Context : Now a days arthroscopic surgeries are very commonly performed and are associated with post-op pain. Various method of relieving pain is present like NSAIDS, Opiods, peripheral nerve blocks and local anaesthetics. In this study we are trying to search a novel method to control post operative pain . The present study aims to compare the effects of intraarticularly instilled Bupivacaine and Neostigmine with Bupivacaine and Fentanyl for pain relief following knee arthroscopic surgery. Aims and objective : To compare the efficacy of bupivacaine and Fentanyl with bupivacaine and Neostigmine administered intraarticularly for postoperative pain relief in patients undergoing knee arthroscopic surgeries and comparing duration of analgesia, hemodynamic parameter and side effects if any. Material and Method- It is a prospective randomized study. Sample size was 75 divided in three groups. ◼ GROUP P - Intraarticular injection 19ml of 0.25% bupivacaine as control group + 1 ml NS ◼ GROUP N- Intraarticular injection of 19 ml of 0.25% bupivacaine + 1 ml (500 mcg ) of neostigmine. ◼ GROUP F- Intraarticular injection of 20ml of 0.25% bupivacaine + 1 ml (50 mcg )of fentanyl. Result : Demographic variable amongst all three groups were matched. In this study mean duration of analgesia time in group P is significantly lower than group N and Group F (p value < .05)however duration of analgesia time in Group N and Group F are comparable but Group N showed slightly higher duration of Analgesia. Conclusion : Thus, we found that addition of neostigmine or fentanyl to bupivacaine increases the duration of analgesia in the post-operative period.

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Background: Infertility represents a common condition, with important medical, economic and psychological implications. Thyroid dysfunction interferes with human reproductive physiology. It reduces the likelihood of pregnancy and adversely affects pregnancy outcome, thus becoming relevant in the algorithm of reproductive dysfunction. Aims and objectives: To estimate serum prolactin, FSH and LH in hypo, hyper and euthyroid female subjects and find their association with thyroid status. Material methods: a cross-sectional observational study was done . 100 infertile females of age group 20-40 years, who were then subdivided into euthyroid, hypothyroid and hyperthyroid cases Serum Prolactin, FSH, LH,TSH,TotT3,TotT4 were estimated by Chemi-luminescence immunoassay method Results: The infertile women with hypothyroidism had significantly higher prolactin levels than the other groups Conclusion: TSH has a positive correlation with serum Prolactin level.Assessment of serum TSH and prolactin levels should be made mandatory in the work up of all infertile women, especially those presenting with menstrual irregularities

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Ovarian malignancy is a common and highly morbid cancer of females. Advanced stage ovarian cancer warrants extensive surgery to achieve the goal of optimal cytoreduction i.e. no residual macroscopic disease, which is an independent prognostic factor contributing to survival of these patients population. The aim of index study is to describe the incidence, pattern and management of ovarian cancer at a tertiary care center in eastern India and also audit the surgeon’s performance in treating these patients surgically and the improvements if any, over a period of 7 years. No such studies focusing on analysis of pattern of ovarian cancer presentation and the optimal surgery rates alongwith outcomes have yet been published from this region. Method: A retrospective analysis of all operated cases of histologically proven ovarian cancer at our institute from December 2009 to March 2016 was carried out. Results: Ovarian cancer was the predominant cohort undergoing surgery for gynecological malignancies. The most common variant was epithelial ovarian cancer and 30 to 50 years was the commonest age group afflicted. The rate of surgery has been increasing consistently over the years and the rate of achieving optimal cytoreduction has improved significantly. The operability was better in the patients receiving neoadjuvant chemotherapy but the primary surgery arm has also seen improvement in achieving optimal cytoreduction. The probability of achieving R Zero has improved from 0.5 in 2009 to 0.95 in 2016. Conclusion: The operative outcome and quality of life of patients has shown considerable improvement in hand of surgeon dealing with such cases at a high volume tertiary care center. This emphasizes upon the significance and need for well equipped, sophisticated, multi-disciplinary tertiary care center catering to population with a high propensity and prevalence of Gynaecological malignancies.

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Background: Preoperative anxiety is not uncommon in patients posted for surgery. The relative position of patients in operating list can be one of the cause of anxiety. Aim: To compare anxiety in patients posted first in operating list to patients posted late in operating list. Materials & Methods: The influence of the relative position in the operating list on pre-operative anxiety was studied in 400 American Society of Anesthesiologist grade 1 patients undergoing major surgery. Two hundred patients were placed first on the operating list (group 1) and 200 were given a time 5 hour later (group 2). Each patient was visited on the evening prior to surgery and again on the morning of surgery. Anxiety was measured at each visit by objective criteria and part 1 of the State-Trait Anxiety Inventory (STAI) questionnaire. Results: In both groups the pulse rate, systolic blood pressure , respiratory rate and STAI questionnaire score were significantly higher on the morning of surgery than on the evening prior to surgery(p<0.05). The increase in pulse rate and systolic blood pressure, respiratory rate was comparable in the two groups. The evening anxiety scores were not correlated with those on the morning visit and could not predict them. Conclusion: There is no effect on anxiety status of the patient due to relative position of patient in operating list.

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Background and Rationale: Induction platin based doublet is standard of care in locally advanced and metastatic NSCLC. Maintenance pemetrexed and tyrosine kinase inhibitior both have shown to improve outcomes in patients with favourable response to induction therapy. Aim: To evaluate and compare outcomes with maintenance pemetrexed and maintenance TKI in EGFR mutation positive and negative patients. Objectives: To calculate and compare Progression free survival, overall survival and factor affecting outcomes with maintenance pemetrexed and maintenance TKI. Material and Methods: Data of patients with locally advanced and metastatic non squamous NSCLC who received induction pemetrexed platin doublet were retrieved from prospectively maintained lung cancer database registered between June 2011 and March 2014.Patients who received maintenance pemetrexed and maintenance TKI being EGFR mutation negative and positive respectively were chosen for final analysis. Kaplan Meir survival analysis was used for Progression free survival and overall survival. Log rank test was used to evaluate and compare factors affecting outcome. Result: Median follow up is 16 months. Out of 268 patients who had favourable response to induction pemetrexed platin doublet, EGFR mutation result was available in 238 (89%) patients. Patients who were EGFRF mutation negative and received maintenance pemetrexed were 138, while those with EGFR mutation positive and received maintenance TKI were 80.Median PFS with maintenance TKI in EGFR mutation positive patients was significantly better than that of maintenance pemetrexed in EGFR mutation negative (11 months versus 8 months; p=0.01), while the overall survival was 19 months and 20 months respectively. Older age, females, non smoker, no baseline effusion and partial response to induction did better with maintenance TKI. Conclusion: Maintenance TKI in EGFR mutation positive non squamous NSCLC delays disease progression more than maintenance pemetrexed in EGFR mutation negative NSCLC. Both option fare favourably to improve outcomes after response to induction therapy.

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Background: Scrub typhus is a rickettsial infection that can be life threatening. There are several outbreaks of scrub typhus have been reported from different parts of India, but still clinicians are not much aware of this. We studied the diversity of clinical manifestations, laboratory investigations, complications and outcomes of scrub typhus in a tertiary care hospital. Materials and Methods: All the cases of acute febrile illness diagnosed as scrub typhus over a period of 10 months (march 2018 to December 2018) were analysed. Diagnosis was based on positive Weil-Felix with titre of ? 1:80. Results: A total of 13 cases of scrub were diagnosed and analysed during the study period. The most common symptoms among the patients were fever in 100% cases, headache, seizure and altered sensorium in 61.5% cases. Other symptoms were nausea, vomiting, breathlessness and urinary symptoms. The pathognomonic features such as eschar was seen in only one case (7%). On investigations, deranged liver function tests (LFT) were present in 61% of cases and deranged renal function tests (RFT) were present in 38% of patients. Thrombocytopenia (92%), meningoencephalitis (61%), acute respiratory distress syndrome (ARDS) (30%) were common complications of scrub typhus in this study. All patients responded dramatically to doxycycline and there was no mortality in this study. Conclusion:- Scrub typhus should be considered as an important differential diagnosis of acute febrile illness if it is associated with thrombocytopenia, deranged LFT and deranged RFT. Although eschar is pathognomonic of scrub typhus, even in the absence of eschar and lymphadenopathy a high index of suspicion and empirical addition of doxycycline is crucial for decreasing mortality.

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Background: Epidural anaesthesia / analgesia is a safe and routinely performed procedure by the anaesthesiologists. Although rare, but there have been many instances of epidural catheter breakage. We present a case report of We present a case report of a 38 years old female posted for vaginal hysterectomy under combined spinal epidural anesthesia. During the procedure, while negotiating the epidural catheter in epidural space, it got sheared off at 5cm mark inside the back. Severed catheter in the back could not be visualized under C- arm digital X ray. Plan for spinal epidural lumbar anesthesia was abandoned and surgery was performed under general anesthesia which was uneventful. CT followed by USG was done to locate the severed catheter on 2nd post-operative day. Severed catheter could not be visualized and surgical removal was not attempted. The patient was informed of the event and counselled to report in case of any adverse symptoms. Conclusion: We want to convey that surgical removal of retained broken catheter should not be attempted routinely as it could provide more complication than leaving it in situ.

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Pain and functional limitations are important clinical features in knee osteoarthritis. Platelet-rich plasma from autologous blood is being used for symptomatic relief in early knee osteoarthritis. The aim of this study was to assess the efficacy of platelet rich plasma in patients of early knee osteoarthritis. All 50 patients received single intra-articular injection of Platelet Rich Plasma in both knees. Assessment was done by VAS pain scale and WOMAC function score pre injection and 1 week and 3 months post injection. Platelet Rich Plasma showed significant improvement in pain and function at 1 week and 3 months post injection. There was no loss of follow-up. Few patients reported pain for 2 days after the injection which resolved spontaneously. We conclude that Platelet-rich plasma therapy is simple, cheap, feasible and minimally invasive intervention for early knee osteoarthritis. It reduces the analgesic intake and improves the function of knee joint in short term.

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Background: Lower respiratory tract infections are among important causes of morbidity and mortality for all age groups. The emergence of multidrug resistant gram-negative organism (MDRO) is an issue of increasing concern. Aims & Objectives: This study was focused on obtaining a comprehensive insight into the microbial profile, its prevalence and the susceptibility patterns of the gram negative bacilli isolates including multi drug resistance in lower respiratory tract infections. Materials and Methods: A total of 1144 respiratory samples (sputum, broncho-alveolar lavage fluid and endotracheal aspirate) were processed for microscopy, culture and susceptibility testing following standard laboratory protocols. Multidrug resistant gram-negative bacilli causing lower respiratory tract infections were studied for their causation of disease. Results: A total of 349 gram-negative pathogens were isolated from respiratory samples during the study period. Among these 213 (61%) gram-negative pathogens were found to be multidrug resistant. Although the percentage of multi drug resistance was higher among Escherichia coli (88% MDRO) and Acinetobacter spp. (80% MDRO), the predominant multidrug resistant gram-negative bacilli isolated were Klebsiella spp. 119 (34%) and Pseudomonas spp. 108 (30%). Among MDROs, other isolates were Citrobacter spp., Enerobacter spp., Proteus spp. and Providentia spp. Conclusion: A large majority of pathogenic gram-negative bacilli isolated were found to be the multidrug resistant. Regular surveillance which directs appropriate empirical therapy and good clinico-microbiological workup of each case of lower respiratory tract infection can reduce the morbidity and mortality associated with MDROs. Bacteriological diagnosis and antibiotic resistance surveillance are indispensible in the effective management of lower respiratory tract infections.

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Background: Clinically significant bloodstream infection (BSI)due to Staphylococcus aureus(S.aureus)isa significant pathogen in community acquired and nosocomial BSI. Methicillin Resistant Staphylococcus aureus (MRSA) are resistant to methicillin and all χ-lactam antibiotics due to possession of mec A gene. Several phenotypic methods for laboratory detection of MRSA: oxacillin screening test, oxacillin or cefoxitin disc diffusion method, oxacillin minimum inhibitory concentration test are used routinely in our setting. Aim: We aim to detect MRSA among blood culture isolates by conventional method (cefoxitin disc) and also to confirm identity of these MRSA strains by molecular method i.e. mecA detection by Polymerase Chain Reaction(PCR). Materials and Methods: This cross sectional study was carried out on 139 S. aureus clinical isolates in Department of Microbiology from blood samples submitted for culture and sensitivity test. Once the isolate was identified as S. aureus, it was further identified as MRSA or Methicillin Sensitive Staphylococcus aureus (MSSA) by use of antimicrobial discs. DNA extraction was done by boiling method. Results: Antimicrobial susceptibility pattern documented resistance of 48.9% of isolates to cefoxitin (MRSA). 80.2% and 63.3% of isolates were resistant to penicillin and cotrimoxazole respectively. All isolates were susceptible to vancomycin. Conventional PCR was carried out for all 139 samples. 51.1% of isolates harbored mecA gene thus identified as MRSA. Conclusion: As expected PCR performed superior, however due to less cost, simplicity and easy availability, cefoxitin disc diffusion test holds a significance as an alternative to PCR for detection of MRSA on routine basis in a resource limited setting like ours.

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Objective : Abdominal wound dehiscence (AWD) is a terminology which is commonly used to explain partial or complete disruption of abdominal wound closure with or without protrusion of abdominal contents. It is among the most feared post operative complications faced by surgeons and is of greatest regard because of risk of burst abdomen, with mortality rates reported as high as 45%. Incidence in literature ranges from 0.4% to 3.5%. This study is designed to highlight the risk factors associated with wound dehiscence, the incidence rate and curative measures to prevent or reduce the occurrence of wound dehiscence and to predict the outcome of the management of abdominal wound dehiscence. Material and Methods : This retrospective study was done in which total number of 50 Patients admitted in the department of gynecological oncology who underwent routine laparotomies and who developed abdominal wound dehiscence were included in the study. Results : A total of 50 patients who developed wound dehiscence were included in the study, Out of these, 05 patients had developed complete disruption of abdominal wound (burst abdomen). 45 (90%) cases had the dehiscence occurring in laparotomies done for malignancy cases. Incidence was highest in cases of midline incision. Conclusion : Burst abdomen is a serious sequel of impaired wound healing. It occurs most commonly in the 31-40 year age group, predominately in laparotomy for malignancy and vertical midline abdominal incisions. Many factors can pre-dispose to this grave complication. Knowledge of the more common mechanisms and how to avoid or overcome these hazards should help to reduce the incidence of this dangerous complication.

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In females abdominal masses are mostly of uterine or ovarian origin. Rarely primary serous peritoneal tumors may present in similar fashion and should be considered as one of the differential diagnosis. A 62 year-old female patient presented to us with an abdominal mass. Her CA-125 was significantly elevated and the radiological picture was suggestive of solid adnexal mass with lymphadenopathy but no ascites. Optimal debulking surgery was performed including Total hysterectomy, bilateral oophorectomy, total omentectomy, lymphadenectomy and appendectomy. Histopathological examination revealed the excised specimen possessing characteristics of metastatic adenocarcinoma of mullerian origin however uterus and adnexa were unremarkable. After excluding other primary causes of metastatic adenocarcinoma, diagnosis of a primary peritoneal carcinoma was finally established. The objective of sharing this case is to emphasize over keeping PSPC in mind while establishing diagnosis of abdominal tumor without ascites for better management and patient outcome.

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A retrospective review of the records of previously treated patients squamous cell carcinoma of buccal mucosa, oral cavity was undertaken from May, 2017 through April, 2018. The cases were studied to ascertain the pattern of lymph node metastases (NM) in neck level. The patients were grouped into three categories, by clinical neck status at the time of neck dissection: elective dissection (ED) in the NO neck, immediate therapeutic dissection (ITD) in the N+ neck, and subsequent therapeutic dissection (STD) in the neck observed which converted clinically to N+. The data support the trend toward selective limited neck dissection in both NO and N+ patients. Further, they provide the foundation for planning of future prospective trials to assess the efficacy of modifications in the extent of neck dissection.

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Background: Benign breast disease is most common problem in female of our society. The aim of study to know the patterns of clinically benign breast disease in females and to co-relate them with the pathological condition. Material and method: This study was conducted on outdoor patients of department of general surgery in Indira Gandhi institute of medical science, Patna Bihar from April 2018 to march 2019. The first 100 one hundred female patients who were treated for benign breast disease were included in this study. Diagnosis was made by a combination of clinical assessment, radiological imaging and tissue biopsy so called triple assessment. Results: In all benign breast disease, the most common presentation was breast lump which comprised 84 cases, of which fibro adenoma is most common with mainly in the age group of 21-30 years. Median age at presentation was 29.5 years. Excision is most commonly used and most satisfactory method of treatment. Conclusions: Benign breast disease present mainly in 21-30 year age group. The clinical diagnosis of the benign breast disease was accurate in 92% cases. The actual factors responsible for this change need further research and study.

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Introduction: Knee is a weight bearing joint which has ligaments and menisci. Its injury is very common which may lead to pain, instability and loss of function. Its diagnosis is usually done clinically which may need confirmation with Magnetic resonance imaging (MRI). We compared the sensitivity and specificity of clinical examination compared to MRI Material and Methods: 50 patients were enrolled in the study. They were clinically examined and then MRI was done. Results: Comparing the clinical test with MRI we found that Clinical tests were moderately sensitive for ACL tear and poorly sensitive for meniscal injury. It was not sensitive for PCL injury. The clinical tests were highly specific for ACL, PCL and medial meniscus but moderately specific for lateral meniscus. Positive predictive value of clinical tests was high for ACL, moderate for medial meniscus but low for lateral meniscus. Negative predictive value was highest for PCL while moderate for ACL, medial meniscus and lateral meniscus. Conclusion: We conclude that clinical tests are less sensitive compared to MRI but moderate to highly specific tool for knee injury diagnosis. It needs MRI confirmation for proper management of injury.

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INTRODUCTION: Clear cell sarcoma like tumor of the gastrointestinal tract (CCS-GI) is an extremely rare type of soft tissue sarcoma with aggressive behavior, which exhibits morphological, immunohistochemical and ultrastructural similarity with malignant melanoma. It is rarely localized in the intestine and the natural history of this tumor is not yet clear^[1]. To date, less than 42 cases of CCS-GI have been described in the literature, as far as the best of my knowledge. CASE PRESENTATION: A 20 year nulliparous female presented with something coming out during straining for defecation and bleeding per rectum since 3 months. Patient was also complaining of constipation off and on. The patient underwent contrast enhanced MRI Pelvis, which revealed mass in anorectal region, 6.5x 3.4cm in size at left pararectal wall which was touching muscularis externa at 3 O’clock. There was mid perirectal mesorectal lymph nodes, 2-4 cm in size. Biopsy from anorectal mass was sent for HPE, which was reported as malignant melanoma. In morphology, tumour cells were relatively large, ovoid to epithelioid with pale eosinophilic to clear cytoplasm. Nuclei were centrally located. Necrosis was present. Immunohistochemistry was positive for S100 and Melan-A. The tumor was immunonegative for CK, HMB-45, CD1a,CD68, CD21 and CD23. Ki-67 was70%. Final impression was Clear cell sarcoma like tumor of the gastrointestinal tract (CCS-GI). CONCLUSION: Herein we present a case of CCS-GI, with discussion on its clinical and pathological features and review of the literature on the subject.

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Background & objectives: The amputation of injured extremities has been performed for over 2,500 years. Despite the advances in limb prosthetic technology, traumatic amputations continue to have a major impact on daily activities and subsequent quality of life. The loss of a limb often has profound economic, social and psychological effects on the patient and their family. However in many cases, amputation of the limb is the only viable option to save the patient’s life. We also did a study to evaluate the pattern of amputation after major trauma and its outccome. Methods: Total sixteen patients were included in the study. All patientswith traumatic injury to the limb leading to non-viability of the major part of the limb (above wrist and above ankle) coming to emergency of BPKIHS giving written consent for the trial were included in the study.All patients underwent emergency amputation. The clinico-radiological outcomes were evaluated for involved limb, level of involvement, cause, active bleeding, Blood pressure, Pallor, infection, type of amputation, infection, phantom pain, phantom limb, Mangled Extremity Severity Score. Collected data were evaluated and various statistical tests applied. Results : Upper limb involvement is more than lower limb, crush injury is more common than road traffic accident, only one case has Ischemic heart disease, only two patients had intact neurology, two case had compartment syndrome, none of the patients had viable distal limb, only three closed amputation was performed primarily, post operatively three had infection, five had phantom limb and pain none of the cases had change of job. Conclusion : Traumatic major limb amputation can occur both in upper and lower limb. Better prosthetic fitting and rehabilitation is needed to make the patient conduct his near normal life style.

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Mesothelioma is a rare condition with 1 in 1 million incidences. Pleura being the commonest site followed by peritoneum. Malignant peritoneal mesothelioma (MPM) presents difficulties and delay in diagnosis due to non-specific symptoms. Here we present a case of 22 year old female who presented with the complaints of abdominal pain and distension. No history of asbestos exposure was reported. A lump was palpable on abdominal and pelvic examination. Computed tomography (CT) scan was suggestive of large solid tumour with fat stranding. Laparotomy was done and a solid mass lesion seen on left side mesentery attached to bowel. The mass was removed. Final diagnosis was possible with histopathological documentation of tumor characteristics, which were consistent with dictating a mesothelial origin.

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Aims and Objectives : To investígate the results of Hypospadias repair in patients having Tunica Vaginalis flap as a second layer after urethral reconstruction Methods: A prospective study on all patients of Hypospadias who had Tunica Vaginalis used as a second layer after urethroplasty was conducted between 01.11.2017 to 31.10.2019. Data regarding nature of hypospadias, any previous surgery, duration of surgery and any postoperative complications were collected. Results collected were analyzed. Results: A total of ten patients had the use of Tunica Vaginalis flap during surgery. Among these, 90% had proximal hypospadias and 10% had distal hypospadias. 50% patients (4/10 proximal & 1/10 distal) had this flap used in Redo-urethroplasty cases with 100% success. 40% cases had this flap used during primary urethroplasty, of which 50% cases had successful repair and other 50% had fistula formation. One patient who had Bracka-stage 2 surgery with this flap reported good cosmetic results. Conclusion: Tunica Vaginalis Flap is a well vascularized, locally available flap that can be used in difficult cases of Hypospadias with tissue deficiency with good results and minimal complications.

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Background & objectives: Lateral condyle humerus fractures are the most common distal humeral epiphyseal fracture. They are usually associated with relatively high rate of complications and the results of non-operative management are not always good. So a randomised controlled trial comparing outcomes of K-wire removal at three weeks vs. six weeks for lateral condyle fractures of humerus in children was done. Methods: All patients aged one to fourteen years with traumatic fractures of the lateral condyle fracture of humerus presenting to the Department of Orthopaedics, BPKIHS giving written consent for the trial were included and randomised in two groups. Fractures duration more than seven days old were excluded. Cases taken were put and randomized according to random excel number generation. After open reduction and internal fixation the k-wire removed at three weeks in one group and at six weeks in another group. The clinic radiological outcomes were evaluated and noted for infection and radiological union. The collected data were evaluated and various statistical tests applied. P value of less than 0.05 was taken as significant. Results: We found statistically significant difference in comparison of union with different age groups (p<0.05). Other parameters were statistically not significant. Three patients developed skin infection, one in group A and two in group B . Three patients did not show radiological union at the expected time of k-wire removal two in group A one in group B and all the cases were above ten years of age. Conclusion: Our study has shown that fracture of lateral condyle of humerus united earlier than 6 weeks and shows no significant difference in short term outcome of K-wire and back slab removal at 3 weeks or at 6 weeks regarding union and infection.

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Esophageal atresia (EA) with tracheoesophageal fistula (TEF) is one of the common neonatal surgical emergencies presenting with excessive salivation, and inability to swallow or pass a firm cathether into the stomach. The present report describes an unusual case of EA-TEF with a long upper esophageal pouch that overlaps the lower esophageal pouch reaching just above the dome of diaphragm. The lower pouch fistula was present at the usual site (Kluth type IIIb6). The redundant upper pouch was excised and TEF was ligated and divided, and an end-to-end esophageal anastomosis was performed. In the post-operative period baby developed sepsis and could not be revived. However, the case was described due to rarity of presentation.

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Meningocele is a common neural tube defect. Mostly seen in lumbosacral region in midline; when encountered at atypical site in form of anterior or lateral position in relation to spine may cause confusion .Cystic gluteal swelling was found to be occult sacral meningocele in this case.

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