Chronic constipation and constipation-predominant irritable bowel syndrome with constipation (IBS-C) are the common functional gastrointestinal problems which affect millions of people worldwide leading to increased health-care costs and impaired quality of life. Existing treatments have not been able to produce satisfactory results in 50% of the patient population. Drugs such as Tegaserod and Lubiprostone were also not clinically preferred because of cardiovascular adverse effects with the former and severe nausea causing intolerance with the later. Linaclotide is a first in class guanylate cyclase type-C receptor agonist, which has not only been found to be efficacious and safe for the treatment of chronic constipation and IBS-C but also has a positive impact on quality of life as demonstrated in placebo controlled clinical trials, with diarrhea as the most common adverse effect. This novel agent has recently been approved on 30 ^th August 2012 for clinical use in patients of more than 16 years of age.

Aim: The aim of this study was to find out the prevalence and causes of piriformis syndrome in patients with complain of low back pain/buttock pain with sciatica attending Regional Institute of Medical Sciences (RIMS), Imphal. Materials and Methods: All the patients in the study group attending Orthopedic and Physical Medicine and Rehabilitation Out-patient Department in RIMS, Imphal were examined. Those with increased symptoms on sitting, localized significant tenderness on palpation of the muscle, presence of one or more of the following tests: Freiberg, pace, beatty, and FAIR (Flexion , Adduction and Internal Rotation) maneuvers with negative X-ray, ultrasound, computed tomography and magnetic resonance imaging findings were subjected to piriformis muscle injection of lidocaine (2%) 2 ml and methyl prednisolone 2 ml (40 mg) for confirmation of diagnosis. Result: Out of 2910 patients, 182 cases (M: 28, F: 154) in the age range of 19-75 years with a mean age of 43 years were clinically diagnosed as piriformis syndrome. Prevalence of piriformis syndrome was 6.25%. Conclusion: Piriformis syndrome is one of the differential diagnoses of low back/buttock pain with Sciatica. Individuals of all activity levels can be affected. Females are more affected than males. Causes are overuse, prolonged sitting, trauma, and vigorous massage. Diagnosis is by exclusion of other causes. Simple injection with local anesthetic and steroid in the piriformis muscle is both therapeutic and confirmatory of diagnosis. Early diagnosis and treatment with injection of piriformis muscle can prevent further complications and risks of surgery, which is also not 100% curative. With proper care, piriformis injection can be carried out without any complication. Long-term study is needed to evaluate the recurrence after injection treatment.

Objective: To study the role fasciocutaneous flap as a method of soft-tissue reconstruction in open tibial fractures soft-tissue defect and to compare their outcome when used as early coverage with that of delayed coverage. Materials and Methods: A total of 30 patients with open tibial fractures (type IIIB) were subjected to fasciocutaneous flap for the soft-tissue defect. Patients were divided into two groups based on the timing of soft-tissue reconstruction comprising of 15 patients in each group. Group I the early group (0-7 days) and group II delayed group (8-30 days). Results: Road traffic accidents accounted for the majority of fractures with 77.7% and 60% in group I and group II. The right leg was involved in 20 patients (66.7%) and left leg in 10 patients (33.33%). Middle one-third of the leg being the predominant site of wound defect 66.7% and 60% in group I and group II respectively. 66.7% of superficial infection was found with the delayed closure (group II) and 46% with early closure (group II). 26.7% of deep bony infection was found to be with the delayed closure and 20% with early closure. 80% of flap survived completely in group I while 73.3% flap survived in group II. In group I the time to union was between 13 weeks and 25 weeks accounting for 73.3% of the cases and in group II the time to union was between 26 weeks and 52 weeks, which accounted for 80% of the cases. The average hospital stay was 13.4 days in group I with 80% ranging in between 10 days and 20 days and in group II the average stay was 22.8 days with 53.3% ranging from 21 days to 30 days. Conclusion: The goals of soft tissue coverage in open fractures are to achieve a safe and early durable coverage, avoid nosocomial infection and optimize the healing and facilitate the future reconstruction. fasciocutaneous flap can reliably and effectively cover traumatic open tibial fractures soft tissue defect.Advantage of fasciocutaneous; they have their own blood supply producing a good durable cover and can be reopened for bony surgery.

Objectives: To determine the urine culture and sensitivity profile in traumatic spinal cord injury (SCI) patients during admission in Physical Medicine and Rehabilitation setting in a tertiary care hospital. Study Design: A retrospective descriptive study. Setting: Department of Physical Medicine and Rehabilitation, Regional Institute of Medical Sciences, Imphal. Study Duration: January 1, 2012 to December 31, 2012. Materials and Methods: All the traumatic SCI patients admitted in the department and whose urine samples were sent for culture and sensitivity were included in the study. There were a total of 18 patients. Urine culture revealing a bacterial colony count of 10 ⁵ colony forming units (cfu)/ml was taken as significant bacteriuria. Results: Of all 18 patients, 15 (83.3%) patients had significant bacteriuria showing only gram-negative bacteria and three (16.6%) patients had sterile urine. All the positive urine samples showed growth of only single bacteria except in one (5.5%) patient. The most common organism isolated was Escherichia coli which was found in ten (55.5%) urine samples This was followed by one (5.5%) each for Klebsiella, Pseudomonas, Providencia, Enterobacter and one with combination of Klebsiella with Pseudomonas. Amikacin and nitrofurantoin were the most sentitive antibiotics encountered in majority of the gram-negative isolates. All the organisms were sensitive to imipenem. Conclusion: Only gram-negative bacteria were isolated from the urine samples of traumatic SCI inpatients with E. coli as the most common organism. Amikacin and nitrofurantoin were the most common sensitive antibiotics.

Objective: To evaluate whether the co-induction technique affects the total induction dose requirement of propofol and thereby reduce associated hemodynamic adverse effects. Materials and Methods: 120 american society of anesthesiologist (ASA) 1 and 2 patients undergoing general and gynecological surgeries under general anesthesia were randomly divided into four groups, i.e., group 1: Normal saline (control group), group 2: Midazolam, 0.03 mg/kg body weight, group 3: Thiopentone, 1 mg/kg body weight and group 4: Ketamine, 0.3 mg/kg body weight. After measuring the baseline hemodynamic variables and 2 min after study drug was given, propofol was administered 30 mg/10 s till the end points were reached -loss of verbal command or eyelash reflex. The total dose of propofol used and hemodynamic parameters were recorded following induction of anesthesia and the study was taken as completed and the rest of anesthesia proceeded as per standard technique. Results: Our study reveals that the total induction dose of propofol was reduced by 33.92% (group 2), 35.08% (group 3), and 42.69% (group 4) from that in the control group (group 1). The fall in mean arterial pressure from baseline in the midazolam (group 2), thiopentone (group 3) and ketamine group (group 4) was 10.88%, 14.58%, and 8.37% respectively. Conclusion: Ketamine reduced the induction dose requirement of propofol to the greatest degree and though, all three co-induction agents offered some degree of hemodynamic stability, ketamine provides the best cardiovascular stability.

Objective: To enquire about the level of awareness regarding various important aspects of palliative medicine among doctors of various departments in four medical colleges in Kolkata through a questionnaire. Materials and Methods: A questionnaire was developed by few members of Indian Association of Palliative Care. It was distributed, to a convenience sample of doctors who worked in various departments in all four teaching hospitals in Kolkata. The distribution and collection of questionnaires was carried out within 4 months. Results: The results suggested that 85% doctors felt that cancer was the commonest reason for the palliative care teams to be involved. Seventy four percent mentioned that pain control was their prime job; 53% said that they are enjoying their encounter with palliative care, so far; 77% thought breaking bad news is necessary in further decision making process; only 22% reported the WHO ladder of pain control sequentially, 35% believed other forms of therapies are useful in relieving pain, 35% thought they give enough importance and time for pain control; 77% said that they had heard about a hospice, among them still 61% thought patients should spend last days of their life at home. Thinking of the future, 92% of the doctors think more and more people will need palliative care in the coming days. Conclusion: Amongst doctors of various departments, there is a lack of training and awareness in palliative care. Almost all the doctors are interested and they are willing to have more training in pain control, breaking bad news, communication skills and terminal care.

Background and Objectives: Scoring system in all areas of medicine is receiving close attention because of the need to evaluate and monitor healthcare delivery and outcomes. The main application is in comparative surgical audit to monitor quality of care provided to the patient with a risk adjusted scoring system rather than using crude morbidity and mortality rates. In this prospective study, the validity of P-POSSUM is tested in patients undergoing major surgery and risk factors for low outcome were noted. Materials and Methods: A total of 277 major general surgical procedures as defined by the POSSUM scoring system criteria were included in the study during the period from September 2010 to February 2012, and final analysis was done. Results: The observed mortality rate was compared with the P-POSSUM predicted mortality rate. On using P-POSSUM the predicted mortality was 37 deaths. An O: P ratio of 0.91 was obtained. There was found to be no statistically significant difference between the observed and predicted mortality rates (χ2 = 7.859, DF = 5, P -value = 0.164). On analysing risk-factors we found that out of the 17 factors considered 10 are found to have significant rate of increment, whereas remaining 7 don't have significant change statistically. Conclusion: This study therefore, validates P-POSSUM as a valid means of assessing adequacy of care provided to the patient.

Background: Injury and death from the passage of electric current through the body is common in both industrial and domestic circumstances. The study has been carried out to find out the incidence of electrocution deaths in Manipur and also to detect the common source of electrocution, and study the pattern of injuries sustained by the victims. Materials and Methods: In this study, medicolegal reports of electrocution cases brought for autopsy during 2007 to 2011 at our centre have been analyzed as regards the history of the cases, police papers, and post-mortem examination findings. The findings were recorded in proformas and analyzed. Results: Twenty five cases (1.02%) were electrocution deaths and males outnumbered females. The highest number of cases was observed in the age group of 21-30 years followed by 31-40 years. Most of the victims were electrocuted on the road side (68%) and the remaining victims were electrocuted in their houses. The most common causative agent was the high tension wire (60%) followed by the home appliances (28%). 80% of the cases died on the spot and the majority of these victims were electrocuted by the high tension wires. All the electrocution deaths in the present series were accidental cases and no homicidal or suicidal cases were observed. Conclusion: The risk of getting electrocuted from the haphazardly installed electric wires without proper maintenance in most parts of this place is indeed a matter of concern. The spread of awareness and adoption of safety measures are important factors required for prevention of fatal electrocution.

Objective: The objective of this study was to determine the incidence of congenital hypothyroidism (CH) in neonates by measuring umbilical cord thyroid stimulating hormone (TSH), born in a Teaching Hospital in Manipur. Materials and Methods: The study was based on the findings from cord blood samples collected from 1,000 babies born to mothers having no systemic (especially thyroid disorders) and obstetrical complications in the last 2 years. Estimation of serum TSH level was carried out by enzyme-linked immunosorbent assay method using Eliscan ^TM (Diagnova) kit manufactured by Ranbaxy Fine Chemicals Ltd. (RFCL) India in the Department of Physiology, Regional Institute of Medical Sciences, Imphal. Results: The mean, median and standard deviation for the TSH values of the samples were 8.833 mIU/L, 6.824 mIU/L and 7.059 mIU/L respectively. Nearly, 29.3% of the babies had TSH greater than 10 mIU/L. One baby was found to be having CH out of the 1,000 screened. Conclusion: CH represents one of the most common preventable causes of mental retardation. The finding of 1 case of CH out of 1,000 new-borns screened indicates that incidence is high in this state. Screening of all new-borns in the future is highly recommended.

Objective: Health care workers (HCW) are at risk of occupational exposure to HIV. The purpose of this study is to carry out post exposure prophylaxis (PEP) after exposure among self reported personals and analyze them. Materials and Methods: Two hundred and twenty five (225) cases of accidental exposure were self reported in the Department of Microbiology from January 2001 till December 2011. Relevant data were recorded and analyzed. HIV antibody testing was done for the status of the source person. A baseline testing for HIV antibody was done before giving PEP. Post exposure testing was done at 3 months and at 6 months. PEP was given as per NACO guidelines. Results: Out of the 225 cases, maximum exposure (109 cases) happened in the age group of 25-34 years. Males were more exposed than females. Majority of the cases (38.6%) reported were doctors followed by nurses (23.1%), laboratory technicians (5.3%) and grade 4 workers (3.1%). 29.7% were outsiders. 39.1% cases reported in less than 2 hours after exposure, 57.7% reported between 2 to 72 hours and 3.1% took more than 72 hours. 59.5% of exposed population were vaccinated against Hepatitis B. Needle stick injury was the commonest form of exposure (65%), followed by spillage and splash (15%), sexual exposure ( 17%), human bite (2.6%) and sharp cut (2.2%). All post exposure testing were found to be non reactive. Conclusion: Needle prick injury is the most common cause of occupational exposure to HIV infection. PEP is protective against transmission of HIV among the exposed HCWs. There is a need for sensitising the HCWs regarding the importance of PEP.

Objective: To determine the spectrum of various bone tumors and their relative frequency at Regional Institute of Medical Sciences (RIMS) Hospital. Materials and Methods: A retrospective review of histopathological reports of all bone specimens received in the Department of Pathology (histopathology section), RIMS hospital for a period of 2 years from January 2009-December 2011 was done. Results: Of the 98 histopathologically diagnosed bone lesions, 50 (51%) were males and 48 (49%) were females, with a male to female ratio of 1.04:1. Age ranged from 7-74 years. Nonneoplastic lesions accounted for 36.7%, while neoplastic lesions accounted for 63.3%. Osteomyelitis was the most common and only nonneoplastic lesion encountered with 36 cases (36.7%). Out of 62 cases of bone tumors, benign tumors made up to 66.01%, while the malignant tumor and tumor-like lesions made up 17.71 and 16.2%, respectively. Age ranged from 8-74 years, in which 34 (55%) were males and 28 (45%) were females with M:F ratio of 1.2:1. Osteochondroma with 22 cases (35.2%) and osteosarcoma with seven cases (11.27%) were the most common benign and malignant tumors, respectively; while fibrous dysplasia with five cases (8.05%) was the most common tumor-like lesion. The age peak incidence was in the 2 ^nd (43.55%) and 3 ^rd (32.2%) decades. Femur was the most common site with 19 (30.6%) occurrences followed by tibia with 18 (29%). Conclusion: Chronic osteomyelitis was the commonest nonneoplastic lesion. Among the bone tumors, osteochondroma and osteosarcoma was the most common benign and malignant bone tumor, respectively.

Background: Pain on injection of rocuronium bromide is a common side-effect in anesthetic practice. This study has been carried out to assess the effect of nitrous oxide on the pain and withdrawal response caused by rocuronium injection. Materials and Methods: A prospective, randomized, double-blind, placebo-controlled study was carried out in the department of Anesthesiology, Regional Institute of Medical Sciences, Imphal to determine the effect of nitrous oxide (N ₂ O) on the frequency and severity of pain and withdrawal reactions after injection of rocuronium. 80 (Eighty) ASA physical status I and II patients undergoing general anesthesia for elective surgery were enrolled. The patients were divided into group O and group N and randomized to receive 100% oxygen (O ₂ ) or 50% N ₂ O in O ₂ for 2 minutes followed by a sub-paralyzing dose of rocuronium 0.06 mg/kg. After induction of anesthesia with thiopentone 5 mg/kg, an intubating dose of rocuronium 0.6 mg/kg was given. The patients were observed after injection of rocuronium 0.06 mg/kg, and asked to rate pain in the arm on a 4-point (0-3) verbal rating scale (none, mild, moderate or severe). After the intubating dose of rocuronium, withdrawal reactions were recorded. Results: Thirty-five patients (87.5%) in the group N and 20 patients (50%) in the group O reported no pain (P <0.001). The pain was mild in 5 (12.5%) and 20 (50%) patients in nitrous group and oxygen group, respectively, (P < 0.001). Withdrawal response after an intubating dose of rocuronium was observed in 4 (10%) and 11 (27.5%) patients in the N ₂ O and O ₂ groups, respectively, (P <0.05). No patients reported moderate or severe pain. Conclusion: Inhalation of 50% N ₂ O in O ₂ reduces the incidence and severity of pain and the withdrawal reactions associated with rocuronium injection.

Background: The data set of carcinoma of unknown primary (CUP) is not used for analyzing the burden and pattern of cancer in a given population. Aim: A retrospective analysis of the cancer registry data was done to see whether CUP can be utilized in the analysis of the burden of cancer in a given population. Materials and Methods: The data of CUP were obtained from the records of a hospital cancer registry of a regional cancer center from January 2010 to December 2011. The cases of CUP considered for the analysis were histologically confirmed malignancies with unknown primary. Results: CUP accounted for 4.5% of all cancers in our analysis. Squamous carcinoma was the major histological type (58%), with the following clinical entities observed in our analysis: CUP of the lymph nodes in 62.4%, of the liver in 21.2%, of the bone in 8.8%, of the peritoneal cavity in 2.7%, of the lung in 1.9%, of the pleural effusion in 1.4%, of the brain in 0.5%, of the ovary in 0.53%, and to the skin in 0.2% patients. The occurrence of CUP in relative proportion for both males and females showed that the majority (60%) of the clinical entity of CUP was seen at the supraclavicular lymph nodes, where a large proportion of cancers were of the head and neck region. Conclusion: The data of CUP to the regional lymph nodes in the head and neck region, though not specific, can be taken into account for the estimation of burden of head and neck cancer in populations with a high incidence of head and neck cancers, which will prevent the underestimation of actual burden of head and neck cancers of the population for advocacy and policy making by the health planners.

Oropharyngeal malignancy is the second most common malignancy of the head and neck surpassed only by carcinomas of the alveo-buccal complex in India (excluding thyroid malignancy). More than 75% of these oropharyngeal carcinomas occur in the tonsillar area. Two-thirds of the patients with tonsillar carcinomas present at advanced stages because early lesions are generally asymptomatic when small. A total of 5 cases of tonsillar malignancy (2 undifferentiated carcinomas, 2 non- Hodgkin's lymphomas, and 1 squamous cell carcinoma were reported and treated in the last 1 year. Four out of 5 cases presented with advanced disease (stage 4) at the time of their first visit to the hospital. A good response was seen in majority with primary radiotherapy or combined chemoradiation. This case series is an attempt to define the presentation, diagnosis, currently available treatment, and prognosis of these tumors.

We present here a case of advanced thymic carcinoma in a 45-year-old lady who came to us with complaints of chest pain, cough, and dyspnea on exertion. Contrast enhanced computed tomography (CECT) of the chest of the patient showed an anterior mediastinal mass with prominent superior vena cava. The patient underwent debulking of the thymic mass; complete resection could not be done because the tumor was found infiltrating the superior vena cava, pericardium, and left innominate vein. The final histopathological diagnosis was a thymic carcinoma. Postoperatively, the patient received 60 Gy of radiotherapy and three cycles of adjuvant chemotherapy consisting of cisplatin, doxorubicin, and etoposide. We conclude that surgery in combination with adjuvant chemotherapy and radiotherapy are beneficial even in patients in an advanced stage of thymic carcinoma.

Subarachnoid hemorrhage (SAH) may occur as a serious co-incidental finding of spinal anesthesia (SA). A case of SAH in a case of lower segment caesarean section following SA is reported in this paper, and it emphasizes the need for early recognition and proper management of such a case as delay in diagnosis may lead to mismanagement.

A 30-years-old female presented to emergency department with a history of fever, epistaxis and bleeding gums since 3 days. She gave history of methotrexate (MTX) prescribed for joint pain (a cumulative dose of 20 mg in 3 days) prior to the presentation. Her blood counts were normal prior to MTX ingestion. But on the day of admission, all the three cell lines were low. She was given 5 units of fresh whole blood and antimicrobial and antifungal coverage during her total stay in the hospital. Her bone marrow finding was suggestive of aplastic anemia/drug induced bone marrow suppression. After 2 weeks of supportive therapy, her blood counts were normal. She was advised to repeat bone marrow examination, which she denied. Her anti-CCP levels were normal and did not meet the criteria for rheumatoid arthritis so advised to stop MTX. Although, pancytopenia associated with low-dose MTX therapy is not expected as early as 3 days after initiation of the therapy, physicians should also be aware of this life threatening adverse effect during the very first days of MTX therapy.

Gestational trophoblastic tumors are a spectrum of diseases spanning from a benign hydatidiform mole, through an invasive mole to a highly malignant form of choriocarcinoma. Choriocarcinoma is a rare, but the most malignant and aggressive neoplasm of all the gestational trophoblastic diseases. It metastasizes to the lungs, liver, and less frequently, the brain. Metastases to the kidneys are rare in the literature, and bilateral involvement is even rarer. It may mimic renal cell carcinoma. Here, we report a case of bilateral renal choriocarcinoma presenting six months after a history of hysterectomy for disorder uterine bleeding.