patients who presented in adulthood, a patient with a defect in the medial wall of the attic, and 3 patients with normal radiological findings. Follow-up ranged from 1 to 11 years (median, 2 years). There were 2 failures following simple fistula closure with cessation of symptoms after vestibular obliteration. No patient was readmitted with recurrent meningitis after definitive surgery. Conclusion. Up to 25% of patients with recurrent meningitis secondary to congenital perilymph fistula may have normal audiological and radiological assessment necessitating exploratory tympanotomy. Vestibular obliteration, rather than simple fistula closure, prevents recurrence. © 2013 American Academy of Otolaryngology - Head and Neck Surgery Foundation.


Gupta A.,Christian Medical College Hospital | Rajshekhar V.,Christian Medical College Hospital
Neurology India | Year: 2016

Background: To review our experience with patients undergoing 3 level cervical central corpectomy (CC) with un-instrumented fibular autograft fusion. Materials and Methods: This is a retrospective study, involving 33 patients with cervical spondylotic myelopathy (CSM) or ossified posterior longitudinal ligament (OPLL) who underwent a 3 level CC between 2002 and 2010. The patients were followed up clinically and radiologically. Their functional status was assessed using Nurick's grading system. Parameters such as intraoperative complications, segmental curvature of the cervical spine, graft subsidence, graft fusion and functional outcome of these patients were assessed. Results: There was transient morbidity in 28.6% of patients, with no permanent morbidity or mortality. We obtained follow up in 29 patients (87.9%) with a mean duration of follow up of 65.1 months (range, 12 to 138 months). The mean difference of segmental cervical curvature on follow up was 3.600 and the average graft subsidence was 5.70 mm. We achieved a fusion rate of 90%. There was no instance of graft extrusion in our series. There was a significant improvement in the functional status of our patients (from Nurick grade 3.55 to 2.42; P = 0.0001), with no clinical deterioration in any patient. Conclusions: Three level cervical corpectomy with un-instrumented fusion is a relatively safe surgery in experienced hands, and can achieve excellent clinical and radiological outcomes. © 2016 Neurology India | Published by Wolters Kluwer - Medknow.


Ebenezer J.,Christian Medical College Hospital | Rupa V.,Christian Medical College Hospital
Otolaryngology - Head and Neck Surgery | Year: 2010

Objective: To determine the predictive value of preoperative clinical, audiological, and radiological factors in diagnosing incudal necrosis in patients with tubotympanic chronic suppurative otitis media (CSOM). Study Design: Case series with planned data collection. Setting: Tertiary care referral center. Subjects and Methods: Patients older than five years of age diagnosed with tubotympanic CSOM who underwent tympanomastoid surgery were recruited. Findings on otoscopy, x-ray mastoid, pure-tone audiometry, and intraoperative otomicroscopy were recorded. Results: Incus necrosis occurred in 24 (16%) of a total of 150 patients. On bivariate analysis, findings of active ear discharge (P = 0.01), anterosuperior location of perforation (P = 0.03), exposure of incudostapedial joint (P = 0.05), edematous middle ear mucous membrane (P = 0.05), middle ear granulations (P = 0.004), foreshortening of the handle of malleus (P = 0.04), moderate to moderately severe hearing loss (41-70 dB HL) (P = 0.000), and air-bone gap > 40 dB (P = 0.001) were found to be associated with incus necrosis. Intraoperative findings of aditus block (P = 0.001) and mastoid granulations (P = 0.005) were also found to be significantly associated with incus necrosis. Mastoid pneumatization and perforation size and site were not associated with incus necrosis. On multivariate analysis, only middle ear granulations (P = 0.04; odds ratio [OR] 3.161; 95% confidence interval [95% CI] 1.087-9.196) and a moderate to moderately severe hearing loss (41-70 dB HL) (P = 0.03; OR 1.720; CI 1.064-2.782) were found to be significant risk factors. Conclusion: Incus necrosis is best predicted by the presence of middle ear granulations and moderate to moderately severe hearing loss (41-70 dB HL). Knowledge of this information preoperatively can influence surgical decision making and preparedness regarding ossiculoplasty and patient consent. © 2010 American Academy of Otolaryngology-Head and Neck Surgery Foundation.


Bugalia A.,Christian Medical College Hospital | Manipadam M.T.,Christian Medical College Hospital | Nair S.,Christian Medical College Hospital
Leukemia and Lymphoma | Year: 2013

Extranodal natural killer (NK)/T-cell lymphoma, nasal type (EN-NK/T-NT) is a lymphoma of NK-cell or cytotoxic T-cell origin, which occurs most commonly in the upper aerodigestive tract. We have studied the immunomorphologic profile and Epstein-Barr virus (EBV) status of a cohort of 35 cases of EN-NK/T-NT of the upper aerodigestive tract (UADT) diagnosed in our institution during the period May 2002 to April 2012. At our institution these lymphomas constitute 0.7% of total non-Hodgkin lymphomas (NHLs) and 5.1% of total peripheral T-cell lymphomas (PTCLs). The median age at diagnosis was 40 years with a male-to-female ratio of 4:1, and the most common site of involvement was the nasal cavity. Morphologically, the neoplastic cells were predominantly medium sized in most cases. Necrosis and angiocentricity were common histologic features. Thirty cases (85.7%) showed NK-cell immunophenotype, CD3+ (29/30, 96.7%), CD56+ (30/30, 100%) and TIA1/Granzyme B+ (30/30, 100%). Five cases (14.3%) showed cytotoxic T-cell immunophenotype, CD3+ (5/5, 100%), CD56- (5/5, 100%) and TIA1/Granzyme B+ (5/5, 100%). EBV-encoded RNA-in situ hybridization (EBER-ISH) was positive in all 35 cases, whereas EBV latent membrane protein-1 (EBVLMP1) was positive in only 19/35 (54.3%) of cases. In conclusion, this is the first large study from India to report the immunomorphologic profile and EBV association of EN-NK/T-NT, which is known to have geographic variation. The frequency of these lymphomas in our study is comparable to that of Western and European countries and much less than that of Far Eastern countries. © 2013 Informa UK, Ltd.


Dutta A.K.,Christian Medical College & Hospital
The Journal of the Association of Physicians of India | Year: 2011

Two decades ago tropical sprue, Immunoproliferative Small Intestinal Disease (IPSID) and infections were common causes of malabsorption in India. It is possible that implementation of preventive health measures and improved sanitation may have changed the spectrum of disorders causing malabsorption. The aim of this study therefore was to assess the spectrum of malabsorption seen at our center during the past nine years. Patients seen at our center with malabsorption from January 2000 to December 2008 were included in this study. The etiological, clinical and investigation details were recorded on uniform structured data forms. The data obtained was retrospectively analyzed. Malabsorption was detected in 124 patients during the study period. The mean age of patients was 31.9+16 years and 60.5% were males. Tropical sprue was the commonest etiology (29%) followed by celiac and Crohn's disease (15.3% each). Other important etiologies included parasitic infestations (9.7%) and immune deficiency disorders (5.6%). Intestinal tuberculosis was seen in only 2.4% patients. We are witnessing a change in etiological spectrum of malabsorption . Celiac disease and inflammatory bowel disorders are emerging as important causes and ImmunoProliferative Small Intestinal Disease (IPSID) and intestinal tuberculosis are on the decline. Tropical Sprue however continues to be the commonest cause as in the past.


Dutta A.K.,Christian Medical College & Hospital
Tropical gastroenterology : official journal of the Digestive Diseases Foundation | Year: 2011

Distinguishing Crohn's disease (CD) from intestinal tuberculosis (ITB) is clinically challenging but important for prognostication and patient management. Patients with diagnosis of CD and ITB were prospectively enrolled in the study from January 2006 to October 2007. The patients were followed up for further 15 months to ascertain that the diagnosis had not changed. Clinical, laboratory, serological [IgG anti Saccharomyces cerevisiae antibody (ASCA)], endoscopic and histologic features were compared between the ITB and CD patients. The ASCA titers were estimated in 100 healthy controls. Patients were diagnosed as ASCA positive when their ASCA titers were three standard deviations above mean of controls. Thirty patients with CD (age 33.9 + 15.2 years, 70% males) and thirty with ITB (age 35.1 + 12.2years, 53.3% males) were included in the study. Features commoner in CD were longer duration of symptoms (p < 0.001), blood mixed stool (p = 0.006), presence of longitudinal ulcers (p = 0.005) and skip lesions (p = 0.008) on colonoscopy and more number of colonic segments involved (p = 0.004). Anorexia was commoner in ITB patients (p = 0.008). Positive ASCA was commoner in CD (30%) than ITB (10%) but did not reach statistical significance (p = 0.1). A combined evaluation of clinical features, endoscopy, histology and response to treatment is the key to differentiate between CD and ITB.


Rajshekhar V.,Christian Medical College Hospital
Acta Neurochirurgica | Year: 2015

The two main manifestations of brain tuberculosis that require surgery are hydrocephalus associated with tuberculous meningitis (TBMH) and brain tuberculomas. TBMH most often responds to medical therapy but surgery is required promptly for those who fail medical therapy. Both ventriculoperitoneal (VP) shunt and endoscopic third ventriculostomy (ETV) are valid options although the latter is more often successful in patients with chronic hydrocephalus than in those with acute meningitis. Patients with TBMH are more prone to complications following VP shunt than other patients. The outcome of these patients is determined by the Vellore grade (I to IV) of the patients prior to surgery with those in good grades (I and II) having a better outcome and those in the worst grade (IV) having a high mortality in excess of 80 %. Patients with brain tuberculomas present clinically with features of a brain mass, indistinguishable clinically from other pathologies. CT and MR features might provide a probable diagnosis of a tuberculoma but most often a histological diagnosis is desirable. Empiric medical therapy is reserved for a small number of patients. Although the treatment of brain tuberculomas is essentially medical, surgery is required when the diagnosis is in doubt, to reduce raised intracranial pressure or local mass effect and to obtain tissue for culture and sensitivity studies. Stereotactic biopsy, stereotactic craniotomy and excision of superficial small tuberculomas and microsurgery are all procedures used to manage brain tuberculomas. The outcome in patients with brain tuberculomas is good if the tuberculous bacillus is sensitive to the anti-tuberculous therapy. The duration of therapy is debated but we suggest at least 18 months of combination therapy with three or four anti-tuberculous drugs and continue the therapy till the tuberculoma has resolved on neuro-imaging. © 2015, Springer-Verlag Wien.


Rajshekhar V.,Christian Medical College Hospital
Neurology India | Year: 2015

Neurosurgeons are often identified with traits such as arrogance and hubris. However, the true legacy of neurosurgeons is excellence. Harvey Cushing, the pioneering neurosurgeon of the United States, is largely responsible for this legacy of excellence. Eminent personalities have agreed that sincere and hard work is necessary to achieve excellence. Excellence in neurosurgery in the domains of surgical work and research will be discussed in the article. Excellence in surgical work should be measured comprehensively and over long follow-up periods using tools such as functional outcomes and quality of life instruments besides morbidity and mortality. For excellence in neurosurgical research, one can use the help of indices such as the h-index and i10 index. No single measure, whether for surgical excellence or excellence in research, however, incorporates a measure of qualities such as empathy, integrity and mentorship. These intangible qualities should be an integral part of the assessment of a neurosurgeon and his/her work. Cushing's attributes of meticulous record keeping, attention to detail, and maximal utilization of opportunities should guide us in our pursuit of excellence. In recent years, it has been suggested that excellence is not the result of an innate talent but can be aspired to by anyone willing to adopt a work ethic that involves several hours of "deliberate practice," feedback and passion. Neurosurgeons should continue to pursue the legacy of Cushing especially in present times when medical professionals are frequently depicted as being driven more by avarice than by Hippocratic principles.

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