Clinical Profile and Outcome of Snake Bite Patients from Tertiary Healthcare Center: In Sub-Himalayan Region: A Medical College-based Study

Objective: Snake bite is an emergency in tropical and subtropical countries. It is a neglected disease and is most commonly seen in rural setups, where people are ignorant about the venomous snake bites. It results in increased mortality and morbidity because precious time is wasted, either in consulting traditional healers or waiting for the development of signs and symptoms of envenomation. Then only the patient is shifted to a health center. Here we studied the clinical profile, management, and outcome of snake bite patients. Materials and methods: This study was done by retrieving the records of patients with snake bites admitted to the Department of Medicine, Indira Gandhi Medical College & Hospital, Shimla, from 1st January 2017 through December 2019. The recorded data was entered in a precoded performa, and analysis was done with respect to various variables. Result: We evaluated the records of 190 patients. The incidence of the bite was higher among females, 62.1% (n = 118). The commonest age group involved was 21–50 years, 70.1% (n = 34). In 55.8% (n = 106), the site of the bite was the upper limb. The daytime bite was present in 54.7% (n = 106). The maximum incidence of snake bites was found during the rainy season, 81.5% (n = 155). 28.4% (n = 54) of patients presented within 6 hours of the bite. Coagulopathy [whole blood clotting test (WBCT) of >20 minutes] and neurotoxicity were seen in 77.9 and 7.9% of patients, respectively. Anti-snake venom (ASV) was given to 87.8% (n = 167) of patients. In 80% (n = 152) of the cases, hospital stay was up to 3 days. Mortality was seen in only two (1.05%) cases. Conclusion: There is a need to create awareness among the community, particularly in rural areas, about snake bite envenomation and early transportation of victims to the nearest health center. Training of health professionals is also needed to manage cases of snake bites efficiently and judiciously, thereby reducing morbidity and morbidity.

Outcome Analysis of Dual Plating in Management of Unstable Bicondylar Tibial Plateau Fracture - A Prospective Study

@#Introduction: Bicondylar tibial plateau fractures account for 10-30% of tibial plateau fractures. Despite recent advancements in the management of unstable bicondylar tibial plateau fractures, the outcomes are often poor. The present study aimed to evaluate the functional outcomes and complications of internal fixation of bicondylar tibial plateau fractures with the dual plating using two incisions. Materials and methods: The present study included 30 patients (26 males; 4 females, mean age 35.6 years; range, 19 to 65 years) with bicondylar tibial plateau fractures who were treated with dual plating between January 2017 to August 2019. Out of 30 patients, 5 patients had Schatzker type (V) and 25 patients had Schatzker type (VI) bicondylar tibial plateau fracture. All patients were treated with dual plating using two incisions. In all patient’s similar standard physical rehabilitation therapy was followed. All complications including intra and post-operative were assessed and recorded. The patients were followed-up for over 24 months. Functional outcomes were assessed with Rasmussen’s functional grading system, Oxford knee score, and range of motion of knee joint. Radiological outcomes were evaluated using Rasmussen’s radiological scoring system. Result: All fractures united with a mean time of 18 weeks. The average knee range of motion was 1.5° - 130° (range: 0° - 10° for extension lag, range: 100° -135° for flexion). Mean Rasmussen's functional grading score at the final follow-up was 26.75. All patients showed excellent or good radiographic results according to Rasmussen’s radiological scoring with a mean score of 8.5 (range 6-10). The postoperative radiographs showed mean MPTA was 84.3° and the mean PPTA was 6.2°. In the present study, complications were encountered in five patients. However, there were no cases of secondary loss of reduction, failure of the implant, malunion, or non-union. Conclusion: The surgical treatment of bicondylar tibial plateau fractures with dual locking represents a significant treatment option and provides rigid fixation in these fractures with good functional and radiological outcomes.

A study of gestational diabetes mellitus and fetal outcome in a tertiary care center

Background: Modern desk-bound lifestyle and unhealthy dietary changes have brought a rise in the prevalence of obesity and gestational diabetes mellitus (GDM). It is associated with severe hazards to the mother and the baby. It is mandatory that early diagnosis ensues and timely and congruous management is undertaken.Methods: In this observational study, 1250 women were included. A standardized questionnaire was formed and their details were noted. Tests for glucose levels, complete blood picture, urine examination were performed. An oral glucose tolerance test was performed on all the patients. Neonatal outcomes in terms of birth weight and the presence of complications were noted.Results: A total 201 (16.1%) of all women were having gestational diabetes mellitus (GDM). Most mothers were in the 25-30 age group. The majority of the women had a BMI between 26-30. 21.9% of babies were having weight >3.5 kgs. 11.4% of babies were <2.5 kgs. Out of 201 neonates, 90 babies were having complications. Major complications in neonates were macrosomia and respiratory distress. Therefore, early diagnosis, glycemic control, and timely and congruous management are advantageous to both mother and baby.Conclusions: GDM complicating the pregnancy results in a higher prevalence of complications in the mother and the neonate. Therefore, appropriate control of the sugar level in mothers is necessary and it decreases the morbidity and mortality rates in the babies as well as the mothers.

A comparative study of vaginal misoprostol versus oral misoprostol for induction of labour

Background: Induction of labour defined as artificial initiation of uterine contractions before the onset of spontaneous labour, after the period of viability, by any methods. The successful outcome depends on the Bishop Score, maternal age and parity. Authors compared the most preferred two routes; vaginal and oral for induction and outcome, adverse events and side effects were noted.Methods: This was a prospective comparative study carried out at SVPIMSR, Ahmedabad, from January 2019 to June 2019, Gujarat, 100 patients who required induction were randomly divided in two groups- Group A received 25µg oral misoprostol, Group B - received 25µg vaginal misoprostol repeated 4 hourly up to maximum five doses in both groups. The induction to delivery interval, mode of delivery, maternal and neonatal outcome and complications were observed.Results: The mean induction to delivery interval was less in vaginal group than oral (18.7 hours in vaginal versus 22.4 hours in oral). Vaginal delivery and caesarean section rates were comparable in both groups. 60% patients in Group A required more than two doses as compared to 36% in Group B. No major complications or adverse events were observed.Conclusions: Both oral misoprostol in a dose of 25μg and vaginal misoprostol 25μg every four hours, to a maximum of five doses, have safety and efficacy for induction. With The vaginal route, delivery occurs in less time and few doses required as compared to oral.

Gender preference for child among reproductive age group women - A cross-sectional study in Jamnagar district

Background: Today, female feticide and gender preference are a big problem in India. Although there is so much emphasis against it, the problem has become aggravated. In this context, various studies showed that the male child preference leads to skewed sex ratio. The present paper is an attempt to determine the view of the people for giving their preference to the male child. Objectives: The objectives were to study the preference of women for gender of child, as well as reasons for preference for it, and association between socioeconomic factors and demographic factors with gender preference. Materials and Methods: It is a community-based cross–sectional study, in which 500 married women of 15–49 years of reproductive age group, 150 randomly selected women from one urban municipal ward, and 350 randomly selected women from seven villages of rural area were constituted the study population. Widow and separated women were excluded from the study. A pre-tested, semi‑structured questionnaire was administered to each individual to collect information. Microsoft Excel 2007 software and the Chi‑square test were used. Results: Almost half of the women (51.4%) have preference for male child. Women from lower age group (65.25%), currently married (66.42%), Muslim religion (72.22%), lower education (59.01%), and low socioeconomic status (66.67%) and those who are laborer (71.83%) have male child preference. Conclusions: This study concludes that more number of females have preference for male child in women of younger age group. Muslim religion and its customs, thoughts, and rearing practices make difference. Lower socio-economic status and poor education are also major contributory factor. Male child will support in old age and will take social responsibilities are the main basic reasons found to be associated with male child preference.

Evaluation of activity of hypothalamo-pituitary-gonadal axis in postmenopausal women suffering from severe acute illness.

Background & objectives: Postmenopausal women constitute an ideal model for studying the extent of hypothalamo-pituitary gonadal (HPG) axis suppression in critical illness as the gonadotropins are normally high and non-cyclical in them. The objective was to assess the impact of acute severe illness in postmenopausal women on the HPG axis and the activities of the hypothalamo-pituitary-adrenal (HPA), the hypothalamo- pituitary-thyroid (HPT) axes; and levels of serum prolactin, by comparison between critically ill postmenopausal women and otherwise healthy postmenopausal women. Methods: Thirty five consecutive postmenopausal women older than 60 yr admitted to medical intensive care with a Simplified Acute Physiology Score II (SAPS II) more than 30 were included. On day five of their in-hospital stay, blood samples were collected for oestradiol, luteinizing hormone (LH), follicle stimulating hormone (FSH), cortisol, androstenedione, prolactin and thyroid profile. Thirty five apparently healthy postmenopausal women were selected as controls. Results: Levels of LH, FSH, thyrotropin, free thyroxin (fT4) and free tri-iodothyronine (fT3) were lower while oestradiol, cortisol and dehydroepiandrosterone were higher among patients in comparison to healthy controls. Prolactin levels were similar in patients and controls. Among sick patients both FSH and fT4 showed a negative correlation (P<0.05) with the SAPS II score. Interpretation & conclusions: In critically ill postmenopausal women, paradoxically elevated oestrogen levels despite gonadotropin suppression suggests a non-ovarian origin. Prolactin remained unaltered in patients despite their illness, possibly reflecting atrophy of lactotrophs in menopause.

Preoperative risk factors and incidence of glaucoma after penetrating keratoplasty.

Glaucoma following penetrating keratoplasty is one of the serious complications due to its frequency of occurrence, difficulty in diagnosis and management, risk of graft failure and irreversible visual loss due to optic nerve damage. The incidence of glaucoma after keratoplasty varies from 9% to 31% in the early postoperative period and from 18 to 35% in the late postoperative period. The aetiology of this disorder is multifactorial and the clear understanding of the various mechanisms that operate during different time frames following penetrating keratoplasty is essential to chalk out the appropriate management algorithms. Methods: Prospective analysis of 100 consecutive eyes which underwent penetrating keratoplasty during the period from September 2009 to December 2010 at Bangalore West Lions super speciality eye hospital was done. The patients were followed up for a minimum period of 9 months. Results: Out of 100 patients mean age distribution was 47 ± 11 years. Of the 100 patients male 68% and 32 female (32%). Out of 100 eyes 38% of them had vision <6/60, 36% of them had vision between 6//36-6/18 and 26% of them between 6/18-6/6. Raised intraocular pressure was found in 15 out of 100 eyes. Mean raise in intraocular pressure was 29 mmHg ± 1.5 mmHg. Out of 15 patients 4 were steroid responders. Mean time of diagnosis of raised intraocular pressure was 5 ± 9.5 months. Pseudophakic Bullous Keratopathy (PBK) in 5 (33.3%) patients, aphakic bullous keratopathy (ABK) in 3 (20%) patients, graft rejection in 2 (13.3%) patients and one each patient (6.7%) of corneal scar, adherent leucoma, chemical injury and congenital hereditary endothelial dystrophy. Aphakic group was at higher risk compared to the other groups and there was not much difference between the phakic and the pseudophakic group. Conclusions: Post penetrating keratoplasty glaucoma continues to be a clinical problem that can be sight threatening in its clinical outcome. It is mandatory that intraocular pressure is monitored on a regular basis. Recognition of the risk factors namely, indications, graft size, lenticular status & associated surgical procedure with penetrating keratoplasty would help in early diagnosis of post penetrating keratoplasty glaucoma. Most of these cases are amenable to medical management.

Titamium oxide (TiO2) assisted photocatalytic degradation of methylene blue.

The aqueous solution of methylene blue(MB) has been subjected to Photocatalytic degradation by UV radiation in presence of TiO2 photo-catalyst containing different concentrations of H2O2. The experiments conducted at different dye concentrations (12 and 20 ppm), catalyst loading, pH and H2O2 dosage (1-10 ml l-1), revealed that the degradation rate is strongly influenced by respective experimental parameters. However the influence of catalyst alone is not predominant in degradation. The decolorization of dye proceed to near completeness when H2O2 is used. The best degradation results are observed at 0.1 wt% of catalyst loading at pH 2 for TiO2/UV system. It has been found that the optimum concentration of H2O2 for 12 ppm and 20 ppm amount of the dye was 2ml l-1 for UV/H2O2 system. The kinetic of degradation of the dye followed the pseudo first order rate. The degradation studies using TiO2/UV/H2O2 system, indicates enhancement in the degradation rate of the dye compared to that of UV/H2O2 system alone.

Surgical training - the challenge of change

The healthcare environment is continuing to change and so too is education and training of surgeons. We now live in an age of increased specialisation, of technology, of accountability, of greater patient education and expectation and mass media attention. The traditional apprentice method and emphasis too much on examinations will have to be changed to a more structured system of training with training standards, regular assessment and feed back. There are new skills to be learnt for future surgical practice and new ways to learn them to become competent. We need to make changes in the institutions and departments to create a learning environment and an organisational system to implement the training programme. The current shortage of surgical work force in the institutions and lack of sufficient teachers committed to teaching and training are major issues that need to be addressed.

Alkyl succinate poisoning.

A case of alkyl succinate poisoning is being reported. Oral ingestion of this compound led to gastrointestinal tract involvement and central nervous system manifestatations suggestive of parkinsonism. The patient recovered completely following conservative management without any sequelae.

Tree species diversity and composition in logged and unlogged rainforest of Kudremukh National Park, South India.

Species composition and diversity in logged and unlogged forests were assesed to understand the regeneration of the residual stand twenty years after logging in Kudremukh National Park, South India. Relative density, frequency and basal area were measured by Point Centered Quarter method to calculate the diversity and stand quality. The logged forest harbored lower stem density of mature trees (508 ha(-1)) than unlogged ones (630 ha(-1)). Indeed, logging operations increased the species diversity in the regenerative phase (seedling phase) due to the creation of larger canopy gaps. The extra radiation reaching the ground, facilitated the colonization of early and late secondary species. Ramakrishanan Index of Stand Quality (RISQ) values in logged forest was higher in comparison with unlogged forest, indicating the dominance of early and late secondary species, especially at sapling phase. The light demanding secondary forest species contribute higher percentage to the overall tree population in logged forest. It is observed from the study that a sufficient period of felling cycle should be practiced to reinstate the same set of species prevailed before logging.

Dystrophin gene deletions in South Indian Duchenne muscular dystrophy patients.

66 unrelated patients from Southern India with Duchenne Muscular Dystrophy (DMD) were studied for intragenic deletion in 18 exons and Pm region of the DMD gene using multiplex PCR. Of these 41 (62.1%) showed intragenic deletions. 78% of the deletions were located at the distal hotspot region (44-55 exons) and 22% of the deletions were located at the proximal region (exon 2-19). Exon 50 is most frequently deleted. Deletions in isolated cases were significantly more compared to familial cases. The lower incidence reported from South India compared to North India, is suggestive of variations in the Southern and Northern population.

Aetiology of severe vitamin A deficiency in children.

BACKGROUND: Severe forms of vitamin A deficiency or keratomalacia are common in young children. Keratomalacia is thought to be associated with malnutrition due to poor weaning practices and manifests at 3 to 4 years of age. As survival rates for infants have increased, keratomalacia is being seen in children less than 6 months of age. Hence, keratomalacia shows two peaks--one in early infancy and the other in the toddler or pre-school age groups. However, the reasons for its occurrence at these ages may be different. METHODS: Records of children admitted to the Nutrition Rehabilitation Centre at the Government Rajaji Hospital during 1971-89 and at the Aravind Children's Hospital during 1991-93 were reviewed for severity of vitamin A deficiency associated with protein-energy malnutrition. Records of 1990 were not available. RESULTS: During 1971-89, 4691 children were admitted to the Nutrition Rehabilitation Centre for Nutritional rehabilitation and treatment of vitamin A deficiency. Of these, 1575 (33.6%) children had corneal involvement due to vitamin A deficiency. During 1991-93, 7439 children in the age group of 0-15 years were seen at the Aravind Children's Hospital--185 had vitamin A deficiency; 133 were below the age of 5 years and 69 had keratomalacia. Fifteen children with keratomalacia were below the age of one year and 12 were below 6 months of age. CONCLUSION: The incidence of severe vitamin A deficiency of keratomalacia shows two peaks; one in early infancy (< 6 months) and the other in the pre-school age group. The first peak is probably related to maternal nutrition and decreased breast-feeding while the second peak is possibly related to poor weaning practices.

Electrophysiological responses of the housefly, Musca domestica nebula (Fr), taste receptors to KCl.

This paper aims at studying the response of the housefly labellar chemoreceptor to stimulation by KCl. These studies are limited to testing various concentrations of KCl solutions (0.005-1 M), using the electrophysiological "tip recording" method and examining the various spike characteristics such as threshold, phasic and tonic response, spike amplitudes, frequency and adaptation; for the anion, cation and water receptors. The large, medium and small hairs all respond to salt. The frontal large, medium and small hairs show a higher frequency response to equimolar KCl than the distal hairs. There is a bilateral symmetry in response pattern. The results are compared with the reported work on Phormia and Calliphora species. The Biedler's hypothesis is also tested for the salt receptors of Musca.

SAFA test as an aid to the diagnosis of ocular tuberculosis.

A prospective double blind study was carried out to evaluate the role of soluble antigen fluorescent antibody (SAFA) test to detect ocular Tuberculosis. The study material comprised 39 patients with suspected ocular tuberculosis suffering from interstitial keratitis, sclero keratitis, granulomatous uveitis, phlyctenular keratoconjunctivitis, Eales disease and central serous retinopathy. The cases of proven ocular tuberculosis showed up as 70 percent strong reactors and 30 percent weak reactors to SAFA while none had a negative response to SAFA. Of these cases skin hypersensitivity reaction was positive only in 40 percent of the cases. The control group revealed a strong SAFA reaction in only 4 percent of cases with a weak reaction in 44 percent of cases. It thus appears that SAFA test can provide a useful addition to the routine tests in diagnosing tuberculosis.

Effect of extracellular pH and DNFB treatment on the mechanical performance of frog skeletal muscle.

isometric tension and maximum velocity of shortening of frog sartorious and biceps muscles were measured at varying pH and compared with the values obtained for muscles treated with DNFB. Both To and Vmax exhibited increase with increase in pH above neutral pH upto pH 9, and decreased as the pH was decreased up to 5. Muscle treated with DNFB at pH 7 showed about 30% decrement but these too improved at pH 9 to almost 105% and 130% respectively compared to untreated muscle at pH 7. Using the number of short duration tetanic contractions, which reduce To and Vmax by half, as an index for the onset of fatigue, high pH was found to have a positive effect in both normal and DNFB-treated muscle. Thus, the crucial factor for onset of fatigue is not a fall in ATP level but acidification and treatment with high pH Ringer's solution partially annuls the effect of acidosis, arising either naturally or from DNFB treatment. One additional role of creatine kinase activity to that of ATP regeneration is suggested to be the maintenance of neutral pH in the sarcoplasm.

Soluble antigen fluorescent antibody test in the serodiagnosis of tuberculous meningitis.

Diagnosis of tuberculous meningitis (TBM) is difficult and frustrating. Modified soluble antigen fluorescent antibody (SAFA) test was applied to 40 CSF and 32 serum samples from 48 patients to assess the efficacy of this test in the rapid diagnosis of TBM. Using this test, false negative results were obtained in 41.6% and 40% of CSF and serum samples. False positive results were obtained in 22.2% and 26.7% of CSF and serum samples respectively. SAFA test was not found to be helpful in the sero-diagnosis of TBM. It is suggested that the best immunodiagnostic test for TBM will be to demonstrate the presence of antigen, antibody and antigen-antibody complex in the CSF for M. tuberculosis.

Coupling of the enzymic activities of myosin ATPase and creatine kinase and its role in muscular contraction.

During muscular contraction the regeneration of ATP, catalysed by creatine kinase (CK), keeps pace with the hydrolysis of ATP by myosin ATPase posing the question of its regulatory mechanism. In the background of F-actin activation of heavy meromyosin (HMM) ATPase activity we have investigated in vitro the role of F-actin in regulating CK's activity in the absence and presence of HMM. For the coupled enzyme system we have also looked into the roles played by the individual reactants. F-actin has been found to appreciably increase CK's activity in the absence of HMM. While HMM alone inhibited CK's activity, there was a several fold increase when F-actin was also present. By a process of elimination we conclude that none of the reactants apart from H+ could be involved in regulating CK's activity in the coupled enzyme system. As no change in the pH of reaction mixture was observed during the reaction, we further conclude that the two enzymic reactions are coupled by proton transfer along F-actin. Implications of the findings for PCr-Cr shuttle and movements of ATP and ADP in sarcomere are discussed.