Publications:-
1. Illness behavior among patients with medically unexplained dizziness
Background: Dizziness is a common symptom to which patients seek ENT consultations. It is a symptom for which the cause can be either medical or psychological factors or both. Dizziness can cause significant distress and lead to multiple consultations. This study aimed to assess patterns of illness behaviors among patients with chronic dizziness and understand the underlying patterns. Methodology: Illness behavior was assessed by illness behavior questionnaire (IBQ), somatic symptoms by Scale for Assessment of Somatic Symptoms and diagnosis by the Diagnostic Criteria for Psychosomatic Research (DCPR) and International Classification of Diseases 10. Results: Of the 301 individuals, 24 had dizziness, most of these individuals had another somatic symptom and majority met criteria for health anxiety on DCPR. On the four subscales of IBQ, health concerns scores were higher in patients with dizziness as compared to other somatic symptoms. There was no significant difference between bodily distress, affective distress, and affective inhibition. Conclusions: This study concluded that patients with dizziness can also have other physical symptoms and high health anxiety and hence it may be necessary to screen patients for the same.
2. Identification of unmet clinical needs in the field of nephrology – A modified bio-design approach
In India, the incidences and risks of Chronic Kidney Disease (CKD) have been rising alarmingly due to the rising prevalence of Hypertension and Diabetes patients. The treatment for CKD is unaffordable for most of the patients suffering from this condition. The lack of access to quality care in rural and suburban India further impacts the plight of CKD patients. These inconsistencies and gaps in effective treatment are equally present in most Nephrology related disorders. To address these issues, the authors used a modified version of the biodesign innovation process, originally developed by Stanford University, to identify unmet clinical needs in the field of nephrology from the perspective of developing new innovative medical devices to fit the evolving MedTech ecosystem in India. A multidisciplinary team, involving a doctor, an engineer and a designer, identified 54 unmet needs with significant negative outcomes from a 1 month clinical immersion held at a tertiary referral hospital in Southern India. 4 rounds of pre-caliberated filters were applied on these needs to identify the ten most compelling clinically validated needs for the phase of invention. This article talks about the modified biodesign process used, the top ten unmet clinical needs identified and the team’s findings during the study
3. Grants, Funding, Awards and Recognition in Healthcare Innovation
Financial planning is crucial for turning an idea into a marketable product, and there are various ways to obtain funding. Bootstrapping involves using personal savings or loans from friends and family, while angel investors can provide larger funds to help establish a business. Venture capitalists are attracted to companies with early customers and strong potential for expansion, while private equity firms and investment banks are interested in established companies with a proven track record. The funding journey is specific to the investment stage, investor type, and their preferences, and national and social media recognition can play a major role in securing funding. For paediatricians looking to start a business, it’s important to understand the various funding options and work to gain recognition for their ideas.
4. Novel Eustachian Tube Dysfunction Management Techniques: Prototype Feasibility Studies in Fresh Cadaveric Specimens
Abstract Background: The underlying etiology and natural history of Eustachian Tube Dysfunction(ETD) is poorly understood, associated with various symptoms and can lead to a predisposition to middle-ear disease and, thereafter, permanent deafness. In developing countries, it is a bigger burden due to negligence and lack of awareness, coupled with the high cost of treatment and limited availability of dedicated effective solutions. This lead to the need to develop an effective solution for patients with chronic ETD as a day-care to avoid middle ear diseases. Materials and Methods: Two cadaveric studies were done in March 2017 and August 2017 to test the utility and usability of various design prototypes and understand the potential barriers in managing ETD. 17 Prototypes were tested and broadly classified into three main categories as per their nature and use- Diagnostic, interventional, diagnostic & interventional. Results: Three designs-an articulating camera, the balloon dilator and one embodiment of the expander showed promise as products to aid in the diagnosis and treatment of ETD. The electrical impedance probe had some merit as a safety feature but a more extensive study will be needed to prove its utility. Conclusion: One prototype demonstrated a promising technique for equalization, mucus clearance, widening and possibly long-term relief for patients with ETD. The cadaver studies suggested the further consideration of three diagnostic technologies and the elimination of several others, further studies for feedback on positioning as well as physiology will be necessary. While slight variations in technology worked with some success, the other concepts showed no further promise.
5. Noxeno-Research & Development of an Affordable Nasal Foreign Body Removal Device in India
Introduction: Removal of Nasal Foreign Bodies (NFB) in the pediatric population is a difficult procedure for General Physicians (GP’s) and pediatricians without adequate expertise in carrying out highly skilled nasal procedures. Given the distribution of ENT specialists in cities and urban regions, most children with impacted nasal foreign bodies are taken to GP’s and Pediatricians who are available in semi-urban and rural regions. They however, are not experts in carrying out skill intensive nasal maneuvers that are required for a successful first attempt. With repeated unsuccessful attempts, extraction becomes complex, dangerous and often warrants removal under sedation or general anesthesia. This paper focuses on the research and development of a dedicated nasal foreign body removal device that is designed for easy removal of NFB’s at the first point of care. Methods: The methodology involved the use of the Stanford BioDesign process for unmet need assessment to identify this need, followed by a rigorous phase of product design & development. Features of the device were validated and incorporated based on an extensive clinical survey on cost, acceptability and feasibility assessment of the device. Results: An affordable nasal foreign body removal device was specifically designed and developed for non-otorhinolaryngologists, especially General Physicians and Pediatricians, while meeting cost, skill requirement and usability criteria’s gathered from the clinical survey. Conclusion: A robust methodology similar to the one followed during the development of Noxeno is needed to be followed for developing clinically effective medical devices which meet the requirements of the user, patient and provides greater market acceptability.
6. A Real-Time Sequential Phase-Shift Approach to Tinnitus Cancellation-A Pilot Study in Southern India
Background: Tinnitus is a common hearing disorder causing significant morbidity to a large number of people in India. There exists limited literature which demonstrates complete cancellation or mitigation of Tinnitus without loss in hearing thresholds. However, there is some data that suggests sequential phase shift approach to tinnitus cancellation. A pilot study done to validate the effectiveness of a real-time sequential phase-shift technology device in South India is presented. Objectives: To evaluate the effectiveness of a real-time sequential Phase-Shift Approach to cancellation of Predominant Tone Tinnitus (PTT). Methods: 13 patients aged 19-65 years suffering from chronic Tinnitus were selected from a semi-urban setting in southern India. The Tinnitus Noise Generating Tool (TNGT) identified the magnitude and frequency of PTT, after which a sequential phase shifter successfully cancelled out the monotone. After the phase cancellation was locked, patient outcomes were measured over a duration of 30 minutes. Results: 12 out of 13 patients’ Tinnitus were classified successfully using the TNGT. 7 out of the 12 patients had PTT. All 7 patients had intermittent dips or cancellations of PTT once the anti-phasic signal was implemented. Conclusion: AReal-time sequential phase-shift solution showed promising results in our pilot study. These result show that such a device can be beneficial in managing Tinnitus in India. Further studies which identify the loss in phase synchronization along with advances in making this technology affordable and wearable are warranted.
7. Use of a Structured Process to Identify Compelling Unmet Medical Technology needs in Emergency Medicine and Critical Care in India
Background: Indigenous medical innovation, addressing specific unmet clinical needs, can bridge numerous gaps in India. The Stanford BioDesign Process is a practical, proven process to identify compelling needs for health technology innovation. Objective: To identify, validate and prioritise a comprehensive list of specific unmet medical technology needs in Critical Care and Emergency Medicine. Methods: A 10-week clinical immersion was carried out by a multidisciplinary team in 22 primary, secondary and tertiary centres across six states in India. Using the Stanford BioDesign Process observations and problems were documented and converted in to need statements. A modified BioDesign filtering process was applied to validate, score and prioritise the unmet needs which included disease-specific filters, technology-specific filters and market-specific filters. Results: 72 observations were recorded. 156 need statements were then passed through the multi-level filtering process. Each need was scored, and the top ten needs were then used to create need specification documents. Conclusion: Unmet need research like ours can help catalyse need-specific innovation in Emergency Care and Critical Care. This research is now being disseminated to create market-ready products that can bridge these gaps and improve health outcomes in India
8. A structured process to identify unmet needs for Medical Device Innovation in Minimal Access Surgery, Neurology & Neurosurgery
According to published estimates, 75% of medical devices and diagnostics in India are imported of which, most are priced at global price points. These devices are neither designed nor priced for the Indian population. As India works toward increasing healthcare access, reducing costs of healthcare and indigenous innovation suitable for the Indian ecosystems will play a big role. It is of vital importance to develop solutions specific to the Indian patient and compatible with the complex healthcare ecosystem. The BioDesign Process for Medical technology innovation was developed by Stanford University. The process extends from conducting observations in the clinical setting, to unearthing needs, developing a concept and thereafter provides a framework to eventually reach the stage of commercialization. We have used an adapted version of this process to identify unmet clinical needs in Minimal Invasive Surgery, Neurology and Neurosurgery in India. The Stanford Biodesign process was devised for mature healthcare systems and hence has been adapted to suit India sensibilities. The clinical immersion spanned across 10 weeks and involved 4 tertiary care centres and 6 rural centres, both primary and secondary, in South India. On completion, we arrived at close to a 100 unmet clinical needs with significant negative outcomes. These needs went through a rigorous four round filtering process to arrive at the top 10 needs. These filters ranged from epidemiology and criticality of disease to competitive landscape and technical complexity. In this article, we present our need identification process as well as our top 10 medical device specific needs.
9. A Case of Isolated Laryngeal Candidiasis Mimicking Laryngeal Carcinoma in an Immunocompetent Individual
Respiratory fungal infections are usually found in immunocompromised individuals who have received either long-term steroid therapy or broad-spectrum anti-microbial therapy or have a non-resolving underlying chronic disease. These infections are seen as a part of bronchopulmonary fungal infections, and their isolated and primary occurrence as laryngeal diseases is highly uncommon. Laryngeal fungal infections can also mimic various diseases, such as gastroesophageal reflux disease, granulomatous diseases, leukoplakia, and carcinoma, thereby misleading the treating team from correct diagnosis and management. It is therefore important to identify the lesion at the earliest point possible to avoid morbid or life-threatening consequences. We report a case of isolated laryngeal candidiasis in an immunocompetent Indian male with an unusual presentation mimicking laryngeal carcinoma. The clinical and histological features are highlighted with a review of relevant literature to demonstrate the possibility of such an isolated fungal lesion, even in an immunocompetent individual.
10. A Structured Process to Generate Ideas in MedTech
The chapter provides an overview of the various methods used today for identifying unmet needs and developing products. The healthcare domain is chosen as the medium for the description. The Biodesign process as developed at Stanford University is described, along with multiple off-shoots and adaptations of the process; specific to the adoption of the process in various countries is described. Success stories and shortcomings of the process with case studies are highlighted. The chapter analyzes other processes-examining the critical factors that lead to the success of these programs. It also analyzes through examples of medical device and medical technology developments, where lack of a structured process has led to ‘failures’ and the key learning from these case studies.
11. Management of Adult Recurrent Respiratory Papillomatosis with Oral Acyclovir Following Micro Laryngeal Surgery: A Case Series
To demonstrate the role of oral acyclovir in monthly regimes after microdebrider assisted excision in 3 patients with adult recurrent respiratory papillomatosis (ARRP). Three patients with ARRP who presented to a tertiary referral hospital in stridor were initially treated with a tracheostomy in order to secure airway. On further evaluation by videolaryngoscopy extensive bilateral laryngeal papillomatosis was noted with history of similar conditions in the past for which they were repeatedly operated. They were admitted and underwent Microlaryngeal surgery and laryngeal microdebrider assisted surgery under general anesthesia. Post operatively a course of oral acyclovir at 800 mg/5 times/day for 5 days was administered. On repeat assessment with videolaryngoscopy at monthly intervals a complete remission of the disease was noted with no residual disease at the end of 1 year in 2 cases. One case had a recurrence. Renal parameters were monitored periodically. It may be concluded that the action of anti viral drugs at regular intervals in addition to a short course of oral steroids lead to rapid recovery and prevented latent virus activation within the laryngo tracheal system hence maintaining long term improvement. This can avoid multiple laryngeal surgeries, repeated respiratory emergencies and risk for malignant transformation in the future thereby reducing morbidity and effect on quality of life.
12. A Portable Color Sensor Based Urine Analysis System to Detect Chronic Kidney Disease
Chronic kidney disease (CKD) is a condition characterized by a loss of kidney function gradually over a period of time with five stages. Usually, in the initial stages, the disease appears to be asymptomatic as a result diagnosis of the disease in the early stages is unlikely. When diagnosed in the early stages (stages 1-2) the disease is completely reversible. For early diagnosis of the disease, we use a system consisting of sensor TCS3200 and a urine strip. The sensor detects the change in color on the strip when the sample is introduced. Change in color of the strip is due to the presence of albumin in urine, which is the primary biomarker considered to detect the early stage of kidney dysfunction.
13. MedTech Innovation using a structured Biodesign process: Barriers and Opportunities
Medical Technology (MedTech) can be defined as the application of science to develop solutions to health problems. It also includes devices, processes and existing systems in the healthcare ecosystem. Biodesign process is the tried and tested methodology of identifying the unmet clinical needs and solving the problems of the healthcare ecosystem by applying science and technology. Hence, biodesign process is nothing but a process of developing systematic MedTech Innovations. Just like there is clinical research for disease and all its aspects like etiology, management etc, the systematic process of identifying problems and finding solutions in healthcare ecosystem is termed biodesign process. The starting point in this whole process is to define the right problem, figuring out all the possible solutions, zeroing on to the right solution and see that it solves the problem efficiently. But ultimately, did that solve the problem? At the first instance, was there a problem at all? These are the questions that arise during the course and biodesign process has the answers to all these questions. This process allows the innovator to ask the right questions and find the right answers in the best possible way, so that any of the time and effort of the team are not futile. The biodesign process established by the Stanford biodesign program gave the basic understanding of the process, which was modified to the Indian healthcare ecosystem to identify relevant problems and innovate suitable solutions.
14. Identification of Unmet Clinical Needs in the Field of Otorhinolaryngology in India – A Modified Biodesign Approach
Background: Otorhinolaryngology {Ear, Nose and Throat (ENT)} related diseases are exceedingly common in India. A huge number of conditions are managed ineffectively due to various reasons. Trained personnel are not accessible uniformly in all geographies, and affordable solutions catering to Indian healthcare system are scarce. Inefficient problem identification contributes to the current poor state of treatment in healthcare ecosystem. There is a clear need for strategic problem identification in the field of Otorhinolaryngology. Methods: A multidisciplinary team of an engineer, a product designer, a doctor and a business graduate was constructed. Following the Biodesign process, the team was immersed in the ENT department of a tertiary care hospital for 8 weeks, wherein it followed clinicians in their day-to-day activities such as out-patient clinics, surgeries and wards rounds and made detailed observations. Various pain points were identified where suboptimal treatment was delivered to the patient. Detailed observations were recorded, which were used to arrive at corresponding need statements. The needs were prioritized based on a custom made ranking scale. Results: Through 2-month clinical immersion, 198 needs were identified in the ENT space. After applying a systematic and scientific filtering method, inspired by Biodesign process, top ten needs were identified, which were successfully cross-validated with several ENT specialists across the country. Conclusion: A strategic method to identify problems and pain points in the ENT space led to the identification of several validated unmet clinical needs. Total of 198 needs were ranked based on criticality, prevalence and incidence, technical complexity and potential market opportunities
15. Balloon Sinuplasty Literature Review: An Assessment of Clinical Studies from 2007 To 2018
Chronic Rhinosinusitis (CRS) is a disease said to affect 1 in 7 people across the globe. It is associated with debilitating symptoms that have a significant impact economically as well as on the patient’s quality of life. It results when the nasal passages and paranasal sinuses are afflicted by concurrent inflammation and infection. Currently the two key options in management include long term medical management and functional endoscopic sinus surgery (FESS). The failure rate of medical treatment ranges from 50-88% in literature, following which patients undergo endoscopic sinus surgery. FESS involves the removal of mucosal and osteoid tissue to achieve adequate disease clearance. In keeping with the principle of regaining physiological nasal clearance and ventilation, balloon sinuplasty was approved in 2005, which dilates the ostia of the diseased sinuses, allows for mucous clearance and improves ventilation. In a survey based study looking at the factors leading to delay in definitive management in patients with Chronic Rhinosinusitis in India it was concluded that there is a need for an affordable, minimally invasive solution for CRS soon after medical management fails. Balloon sinuplasty or balloon catheter dilation (BCD) is a relatively novel procedure would be a suitable option to bridge this gap. This article is a review of literature on the efficacy and safety of balloon dilation as a standalone procedure, in comparison with FESS or as a hybrid procedure with balloon sinuplasty being conducted along with FESS.
16. A biodesign based study on chronic tinnitus and evaluation of adaptive noise cancellation technology in its management
Advancements in technology have aided doctors and patients alike. However, there are always unmet needs and gaps in the market to be filled. In the audiology space, despite many technologies that address tinnitus, successfully implementing a solution for tinnitus is one such challenge. Tinnitus is the perception of sound in the absence of an acoustic stimulus and is heard only by the patient. It has an estimated prevalence of 50 – 70 million people in India, and about 17% of the world population develops this condition sometime in their life. There is a need for a solution that is affordable, and accessible to the majority population. In this study, a structured unmet needs analysis process that is based along the lines of the Biodesign approach has been employed to study and assess this unmet need. An understanding of the current treatment gaps and stakeholder analysis was done, which led to the formulation of a detailed need specification. The proposed concept involves determination of the subject’s tinnitus frequency and pitch followed by the application of adaptive noise cancellation techniques to eliminate the noise heard by patient in real time. The implementation of the Biodesign methodology, scientific research on Tinnitus, a technical feasibility study was performed and results of the initial concept study is presented in this paper.
17. Near complete tracheal rings in an adult male cadaver associated with variation in V2 and V3 segments of vertebral artery
During routine dissection in an adult male cadaver, the presence of long segment nearcomplete tracheal rings associated with variation in the second (V2) of right vertebral artery (VA) and third (V3) segments of the left VA was encountered. This case report highlights the normal lifespan of an individual despite anatomical variations that are reported to be incompatible with life. Congenital complete and near-complete tracheal rings are extremely rare tracheal deformities, and long-segment occurrences of these variations are usually incompatible with life. They are reported to be associated with cervical chondrogenic anomalies and craniosynostotic syndromes. In the same cadaver the left VA entered the foramen transversarium (FT) of C6 vertebra and exited through the FT of the axis. It formed a loop below the arch of atlas and entered the vertebral canal between the atlas and axis, completely bypassing the FT of the atlas. A branch from the loop divided into two branches, one of which supplied the dorsal ramus of C1, the other ending in the surrounding neck musculature. The right VA was normal, except that it entered the FT of C5 vertebra bypassing C6 vertebra. It was noted that the calibre of the VA on the left side was considerably more than that on the right. Variations in the vertebrobasilar system have a potential clinical impact, since they are the feed arteries of the brain.
18. Diagnostic Dilemma Of A Midline Destructive Disease – A Case Report
Midline Destructive Disease (MDD) is a condition that includes Idiopathic Midline Destructive Disease, Wegener Granulomatosis, Lymphomatoid Granulomatosis, Polyarteritis Nodosa, Allergic Granulomatosis, Foreign Body Granuloma and Limited Wegeners. The term idiopathic is applied to a MDD when extensive diagnostic workups have failed to reveal anything other than inflammation and necrosis. It remains localized to the head and neck and can be differentiated histologically from other MDD by the presence of sheets of characteristic polymorphonucleocytes. A case of Idiopathic Midline Destructive Disease in a 55 year old patient is presented to highlight the issues faced in management.
19. Submental Epidermoid Cyst- A Case Report
Epidermoid cysts are rare lesions in the head and neck and are most often located in the submental region. They are usually due to surgical or accidental events leading to traumatic implantation of epithelial cells into deeper tissues. It is uncommon to find an Epidermoid cyst without this history. We operated on a 30 year old male patient who presented with a 10 year history of a slow growing painless midline neck swelling and had no history of any trauma or surgical procedures in the head and neck area. The cyst was excised under general anesthesia and found to be in the submental region extending to the left parapharyngeal area. A histopathological examination revealed a connective tissue wall lined by squamous keratinizing epithelium without any identified adenexal structures suggestive of an Epidermoid cyst. This case was noteworthy due to the absence of any apparent cause explaining implantation of epithelial cells in this region.
20. The mystery of the disappearing cyanosis
I was working as an emergency duty doctor in a hospital, when, on one seemingly peaceful night, I received a call about one of the patients. I walked up to the ward and saw an anxious looking nurse, who muttered to me, “Hurry up doctor, the patient in that room is turning blue.”
21. An assessment of postoperative pain in patients undergoing tonsillectomy
Aim. The aim of this study was to identify and assess the relative effect of various factors responsible for postoperative pain in patients after tonsillectomy.
Methods. Fifty patients aged between 3 and 70 years, who were scheduled for tonsillectomy, in the ORL department of a tertiary referral hospital, were enrolled for this study. Informed consent was obtained before hand, and patients were chosen consecutively. Pre-, intra- and postoperative parameters such as use of analgesics, duration of surgery, amount of blood loss, use of ligatures, cautery etc. were recorded. Surgeons were questioned regarding possible factors which influenced the level of postoperative pain. Patients were explained about the Wong Baker’s Visual Analogue Pain scale prior to surgery, and then tested in the postoperative period at 1 hour, 24 hour and 48 hour time intervals. The degree of pain was correlated to the parameters recorded. Institutional Ethical Review Board permission was granted for the study.
Results. The results concerning 50 patients (mean age of 13.5 years) over a six-month period showed the mean Visual Analogue Score at 1 hour after surgery was 7/10, at 24 hours was 6/10 and at 48 hours was 3.5/10. Factors such as age, sex, preoperative education, pre- and postoperative antibiotics, pre- and postoperative analgesics, grade of tonsillitis, experience of surgeon and method of surgical dissection did not affect the degree of postoperative pain significantly. However, the use of ligatures, cautery and increased amount of blood loss during surgery lead to increase in postoperative pain levels (P<0.05). Shorter duration of surgery, early and frequent oral intake of cold/bland diet in the postoperative period reduced the postoperative pain significantly (P<0.05).
Conclusion. The use of ligatures, cautery and increased amount of blood loss during surgery lead to increase in postoperative pain levels (P<0.05). Shorter duration of surgery, early and frequent oral intake in the postoperative period reduced the postoperative pain significantly (P<0.05).
22. A Case Of Fluid In The Right Occipital Condyle Secondary To Persistent Increase In Intracerebral Pressure
In a case of Cerebrospinal Fluid (CSF) leak from the ear, radiological investigations are mainly performed to examine and evaluate the mastoid bones. Occipital condyles are often overlooked. The usual causes for CSF to leak into the ear are related to factors that cause an increase in intracerebral pressure. Similar factors may also be responsible for the formation of a pneumatocele and subsequent pneumatisation of the mastoid and occipital bones. Pneumatization in the skull is normally confined to the mastoid process. Pneumatization in bones other than the temporal bone such as the occipital bone is exceptionally rare and has very few cases reported so far. It has been postulated that occipital pneumatization is a consequence of communication between the temporal and occipital bones. Persistently increased intraluminal pressure has been proposed as a mechanism of pneumocele formation which later progresses to pneumatisation of occipital bones. Fluid in the occipital bones following increased intracerebral pressure has not yet been reported. Isolated cases of pneumatocysts within the occipital condyle however have been documented. If the cause for such pneumatisation or fluid accumulation is left untreated then complications such as spontaneous intracranial epidural accumulation of air, fracture of C1 and the occipital bone, spontaneous subcutaneous emphysema and pneumatocele formation can occur leading to severe morbidity and mortality. We present a case of CSF Rhinorrhea and Otorrhea in a 41 year old male secondary to a space occupying lesion in the right lateral ventricle of the brain with fluid in the right occipital condyle with a review of relevant literature.
23. Tracheal resection with end-to-end anastomosis for post-intubation cervical tracheal stenosis: study of 14 cases
Background and objectives: The incidence of acquired laryngeal stenosis is increasing. This retrospective study aimed to assess the long term results of circumferential resection with end-to-end tracheal anastomosis for isolated post-intubation stenosis of the cervical trachea, and to review the relevant literature.
Methods: Twelve male and two female patients (aged 16-30 years, mean age 24 years) treated between February 2003 and December 2008 were included. Hospital and office records were reviewed and relevant surgical details recorded.
Results: Indications for tracheal resection anastomosis were post-intubation stenosis (78.57 per cent) and trauma (21.42 per cent). One to five tracheal rings were resected (i.e. 1-2.5 cm of cervical trachea). Tracheal anastomosis was considered successful if the patient remained asymptomatic for 24 months of close follow up (involving regular flexible bronchoscopy and neck X-ray). The anastomotic success rate was 92.85 per cent.
Conclusion: Tracheal resection and end-to-end anastomosis is relatively safe and reliable for definitive treatment of benign tracheal stenosis in appropriate patients. Local application of mitomycin C prevents granulation and aids long term airway patency.
24. Unilateral Orbital Proptosis Secondary To A Carotico-Cavernous Fistula: A Case Report
Carotico- Cavernous Fistulas (CCF) are caused by the laceration of the intercavernous portion of the carotid artery, or one of its intercavernous branches resulting in arterialisation of blood within the cavernous sinus. There are four types (A,B,C,D) of CCF out which type A (Direct type) and types B, C, and D (Indirect types) occur spontaneously. Prompt diagnosis and treatment of this condition can prevent visual loss, development of secondary glaucoma and intracranial hemorrhages.A unilateral orbital proptosis associated with sinusitis is an indication for endoscopic decompression. In our case even though there was unilateral orbital proptosis along with sinusitis, endoscopic surgery was unnecessary and did not significantly effect the course of patients illness. We present a case of unilateral orbital proptosis in a middle aged male with an indirect type of CCF detected on Magnetic Resonance Angiogram. The role of MR imaging and indications for endoscopic surgery in a unilateral orbital proptosis with review of relevant literature is discussed in this paper.
25. Meningioma presenting as a mass in the External auditory canal.
26. Acute Onset Dysphagia Secondary To Cervical Injury In A Young Male – A Case Report
Dysphagia may have oropharyngeal or esophageal causes. Extrinsic compression of oesophagus or intraluminal abnormalities in the esophagus can cause dysphagia. Anatomic causes of dysphagia are tumors, abscesses, and cervical bony outgrowths (osteophytes). Anterior cervical osteophytes can rarely cause dysphagia due to mechanical compression and inflammatory reactions in the tissues around the esophagus. For this reason Non steroidal anti-inflammatory drugs might have a role in improving patient symptomatology. We present a case of a young man with cervical osteophytes presenting with an acute onset of dysphagia following mechanical injury to the neck that improved rapidly with non steroidal anti-inflammatory medications. The report is discussed with a review of relevant literature.
27. Mucormycosis Of The Paranasal Sinus With Gas Forming Maxillary Osteomyelitis – A Case Report
Mucormycosis (MM) is a deep, opportunistic mycosis caused by filamentous fungi included in the order Mucorales that belong to the class Zygomycetes of fungi. It is recognized as one of the most rapidly progressive lethal form of fungal infection in human beings with a high mortality of 70–100%. The term osteomyelitis designates inflammation of the bone and its marrow cavity. Osteomyelitis and Mucormycosis have been known to be associated with intraosseous gas collection. However these have never been noted in the paranasal sinuses. These gas-forming infections can be caused by strict aerobic or facultative anaerobic bacteria such as Klebsiella, Escherichia coli, Salmonella, Streptococcus, and Staphylococcus. Their coexistence with fungal infections can lead to dreadful complications. This report highlights a rare case of Mucormycosis of the paranasal sinuses in an immunocompromised man with associated gas forming osteomyelitis of the facial bones. This report also emphasizes on the importance of a prompt and early management in such a condition due to the rapidly progressing bony osteomyelitis with gas- forming organisms that are co-existent with fungal infections along with a review of relevant literature.
28. Low cost calibrated mechanical noisemaker for hearing screening of neonates in resource constrained settings
In a controlled setting, health workers with primary education can be trained to use a mechanical calibrated noisemaker made of locally available material to reliably screen for severe-profound hearing loss in neonates. The monitoring of auditory responses could be done by informed parents. Multi-centre field trials of this strategy need to be carried out to examine the feasibility of community health care workers using it in resource constrained settings of developing nations to implement an effective national neonatal hearing screening programme.
29. Near complete tracheal rings in an adult male cadaver associated with variation in V2 and V3 segments of vertebral artery
During routine dissection in an adult male cadaver, the presence of long segment nearcomplete tracheal rings associated with variation in the second (V2) of right vertebral artery (VA) and third (V3) segments of the left VA was encountered. This case report highlights the normal lifespan of an individual despite anatomical variations that are reported to be incompatible with life. Congenital complete and near-complete tracheal rings are extremely rare tracheal deformities, and long-segment occurrences of these variations are usually incompatible with life. They are reported to be associated with cervical chondrogenic anomalies and craniosynostotic syndromes. In the same cadaver the left VA entered the foramen transversarium (FT) of C6 vertebra and exited through the FT of the axis. It formed a loop below the arch of atlas and entered the vertebral canal between the atlas and axis, completely bypassing the FT of the atlas. A branch from the loop divided into two branches, one of which supplied the dorsal ramus of C1, the other ending in the surrounding neck musculature. The right VA was normal, except that it entered the FT of C5 vertebra bypassing C6 vertebra. It was noted that the calibre of the VA on the left side was considerably more than that on the right. Variations in the vertebrobasilar system have a potential clinical impact, since they are the feed arteries of the brain.
30. Do patients with allergic rhinitis have a particular personality trait?
In psycho-allergological research, the potential relevance of personality factors in the maintenance and exacerbation of atopic symptoms is still a matter of debate. More attention should be paid to the psychological status of allergic rhinitis patients, and appropriate treatment should be provided to improve their symptoms and quality of life.
31. Students’ Perceptions Of The Use Of Dramatics In Medical Education: Early Explorations
Background & objectives: By introducing a novel methodology that combines medical education with dramatics, medical and non-medical health professional students are able to learn and understand concepts in a more experiential and entertaining manner. This process is termed medical theatre.Methods: Two structured medical theatre workshops were conducted between May and June 2011 for 56 medical and nursing undergraduate students. The facilitators included doctors and professional theatre artists. During the workshop, the students were exposed to the basics of theatre and script writing skills. The process of a converting a medical topic into various forms of theatrical outcomes was then demonstrated. The students then chose a medical topic and implemented the medical theatre process. The workshop concluded with a student performance of two pre-written scripts where they experienced an event of fun with learning.Results: 92% (1st workshop) and 96% (2nd workshop) of the participants found the methodology extremely useful with respect to understanding the topics. All participants enjoyed the medical theatre experience. More than 85% of the students felt that this methodology should be included in the medical curriculum in an appropriate form.Interpretation and conclusion: This article highlights the introduction of an innovative teaching methodology that aims to teach medical topics using theatrical methods. The initial exposure of medical theatre was well accepted by the participants. This methodology, however, is not a substitute for conventional teaching and learning methods in every subject area. It does, however, provide an alternate option to learn medical topics in a unique manner.
32. A structured process for unmet clinical need analysis for medical device innovation in India: early experiences
It is estimated that approximately 75% of medical devices and diagnostics come to India from imports. A WHO report on medical devices highlighted that most devices present in developing countries have been designed for use in developed countries. Consequently, when these medical devices are implemented in India, they are either unaffordable or are maladapted to fit the complex healthcare ecosystem. A strong need exists to develop technologies that are intentionally designed to suit the Indian healthcare system. To address these issues, we have applied a modified version of the biodesign process, originally developed by Stanford University, to identify unmet clinical needs in the field of emergency medicine at a tertiary referral hospital in southern India. Since the biodesign process was originally created to identify unmet needs in a more mature Medtech ecosystem, we have altered its implementation to make it more suitable to the evolving Medtech ecosystem that prevails in India. At the completion of 2 months of clinical immersion by a multidisciplinary team, 100 unmet needs with significant negative outcomes were identified. The team then took all the need statements collected during the period of the clinical immersion and applied four rounds of precalibrated filters to arrive at the top 10 most compelling clinically validated needs that would be selected for the phase of invention. In this article, we present our reasons for making modifications to the biodesign process, our results and our experiences while implementing this process in an Indian healthcare system.
33. A biodesign based study on chronic tinnitus and evaluation of adaptive noise cancellation technology in its management
Advancements in technology have aided doctors and patients alike. However, there are always unmet needs and gaps in the market to be filled. In the audiology space, despite many technologies that address tinnitus, successfully implementing a solution for tinnitus is one such challenge. Tinnitus is the perception of sound in the absence of an acoustic stimulus and is heard only by the patient. It has an estimated prevalence of 50 – 70 million people in India, and about 17% of the world population develops this condition sometime in their life. There is a need for a solution that is affordable, and accessible to the majority population. In this study, a structured unmet needs analysis process that is based along the lines of the Biodesign approach has been employed to study and assess this unmet need. An understanding of the current treatment gaps and stakeholder analysis was done, which led to the formulation of a detailed need specification. The proposed concept involves determination of the subject’s tinnitus frequency and pitch followed by the application of adaptive noise cancellation techniques to eliminate the noise heard by patient in real time. The implementation of the Biodesign methodology, scientific research on Tinnitus, a technical feasibility study was performed and results of the initial concept study is presented in this paper.
34. RDS affected neonatal conditions and the health care situations in different health care settings
Respiratory distress syndrome (RDS) is a common lung disorder and foremost contributor to neonatal mortality worldwide. The technologies for RDS-treatments in resource constrained settings are insufficient. The objective is to better understand the scenario of the RDS-affected neonatal conditions and the health care system in different health-care settings.
35. Factors that Delay Definitive Management of Chronic Rhinosinusitis in India: A survey based study
36. Incidence of Nasal Foreign Body Impaction in India: Determined Using Literature Search, Interviews and Surveys
Background: A Nasal Foreign Body (NFB) is an external object which gets lodged in the nasal cavity and may have certain risks such nasal infections, aspiration, edema etc. There exists limited literature with respect to the number of annual cases of nasal foreign body impaction in India. A survey and study was carried out to determine the incidence of nasal foreign body impaction cases in India. Objectives: To determine the incidence of nasal foreign body impaction cases in India. Methods: Determination of the total number of all units and sub-units in the healthcare system was carried out including community health centers and private clinics followed by calculation of the number of cases of foreign bodies seen annually in each of the units by interviews and surveys. Data was extrapolated via assumptions made by industry experts and clinicians through multiplying the cases per center with the number of centers to obtain total number of cases of impacted nasal foreign bodies. Results: The approximate incidence of nasal foreign body impaction cases in India is 34.4 Million. Conclusion: Despite the drawbacks of the various assumptions, the results obtained in this study through this methodology are a reasonable approximation of the total number of cases of nasal foreign body impaction occurring in India annually. This methodology can be utilised to determine incidence of similar cases in other domains. Better healthcare data infrastructure in India can reduce the need for such assumptions and result in the generation of more accurate data.