Kauverian Medical Journal

Editor's Message

Dr. Venkita S. Suresh — 2026-04-08

Editor's Message

Beyond atherosclerosis: Investigating the significant association between hyperhomocysteinemia and cardioembolic stroke subtypes in young patients

Allfrid Rajkumar — 2026-05-08

Background: Hyperhomocysteinemia (HHcy) is traditionally viewed as a driver of arteriopathy. However, clinical observations increasingly suggest a "cardio-toxic" role. This study evaluates the specific link between elevated total Homocysteine (tHcy) and cardioembolic stroke in a cohort of young adults, where traditional atherosclerotic burdens are typically lower.

Methods: A 12-month prospective study of 196 ischemic stroke patients (<50 years) was conducted. Stroke aetiology was categorised via modified TOAST criteria. Fasting tHcy levels were analysed, with HHcy defined as >15\mu mol/L. Results: HHcy was present in 38.7% of the cohort. While Large Artery Atherosclerosis was present in only 6% of cases, Cardioembolic strokes accounted for 9%. Statistical analysis revealed a significant positive correlation between tHcy levels and cardioembolic events (p < 0.05). Notably, patients with tHcy >30 \mu mol/L showed a higher propensity for cardioembolic origins compared to other subtypes.

Discussion: Our findings suggest that HHcy may serve as a biomarker for a prothrombotic endocardial environment. The association with cardioembolism— historically less explored than the Hcy-atherosclerosis link—points toward Hcyinduced atrial remodelling or endocardial oxidative stress as potential drivers of embolus formation in young patients.

Conclusion: The significant relationship between increased Hcy levels and cardioembolic stroke warrants a re-evaluation of current screening protocols. In regions like Ukraine, where Hcy testing is not yet obligatory, the "Hcy-Cardiac Axis" may represent a major undiagnosed contributor to the young stroke burden

Technological evolution in radiation oncology: A comprehensive institutional audit of clinical workflows, dosimetric precision, and outcomes following transition from legacy 2D radiotherapy to high‑precision digital platforms

Balachandran Sathish — 2026-05-08

Background: The evolution of radiation oncology technology from legacy two‑dimensional (2D) planning systems to high‑precision digital radiotherapy platforms has fundamentally altered oncologic treatment delivery. This institutional audit evaluates the epidemiology, treatment utilization, workflow kinetics, dosimetric capability, and clinical outcomes associated with this technological transition within a tertiary regional cancer center.

Methods and Materials: A retrospective institutional audit was conducted on 1,192 consecutive oncology patients treated between January 2023 and February 2026. The cohort was stratified into a legacy conventional radiotherapy cohort (n=1,060) and a high‑precision digital radiotherapy cohort (n=132). Clinical variables included demographic characteristics, cancer site distribution, stage at presentation, systemic comorbidities, treatment modality utilization, and radiotherapy technique distribution. Disease control rate (DCR) was calculated using verified follow‑up outcomes.

Results: The median age of the cohort was 56 years with a female predominance of 64.5%. Breast cancer, head and neck malignancies, and gynecologic cancers represented the dominant disease triad, accounting for 67.4% of the institutional workload. More than half of the patients presented with advanced disease (Stage III– IV, 53%). Radiotherapy was utilized in 70% of patients. Adoption of modern high‑precision radiotherapy techniques including VMAT, IMRT, and stereotactic radiotherapy enabled improved conformality, enhanced organ‑at‑risk sparing, and reduction in treatment interruptions. Disease control rate improved from 66% in the legacy era to 79.7% following adoption of precision radiotherapy.

Conclusion: Transition from legacy radiotherapy techniques to modern digital precision platforms significantly improves treatment precision and disease control outcomes. These findings demonstrate that technological modernization can meaningfully elevate oncologic care even in resource‑limited regional centers.

Reduction in chemoport-related complications following protocol based quality improvement: A single-center audit

Surendhrakumar — 2026-05-08

Background: Totally implantable venous access devices (chemoports) are indispensable in oncology practice but may be associated with infectious, thrombotic, and mechanical complications. We audited our institutional outcomes and assessed whether protocol-based quality improvement reduced complications.

Methods: A retrospective audit of chemoport procedures performed from January 2018 to February 2026 was conducted at a tertiary cancer center. Procedural approach, complications, and outcomes before and after protocol implementation in 2024 were analyzed.

Results: Fifty-four chemoports were inserted and 26 removed. Nineteen complete insertion-removal cases were included for complication analysis. Pre-protocol complication rate was 23.5%, including infections, thrombosis, malrotation, and catheter displacement. After implementation of a standardized protocol, complication rates reduced to 8%, with no malrotation or thrombotic events observed.

Conclusion: Standardized insertion and handling protocols significantly reduced chemoport-related complications and represent a practical quality improvement strategy.

Telemedicine services in diabetes care: An audit

Gowri P — 2026-05-08

Background: The COVID-19 pandemic and subsequent nationwide lockdown in March 2020 necessitated a rapid shift in healthcare delivery to ensure continuity of care for chronic conditions. Following the legalization of telemedicine by the Medical Council of India (MCI) on March 25, 2020, our institution embarked on a structured journey to implement virtual care for patients with diabetes

A high-risk challenging PDA device closure: Closing the window percutaneously in a sick infant

Vinothkumar.S.P — 2026-05-08

Background: Patent ductus arteriosus (PDA) in symptomatic infants often leads to failure to thrive and recurrent lower respiratory tract infections (LRTI). While surgical ligation was traditionally the gold standard for small, sick infants, percutaneous device closure. While surgical ligation was traditionally the gold standard for small, sick infants, percutaneous device closure is increasingly performed as a less invasive alternative, despite significant technical challenges in low-weight patients.

Paraquat poisoning: A silent and deadly threat

Princy — 2026-05-08

Background: Paraquat poisoning is a life-threatening condition with a high mortality rate, especially in developing countries like India. This article presents four patients with paraquat ingestion with severe complications, including fatal outcomes despite early hospital admission and aggressive management such as hemoperfusion. It highlights epidemiology, clinical presentation, management strategies, and emphasizes the importance of prevention and awareness, particularly among young individuals.

Idiopathic sclerosing encapsulating peritonitis (abdominal cocoon): A case series on clinical features, imaging, and surgical outcomes

Arjun Aravindh — 2026-05-08

Background: Sclerosing encapsulating peritonitis, also known as abdominal cocoon syndrome, is a rare cause of small bowel obstruction characterized by encasement of the intestines within a fibrocollagenous membrane. Preoperative diagnosis is often challenging due to nonspecific clinical presentation and overlapping imaging features. We present a case series of two male patients who presented with features of acute intestinal obstruction. Both patients had a history of abdominal pain, bilious vomiting, and obstructive symptoms. Contrast-enhanced computed tomography (CECT) revealed cluster of small bowel loops resembling an internal hernia. Intraoperatively, a thick fibrous membrane encasing the small intestine was identified in both cases, pointing to the diagnosis of idiopathic sclerosing encapsulating peritonitis. Both patients underwent surgical management with complete excision of the fibrous membrane and adhesiolysis. One case required extensive dissection due to involvement of the entire small bowel, while the other involved segmental bowel encasement. The postoperative course was uneventful in both cases, with gradual return of bowel function and favourable recovery. This case series highlights the importance of considering abdominal cocoon syndrome as a differential diagnosis in patients presenting with intestinal obstruction. Early recognition and timely surgical intervention are crucial for optimal outcomes.

Biliary cystadenoma in young females with favorable surgical outcomes: A case series

Arjun Aravindh — 2026-05-08

Background: Biliary cystadenoma is a rare cystic neoplasm of the liver with potential for malignant transformation, often presenting with nonspecific clinical features. Preoperative diagnosis can be challenging due to overlapping imaging characteristics with other cystic hepatic lesions and variable tumor marker levels. We present a case series of two female patients with biliary cystadenoma who exhibited distinct clinical and radiological presentations. The first case involved a young female presenting with acute symptoms, obstructive jaundice, and markedly elevated CA 19-9 levels, mimicking a malignant lesion. Imaging revealed a large multiloculated cystic lesion with biliary compression, and intraoperative findings confirmed biliary communication, making surgical excision technically demanding. The second case presented with a more indolent course, mild symptoms, and typical imaging features without biliary involvement, allowing for straightforward surgical management. Both patients underwent complete surgical enucleation, and histopathological examination confirmed biliary cystadenoma without evidence of malignancy. The postoperative course was uneventful in both cases, with favorable outcomes. This case series highlights the varied clinical spectrum of biliary cystadenoma, the limitations of tumor markers such as CA 19-9 in differentiating benign from malignant lesions, and the importance of complete surgical enucleation for optimal outcomes.

Out of body: Next generation life support

S Maniraj — 2026-05-08

Background: A male patient with ankylosing spondylitis on tofacitinib presented with severe bacterial pneumonia that rapidly progressed to refractory acute respiratory distress syndrome (ARDS)

Seeds of doubt

Shadiya Sulthana S — 2026-05-08

Background: A patient returning from India presented with a two-month fever of unknown origin and elevated inflammatory markers, initially suspected of having infective endocarditis due to a mitral valve vegetation. This case underscores the diagnostic challenges of differentiating intracardiac masses in travelers, requiring careful evaluation of both imaging and clinical findings.

Uterine artery embolization (UAE)

S. Zakir Hussain — 2026-05-08

Background: Uterine Artery Embolization (UAE) has emerged as a highly effective, minimally invasive alternative to traditional surgery for various gynecological and obstetric conditions. This report presents two distinct cases that highlight the clinical utility and versatility of UAE

Pulse matters: The clue that saved a life

P. Suganya Ramesh — 2026-05-08

Background: Acute Aortic Dissection (AD) remains one of the most challenging diagnoses in the emergency department due to its ability to mimic other lifethreatening conditions, including acute coronary syndrome (ACS), syncope, stroke, and limb ischemia. In cases of painless presentation, the risk of misdiagnosis is high, potentially leading to catastrophic outcomes such as inappropriate thrombolysis.

A case of quadriparesis with type 2 respiratory failure: A diagnostic conundrum

Arpana Singh — 2026-05-08

Background: Acute flaccid paralysis with respiratory failure is commonly attributed to Guillain-Barré Syndrome; however, other causes should be kept in mind.

Case Report: A 41-year-old woman presented with acute ascending weakness, areflexia, and respiratory failure requiring intubation. Initial clinical suspicion was Guillain–Barré Syndrome. However, Laboratory evaluation revealed severe hypokalemia (serum potassium 1.1 mEq/L) and normal anion gap metabolic acidosis (pH 6.9, HCO₃⁻ 14.6 mmol/L). Urine anion gap was positive, consistent with distal renal tubular acidosis. MRI showed pontine demyelination. In view of suspected combined central and peripheral demyelination syndrome, autoimmune workup was done, which revealed ANA, anti-SSA, anti-SSB, and anti-RNP positivity. The patient improved with intravenous potassium replacement, IVIG, Steroids and immunosuppressants. She was extubated on hospital day 4.

Why should an Emergency Physician be aware of this? Autoimmune polyradiculoneuropathy secondary to connective tissue disorder is a reversible cause of respiratory failure that can mimic Guillain–Barré Syndrome and hypokalemic periodic paralysis. Early recognition with prompt initiation of immunosuppression can be lifesaving.

Carcinoid syndrome associated severe tricuspid regurgitation

Shalini.K — 2026-05-08

Background: Carcinoid heart disease is a serious complication of metastatic neuroendocrine tumors caused by prolonged exposure to circulating serotonin and other vasoactive substances. It predominantly affects right-sided cardiac valves and commonly presents severe tricuspid regurgitation. We report a 65-year-old female with Grade II ileal neuroendocrine tumor with liver metastasis evaluated for preoperative cardiac fitness. Echocardiography revealed severe tricuspid regurgitation, severe pulmonary arterial hypertension (PASP 67 mmHg), dilated right-sided chambers, and mild left ventricular dysfunction (EF 45%). Coronary angiography demonstrated normal epicardial coronary arteries. Histopathology confirmed a well-differentiated Grade II neuroendocrine tumor with chromogranin and synaptophysin positivity and Ki-67 index of 5–6%. The findings were consistent with carcinoid heart disease. Early recognition is essential for optimal perioperative and subsequent post-operative management of TR.

Digoxin toxicity: A case report emphasizing the role of therapeutic drug monitoring

Johnson — 2026-05-08

Background: Digoxin has a narrow therapeutic spectrum ( range), making toxicity a significant clinical concern. We report a case of an elderly patient with multiple comorbidities, including left ventricular dysfunction and atrial fibrillation, who developed digoxin toxicity, presenting with nausea, vomiting, fatigue, bradycardia and conduction abnormalities. Contributing factors included possible drug interactions, impaired renal function, and chronic therapy. Detecting the Serum digoxin levels will be helpful in confirming the diagnosis. Prompt recognition, withdrawal of digoxin, correction of electrolyte imbalance, and supportive management, which may include Digoxin Antibodies, are urgently required to achieve clinical stability and safety. This case highlights the critical role of therapeutic drug monitoring (TDM) in optimizing digoxin therapy, preventing toxicity, and guiding dose adjustments, especially in high-risk populations.

A case of Eisenmenger syndrome with obstetric complication

Shirlin M.S — 2026-05-08

Background: Eisenmenger Syndrome is a serious complication of untreated congenital heart disease where long-standing hypertension causes reversal of blood flow, leading to hypoxemia. We report a 27-year-old female with a large atrial septal defect who later developed Eisenmenger syndrome with severe pulmonary hypertension. Her condition became complicated during pregnancy, which resulted in a missed abortion and medical termination. She later presented with cough and vomiting of dark brown material, and investigations showed gastric erosions. She was managed with supportive treatment, antibiotics, and acid-reducing therapy and improved clinically before discharge. This case highlights the importance of early diagnosis of congenital heart disease, careful monitoring in pregnancy, and multidisciplinary care to prevent serious complications.

Academics at Kauvery Hospitals

Chandru B — 2026-05-08

Background: A "learning hospital" framework prioritizes clinical safety and economic efficiency through rigorous academic integration. Kauvery Hospitals has established a multi-center academic infrastructure accredited by the National Board of Examinations (NBE).

Establishing a dedicated gastrointestinal bleeding centre in Chennai: Proceedings of a multidisciplinary panel conference and an evidence-aligned implementation framework with a prospective registry proforma

Deepak Kumar R — 2026-05-08

Background: Acute GI bleeding requires time-critical recognition, resuscitation, and rapid access to endoscopic and/or radiologic hemostasis. Variation in pathway execution contributes to avoidable transfusion, delayed definitive therapy, rebleeding, and mortality.

Objective: To summarize the proceedings of a Chennai panel conference convened as a prelude to launching a dedicated GI Bleed Centre, and to present an evidencealigned implementation framework including a prospective data collection proforma for 12-month local benchmarking.

Methods: Structured meeting report with narrative evidence synthesis. Conference themes were mapped to clinical questions across five domains (front-door recognition/triage; endoscopy pathway; Intervention Radiology/surgery escalation; variceal bleeding; lower GI bleeding and systems design). Evidence mapping prioritized high-authority guidance and landmark trials, including American College of Gastroenterology- Upper Gi Bleed guideline(ACG-UGIB) (2021) , European Society Of Gastrointestinal Endoscopy- Nonvariceal Upper Gastrointestinal Bleeding(ESGENVUGIH) guideline (2021) , ESGE Lower GI Bleed guideline (2021) , American Association For the Study Of Liver Disease(AASLD) portal hypertension/varices practice guidance (2024) and Baveno VII consensus (2022).

Results: Proceedings emphasized a “physiology-first, pathway-driven” model: (i) Use risk scores primarily to identify very-low-risk discharge candidates; (ii) Apply restrictive transfusion as default; (iii) Perform early endoscopy within 24 hours after stabilization for non-variceal UGIB; (iv) Integrate CT- Angiography-to-Intervention Radiology pathways for brisk bleeding; (v) Treat variceal bleeding as “double disease” requiring immediate vasoactive agents and antibiotics, and defined triggers for early Transjugular Intrahepatic Portosystemic Shunt(TIPS) in selected high-risk patients. A prospective registry proforma is provided to measure door-to-therapy times, bundle adherence, complications, rebleeding, and mortality.

Conclusion: A dedicated GI Bleed Centre can be operationalized through single-call activation, standardized checklists, 24/7 hemostasis capability and Key Performance Indicators (KPI)-driven audit, supported by prospective local data capture.

When time pauses, medicine listens: The story of parkinson’s disease

Samyuktha D V — 2026-05-08

Background: Parkinson’s disease is one such story — not just of neurons and neurotransmitters, but of people navigating time, identity, and change. To understand it fully, we must move beyond prescriptions and protocols and listen to the lives unfolding within them.

Diagnostic Images: MRCP spectrum

Meenakshi Paramasivan — 2026-05-08

Diagnostic Images: MRCP spectrum