A study to validate thoracic trauma severity score in chest trauma patients

Background: Aim of this study was to validate thoracic trauma severity score (TTSS) in assessing the requirement of mechanical ventilation, mortality, and predicting prognosis in chest injury patients.Methods: This study was conducted in department of general surgery, Dr. S. N. Medical College, Jodhpur, Rajasthan, from December 2018 to September 2019. This was a single centred, prospective, observational study, conducted in 110 patients, aged >18 years, of isolated chest injury, excluding polytrauma patients. Data was summarized in the form of proportions, histograms and tables to show relationships of parameters with results. Data was presented as mean±SD and proportions as appropriate. Chi square test, z test or t tests were used wherever necessary for association analysis between categorical variables. Diagnostic test characteristics for mortality and complications was calculated from the ROC curves. A two sided of p values of less than 0.05 was considered statistically significant.Results: Most common mode of chest injury was blunt trauma and most common age group affected was 42-54 years. Maximum mortality was seen in TTSS between 16-20, shows higher the TTSS more the mortality. Ventilator requirement was more in high TTSS. Patients with higher TTSS had longer hospital stay as compared to patients with lower TTSS.Conclusions: On application of TTSS on admission, TTSS had direct correlation with need for oxygenation, ventilator need, duration of hospital stay, mortality or outcome in chest trauma patients. Thus we recommend TTSS as a good useful score for evaluation of prognosis, outcome and mortality in chest trauma patients.

Pancreatoblastoma with multiple peritoneal metastases: a rare entity with atypical presentation and review of literature.

Pancreatoblastoma is a rare primary pancreatic neoplasm that predominantly effects young children and characterized by unique clinical features. Its biological behavior is aggressive with frequent local invasion and metastases. Only hundred cases have been reported in medical literature and its radiological features have been infrequently studied. We report the sonographic, contrast enhanced computed tomography findings of pancreatoblastoma in a 3 year old boy.

Vitamin B12 and folic acid deficiency presenting as acute febrile illness: a case report.

Megaloblastic anemia is not uncommon in India, but data is insufficient regarding its presentation as pyrexia. We report the case of a patient who presented with pyrexia and anaemia, which after exclusion of infective, inflammatory or endocrine causes was attributed to megaloblastic anaemia secondary to vitamin B12 and folic acid deficiency. The patient’s fever responded to treatment of vitamin B12 and folic acid deficiency.

Indian common krait envenomation presenting as fulminant myocarditis and coma: a case report.

Fulminant myocarditis is an unusual manifestation of cardiotoxicity with severe elapid snake envenoming and is meagrely reported with snake bite due to Indian common krait. We report a 12-year-old boy who was admitted in complete locked-in state and hemodynamic instability after severe neurotoxic snake envenoming by Bungarus caeruleus (Indian common krait). His hospital course was complicated with recurrent episodes of sustained ventricular tachycardia requiring defibrillation; and cardiogenic shock requiring inotropes, vasopressors and intraaortic balloon counterpulsation. Severe heart failure features secondary to fulminant toxic myocarditis persisted even after full neurological recovery requiring prolonged standard medical heart failure therapy. Patient subsequently achieved full clinical recovery and regained normal left ventricular systolic function. We also reviewed the literature on cardiac manifestations, possible mechanisms and treatment of patients with cardiotoxicity due to elapid snake bites. The importance of anticipating severe cardiovascular complications is highlighted to help formulate appropriate therapeutic strategy.

Sphingobacterium multivorum causing fatal meningoencephalitis: a rare case report.

We report a case of fatal meningitis caused by bacteria, Sphingobacterium multivorum, probably first time being reported from India. S. mulivorum has been isolated from various clinical specimens but it is only rarely been associated with serious infections. Sphingobacterium species are generally resistant to aminoglycosides and polymyxin B. Susceptibility to β-lactam antibiotics is variable, requiring testing for individual drug. This 36 year male had two weeks history of high-grade fever with altered sensorium and occasional seizures. Patient admitted with septicemia and subsequently developed meningitis and succumbed to his illness after being discharged against medical advice. His CSF culture yielded S. multivorum subsequently confirmed by mini API, bioMérieux Inc. Marcy-l’Etoile France. Due to its rare association with common clinical conditions, it requires a high degree of suspicion and expertise to prove its presence in clinical specimens. Since this bacterium is inherently resistant to many classes of antibiotics, a vigilant and efficient microbiological work up is needed to establish its diagnosis and prompt treatment.

Endothelial dysfunction in patients with metabolic syndrome: a prospective study in a rural institute in India.

Background: The objective was to evaluate endothelial dysfunction in patients with metabolic syndrome. Methods: This prospective, cross-sectional, hospital based observational study included 45 patients with metabolic syndrome and 20 age and sex matched controls who attended hypertension clinic, diabetes clinic, general medicine OPD and patients admitted in wards department of medicine, UPRIMS&R, Saifai, Etawah, UP, India. All patients who fulfilled inclusion criteria were subjected to the color Doppler of the brachial artery in the department of radio-diagnosis of the same institute. Results: Of the 45 patients with metabolic syndrome included in the study, 22 patients (48.9%) were males and 23 patients (51.1%) were females. Ten males (45.5%) had a waist circumference of >90 cm whereas 20 females (87%) had waist circumference of >80 cm. 9 males (40.9%) had abnormal waist hip ratio whereas 22 females (95.7%) had abnormal waist hip ratio. 43 patients (95.6%) had a SBP >130 mm of Hg whereas 39 patients (86.7%) had a DBP >85 mm of Hg. 24 patients (53.3%) had impaired fasting blood sugar i.e. >100 mg/dl ,25 patients (55.6%) had a TGL level >150 mg/dl, and 9 males (40.0%) had HDL < 40 mg/dl whereas 18 females (78.3%) had HDL value < 50 mg/dl respectively. The mean brachial artery baseline diameter were 3.50 ± 0.39 mm in males and 3.25  0.29 mm in females respectively, FMD percentage was 14.91  3.56 in females and 14.53  4.02 in males, and GTN mediated dilatation were 27.67  9.83% in females and 27.62  6.85% in males respectively. Conclusion: Estimation of Endothelial Dysfunction in patients at risk of developing full blown Metabolic Syndrome may predict the cardiovascular morbidity and mortality in these individuals even before fulfilling the 3/5 criteria of NCEP/ATP III Guidelines for the diagnosis of metabolic syndrome.

Tropical endomyocardial fibrosis: an overview.

Tropical endomyocardial fibrosis is the commonest form of endemic restrictive cardiomyopathy that affects mainly children and adolescents, and is geographically restricted to some poor areas in the tropical and subtropical regions of the world such as Africa, Latin America and Asia including southern districts of India especially in the coastal belt of Kerala state. Sub-endocardial fibrosis affecting the apices and the inflow tracts of the right or left ventricle, or both; and varying degree of atrioventricular valve regurgitation defines the disease. Chronic systemic venous hypertension and severe pulmonary hypertension are characteristic features of right ventricular and Left ventricular endomyocardial fibrosis respectively. Due to lack of resources for research in the disease endemic areas, the exact epidemiology, etiology and pathogenesis remain unknown, and the natural history is incompletely understood. Various infections and toxic factors were postulated regarding its etiology. During the last few years, incidence of the disease has decreased considerably because of the significant improvement in the living standards of the people with the corresponding decline in the childhood malnutrition, infections, worm infestations and associated eosinophilia. It is a condition with high morbidity and mortality, for which no effective therapy is available. However, surgical management improves the natural history of this disease to some extent. We have conducted a systematic review of the most intriguing aspects of epidemiology, natural history, clinical picture and management of endomyocardial fibrosis, proposing new ways to increase research into this challenging and neglected cardiovascular disease. We relied primarily on articles in the MEDLINE database with either ‘‘endomyocardial fibrosis’’ or ‘‘endomyocardial sclerosis’’ in the title.

Echocardiographic assessment of the impact of cardiovascular risk factors on left ventricular systolic function in patients with acute myocardial infarction.

Background: Objectives of current study were to determine the magnitude of left ventricular systolic dysfunction in patients with acute myocardial infarction in the rural sub-population of Uttar Pradesh in India and to evaluate the impact of cardiovascular risk factors on the risk of impairment of left ventricular systolic function. Methods: One hundred and fifty seven consecutive patients with first acute myocardial infarction were enrolled into the study. Most patients were male (73.2%) and the mean age of presentation was 52.7 years. Two dimensional echocardiography was utilized to assess conventional parameters such as Left Ventricular End-Diastolic Diameter (LVEDD), Left Ventricular End-Systolic Diameter (LVESD), LV End-Diastolic Volume (LVEDV), LV End-Systolic Volume (LVESV) and Left Ventricular Ejection Fraction (LVEF). The LV volumes (end-systolic and end-diastolic) and LVEF were calculated from the conventional apical two-and four-chamber images using the biplane Simpson’s technique. LV systolic function was considered depressed when LVEF was less than 45%. The chi-square test was used in the statistical analysis to compare proportions and a logistic regression model was used to assess the independent effect of the each variable. Results: The study projects a high proportion (42.7% of the patient population) of left ventricular systolic dysfunction in patients with Acute Myocardial Infarction (AMI). No association was found between gender or age and LV systolic dysfunction. The proportion of patients with diabetes mellitus was higher in the sub-group of patients with impaired LV systolic function (45.2% vs. 30.2%, P = 0.01); the proportion of patients with history of current or past smoking was also higher in the sub-group of patients with impaired LV systolic function (48.9% vs. 34.2%, P = 0.03). On the other hand, hypertension and dyslipidemia were not associated with impaired LVEF. After adjustment of other variables, diabetes and smoking were associated with a significantly higher risk of LV systolic dysfunction (diabetes: OR = 3.73; 95% CI = 1.25-11.16; smoking: OR = 3.8; 95% CI = 1.37-11.05). Conclusion: Since the proportion of patients with LV systolic dysfunction in patients with AMI remains relatively high, LV systolic function variables such as LVEF and LVESV should be echocardiographically evaluated in all patients with AMI. Since the post-infarction LV systolic function remains the single most important determinant of survival, treatment of AMI patients should be aimed at limitation of infarct size and prevention of ventricular dilation. Moreover, cardiovascular risk factors such as diabetes mellitus and smoking have a significant impact on the likelihood of impairment of LV systolic function in patients with AMI and hence could influence long-term prognosis.

Pattern of macrovascular disease phenotypes amongst newly diagnosed type 2 diabetic patients in a rural institute in Uttar Pradesh, India.

Background: The objective of current study was to determine the proportion of Macrovascular Disease (MVD) phenotypes amongst newly diagnosed type 2 diabetic patients in our institute by dividing the cases into sub-groups according to the MVD sites involved (NMVD - no macrovascular disease; NSCS - non-significant carotid stenosis; CBVD - cerebrovascular disease; CAD - coronary artery disease; PAD - peripheral artery disease; PVD - polyvascular disease) and studying the anthropometric, clinical and laboratory parameters in each group. Methods: The study included a cohort of 136 newly diagnosed patients with T2 DM. Demographic, clinical and laboratory parameters were included in analyses. Standardized procedures were used to assess the risk factors of associated metabolic syndrome (MetS). Results: The proportion of patients with MVD was 27.94% amongst the participants in the study. The majority of patients with MVD were in the CAD group (15.44%). Age, male sex and smoking history were independent risk factors in the CAD and PAD groups (P <0.01). A low HDL-C value was an independent risk factor in the CAD and PVD group P = 0.03). Very high frequencies of MetS were observed in the PAD and PVD groups (90% and 91.7% respectively). Prevalence of PVD was three times more common in males as compared to that in females. All patients with PAD had associated CAD also. Conclusion: This study projects a high proportion of MVD amongst newly diagnosed Type 2 diabetics in rural sub-population in Uttar Pradesh. High rates of mortality and morbidity in these patients due to macroangiopathy warrant early screening of MVD to ensure timely preventive and therapeutic measures.

Neurocysticercosis with initial clinical presentation of acute cysticercal meningitis coexisting with anterior chamber intraocular cysticercosis: a case report from a rural institute in India.

Acute cysticercal meningitis coexisting with intraocular cysticercosis is an extremely infrequent clinical presentation of neurocysticercosis. We report a 26 year old male, who presented with signs and symptoms of acute eosinophilic cysticercal meningitis with intraocular cysticercosis in the anterior chamber of left eye. Diagnosis was confirmed with demonstration of cerebrospinal fluid (CSF) eosinophilia, cysticercus specific IgG antibodies by CSF ELISA, sterile bacterial, mycobacterial and fungal CSF cultures, cystic lesions containing characteristic scolices consistent with neurocysticercosis on neuroimaging and histopathological demonstration of cysticercus cellulosae larva viscoexpressed from the eye. The importance of having high index of clinical suspicion highlighted along with need of examining cerebrospinal fluid with Wright-Giemsa stain so as not to miss cerebrospinal fluid eosinophilia and diagnosis of this extremely under-reported clinical entity, when there is concurrent presence of brain and other extracerebral lesions consistent with cysticercosis.

Prevalence of Psychiatric Morbidity in Visually Impaired Children.

This study was done to measure psychiatric morbidity and associated sociodemographic variables among visually impaired children. 92 students of age range 6-20 years from four schools for the blind, in Ranchi, were screened with verbal Hindi translation of General Health Questionnaire-60. Diagnostic Interview Schedule – Parent version was applied to establish psychiatric diagnosis on primary caretakers of those who scored above cutoff. Fourteen scored above cutoff and psychiatric diagnoses of 8 children were established. The prevalence of psychiatric morbidity among visually impaired children was found to be 8.69%. No socio-demographic variable was associated with the occurrence of psychiatric illness.

The Spectrum of Renal Osteodystrophy: A Clinical, Biochemical, Radiological and Histopathological Study

The chief mineral source of Jammu province is bauxite, an aluminium ore, so a possibility of water being heavily polluted with aluminium is prevalent. Hence, in an effort to relate this regional geographical aspect with aluminium bone disease (ABD) in chronic renal failure (CRF), 50 cases of CRF were prospectively evaluated. Patients were subjected to a thorough history and clinical examination. Biochemical parameters along with raiological skeletal survey and iliac crest bone biopsies were undertaken. Sixty-eight per cent of CRF patients were also consuming aluminium containing phosphate binders (ACPB) at that time. The study revealed an occurrence of ABD in 10% of CRF patients. It was found predominantly superimposed upon osteomalacia (8%) and mixed osteodystrophy (2%). Superimposed ABD on osteomalacia was found more frequently in pre-dialysis (10.8%) than after haemodialysis group (7.69%). Moreover, the incidence of ABD superimposed on osteomalacia and mixed osteodystrophy was higher in the ACPB group (14.7%) than the post-haemodialysis group (7.69%). Correlating, the pre-dialysis, post-haemodialysis and ACPB ingestion status of CRF patients on one hand and histologically proven ABD on the other, it was deduced that the majority of cases of CRF having ABD was seen in ACPB ingestion group (14.7%) followed by pre-dialysis (10.8%) and post-haemodialysis (7.69%) groups. Thus it was concluded that in the present work, ACPB ingestion was the major source of aluminium deposition in bones of patients with CRF rather than the water used in dialysis or possible pollution of drinking water with aluminium in our province.

A Clinical Study of Aluminium Phosphide Poisoning

The present prospective study 01'56 cases of Aluminium Phosphide (ALP) poisoning in Govt. Medical Collage Hospital Jammu, found out the prevalence of Deliberate self-poisoning self (DSP and accidental ingestion in young population in age group of 16-30 years. Male-female ratio was 1.03: 1.00; having marital discord and family quarrels as prominent predisposing factors. The majority of patients had gastrointestinal (GIT) symptoms (73.2%), cardiac arrthymias (62.5%) and shock (53.3%). The commonest clectrocardiographic (ECG) abnormalities were tachycardia (96%), atrial fibrillation (58%) and venticular-ectopic (VE) beats (59%). The management was supportive in the form of stomach wash, intraravenous (I/V) fluids, dopamine, hydrocortisone, sodabicarbonate and assisted ventilation in intensive care unit (lCU) setting and mortality rate was 75%. The fatal dose was 300 to 600 mg and fatal period as 2 to 16 hours.

Aluminium Phosphide Poisoning: A Challenge for the Physician

Acute Aluminium Phosphide ( ALP ) Poisoning by insalational or ingestional exposure is seen world wide. Except in Morocco, Denmark and India, nowhere in the world, it is ingested for deliberate self-poisoning ( DSP ), The rural belts of North states of India are worst affected with high and variable mortality rates in the young population with male dominance. The poison affects all systems; the shock, carding arrhythmias wityh varied electrocardiograph (ECG ) changes and gastrointestinal (GIT ) features being the most prominent. The role of magnesium sulphate (Mg So4) in reducing the cardiac arrhythmias and mortality is well documented and the problem needs multi-faceted approach in the form ofpreventive measures, strengthening ofmedical-aid services at gross root levels, stringent restricitions on supply of ALP in open market, updating the management techniques and overall a search for an antidote.