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Background: Tracheostomy is most commonly performed in patients who have difficulty in weaning off a ventilator. This surgical procedure is associated with complications. The present study was aimed to evaluate the outcomes of tracheostomy with primary and secondary objectives. Methods: This study was done in department of ENT, KIMS Health, Trivandrum, Kerala. Based on the inclusion and exclusion criteria 81 patients were included in the study. Study procedure was explained and informed consent was obtained from close relatives or kin of patients. Demographic, clinical and complication data was collected from the patients and analysed with Statistical Package for Social Sciences (20.0 version) software. Correlation was done between complications and period of decanulation. Results: The study was done in 81 patients under gone tracheostomy. Maximum number of patients had age between 61-80 years. Males were more number than females. Portex type of tube used in maximum patients. 70 patients underwent elective and 11 underwent emergency tracheostomy. 74 patients underwent surgery in operation theatre and 5 in an ICU. Prolonged ventilation is the major indication for tracheostomy. Out of 81 patients 55 did not show any complications. 9 patients developed granulations. Significant correlation was observed between complications with period of decanulation. Conclusions: Postoperative care, regular follow up and proper nursing home care is essential for the patients who require prolonged tracheostomy and also to prevent complications with speedy recovery.

Introduction: Clinical and radiological parameters might not be sufficient to diagnose the aetiology of exudative pleural effusions accurately. Often, thoracoscopy serve as an important added tool in the correct diagnosis. Aim: To analyse the diagnostic accuracy of initial diagnosis (clinical and radiological) compared with thoracoscopic biopsy. Materials and Methods: This was the retrospective study done on all the consecutive medical thoracoscopic procedures conducted in tertiary care centre (pulmonology wing), Trivandrum, India from May 2010 to April 2016. All thoracoscopic procedures were conducted in adult patients above the age of 18 years. Kappa statistics was performed to find the diagnostic accuracy. Results: During this period, 94 diagnostic medical thoracoscopic procedures were performed. Majority of them were males (68.1%) and mean age was 54.8±13.53 years. Main diagnostic indications were undiagnosed exudative effusions (85.4%) and emphysema (7.1%). Tuberculosis was the most common initial diagnosis prior to the procedure (70.2%). Histopathology reports showed tuberculosis as the most common final diagnosis (45.7%), followed by malignancy (38%) and chronic inflammation (6.4%). Four patients who were not biopsied were excluded from diagnostic accuracy analysis. When thoracoscopic biopsy was taken as the gold standard, sensitivity was found to be 67.4% for initial diagnosis of tuberculosis and only 13.9% for malignancy. But specificity was found to be more for malignancy (81.5%) than tuberculosis (27.7%). Overall diagnostic accuracy of initial diagnosis was found to be 46.7% for tuberculosis and 54.4% for malignancy. There was minimal or no correlation (R=-0.173) between the diagnostic outcome and type of anaesthesia (local or general anaesthesia). There was no significant difference in occurrence of complications between local and general anaesthesia (p-value=0.717). Conclusion: Medical thoracoscopy had an important additional diagnostic value in management of pleural diseases as evidenced by slight agreement between initial and final diagnosis.

Drugs like chloroquine (CQ)/ Hydroxy chloroquine (HCQ) had been widely used as treatment options at the start of pandemic with little supporting evidence. American Thoracic Society (ATS) led International Task Force had come up with some important `suggestions’ regarding CQ/ HCQ usage initially. They have suggested to use these drugs in covid 19 patients with severe pneumonia on a case by case basis. However, the role of HCQ prophylaxis, the effect of combination with macrolides, benefit versus risk assessment, age group profile and the exact definition of severe pneumonia remain unanswered among others. Now, it had become quite obvious that our perceptions based on some observational studies were completely wrong.

Renewable energy-based energy conversion technologies have become more relevant due to environmental considerations even though they are intermittent in nature. As a result, the concept of microgrid and microgrid control techniques have been evolved as major areas of power system research. Among different inverter control methods, the droop-based control method is more popular in microgrid systems due to its simplicity and non-requirement of expensive communication systems. The transient performance, power-sharing accuracy and decoupling between real and reactive power are improved by modifying the natural droop control method. In this study, the selected microgrid system consists of two inverters operating in parallel, two interconnecting lines and three loads. A state-space model of the microgrid is created based on the small-signal stability and the transient response is improved by introducing virtual impedance and dynamic droop gains. The different controller parameters are optimised using particle swarm optimisation ensuring stability. Eigenvalue analysis is done to analyse stability. The analysis of the response of the system for various disturbances validates the effectiveness of the proposed controller. The strategy developed ensures improved power-sharing capability with high values of natural droop gains without compromising stability by using optimised dynamic droop gains.

Dysphagia is a broad term encompassing various symptoms due to any condition affecting the normal mechanism of swallowing. The symptoms are often varied like inability to swallow solids and/or liquids, cough on taking liquids, recurrent episodes of aspiration pneumonia and so on. Zenker‘s diverticulum is a not so common condition in which the patient usually presents with hallitosis, delayed regurgitation of feeds in an unchanged manner and foreign body sensation in the throat. Another rare condition is an osteophyte indenting onto the esophagus and causing dysphagia. A 63 year old male presented to the laryngology out patient department with symptoms of food sticking in his throat and regurgitation of feeds in unchanged form which occurred hours after the initial meal. As clinical evaluation and flexible endoscopic evaluation of swallowing were unremarkable he was subjected to a fluoroscopy. Fluoroscopy showed prominent osteophytes at fourth cervical vertebra (C4) and seventh cervical vertebra (C7); the higher one obliterating the apex of right pyriform fossa thereby leading to occasional stagnation of barium in the right pyriform fossa which mimicked a pouch. A computed tomography confirmed the finding of an osteophyte compressing on the lower end of the hypopharynx and giving rise to symptoms similar to that of a pharyngeal pouch. He consequently underwent an osteophyte excision via anterior cervical approach following which he was relieved of his symptoms.

Background: Non-malignant lesions of the larynx constitute an interesting array of lesions. The significance of non-malignant lesions lies in the fact that it cannot only cause change in voice but, at times, can lead to breathing difficulty or life-threatening stridor.Methods: This was a prospective observational study done between November 2019 - July 2020. All the details were filled up by the principal investigator in a structured study proforma. This proforma contains data regarding essential demographic details, clinical features, ENT examination, flexible video laryngoscopy findings, stroboscopy findings, voice handicap index, diagnosis and management. Statistical method and data analysis in this study we tried to describe the analysis process with appropriate methods and principles of statistics, using the data collected from the patients, participated in this study. Results: The most common non-malignant lesion among the 50 patients studied was vocal cord polyp; second most common being the vocal cord cyst. The relation of hoarseness of voice, difficulty in breathing, smoking or alcohol intake with non-malignant lesions showed a statistically significant result. On interpreting the stroboscopic findings of various lesions, all cases of vocal nodule showed an hourglass-shaped glottic closure.Conclusions: These lesions can create a lot of mental and emotional tension in the patient and the family. Early diagnosis of the lesions can lead to effective management and functional recovery. Stroboscopy is valued for its excellent ability to examine the structure and the function of the glottis during phonation.

Droop control is widely used for inverter dominated microgrid due to its simplicity and lack of expensive communication interfaces. It mimics the governor action of alternator by controlling frequency and magnitude of voltage to regulate active and reactive power flow respectively. A reduced order small signal model is developed for a microgrid system with two inverters, two interconnecting lines and three loads. The stability of the system is improved by the optimal setting of droop gains using particle swarm optimization after defining suitable objective function. The eigenvalues which are present near imaginary axis are shifted towards left using state feedback control for improving stability. Hence a new control scheme is proposed in this paper by combining state feedback control with droop control to improve the transient performance. The response of the system for change in load current verifies the effectiveness of the proposed control method.

Transnasal esophagoscopy (TNE), the latest addition to a laryngologist’s armamentarium, is a procedure which involves the endoscopic examination of the nasopharynx, larynx, hypopharynx and the esophagus via a small calibre scope passed transnasally. TNE was first performed by Reza Shaker, a gastroenterologist in 1994.

The concept of microgrid has become more relevant due to the increase in the use of distributed energy resources. However, the important factors which are to be considered are their ability to control the power flow and stability of the system. Droop control strategy requires no communication system and realizes the “plug and play” function between source and load. In this paper a state space model of such a system is developed based on small signal disturbances. Eigenvalue analysis of the system is also done and the parameters which determine the stability of the system are identified. The optimum values of these parameters are found out by increasing the stability of the system using particle swarm optimization (PSO) technique. The simulation is done by MATLAB coding and the results show that the values of the optimized parameters will improve the stability of the system by shifting the eigenvalues away from the imaginary axis as far as possible on the left half of s plane.

Introduction: Though FeNO is widely used as a marker of eosinophilic inflammation in asthma, it is seldom practised in India. Objectives: To assess the usefulness of FeNO in measuring response to inhaled corticosteroids in asthma. Methods: This prospective observational study was conducted in a tertiary care centre from January to December 2016(12 months). Study included all patients presenting for the first time in clinic with newly detected or already diagnosed asthma. Patients with FeNO value of greater than 25ppb were included. Repeat FeNO analysis was done after 8 weeks of treatment with Formoterol and budesonide combination inhalers. Asthma Control Test was measured to assess clinical response. Statistical analysis was done using EPI INFO. Results: A total of 51 patients were included. Females outnumber males (29 vs. 22). Mean age was 32.08. During initial evaluation, 47% had mild asthma and 7% moderate . During initial presentation, 90% of patients presented with uncontrolled stage. After 8 weeks of treatment, 62% of patients were in controlled stage.Initially, 60.7% of patients had FeNO between 51 to 100 ppb while17.6% had >100 ppb. After 8 weeks of treatment, 39% had normal values ( Conclusion: A high initial FeNO value and a greater subsequent decline are good predictors of corticosteroid response, thus identifying suitable phenotypes in resource-limited setting.

Maternally inherited diabetes with deafness is rare diabetes caused by a mitochondrial DNA defect. 85% of cases are associated with m.3243A>G mutation. It is important to diagnose this form of diabetes because of the unique management issues and associated comorbidities. A very strong family history of diabetes, deafness and presence of retinal dystrophy should prompt an investigation for MIDD. Microvascular complications out of keeping with duration of diabetes are another clue to the diagnosis. Retinal and renal manifestations of mitochondrial disease may be confused for diabetic complications. Glutamic acid decarboxylase (GAD) autoantibody negativity in a nonobese diabetic is another clue. Cardiac conduction defects and GDM may also raise suspicion as to the diagnosis. Recognizing this etiology of DM should promote family screening, genetic counseling, screening of associated comorbidities, avoidance of metformin, and cautious use of statins. We report a 77 years old lady with MIDD who was being followed up as insulin requiring type 2 diabetes. We then identified 5 more patients with MIDD in the same clinic. They all had A3243 mutation with characteristic clinical presentation. The pharmacological approaches discussed in the paper are unlikely to work in these patients as they were diagnosed late.

Background: The role of the autonomic nervous system in the complex link between insulin resistance and cardiovascular risk remains unclear. Increased sympathetic nervous system activity has been implicated in the pathophysiology of insulin resistance but is confounded by a number of factors. Methods: We have therefore examined the relationship among cardiac autonomic control, insulin resistance, habitual physical activity, resting energy expenditure (REE), and anthropometric variables in a subset (107 boys, 101 girls, age 9 ± 0.25 yr) of the EarlyBird cohort. Cardiac autonomic activity was assessed using time domain and power spectral density analysis methods of heart rate variability. Insulin resistance was measured using homeostasis model assessment of insulin resistance (HOMA2-IR). Results: Girls, in comparison to boys, showed significantly higher resting heart rate and lower systolic blood pressure (BP); were more insulin resistant; undertook less physical activity, and had lower fat-free mass and REE. Increasing fasting insulin and increasing insulin resistance were associated with increasing BP. Conclusion: The data suggest early gender differences in predictors of cardiac autonomic control. Pubertal staging was not undertaken in this study, and we plan to evaluate this in future studies to further clarify these associations.