Study of clinical and epidemiological profile of poisonous snake bite in a tertiary centre in North Kerala

Background: Snakebites are well-known medical emergencies in many parts of the world, especially in rural areas.The incidence of snakebite mortality is particularly high in South-East Asia. Rational use of snake anti-venom can substantially reduce mortality and morbidity due to snakebites. Snake bite is an important health problem in India also especially in North Kerala which has an agricultural background. There is a lack of study regarding this topic in this area. North Kerala differs from other areas in the country as hump nosed pit viper bites are more common here due to its proximity to western Ghats where it .Anti snake venom is ineffective to bites by hump nosed pit viper. Authors objectives  was to assess the clinical and epidemiological profile and outcome of poisonous snake bites.Methods: Retrospective observational study done among patients with snake bite with envenomation admitted in Academy of Medical education, Pariyaram, Kannur, Kerala from January 2018 to September 2018.Results: There were 90 cases of venomous snake bite during the study period. Of these males were predominant (70%). Majority were in the age group between 20 and 40. Majority of bites occurred in the months of June and July. Bite in the extremities were more common. Nine patients were brought 1 day after the bite. Snake identified most common was Russell’s viper followed by pit viper. Majority of the systemic envenomation was hemotoxic 80 patients (85%).Conclusions: The study stress the fact that snake bite is an important problem in North Kerala. The study also shows that delay in treatment is a major risk factor for morbidity. Hump nosed pit viper bites are more common in this area.

Photoprotection Comprising Oil Derived from Dromedary Camel Hump Fat

Aims: Camelus dromedarius (dromedary or one-humped camels) are known to endure harsh conditions including extreme temperatures and high solar ultraviolet (UV) radiation in desert wilderness areas. This remarkable survival in the harsh desert conditions is attributed to distinctive bodily features enabling them to cope with this toxic environment. The present study hypothesized that the oil rendered from camel hump fat, consisting of saturated fatty acids with omega 3, 6, 9 and Vitamin E, has contributed to shield/protect/prevent UVA radiation damage. Place and Duration of Study: This study was conducted in College of Veterinary Medicine, Baghdad University, Iraq, between June 2011 and July 2012. Methodology: White BALB/c mice aged about 3 - 4 months weighing 24 - 31 gm were divided into four groups. Mice were shaved and three groups received different treatments of daily exposure to UVA radiation and one group was untreated as a control. Results: Histopathological examinations of mice treated with camel oil prior to or following UVA radiation demonstrated that the camel oil acts as a protective agent, namely, protection of mice skin tissue from radiation-induced apoptosis. The mice treated with oil derived from cows and fat-tailed sheep demonstrated no improvement or worse results than untreated (control) mice. The results suggest that the camel oil protects the mice from UVA radiation injury and also acts as an injury-mitigator when applied following UVA exposure. Conclusions: The major components in the camel hump fat including saturated fatty acids and noticeable values of omega 3, 6, 9 and Vitamin E have contributed to shield/protect/prevent UVA radiation damage, and may also have unique anti-tumor properties with novel dual radiation-protection and mitigation/healing properties.

Nasal Hump Correction Using Modified Autospreader Graft: Report of Two Cases / 대한이비인후과학회지

It is common to find a nose with a hump, lower nasal tip and a radix among Koreans. A common procedure as an aesthetical improvement for such feature, involves rasping of the hump, while lifting the tip and the bridge at the same time. As for the hump, en bloc resection is a well-known, traditional surgical method, but it may cause an open roof deformity, which leads to a high possibility of infection if dorsal augmentation using silicone was performed through it as it connects the nasal cavity and dorsum. To overcome this complication, the hump on the bony portion and cartilaginous has been improved by a modified autospreader graft. Also, the graft can also be used for tip-plasty in dorsal augmentation using silicone, septal extension graft, strut and onlay graft. As a result of constant monitoring for a year, the reformation of the hump and infection was not found.

Hump-nosed viper bite: an important but under-recognized cause of systemic envenoming

Hump-nosed viper bites are common in the Indian subcontinent. In the past, hump-nosed vipers (Hypnale species) were considered moderately venomous snakes whose bites result mainly in local envenoming. However, a variety of severe local effects, hemostatic dysfunction, microangiopathic hemolysis, kidney injury and death have been reported following envenoming byHypnale species. We systematically reviewed the medical literature on the epidemiology, toxin profile, diagnosis, and clinical, laboratory and postmortem features of hump-nosed viper envenoming, and highlight the need for development of an effective antivenom.

Presumptive thrombotic thrombocytopenic purpura following a hump-nosed viper (Hypnale hypnale) bite: a case report

Hump-nosed viper bites are frequent in southern India and Sri Lanka. However, the published literature on this snakebite is limited and its venom composition is not well characterized. In this case, we report a patient with thrombotic thrombocytopenic purpura-like syndrome following envenoming which, to the best of our knowledge, has not been reported in the literature before. A 55-year-old woman from southern Sri Lanka presented to the local hospital 12 hours after a hump-nosed viper (Hypnale hypnale) bite. Five days later, she developed a syndrome that was characteristic of thrombotic thrombocytopenic purpura with fever, thrombocytopenia, microangiopathic hemolysis, renal impairment and neurological dysfunction in the form of confusion and coma. Her clinical syndrome and relevant laboratory parameters improved after she was treated with therapeutic plasma exchange. We compared our observations on this patient with the current literature and concluded that thrombotic thrombocytopenic purpura is a theoretically plausible yet unreported manifestation of hump-nosed viper bite up to this moment. This study also provides an important message for clinicians to look out for this complication in hump-nosed viper bites since timely treatment can be lifesaving.

Hump-nosed viper bite: an important but under-recognized cause of systemic envenoming

Hump-nosed viper bites are common in the Indian subcontinent. In the past, hump-nosed vipers (Hypnale species) were considered moderately venomous snakes whose bites result mainly in local envenoming. However, a variety of severe local effects, hemostatic dysfunction, microangiopathic hemolysis, kidney injury and death have been reported following envenoming byHypnale species. We systematically reviewed the medical literature on the epidemiology, toxin profile, diagnosis, and clinical, laboratory and postmortem features of hump-nosed viper envenoming, and highlight the need for development of an effective antivenom.

Presumptive thrombotic thrombocytopenic purpura following a hump-nosed viper (Hypnale hypnale) bite: a case report

Hump-nosed viper bites are frequent in southern India and Sri Lanka. However, the published literature on this snakebite is limited and its venom composition is not well characterized. In this case, we report a patient with thrombotic thrombocytopenic purpura-like syndrome following envenoming which, to the best of our knowledge, has not been reported in the literature before. A 55-year-old woman from southern Sri Lanka presented to the local hospital 12 hours after a hump-nosed viper (Hypnale hypnale) bite. Five days later, she developed a syndrome that was characteristic of thrombotic thrombocytopenic purpura with fever, thrombocytopenia, microangiopathic hemolysis, renal impairment and neurological dysfunction in the form of confusion and coma. Her clinical syndrome and relevant laboratory parameters improved after she was treated with therapeutic plasma exchange. We compared our observations on this patient with the current literature and concluded that thrombotic thrombocytopenic purpura is a theoretically plausible yet unreported manifestation of hump-nosed viper bite up to this moment. This study also provides an important message for clinicians to look out for this complication in hump-nosed viper bites since timely treatment can be lifesaving.

Correction of Hump Nose Considering the Characteristics of Korean Nose / 대한이비인후과학회지

The Korean hump nose often differs from Caucasian hump nose in that the size of the nasal hump is not prominent and the hump is frequently associated with a low nasal dorsum and radix with under-projected nasal tip. Therefore, typical reductive rhinoplasty techniques are not effective in managing the characteristic anatomy of the Korean hump nose. Because Korean hump nose patients have all kinds of nasal deformity including low dorsal profile, abnormal tip projection, tip rotation and deviation, surgeons should be skilled at various techniques of rhinoplasty. Removal of hump should be performed gradually considering the balance of nasal tip and nasal dorsum and radix. Small hump with low radix can be corrected by radix augmentation. If the hump is big, the hump should not be remained by too conservative removal of the hump. Most hump in Korean nose may be corrected well by using nasal tip and dorsal augmentation with the appropriate hump removal. The strengthening and augmentation of nasal structure using autologous cartilage may accomplish the balanced correction of hump nose aesthetically and functionally with tailored removal of hump in Korean patients.

Surgical significance of variations in anatomy in the biliary region.

Variations in the anatomy of the gallbladder, the bile ducts, and the arteries that supply them and the liver are important to the surgeon, because failure to recognize them can cause iatrogenic injury to the biliary tract. A surgeon should be always be careful while operating in this area. In addition these anomalies are associated with a range of other congenital anomalies, including biliary atresia and cardiovascular or other gastrointestinal malformations, biliary lithiasis, choledochal cyst, anomalous pancreaticobiliary junction etc, so a look out for other anomalies should be carried out simultaneously.

Risk Factors Associated with Bites due to Two Viperid Snakes: A Case Control Study.

Aims: This study was to assess victim’s environmental and behavioural risk factors that promote bites from two viperid snakes. Study Design: A case control study. Place and Duration of Study: Medical wards, General Hospital, Kurunegala, Sri Lanka, between June to December 2010. Methodology: Cases were recruited prospectively from consecutive admissions to the General Hospital, Kurunegala, Sri Lanka with proven viperid bites. Age and gender matched control group was selected from relatives and neighbourhood of the cases in a ratio of 1 case: 2 controls. Results: There were 56 cases and 112 controls with mean age 44 years and 45 years respectively. Of the 13 risk factors assessed, 7 risk factors showed a significant association with viperid bites. Those were (1) being in an ill lit place (OR, 95% CI= 6.6 (3.25-13.4), (2) being in outdoor places (OR, 95% CI= 148.8 (43.7-506), (3) working in a field (OR, 95% CI= 175 (31.4 – 976), (4) occupation as a field worker (OR, 95% CI= 5.3 (2.3-12 ), (5) low level of financial status (OR, 95% CI=9.9(2.75- 35.5), (6) lack of attached toilet (OR, 95% CI= 7.38 (2.15- 25.3), (7) presence of small rodents in the compounds (OR, 95% CI= 11 (4.88-24.9). Conclusion: Identifying easily remediable risk factors would help in preventing viperid snake bites.

Mal de pott en niños: revisión de un caso / Pott’s disease in children: report of a case

El mal de Pott, también llamado espondilitis tuberculosa, es la más frecuente de las afecciones esqueléticas de la tuberculosis, representando el 40 de las tuberculosis osteoarticulares. Se produce mediante siembra hematógena a los cuerpos vertebrales en la fase de bacteriemia durante la primoinfección tuberculosa. Tiene manifestaciones clínicas muy insidiosas, por lo cual el diagnóstico suele ser bastante tardío con deformidad cifótica de la columna y secuelas neurológicas importantes, siendo los síntomas principales dolor de espalda y trastornos de la marcha. Presentamos el caso de una niña de diez años con mal de Pott, cuyo diagnóstico se confirmó mediante biopsia por abordaje directo y estudio bacteriológico.

Pott’s disease, also called tuberculous spondylitis, is the most frequent of the skeletal conditions of tuberculosis, representing 40 of the osteoarticular tuberculosis. It is produced through hematogenic spread in the vertebral body in the bacteremia stage during the tuberculous primo-infection. It has really insidious clinical manifestations, therefore, the diagnosis is usually delayed with the emergence of cifotic deformity of the column and important neurological consequences, being backache and walk disturbance the principal symptoms. We present the case of a 10-year-old girl with Pott’s disease whose diagnosis was confirmed through biopsy by direct approach and bacteriological study.

Correction of Hump-nose Depending on Size of Hump

Nose is the most three dimensional structure located on the central portion of the face. Therefore, the nasal shape is one of the most important factors on deciding upon one's impression. Hump-nose is characterized by nasal hump, acute tip angle, drooping or/and under-projection of tip, and broad nasal dorsum. Because of these characteristics, recently more patients with hump-nose are inclined to correct their problematic nose. The purpose of this study was to classify hump-nose according to hump size and provide proper operating methods in each group. From August 2003 to August 2005, in 46 cases, we classified the hump nose into three groups, small(group A; n=30), medium(group B; n=6), and large(group C; n=10) in accordance with size and location of hump and in each group we effectively corrected the hump with our proper operating methods. In the large group, one case of tension nose temporarily appeared but soon improved and we obtained satisfactory results in the other cases.

The Effect of Patellofemoral Overstuffing in Total Knee Arthroplasty

PURPOSE: We aimed to evaluate effect on maximum knee flexion by patellofemoral overstuffing after total knee arth- roplasty MATERIALS AND METHODS: As a prospective inspection we have measured anterior hump height of distal femur in the preoperative true lateral radiographic view in those who had taken total knee arthroplasty with Genesis II which is external rotation laden prosthesis allowing to be inserted parallel to femoral anterior cortex. We compared the thickness of anterior hump height resected during operation and thickness of anterior flange of femoral prosthesis and then considered post operative thickness of patella to estimate the effect of patellofemoral overstuffing in 55 cases comparing maximum knee flexion. RESULTS: The average thickness of resected femoral anterior hump was 7.14+/-1.91mm. Average in hump overstuffing was 1.32+/-1.09mm and postoperative maximum flexion angle was average of 125.6+/-15.5 degree with average decrease of 1.8 degree. In 29 cases, Average of 1.35mm of overstuffing occurred in patella overstuffing and postoperative maximum flexion angle was average of 131.0+/-16.4 degree with average increase of 2.1 degree. Considering change of anterior femoral hump height and thickness of patella, preoperative and postoperative average maximum flexion angle was 128.9+/-14.9, 128.0+/-14.5 degree, repectively in patellofemoral overstuffing with average decrease of 0.9 degree. CONCLUSION: We concluded that the patellofemoral overstuffing does affect the decrease of the angle of maximum flexion in total knee arthroplasty and the effect of hump overstuffing is superior than patellar overstuffing effect.

Treatment of Buffalo Hump Using Liposuction

Buffalo hump is a manifestation of Cushing's syndrome. Herb medicine is popular in Korea, and it might cause Cushing's syndrome. Using power-assisted liposuction device, we treated a woman with buffalo hump deformity due to herb medication for 2 years. The histologic study of hump was normal fat cell. So, the hump can be removed easily using liposuction, and it may be an effective method to treat the facial and cervical deformity in Cushing's syndrome.

Reduction Rhinoplasty

Rhinoplasty is a complex operation that requires precise preoperative diagnosis to select the appropriate surgical technique. In reduction rhinoplasty, I generally use the external rhinoplasty approach. Most dorsal humps are comprised primarily of cartilage, and overreduction of the bony dorsum must be avoided. The decision concerning the extent of hump removal should be determined preoperatively. Following hump removal and to close the open roof, osteotomies are considered for repositioning and reshaping the nose. A medial osteotomy is defined as the separation of the nasal bones and the bony septum. This can be further subclassified as medial oblique and paramedian osteotomies. I prefer to use a fading medial osteotomy(medial oblique). The fading medial osteotomy avoids those deformities created by extending osteotomies into the thick frontal bone. A lateral osteotomy may be used to narrow a wide nasal base, or to close open roof deformity. "Low-high", "low-low" and double osteotomies have been described. After dorsal hump removal and osteotomies, I frequently use spreader grafts to reconstruct middle nasal vault.

Correction of the Nasal Profile in Mild Hump by Tip Plasty and Resection of Depressor Septi Nasi Muscle

Oriental hump nose is characterized by mild degree of the hump, broad dorsum, low nasal height and drooping tip. The conservative rasping of hump or humpectomy and osteotomy is too invasive to the patient with mild hump and may yield unnecessary complications for example under or over correction, nasal stenosis. For these reasons we have performed augmentation tip plasty by shield graft with columellar strut using autogenous conchal cartilage and resection of the depressor septi nasi muscle to 8 patients with mild hump. All patients have been very satisfied with the result and no serious complications were noted.

Retrospective Photogrammetric Analysis of Surgical Correction of Korean Hump Nose

A nose is an important organ in a human body and it is an anatomical structure which plays significant roles functionally and cosmetically in many respects of one's whole life. Therefore, the authors have thought that for improving the quality of the cosmetic surgery, it is worthy to analyze and consider the reasonabilities of each case of all cosmetic or reconstructive operations which may result in the modification of nasal structures. As the common criterion of the beauty is globalized, many plastic surgeons in Asia including Korea have developed the regionally adapted concepts of the rhinoplasty, whereas they have not been successful in introducing a new concept of correcting a hump nose other than the prevailing concept of the 'reduction'. Accordingly, for the purpose of reducing the unnecessary procedures of the surgical operations and the consequent unwanted results from the conventional treatment on a hump nose. The authors have made a retrospective analysis on photographic profile data of 27 cases which have been available for the past 7 years, in comparison with the prevailing ideal criteria, in order to confirm reasonabilities of operations on patients group corrected with the conventional formulars. The analysis showed us that the hump nose in each of 27 cases was less protruded than the ideal criteria data. We found out that, if the nasal framework is not deviated, the nasal hump is not the object to be removed, but the touchstone of the augmentation rhinoplasty, in terms of non- destructive cosmetic operations.

The Explanation of Postoperative Change of Vertebral Rotation and Rib Hump Using 3 Dimensional Finite Element Scoliosis Model / 대한척추외과학회지

STUDY DESIGN: An analytical study using a mathematical 3-D finite element model for thoracic scoliosis. OBJECTIVE: To find the important kinematics and post-operative changes of the spine and rib cage, in the corrective surgery for scoliosis, using the rod derotation method. SUMMARY OF LITERATURE REVIEW: A conventional corrective surgery for scoliosis was performed, based on empirical knowledge, and an increase in the secondary postoperative change in the rib hump, and a shoulder level imbalance, were reported. However, no analytical data exists for the kinematics and optimal correction method. MATERIALS AND METHODS: A mathematical finite element model of a normal spine, including the rib cage, sternum, both clavicles and pelvis, was developed. Using geometric mapping, with standing radiographs and CT images, a 3-D FEM of scoliosis was reconstructed, after translating and rotating the 3-D FEM of a normal spine, with the amounts analyzed from 12 built-in digitized coordinate axes for each vertebral image. With this model, three elements; distraction, translation and derotation, in operative kinematics, were investigated by analyzing the Cobb angle, apical vertebrae axial rotation (AVAR) and thoracic kyphosis. A simulation of a segmental pedicle screw fixation, with rod derotation for scoliosis, was performed. The changes in the Cobb angle, kyphotic angle, AVAR and rib hump were compared after 0 degrees, 15 degrees, 30 degrees, 45 degrees, 60 degrees and 90 degrees rod derotations. RESULTS: In kinematics, the vertebral rod derotation of a major curve, without rod deformation, is less influential in the correction of scoliosis, simply causing an increase in the rib hump. During the simulation, the co-action of distraction and translation, during rod insertion, has a major impact on the decrease in the Cobb angle and in the maintenance of the kyphotic angle. However, after a 30 degrees rod derotation, a decrease in the kyphosis, and increases in the rib hump and AVAR were observed. CONCLUSIONS: The distraction and translation factors were more important in operative kinematics than the rod derotation. With excessive rod derotation, the Cobb angle progressively decreased, but increases in the secondary change in the rib hump and rotation of the apical vertebrae were found.

Correction of the Nasal Hump considering the Height of the Nasal Root

Oriental hump nose is characterized by mild degree of the hump, broad dorsum, low nasal height and drooping tip. Therefore, conservative humpectomy followed by either tip-plasty or augmentation rhinoplasty yields more satisfactory results than classical Joseph's nasal hump reduction. However, the degree of the hump as well as the length of the nose can be affected by the height of the nasal root. That is, if the nasal root is too low, the hump nose may stand out and the nose will seem longer than the actual measurements. We think that it is important to consider the height of the nasal root in the course of the nasal hump reduction. During the last 2 year periods, we have classified twenty eight patients with hump nose into three groups, low(group A: 7 patients), moderate(group B: six patients) and high(group C: fifteen patients), based on the nasal root height. Each group went through different operative procedures according to their nasal root height and favorable results were obtained.