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Cochin Clinical Society Meeting November 2021

Nov 18 | 2:00 PM

With this very first session of Cochin Clinical Society, we bring to you 5 exciting back-to-back case presentations. 1 When Stuck at Crossroads - Ablative or Cosmetic & Function Preserving Route? - Dr Thomas Varughese 2. 3-D Printing Assisted Facial Harmonisation - Dr Madhu K S 3. A Case of Placenta Accreta - Dr Smitha Pratheesh 4. A Case of Post Covid Encephalitis - Dr Minu George 5. Red, Red Out of the Blue - Dr P Subramaniam

[Music] good evening everyone i am dr naveda and on behalf of netflix i welcome you all uh to the first session that we are hosting along with uh coaching clinical society uh for this session today uh we have uh five esteemed doctors who are gonna present various uh cases and different fields as specialities thank you so much and i'll stop the presentation now and uh dr subramaniam you can take it from here yeah good evening everyone i hope i am audible to all so after a long break due to the covet epidemic pandemic we could not post this question from the society face to face with our doctors here in cochin but thanks to the pandemic now we are able to do it online and we are able to get more attendees because irrespective of where you are what you are doing right now all of us can join and go through these interesting cases so coaching clinical society has been here almost more than two and a half decades and uh and thankful for chairman dr assante nair to take it forward dr amish shinoy and all my senior colleagues of the sql ccs management so renamed city is glad to join this uh ccs and we are also glad to take it forward in the online platform to start the ball rolling so without much i do i will just briefly introduce our speakers we society revived you can go ahead and get started yeah thanks a lot thanks a lot mel so we have uh five uh interesting cases from the department of oncology surgery plastic surgery gynecology neurology and neurosurgery so without much i do i'll just introduce the first case it is by our very senior uncle surgeon he will take you through the travels of a case where a man could not even swallow or even talk properly and how he made his life possible and easier with his surgical skills and philosophy of onco surgery so without wasting much time i invite dr thomas varghese to present his case good evening to all the friends in question political society after the pandemic of two years it is my uh proud honorable privilege to be the first batsman in this game and though it's an unfamiliar turf okay new app so let's see how the things go and my patient whom i want to present he was a 25 year old male he had progressive change in voice with the nasal twine ineligibility information he had hearing loss on the right side a dysphagia to solids weight loss complete nasal blockage sleep disturbances in the sense he could not sleep without opening his mouth while sleeping so all these problems were there since one year and it aggravated uh since the last six months so the the clinical sign what we are seeing in this video will demonstrate what was his condition in the intraoral cavity video please [Music] [Music] uh [Music] [Music] [Music] so now this is the clinical situation and then unless he speaks we won't be able to understand what was his real issue on his voice he lost his job he was a marketing executive he lost the job because the clients could not understand what he was talking and he's snoring in the family members till he is snoring so loudly that others could not sleep and there was a complete blockage of of the nose video please um um [Music] [Music] foreign [Music] examination beyond the as the lateral aspect of the neck below the mandible there is a bulge intra hourly as we have seen there's a large uh swelling which is arising from the from within and pushing the soft palate forwards and while closing his mouth he could not tolerate for a few seconds because he gets talking effect so this is the way he presented so therefore we have a very good radiology department dr anil senior radio diagnosis doctor of hospital he gave us a beautiful mri picture we can see the mri assume you can see how large more than 10 to 12 centimeter sized tumor occupying the paraphernalia space and on contrast we can see it is well circumscribed but filling the whole of the parapharyngeal space and to make it so we had done a video reconstruction of the mandible also and having said all these things we decided to move on then i did a bronchoscopic evaluation of his nasal cavity as well as his hypopharynx and nasopharynx video please as we proceed with the bronchoscopic evidence you can see a smooth voltage i wanted to check whether the mucosa was intact in the nasal cavity on the lateral aspect and plus and the how much is the blockade whether operatively or intraoperative so therefore uh the bronchoscopic evaluation of the next part will be the the order of firings the nasa bearings however was not showing any as you see here the nasopharynx was rather not having that much of bulge towards the uh lower part and the larynx was absolutely fine both pyrofoam forces were normal and the base 10 also was actually normal slides please so now having done all these preliminary investigations uh i thought it is appropriate to have a literature review but as we all know the paraphernalia tumors are very rare i will come to the discussion part but however most of the literature says the discussions based upon anecdotal cases therefore several approaches have been described and discussed you approach this tumor whether from the neck or through parotid or through intraoral cavity and even be using endoscopes or robots so there are there is no consensus in approaching the tumor so therefore uh i have decided to analyze on table as to how it goes uh this is the modified incision for the parotid surgery and i extended to the neck and we can see the marginal mandible are received i have removed only just a small portion of the tail of the parotid without touching the rest of the parabola at all and the cervical branch also we can see going down and the mandible and the the muscles posterior believe diagnostic and durability of diagnostic all these things are displayed well the sub mandible or gland also is not removed but pulled to the lateral side so that the space could be created so then i thought it whether can we do this procedure without what is discussed described in the literature which means without an antibiotic without an incision in the soft palate can i get away and do a procedure which is different than what is described in literature so therefore it just decided to do the surgery video please through the cervical root as we see here that's a tumor which is in the paraphernal space and since the mri showed that it's well delineated tumor the entire tumor could be removed in just 15 minutes time and actually we expected some amount of bleeding but there was no bleeding no hemorrhage and all the structures were kept intact no muscle was cut no aversion of any other structures vital structures there and a well-encapsulated tumor could be removed from the biopharyngeal species which otherwise would have lasted for about seven hours time if multiple autonomy was done or if palette was cut we can understand how much poor quality of life it will be and the tumor could be completely removed intact next please slide please [Music] so having the cavity was just checked for how much it is almost 10 to 11 centimeters it's the space that was occupied in the paraphrasing area with this tumor and as i mentioned no bleeding no hemorrhage no injury to any of the structures and see the size of the tumor that's a large tumor and it was almost 10 into 10 centimeters in size weighing about 400 grams and it is recycled with entire capsules non-neurovascular injuries no mandible manipulator or soft pilot cuts only the tail of the parotid was resected submandibular cellular glass gland was kept intact and all the muscles were intact the whole surgery could be finished in one hour and fifteen minutes came to scheme and normally and no transfusion at all for this case and the final pathology as you say it became a salivary gland tumor benign though and a small review of literature the paraphernalia space is like an inverted pyramid-like structure actually it is a potential space and then the base of the pyramid is this base and effects of the pyramid will be the greater corona of hyoid bone and the boundaries are the superior leaders called base inferior the hyoid bone and utility turbo metabolography posterior will be preventable fascia medial wing bucca pharyngeal fascia and lateral will be superficial layer of diffusion it is interesting to note that there's a fascia which extends from that styloid process to the tensor velocity which divides this uh um paraphernalia space into a pre-styloid and a post spy style of everything that is vital and important are all based are located in the post-style area which includes internal carotid artery internal jugular vein the the nerves from 9 to 12 are all located within this whereas the pre-styler usually harbors some lymphoid tissue or little fat or in certain situations the the deep level of parotid actually occupies the space so that is the importance of uh pre-cylo space and as i discussed already we can see the anatomically how the different vital structures are based in the pre style of space the posterior space and the muscles like stylo hyoid stylopharyngeals and sterogloss etc i can see in the picture literature and i have saved everything but you see the post the intraoperative picture all anatomically nothing was injured or affected at all and there are several approaches which i am going to discuss now uh to remove this parapharyngeal tumor and the widely discussed uh method or root is trans cervical up but in a trans cervical approach the uh certain points are very important which means the tumor is big like this or more than 10 centimeters or larger tumors usually the submandibular gland is removed the incision through the fascia deep to the submandibular space increased exposure is done by releasing the digastric muscles stylohyoid styloglossus from the hyoid even cut the stylomandibular ligament and in most of the literature that is discussed we have to do a multiple automate and then approach the tumor i have not done any of these things in this approach and therefore it's an extremely rare tumor most of the clinicians will have only very few uh number of cases they have in their lifetime and no consciousness in surgical approach because of the positive cases all the described approaches necessitates either tissue violation resections swing procedures sometimes nerve and vascular complications are there even hemorrhages are there these can lead to morbidities like a long hospital state and long term tube feeds mandibular or soft palatal issues and diminished quality of life and the described approaches are transfer rotated where you remove the hole perhaps and then approach to the parotid to the reference space transoral where you have to cut the soft palate and enter into the space most of the time it is combined with cervical approach and a transversal approach will be having a mandibular screen and the cervical approach with multiple swing is described uh cervical transferential approach is there combined endoscopic approaches there and robotic approved all these approaches somewhere or other there will be mandible will be cut to get a better approach for a big tumor like this and the anatomy has been mentioned uh the mandible if it is cut it is the ascending arms like this or if the body is a mandible then it's para median you cut the horizontal ramus and soft palate cut is shown on the upper part similarly the the bone cuts if it is required i have done the ct in 3d imaging so that you know we are handy to have the board cutie required and i have him as a follow-up [Music] ah next video please [Music] [Music] so this tells his voice is compact he could sleep he was here the hearing loss was there for his right side that has come back and he started leading a normal life in one month's time after returning after surgery now i reviewed him after four months but he was operated in march four months down the lane uh we can see the uh the original tumor on the left side or the other image and the next image shows the palatal status at the current moment please play the video first video now if you look at the palette [Music] so next uh slides please see in a matter of uh four months he got his job back back to the same job as a great amount of happiness in his family his occupational rehabilitation and we can see the original next next car incision under the hardly any visible scar on his neck and how did this technique differ from the conventional or what is described in literature no formal paradigm was done by me only just the tail where the original tumor was showing no multiple atom your swing was done no cuts on the soft palate is no violation of unwanted areas the huge tumor almost 10 centimeter size for the giant paraphernalia space cleomorphic adenoma that was what was removed from him and no blood loss transfusion no hemorrhage very small very short hospital state and uh he could have a full diet on the first post and final outcome the disappearing scar so no morbidity is an early rehabilitation and best quality so what's a take home message when no consciences exist in a surgical field it is always better to steer own pathway which will offer a better quality of life than the existing one when we are stuck at crossroads in a surgical decision making lateral thinking many times may pay dividends in fact i have kept all my friends ready to join me like asian activities actually surgeon plastic surgeon both the plastic surgeons arjun and madhu but i could not take any help of any of them i could finish it by myself and cosmetic and function preserving surgeries are more appealing and coming to health economics having if i have done all these multiple automations quality all excision and all we can add we can understand how much doubled or tripled his expenses so health economics plays a very important role in modern era in planning and there's a small self-learned message also in freestyle or tumors we may not necessitate even a temporary request however large the tumor may be and that is what i could learn myself from this uh surgical exercise for this patient who could have a normal life after the procedure and thank you very much for your passion here yeah thank you dr thomas uh we have discussion uh for maybe a couple of questions before we go to the next case is this nodule from dr prem ashish is this nodule uh for testing to make sure it's not carcinogenous i mean i don't know what he meant by that anyway uh it was the radiology plays the most important role in decision making because these are inaccessible sites and hunting for a biopsy ah always in any tumors the dictum because they have surgical oncologist you approach it as if it is a cancer and then you open it fine okay then i think it has to go anyway thanks a lot dr thomas very interesting uh surgical approach and glad to hear that the patient was functionally reserved at the end of the surgery without any mutating dissections needing repeat surgeries so i [Music] invite dr madhu for the next case with a very similar surgical skills done this is a story of a i think two stories of two individuals where they wanted to get their face completely changed in sync with their remaining body so he will take you through the technology advancements in plastic surgery in this very rapidly developing field of uh sex reassignment surgery over to you doc thank you uh thank you dr dominion for the invoice so welcome all from renamed city family so today i will be discussing regarding the use of 3d printing in facial harmonization so i am actually not describing all uses of 3d printing because the use of 3db is really endless so we are just mentioning what we use it for so what is facial harmonization so harmony is described as a consistent orderly or a pleasing arrangement of parts and the beauty is all about proportions it should be harmonic as well so this word proportion it implies a mathematical expression of beauty so if if there is any disharmony which is visible always the attention of the uh other people will be drawn to the disproportionate part so that is why most of the patients come to us for a correction of their facial features i am just giving you a just uh an idea of 3d printing i think most of you might have been an idea so three depending is uh they actually use a computer reader design software to create three dimensional objects it is made by a process called as a layering so it uses different uh materials like abs poly lactic acid polyvinyl alcohol nylon high density polypropylene etc etc so what we use in medical scenario mainly is abs and pla i'll come to the readers later so this is what a 3d printer looks like it moves x y and z axis to deposit layers over layers and finally make what we want so we can just see the image where we were actually 3d printing the skull of a patient this is for mainly for interop reference as well as help in planning the different cuts that we made so what are the phases of 3d printing so first there will be an image acquisition so in medical area the main source of image acquisition will be image of the patient so it could be a ct or an mri and then it should be processed with the software and then the printing comes which is basically by process called layering different layers will be deposited one hour so there are many uses like it can be used as a reference like anatomical models of the skull can be made for teaching for education for demonstration and guides can be made for surgical techniques and external devices like a prosthesis or a spleen can be made which fit the patient uh exactly and implants can also be 3d printed so these are the possibilities and the evaluation if you say initially we could see the radio reconstruction from a ct scan in a computer later it was we were able to print it so initially it was used only in planning sessions later it came to the operating room for references and surgical simulation can be done and various surgical guides and cutting jigs can be made so the cuts will be more precise in the operating room so uh these things are used in a lava zone reconstruction where we repair a sector piece of the mandible we can reconstruct with the vascularized fibula of the same patient so in such cases we can actually make cutting guides as you can see in the video lower center image there is a cutting gate which is fixed onto the fibula after harvesting it and we can just make the cuts depending upon the guide and it will exactly fit into the mandible of the patient so these are the uses that can be used right so it also helps in making hardware for a granule facial distraction mandibular distraction etcetera etcetera and come to aesthetic surgery what are the uses mainly uh we can actually 3d print naughty not only the heart issue like a skeleton we can also make 3d print of the soft tissue as well so if we see a traditionally we were using pictures to demonstrate to the patient like the before and after result of a patient patients will ask for active as a cosmetic surgeon usually the patient asks doctor do you have an image of patient that you operated previously so instead of showing the two dimensional images if we show three dimensional images actually i mean three dimensional 3d prints they get more clear idea and we can even make a 3d print of the same patient and discuss what he requires in front of him because usually patient won't be able to see his face from all angles he can only see straight then he has to resort to photographs for the other lateral view android so if we have a 3d print of the same patient we can actually discuss exactly what he requires in front of him and in operating room also it helps a lot like we used to take pre-operative photographs and use it as a reference in it but if you have a 3d print we can sterilize it and take it into the table so we can have a live demo like you can see here uh a 3d print of the patient's nose is already made and we can use it during the surgery for interoperative reference to what it was before the incision most of the time after putting the incision we won't be able to see what it was before the incision so we could use it for as a reference and we can even make simulations of what we are going to do and we can make a 3d print of the simulator here you can see that a final result of the patient is simulated with the software and a print was made and he the surgeon has actually tried to attain and he has actually attained it so such references could be useful i'm just i was just giving a brief outline so now to one of the two sample cases uh this is a first case uh this is a case of a gender incongruence also known as a transgender status this is a male to female transgender and the patient wanted his facial features to match more with the gender that she decided to proceed with so in this patient if we see we can see that the eyebrows and the bond and the frontal uh sinus area were more prominent and he has a very square do you can see the angle of the mandible is very wide and is very manly and as well as the chin chin is very broad actually in this patient so patient wanted what we usually call a v line of the mandible so a broad mandible is not i mean desired by most of females they want a weak so the surgery is called a v-line surgery so we used a reference like a 3d print of the patient's skull to help us go ahead with the circle i will just show a few of the pictures so that you can understand so here actually from the ct scan of the patient we have made a 3d 3d print of the patient's curve and we sterilize it and took it to the operating theater so that we could have a interoperability reference so here actually we wanted to make the frontal bone less prominent so we have actually measured the frontal sinus from the ct scan and we marked it on the model so we could actually replicate the marking in the operating room without any difficulty and then again come when we come to the angle part you can see in this image that pink colored part of the angle we have actually decided to resect that much angle so that the square the squarish look of the angle of the mandible can be taken care of so while making such cut cuts without any [Music] uh i mean without any safety measure the difficulty is that the inferior alveolar nerve it actually passes along the lower border not exactly in the long border but maybe one or two centimeter above the lower border of the mouth so sometimes if we cut without reference because mainly the it is a very difficult area to approach we are putting a indra oral incision and we are totally de-gloving the muscle from the lateral surface of the mandible and we are actually working in a very tight and small space so even retractors won't have enough space so it is very difficult to mark or plan exactly how much of the bone we have to remove that so sometimes if we make the cut a little above we may actually injure the nerve so what we used in this patient is we made cutting guides so what we did is we actually uh surface marked the inferior algebra now on the 3d print and decided how much we can actually remove and we made cutting guides using acrylic uh it is made by our prosthetic team and we can autoclave the uh cutting head and we take into the operation so once we de-glove the mandible we can place the cutting guides along the mandible it will fit exactly as it fit on the 3d print model and we can mark very easily once the cutting guide is placed over the mat so it is easy and it is much safer to make a cut because it is a very blind area where we were cutting so this is the restricted mandible angle after the surgery you can see that the resected specimens almost matches the cutting edge that we need so and we the patient had a broad chin also so we decided to make the chin more pointed so this is a v-line i mean uh surgery for genoplasty was done we have actually removed a central one centimeter part of the chin so that the chin defining points which were too lateral they were brought more medially so instead of a very broad chin the patient got a very narrow chin so this was the image after a week this is actually a photo sent by the patient here also we can see that the chin has become more narrow this and we along with the surgery we actually did a draw lift also [Music] bulge along the series because of the bralette it will the bulge will disappear once uh the edema and everything separates so this was amazing picture which was sent by the patient after a week and this is the picture of the patient patient after two months now if in this image if you see you can see that the rows are lifted the forehead is more uniform and smooth and the broadness of the angle of the manual is totally gone the patient has got attained a very v-shaped mandible and a very pointed seam so we could have done it even without that but with the 3d print and with the help of cutting guides we were very relaxed while making the making the cuts you are sure that we are not going to make any uh inherited injury to any help and uh i'll show one more case this is another patient again this uh male 2 female transgender status patient and in this patient if we see he has a very male i mean uh face it's a very prominent forward uh then nose in this patient previous patient we didn't have the test the nose but in this patient we can see the nose is also very very long and pointed nose with a dropping tip in this patient the cheek is also very wide it is very prominent the width of the face is much more than the previous patient again the angle are more prominent and the chin is very broad so in this patient we went in two stages in the first stage we address the forehead as well as the nose so this is the picture after rhinoplasty we can see how the left picture is after another t you can see the we have actually reduced the length of the nose to make it more feminine and we have actually rotated the tip so that uh mainly manliness can be reduced as much as possible when we address the forward also order is not visible in this photograph then as a second stage we decided to reduce the width of the cheek basically we have moved the body of the zygoma inwards by making a fracture of the angle of the mandible as well as the other buttresses i'm sorry the arch of the sigma as well as other buttresses so the arch fracture was done through endoscopic approach you know in small incision inside the hairline we go inside the deep temporal fascia and decide i mean detect from that so uh this is again showing how we did the angle of the mandible in this patient again the pink colored part is the part that we have decided to uh resect if we see just above that we have made a we have shown a line that is the surface marking of the inferior alveolar now so we have kept one centimeter gap between the nerve and the cutting edge so that inner injury can be avoided and towards the chin uh that we can see we you can see that we have marked a one centimeter segment in the center that segment we will remove so that the chin defining points can be made more medial and the scene can be made more pointy so this is the picture of the same patient uh maybe after one and a half months or so so you can see that the width of the face the sigma prominence is drawn i will show the comparison from the previous image you can see here the sigma prominence is almost gone and the angle has become more realigned the mandible totally has attained a v shape and the chin from the broad chin he has attained a very narrow chain and the nose is also and this actually this kind of surgery is that it transforms the whole life of the patient so these are the two cases where we have i mean now we have used the cases i mean uh 3d print for most of the facial feminization cases i have decided to just show or do these two cases so thank you what we have done does not mean that is only use of 3 depending the use could be endless but this what we use it for i'm just sharing this to create awareness uh in our own footprint so that's all uh thank you all and this is the facial facial aesthetic team and dynamic city thank you me dr mathur my mother thank you yeah yeah thank you thank you very much [Music] is thank you sir um good evening one and all uh welcome to uh welcome from brunei university um here i'm there to present an interesting case of placenta krita why placenta krita nasintakrita it's a spectrum disorder okay placenta is abnormally adherent and or it can be deeply invasive okay uh incidence has raised from over the years from 1 in 30 000 cases to one in 533 um that is over the past years and uh it results in um up to seven percent an alarming rate of mortality uh rate and most and is one of the most common indication for birth related heat spectrum that is up to forty to sixty percent and the two positive pointers uh to placenta accreta is uh in a case of prior cesarean section and uh when it is equally associated with a passenger so this is my case um which we did in our department uh she is a um gravida three paragon leaving one abortion one uh with 36 weeks of gestation and she was a case of previous cesarean section all her antenatal visits were uneventful with a regular antenatal checkup at our hospital but she had only one complaint of vaginal pain from around 16 weeks of gestation and on her empty scan third month scan showed a placenta completely covering us and at around 20 weeks anomaly scan um the same finding we could note that was an anterior placenta which was completely covering the eyes again and the same patient she had no episode of vaginal bleeding and at around 32 weeks she was admitted with severe vaginal pain and loying to groin pain and was started on iv analgesics she had a history of renal calculate um on investigation and university showed a uh right uh renal calculus and following which arrived dj stenting was done and in the same admission we went in for a growth scan which confirmed our diagnosis of a grade 2 placenta previa and from which we did an mri scan which showed a gravity uterus with single pregnancy septalic presentation and pdf placenta covering the internal loss that is a great proof placenta previa and in the mri there is thinning of myometrium with loss of trilamina pattern of uterine wall anteriorly and inferiorly suggestive of a placenta in greater and they were suspicious of a placenta per creta involving the dome of the bladder so um now this was a difficult thing we have to um advise the patient and bystanders uh we had to counsel them regarding the need for the elective caesarean section at around 36 weeks of gestation and along with cesarean section we had planned for an obstetric hysterectomy so she was admitted around 36 weeks of gestation and adequate blood and blood products were arranged and a multidisciplinary approach was given and written an informed consent was taken and an elective caesarean was done along with ligation of blood vessels going to the bladder anterior placenta was cut through and the liver male baby of weight 2.573 kg was delivered with a good ab casco followed by uh followed swiftly by an obstetric hysterectomy so this is the image um the first image is a specimen of the uterus you can see the umbilical cord and you can see the um placenta is firmly adherent to the uterine muscle and just a thin layer of serosa is covering the placenta that is the complete there is morbid adherence of plasma to the uterine muscle and the second picture shows the inside of the uterus and you can note the placenta is fully adherent along with the umbilical cord it's just to uh see how how much is the depth of the invasion and the third picture is the alarming picture which we saw while uh opening the abdomen can you play this video um so i actually wanted to explain every step um this was like uh first on opening the um abdominal wall um we could uh see um the placenta bulging through the um anterior wall of the uterus so um we had to uh go for a lower transverse uh incision and we cut through the plasma and we extracted the baby and um uh first uh first before that we had to push down the uv fold and uh we did uh proceeded with a certain section we extracted the baby and um we soon proceeded with um obstetric hysterectomy and sticky hysterectomy you can see the last thing is uh we have exteriorized the uterus uh prior to uh proceeding with the procedure so uh one fine blood was transfused intraoperatively to the patient and post-operative period was uneventful and she was started on low molecular weight apparent and continuous bladder drainage was kept and she was discharged on day four uh with continuous bladder drainage that is we uh kept it for another one week uh to reissue about regarding the integrity of the bladder so what is placenta creature spectrum this refers to a range of pathological adherence of placenta including placenta and greater placenta per creta and what is placenta agrita placenta attaches firmly to the wall of the uterus and does not invade the muscle layer in placenta in krita placid attaches more firmly to the uterus and is embedded in the organ muscle wall and in placenta per creta placenta attaches itself and grows through the uterus and potentially to the nearby organs so what is the pathophysiology of this condition uh this partial or total absence of deciduous basalis and defective development of the fibrinoid uh layer resulting in abnormally fur firm adherence defect of the biological function of the trophoblast leads to excessive invasion of the myometrium and there is shift of flaccid blood supply from a spiral athlete ah as found in a normal plantation to a supply from a layer deeper that can be from a radial or an aqueous artery so in such condition there is high velocity blood flow in uteroplasmal circulation in classical anatomy and in 3d doppler we can see hypervascularization pattern in the plasma blood flow so how can we prevent this um this can be by correct surgical technique while closing the uterine incision and by uh primary prevention of the first cesarean section and avoiding uh vigorous curettage during any vnc or any procedures like that and treatment of postpartum endometritis so what is the role of ultrasound in diagnosing placenta um accreta so uh transmit general ultrasound is more sensitive in confirming placement location and diagnosing plasma previa at 20 weeks uh in first trimester an anteriorly placed uh gestational sac can be suspicious uh but it's not confirmatory and in second trimester loss of ah retroplacement in sonolus in space or electroplastic myometrial thickness less than one mm um can be a leading uh to uh placenta creator in the case of previous cesarean section so colored opera um gives you a better uh diagnosis and with better finding uh suggestive of hypervascularity of serosa bladder interface and diffuse or focal they can be diffuser focal lacunae flow vascular leaks with turbulent flow you can see a more ethanol cyst appearance uh gaps in biomaterial blood flow and vessels bridging placenta to the uterine margin obliteration of clear space between placenta and the uterine wall and a 3d color doppler is superior in diagnosing a placenta so but um the thing is but none of these features or combination of features are associated with placenta a creator spectrum so spectrum it's like um can vary from accreta to prefer krita to increta so uh it's difficult to differentiate so um it predicts it can predict a depth of invasion or a type of class integrator spectrum but then only once you open um up you can see what is inside so mri is very much useful in showing the parameter extension in our case itself um there was a query even in mri uh whether it is invading to the dome of the banner but once when we opened um thankfully there was no invasion into the dome of the bladder so um it can be equivocal to usd finding of abnormal placentation and evaluation of the posterior mri specifically used in evaluation of a posterior placenta in patients with risk factors or in our base patients and it can be mri can be complementary road and especially delineating the extent of usd diagnosed placenta per creta so this is one of the procedure you can go about like if you want to preserve the uterus um you can go about with this procedure that is called the triple p procedure is novel you you transparent procedure for placenta accreta spectrum perioperative placental ultrasound localization of the superior edge of the placenta is made and pelvic revascularization of the preoperative placement of intra arterial balloon catheter is done and the plasma what we do is placental non removal plasma is kept in place with ah end block myometrial excision and u prime repair so but if there is more invasion we can't do this procedure and same if a minimal invasion is there you can go for this triple p procedure surgical techniques uh what we do is first we have to on opening inspection anterior surface of the uterus preferably lower uterine segment should be inspected followed by the lateral surface presence of any lateral vascular channels should be should not be disturbed and uterine incision preferably should be a classical or a transparent caesarean section uh should be done to avoid um cutting to the placenta ah then we followed by the delivery of the fetus and followed by closure of the uterine incision ah whipstitch can be used so uh the deadlies of akrita are delayed referral delayed cesarean that is uh always we have to do an elective caesarian section so when an emergency cesarean section is done that is not preferred and a delayed decision for hysterectomy uh deficiency of time availability extensive additions no time for pre-operative devastation deficiency of blood and blood products deficiency of icu beds and deficiency of multiceptionary senior team so the take home message is we should have a multi-disciplinary approach that is we should have a team of senior obstetrician a urologist and a neonatologist and this factors should always be born in mind in ah previous cesarean case and it should be thoroughly investigated for plasma creator and high index of suspicion means she should be always counsel to deliver in a tertiary center and blood and blood products should be readily kept and in case of any suspicion forcible and unnecessary attempt to claw off placenta should be avoided thank you thank you dr smither we have around 60 audience uh you can please put in your questions in the comment section so that the panel can keep answering your questions while the presentation is on so for lack of time i think we go to the next interesting case from dr minoo george from the department of neurology this is about an interesting case where post-covid symptoms have to be differentiated with other causes of a particular problem the patient had so over to you dr minoo from department of neurology okay thank you so uh myself uh very good evening myself dr minoo joj uh consultant neurologist renee medicity hospital so in this era of cobit 19 pandemic we we the department of neurology uh thought we will present a rare complication a rare intracranial complication associated with corvid 19 infection so this is a clinical scenario of a 79 year old female who was a diabetic and hypertensive was presented to who presented to the er on 22nd of may with history of breathlessness fever altered sensorium and one episode of seizure and the seizures were of generalized tonic lonic semiology and uh she was in the year she was evaluated for coveted antigen and followed by covet artificial which don't deposit it alexa sorry on examination at ear patient was drowsy her uh gcs was e2 v2 m4 or 8 out of 15 she was moving all for her all her all four limbs with bilateral flexor plantar response and on investigation uh i have highlighted the um abnormal findings which showed hyponatremia of serum sodium of 120 milligrams per liter she hyperglycemia her grbs was 277 milligrams per deciliter her serum osmolarity was 281 which was within normal limits and her ct just was done which showed a city severity score of 17 out of 25 showed severe pneumonia with elevated inflammatory markers including crp of 136 for retina 403 and cpk of 386. um as usual she was admitted to red icu in our hospital she was ventilated for almost five days she was in the icu for almost 11 days uh she was given her a middle receiver along with steroids dexona 8 grams iv tid followed by tapering dose miropinum and correction of hyponatremia along with control of sugars in view of sieges a neurology consultation was sought initially she was loaded with levitra satan followed by maintenance dose we did a ct brain which was normal however as per our hospital protocols we couldn't do mri and eeg due to covet positive status she was gradually improved and was shifted toward her inflammatory markers came down and was just discharged on 6th of june with anti-epileptic levator saturn and other covet associated medications so at this stage what may be her possible etiology of sushi so this is an elderly female who is a non-diabetic presented with one episode of generalized seizure in a um in covet positive status so we thought two differentials that is cesia may be secondary to hyponatremia that is it is a metabolic cause or it may be seizure due to covet 19 positive status that is an infection triggering acute symptomatic seizure so um however we couldn't find out the exact ideology and she was discharged um we corrected the hyponatremic status the cobalt 19 infection was treated and she was discharged on um levitra saturn maintain his toes however after um almost six days that is 20 days after her rdpcr turned the positive her first admission was on 22nd of may her second admission was on 13th of june she came with two episodes of right-sided focal session this time she presented with focal seizure her first admission was with generalized decision followed by positive moments of the right side maybe todd's policy we thought initially like that and this time in the emergency her covert rt pc turned and was negative so on examination uh she was drowsy and was in the postictal stage his gcs was e2 v2 m4 vp was normal pupils were equal and reacting to light she had positive of right side of the body maybe due to postal status or towards policy dtr was sluggish lander was flexor and sensory and cerebellar science could not be elicited we went ahead with investigations she had mild anemia her esr was 26 crp was 30.65 minimally elevated but her sugars were very high near to 400 that is 356 milligrams per deciliter she had a pseudo hyponatremia of 128 milligrams per liter potassium was within normal limits and her serum osmolarity was calculated to be 298 which is a bit high her renal and liver parameters were within normal limits we did an hsv pcr for her which was negative and the csf study was done sorry initially the css study was done which showed no cells with normal protein that is 45 for a diabetic patient was considered normal and sugars were within the normal limits and the sugars were within the normal image her csf hsv pcr also turned negative but we couldn't do an auto email panel for this lady because of financial constraints so uh we uh since the rtpc turned negative we went ahead with our evaluation like eeg here um i will briefly give an introduction about the eeg eg or electro uh encephalogram is an is a study that is routinely done in your electrophysiology lab to assess the electrical activity of the brain so we can see two tracings here that is uh black tracing and blue tracing the black tracing is from and from the left side that is depicted as um odd numbers that is fp1 fp1f3 like that and the blue tracing is from the right side of the brain that is depicted as fba2 f4 that is even numbers so it is written as left side of the brain right side left side and right side like that it goes the order and here we can see in the first two uh that is the first uh four lines and the second four lines we can see some periodic pattern arising so uh in the first in this age we can see some periodic patterns arising from the left as well as the right side of the brain so these periodic patterns that is arising these periodic patterns are actually epileptic patterns which are arising from both sides they are the uh the terminology given for them is biplots that is bilateral independent periodic lateralized epileptic from discharges these discharges are typically seen in viral infection or some metabolic patterns so um this was the first eeg of the patient we couldn't do this eeg when during her first admission when she was admitted with covet positive status this was her second eeg in this again we can see the tracings that is the black racing and the blue tracing this we can see that the black tracing again there are some abnormal patterns which are coming regularly predominantly now from the left side so what is does this indicate this indicate that she has some abnormality in the brain in the left side that is most probably in the left um that is f indicates frontal c central p parietal like that so here more um abnormality can be we can localize using eeg that is more abnormality will be in the syndrome parietal region like that so ah that from this eeg we can come to the inference that the abnormality will be mostly in the left side of the brain and possibly in the parietal region that much we can access from it and now i will come to this mri of this patient here we can see i have depicted in the arrow this is a diffusion weighted and adc image the diffusion weighted image shows some hyper intensity over the left right parietal parietal region left parietal region hyperintensity and the adc showed minimal diffusion restriction so this was the mri brain of the patient done on 13th of june on her admission and the flyer also we can see that is uh um the cortical as well as a subcortical region so this was the mri of the patient so uh in this case uh case what would be the differentials one may be the patient is having a seizure secondary to a hyperglycemic state we all know that seizure can happen secondary to hyperglycemic state so hyperglycemic state may be either due to diabetic ketoacidosis or non-ketotic hyperglycemic uh state that is hyperglycemic hyperosmolar state so all we all of you know that in diabetic ketotic state the patient is having relative acidosis and ketosis so acidosis and ketosis is a protective phenomena for seizure and dka usually never ever cause seizures usually this is because in case of acidosis the gaba that is the neurotransmitter in the brain production increases and this gaba is actually a inhibitory neurotransmitter and in the presence of this inhibitory neurotransmitter it decreases the neuronal hyperexcitability and we know that seizures are due to neuronal hyperexcitability so never in a case of diabetic ketosidosis the patient develops seizure never i mean usually never may happen but usually never but it is not in the case like uh the case in hyperglycemic hyperosmolar state in that state the patient is in the non-ketotic state and acidosis is not usually the patient have got hyper osmolarity that is the serum osmolarity will be in the range of 320 or 340. in the state there will be severe hyperglycemia and there is no much acidosis so this hyperglycemic stage itself can cause activation of potassium atp dependent potassium channels and caffeine provokes issues so hyperglycemia especially hyperglycemic hyperosmotic state can provoke special seizure and even the state of hyperglycemia can proposition and in this patient we can we have seen that um the serum osmolarity was in the range of 298 with pseudohyponatremia this not in the level of hhs but however uh the patient's seizure may be attributed due to hyperglycemic state and the second was due to seizure due to focal encephalitis so uh how can um focal encephalitis is sorry focal encephalitis is very uh known very common and this can known to happen in a patient with the covet post covets equally so how can you differentiate between this hyperglycemic state and focal encephalitis so this is a table which shows features clinical as well as um investigation which shows how can we differentiate between hyperglycemic seizure and cochlear encephalitis in a case of hyperglycemia the patient can present with altered sensorial seizures and usually the hyperglycemic seizures present with occipital lobe involvement and so the patient will have visceral disturbance whereas in case of focal encephalitis visual disturbances will be rare the patient usually present with fever altered sensorium and seizure the lab findings we know the patient in with hyperglycemia will have hyperosmonasty pseudohyponatremia and hypokalemia may be associated but in case of focal encephalitis they will have normal sugar if not diabetic normal osmolarity and normal serum electrolytes the seizure types in case of hyperglycemic status may be a focal or a generalized seizure but in case of focal energy it will be always a cochlea and coming to eg pattern as i have already shown the focal encephalitis usually present with biplates that is there will be periodic patterns arising from both sides of the brain as i have shown in the earlier easy whereas in hyperglycemic state it will be focal intel pattern intel pattern means seizure pattern it will be usually in the focal that is i told already that hyperglycemia usually affect the hospital so it may be arising from it the eeg shows occipital lobe seizure and that's why the visual disturbance and the mri mri in case of focal encephalitis will show d2 hyperintensity with diffusion restriction in adc low intensity with diffusion restriction the reason for p2 in focal encephalitis is i is evident that is it is maybe to edema caused by encephalitis whereas why there is hypo intensity in hyperglycemic state hypointensity is due to iron accumulation and hypoxic state so iron accumulation that is mineral accumulation occurring in hyperglycemic state is responsible for t2 hypo intensity in a case of hyperglycemic treatment and usually with treatment focal encephalitis needs a prolonged treatment and seizures are usually refractory whereas in case of hyperglycemic state this uh the seizures are usually um well controlled and are reversible and this is the mri comparing a patient with hyperglycemia and focal encephalitis the right side is the focal inhibitors which showed d2 flyer images with the hypo intensity in subcortical white matter region whereas in focal encephalitis in this patient there is hyperintensity in the subcortical region this is the comparison of the ease in case of hyperglycemia and focal encephalitis in hyperglycemia the eeg showed focal excel patterns that is usually from the occipital lobe whereas in case of focal encephalitis it shows ah abnormal uh plants that is it may be either biplates or unilateral plants so ah in this patient we saw the mri pattern it was a focal seizure though the patient had hyperglycemia the pattern of mri as well as the eeg favored more of focal encephalitis than a hyperglycemia-induced disease the patient's serum osmolarity was 298 a bit high the patient had pseudohyponatremia and high sugars but however when we thought the eeg as well as the mri pattern we thought in favor of focal encephalitis most probably secondary to orbit 19 infection her hsb pcr was done it was negative and autoimmune panel was tried but they were not willing for rotating panel due to financial constraints so uh in view of focal encephalitis considering the autoimmune etiology we gave her iv methylprednisolone one gram iv once daily for five days followed by oral steroids she was given empirical iv acyclovir um though hsp pcr was negative for 10 days uh antibiotic coverage was given with safa parasauron sulphate and combination liberalization was given and initially she was on lego tracer but she we had to add her on for spiritual and lacrosse and glycosamide which are both are very good anti-epileptic drugs for focal seizure and her seizures got initially controlled and of course we controlled their sugars with endocrinology support this was a rayji after treatment here we can see that again uh similarly as i told uh the electrical tracings the left side and the right side of the brain here we cannot see any periodic patterns but however there are some slowings throwings from both side of the brain left as well as the right but left sided slowing is more evident so bloods has decreased but there is flowing so indeed it indicate that the seizures has come down but the patient had still some focus of um ailment that is some focus of problem in that side of the brain so further course of the treatment her sensoring gradually improved however she had recurrent left right focal seizures during her hospital stay which gradually improved with anti-epileptic her sugars were well controlled with insulin she was discharged on 24th of june with minimal right-sided weakness and she was disturbed on rise tube and catheter institute on follow-up she had occasional focal session however relatives were not willing for further admission and evaluation due to financial constraints she was maintained on oral anti-epileptics the vitra saturn lacrosse med and phosphonytoid and later lost follow-up so coming to a short review of literature actually the complications intracranial complications following covet infection is not well studied so the diagnostic criteria of encephalitis as we all know is fever seizures focal brain abnormalities disturbed mental status and csf showed lymphocytic pleocytosis but in this patient the csf was normal but other other criteria was satisfying along with mri and eeg criteria and it was in japan which was first reported a a case of cobit 19 associated viral miniature encephalitis the kovid 19 patients present with marked increase in inflammatory cytokines both in the csf as well as the plasma like interleukins um in metana in a meta-analysis conducted by co and the atar the average type from the diagnosis of cobit 19 the onset of encephalitis is 14.5 days in our patient also the patient had coveted 19 infection on 22nd of may and she came with focal encephalitis after uh 40 after 20 um 19 days of covet positive status and these patients will have deranged clinical parameters including raised serum inflammatory markers and case of glucitosis so the take home messages i would like to say are seizures associated with is common in the present era and the exact ideology has to be evaluated the major differentials include as i already told post-covert focal encephalitis are post-covered encephalitis and hyperglycemic status hyperglycemic seizure can easily be controlled and reversible where a seizure secondary to focal encephalitis is difficult to treat and may be irreversible and appropriate identification and treatment is very essential for control of seizures and patient well-being so here i would like to thank dr suresh kumar radhakrishnan senior neurologist renee medicity for guiding me in this presentation and my colleague dr nina bibi for providing me with some of the images thank you thank you dr minoo i think there's one question for you this is from dr lingam from pondicherry he has asked can hypoglycemic isemia hypoglycemia can also precipitate seizures and if yes what is the pattern of these tissues hypoglycemia can present with seizures yes hypoglycemia can present with seriousness any particular problem with hypoglycemia lsi it hypoglycemia usually present with generalized tonic longitude but hyperglycemia can present with both focal as well as generalization okay so i think we very good presentation and very accurate diagnosis on the basis of the correlation with the imaging and also the blood picture so thank you dr minoo i think we come to the last presentation in this uh platform today uh nivida can you put on my slides yeah if i'm audible i'll continue otherwise i'll switch off my video in case anything is so the audio seems to be fine yeah so this is the last case of the day and uh it was very nice to hear to the last four presentations and let us see how interesting this case also turns out to be so it is red red out of the blue by the middle of the presentation all of you will know why i am talking about the red red out of the blue so the medical field is replete with cases shouted in mystery that has baffled even the most astute of clinicians and we have seen that these are the cases which are the basis of advancements in medical science and also to remind the clinician to use wisdom common sense and patience above all to ensure patient safety and medical prudence so i shall walk you all through one such case that my department encountered for the and we have been with this case now for the last two years and it still doesn't fail to intrigue the minds of some of the best clinicians of the day and the case continues to define logic and remains a mystery to this day as i speak as of now so it all began in the month of september 2019 almost two years ago we had a 17 year old girl in early september 2019 with complaint of headache and backache for two weeks there was no history of trauma and she was immediately evaluated in the orthopedic opidi and x-ray was ordered by the orthopedic surgeon this is the x-ray of the lumbar cycle spine not remarkable pretty normal for a 17 year old girl and the pelvis apv was also normal since the exercises were insignificant and the patient had back pain which was quite severe never before in her life she had the back pain like that though there were no deficits the parents insisted on further evaluation mri and this is the t2 weighted sagittal mra of the lumbar cycle spine which was done on the insistence of the patient's family as you can see there is a large hypo intense collection in the spinal canal just posterior to the thicker sac the hypointense that is all blood and it is actually intradurable that is subdural blood and the radiologist proceeded to investigate the rest of the spine and we he found that the blood column extended till d8 level as you can see in this thoracic spine and when the and you can see the full extent from d8 to s2 and the t2 axial images of the mri also is showing that the all the roots are lifted up anteriorly in front of the blood column posteriorly and this is it and the t1 also shows that the dura is outside the blood column hyperintense so it is clear subdural hematoma and there was no trauma so it is a spontaneous so at this juncture the patient was referred to me and i promptly admitted to the patient for further evaluation there was no history suggestive of bleeding diathesis no history of drug abuse no history of snake bites no steer consumption of naturopathy medications and we ran a psychometry check too and there were no deficits so it turned out to be a case of massive spontaneous acute posterior spinal subdural hematum idea to cs2 now on a hunch we decided to go ahead for the brain also because there are avms which are known to explode and cause blood to settle down in the spinal canal and when the mri was the brain was done we were surprised to find a very large spontaneous chronic subdural hematum on the right side you can see the layering of the blood on the right side and there was a mass effect also and strangely the patient had no deficits these are the coronal views these are the axial views so it is a case of spontaneous craniospinal acute subdural hemoglobin it was failed to investigate further with the study of the brain and spine vasculature and we did mr angiogram and that ruled out any area at least on mr so multiple opinions were sought by the family from various neurosurgeons in the city and however he managed conservatively with parasternal tablets there was heavy pressure from some quarters to go ahead and operate her but there was no deficit so after a week of admission ct of the brain was done and which showed a resolving subdural as you can see in the excel cp and the patient remain clinically stable throughout the hospital stay the back a can headache completely resolved with symptomatic treatment and we ran a complete battery of hematological tests in collaboration with the lab in amrita institute and the full battery of tests was done from the reference level laboratory there it was all normal so discharge after 10 days there were no deficits and we advised regular follow-up and after a month she came mri was done it showed resolving brain subdural and also the spine you can see there is hardly any subdural left in the thoracic cavity and in this lumbosacral extending from l5 to s1 is small subdural is remaining now a year by passed uneventfully then later on after another month and a year after she was discharged came a red board from the blue so it is a again a red bolt of bleeding from the blue and this time she had sudden onset headache out of the blue and when we ordered a ct scan it showed as you can all see i hope the image is visible you can all see the subdural blood on the left side now previously she had on the right side and now it is on the left side and you can see the blood layering on the left side and mri of the spine obviously followed naturally because of her past experience with her and the spine also you can see there was no blood in the thoracic but there was blood in the lumbar sacral area you can see if you can zoom in the image you can see the hypotense blood in the l4 alpha s1 so another round of hematology concentrations were done and this time the astromedicity group also was robbed in and their hematologists were also asked to run through that case and all letters were done again which was found to be normal she again recovered unevenly with conservative management and this later this year that is in 2021 we sent her to sri chaitanya ternary institute of medical science where my colleague in the radiology department did a 6 vessel that means all the external keratins internal carotids and the vertebrals dsa as well as whatever possible spinal dsa was done and they ruled out any vascular malformation especially the dural avm though the blood had not completely resolved but they did this and the only incriminating etiology which we could point out was the history of intake of mephthale that is mephenamic acid receiving both the events which she took for relief of vascular headache which we believe may have been the cause in very rare reports are seen methyl altering the platelet function so the patient right now is perceiving a bsc nursing in pumkur a repeats carino spinal angiogram after full resolution of the sdh is being planned in the next summer vacation and as per literature this is a very young case we have not had in the literature spontaneous subdural of the brain and spine idiopathic ethology no deficits maximum number of spinal levels of spontaneous sdh and cryonospinal occurrence of sdh and most important manage conservatively because whatever literature we saw it was all operated upon as an emergency operation because mainly due to the presence of deficits here we exercised caution and wisdom and common sense when we refused to operate and she recovered uneventfully so she continues to be the close follow-up thanks to the faith of the family in our team and the before we close the spontaneous subdued hematoma all of us should remember it can be coagulopathies child abuse aneurysms avms hypotension intracranial hypotension drug abuse extreme sports none of them were there in this child so the take home message like in all interesting cases we encounter in this coaching clinical society is a exhaustive history full cranospinal imaging in cases of spontaneous bleed in the chronospinal axis and a thorough neurophthalmologic examination for ocular causes and neuro cutaneous examination for syndromic diagnosis complete neurovascular imaging and intervene only if necessary so with these closing remarks i really thank all of you for patiently listening to us late into the night before your dinner the fine interesting case of renamed city and uh i hope these cases has equal interest in all of you to bring your own cases in our next edition of coaching clinical society so we purposefully did not keep a price for this because it's an online presentation and but we wanted more and more comments possibly that because it's a new platform the audience were shy probably to ask more questions which and otherwise happens during the face-to-face presentations so i think as time passes and all of us are well worth so we intend to have this uh society meeting every month and the future formats we can also have multiple hospitals contributing their case and we can have we can have an email site also where the continuous queries can be answered and it should be a guiding light for all the clinicians to share their interesting cases and will hopefully next time though i think we stuck to time with a little outage of around 10 minutes but still it's okay so the the next with the continuing code and also the possibly the third wave of code about to raise its head i think for some time we will have this online platform only for the virtual clinical society and uh while we are with this we from the management of coaching society we'll let you know the next hospital which will be hosting this meet and there will be meets where multiple hospitals may be from the whole aeronautical district or mainly from kerala and even from the whole of india can contribute interesting cases and we can have this on a larger platform with a larger audience thank you everybody i think i thank my present school presenters for their interesting cases and their efforts to put on the slides which are very clear though we are all in the digital platform the images i had appreciations on this small platform with the mobile platform but they were crystal clear thanks for the whole netflix team also to cost us with this first edition of the online coaching clinical society thank you i'm looking forward to more interesting presentations from the doctors in the future editions thank you all good night thank you so much and good night

BEING ATTENDED BY

Dr. Sanjay Patel & 239 others

SPEAKERS

dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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dr. Thomas Varughese

Dr. Thomas Varughese

Senior Onco-surgeon, Renai Medicity Hospital

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dr. Madhu K S

Dr. Madhu K S

Consultant Plastic Surgeon, Renai Medicity Hospital

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dr. Vasantha Nair

Dr. Vasantha Nair

Clinical Professor, Centre for Endocrinology and Diabetes, AIMS

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dr. Smitha Pratheesh

Dr. Smitha Pratheesh

Senior Specialist, Obstetrics & Gynaecology, Renai Medicity Hospital

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dr. Minu George

Dr. Minu George

Consultant Neurologist, Renai Medicity Hospital

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dr. Subramaniam P

Dr. Subramaniam P

Lead Consultant Neurosurgeon at RENAI MEDICITY

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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dr. Thomas Varughese

Dr. Thomas Varughese

Senior Onco-surgeon, Renai Medicity Hospital

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dr. Madhu K S

Dr. Madhu K S

Consultant Plastic Surgeon, Renai Medicity Ho...

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dr. Vasantha Nair

Dr. Vasantha Nair

Clinical Professor, Centre for Endocrinology ...

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dr. Smitha Pratheesh

Dr. Smitha Pratheesh

Senior Specialist, Obstetrics & Gynaecology, ...

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dr. Minu George

Dr. Minu George

Consultant Neurologist, Renai Medicity Hospit...

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dr. Subramaniam P

Dr. Subramaniam P

Lead Consultant Neurosurgeon at RENAI MEDICIT...

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