Popliteal artery pseudoaneurysm due to femur exostosis.

Vascular complications of femur exostoses are rare, with popliteal pseudoaneurysm being the most common. After establishing the diagnosis, surgical treatment is mandatory. A 35-year-old woman presented with a painful pulsatile swelling in the lower medial aspect of the left thigh. Investigations revealed a pseudoaneurysm arising from the left popliteal artery adjacent to femur exostoses. Skeletal survey revealed multiple exostoses involving the upper and lower limbs. Surgical excision of the pseudoaneurysm was followed by ePTFE patch repair of the defect and excision of the exostoses. The patient was discharged after 5 days and followed up for 6 months with excellent results.

Osmotic demyelination syndrome following slow correction of hyponatremia: Possible role of hypokalemia.

A 47-year-old male presented with hyponatremia that was corrected slowly as per the recommended guidelines. The patient improved initially but went on to develop a quadriparesis with a locked-in state due to a central as well as extrapontine myelinolysis and subsequently succumbed to an intercurrent infective illness. The patient had associated hypokalemia. Hyponatremia can result in central pontine myelinolysis even when the electrolyte disorder is treated slowly, and the concomitant hypokalemia seems to play a contributory role in the pathogenesis of the neurological disorder.

Fat embolism syndrome in long bone trauma following vehicular accidents: Experience from a tertiary care hospital in north India.

BACKGROUND: Fat embolism syndrome (FES) is a clinical problem arising mainly due to fractures particularly of long bones and pelvis. Not much literature is available about FES from the Indian subcontinent. MATERIALS AND METHODS: Thirty-five patients referred/admitted prospectively over a 3-year period for suspected FES to a north Indian tertiary care center and satisfying the clinical criteria proposed by Gurd and Wilson, and Schonfeld were included in the study. Clinical features, risk factors, complications, response to treatment and any sequelae were recorded. RESULTS: The patients (all male) presented with acute onset breathlessness, 36-120 hours following major bone trauma due to vehicular accidents. Associated features included features of cerebral dysfunction (n = 24, 69%), petechial rash (14%), tachycardia (94%) and fever (46%). Hypoxemia was demonstrable in 80% cases, thrombocytopenia in 91%, anemia in 94% and hypoalbuminemia in 59%. Bilateral alveolar infiltrates were seen on chest radiography in 28 patients and there was evidence of bilateral ground glass appearance in 5 patients on CT. Eleven patients required ventilatory assistance whereas others were treated with supportive management. Three patients expired due to associated sepsis and respiratory failure, whereas others recovered with a mean hospital stay of 9 days. No long term sequelae were observed. CONCLUSION: FES remains a clinical challenge and is a diagnosis of exclusion based only on clinical grounds because of the absence of any specific laboratory test. A high index of suspicion is required for diagnosis and initiating supportive management in patients with traumatic fractures, especially in those having undergone an invasive orthopedic procedure.

Knowledge, attitude, and practices about the seasonal influenza vaccination among healthcare workers in Srinagar, India.

BACKGROUND: Healthcare workers (HCWs) universally have a poor uptake of influenza vaccination. However, no data are available from India. OBJECTIVE: To explore knowledge, attitudes, and practices associated with influenza vaccination in HCWs in a temperate climate area in northern India. PATIENTS AND METHODS: A self-administered questionnaire was offered to all HCWs in three major hospitals of Srinagar and information sought on motivations, perceptions, preferences and practices regarding influenza vaccination. RESULTS: Of the 1750 questionnaires received, 1421 (81%) were returned. Only 62 (4·4%) HCWs had ever received influenza vaccination even as 1348 (95%) believed that influenza poses adverse potential consequences for themselves or their contacts; 1144 (81%) were aware of a vaccine against influenza and 830 (58%) of its local availability. Reasons cited by 1359 participants for not being vaccinated included ignorance about vaccine availability (435; 32%), skepticism about efficacy (248; 18%), busy schedule (166; 12%), fear of side effects (70; 4%), and a perception of not being-at-risk (82; 6%). Sixty-one percent (865) believed that vaccine programs are motivated by profit. Eighty-eight percent opined for mandatory vaccination for HCWs caring for the high-risk patients, as a part of 'employee health program'. Most of the participants intended to get vaccinated in the current year even as 684 (48%) held that vaccines could cause unknown illness and 444 (31%) believed their adverse effects to be underreported. CONCLUSION: Influenza vaccination coverage among HCWs is dismally low in Srinagar; poor knowledge of vaccine availability and misperceptions about vaccine effectiveness, fear of adverse effects and obliviousness to being-at-risk being important barriers. Multifaceted, adaptable measures need to be invoked urgently to increase the coverage.

An outbreak of influenza B in an isolated nomadic community in Jammu & Kashmir, India.

BACKGROUND & OBJECTIVES: Community outbreaks of disease amongst nomadic populations generally remain undocumented. Following a reported increase in acute respiratory tract infections (ARI) in May 2011 in a nomadic population of Sangerwini in Jammu & Kashmir, India, we examined the patients with ARI symptoms and their nasal swabs were tested for influenza virus. METHODS: Patients with ARI (n=526) were screened from May 14 to 23, 2011 and nasopharyngeal swabs collected from 84 with Influenza like illness (ILI) for bacterial cultures and influenza virus testing. Samples were tested for influenza A and influenza B by real time (RT)-PCR. RESULTS: Twelve (14.3%) of the 84 patients tested positive for influenza B, compared to only one (0.9%) of 108 patients with ILI in a parallel survey performed in Srinagar during the same period, suggesting a localized outbreak in the isolated nomadic community. All presented with respiratory symptoms of less than seven days. Familial clustering was seen in 40 per cent (25% of influenza B positives). Average daytime temperatures ranged from 15-16 ° C compared to 22 ° C in Srinagar. Four patients developed pneumonia whereas others ran a mild course with a total recovery with oseltamivir and symptomatic therapy. INTERPRETATION & CONCLUSION: Our report of confirmed influenza B in this underprivileged nomadic population argues for routine surveillance with efforts to improve vaccination and infection control practices.

Vitamin d toxicity in adults: a case series from an area with endemic hypovitaminosis d.

Vitamin D deficiency state is endemic to the Kashmir valley of the Indian subcontinent. Physicians often treat patients with high doses of vitamin D for various ailments and on occasion the prescribed doses far exceed the requirements of the patients. Ten cases of hypercalcemia due to vitamin D intoxication are presented with features of vomiting, polyuria, polydipsia, encephalopathy and renal dysfunction. All the patients had demonstrable hypercalcemia and vitamin D levels were high in nine of the 10 cases. The patients had received high doses of vitamin D and no other cause of hypercalcemia was identified. Treatment of hypercalcemia resulted in clinical recovery in nine cases. We conclude that hypervitaminosis D must be considered in the differential diagnosis of patients with hypercalcemia in endemically vitamin D deficient areas. A careful history and appropriate biochemical investigation will unravel the diagnosis in most of the cases.

Pandemic and seasonal influenza viruses among patients with acute respiratory illness in Kashmir (India).

BACKGROUND: With the emergence of pandemic influenza A (2009A/H1N1) virus in India, we sought to determine the prevalence and clinical presentations of seasonal and pandemic influenza viruses among acute respiratory illness (ARI) patients from Srinagar, a temperate climate area in northern India, during the peak winter season. METHODS: Combined throat and nasal swabs, obtained from 194 (108 male) presenting with ARI from January to March 2010 (Week 53-week 10), were tested by RT-PCR for influenza A and B, including 2009A/H1N1 viruses. HA1 gene of selected 2009A/H1N1-positive samples was sequenced, and phylogenetic analysis was carried out. RESULTS: Twenty-one (10·8%, age 15-80 years, median age 40 years) patients tested positive for influenza viruses: 13 (62%) for 2009A/H1N1 virus, 6 (28·5%) for seasonal influenza A (H3N2), and 2 (9·5%) for influenza B. Twelve of the 13 patients with 2009A/H1N1 presented with febrile ARI, and eight had associated comorbidities. All of the patients recovered. Phylogenetic analysis of HA gene (n = 8) revealed that all strains from Srinagar clustered in 2009A/H1N1 clade seven along with the other 2009A/H1N1 strains from India. Amino acid substitutions in the HA protein defining clade seven (P83S, S203T, and I321V) were found in almost all isolates from Srinagar. CONCLUSIONS: Both seasonal and 2009A/H1N1 viruses appear to be associated with ARI in Srinagar. The 2009A/H1N1 in Srinagar is genetically similar to globally circulating clade 7 strains, with unique signature sequences in the HA gene. Further investigations into ascertain the role of these mutations in possible alteration of the virulence and transmissibility of the virus are needed.

An elderly male with tubercular osteomyelitis of the chest wall.

Primary tuberculosis of the ribs is rare. A 70-year-old male presented with a 6-month history of a chest wall swelling that ruptured over few weeks to lead to a chronic discharging sinus. He had been administered multiple antibiotics, but the discharge continued. Clinical examination revealed anaemia, cervical lymphadenopathy and a 2-cm splenomegaly. Investigations revealed a normochromic and normocytic anaemia (Hb 7.0 g/dl), an ESR of 60 and a positive tuberculin sensitivity test of 25 mm. Surgical excision of the sinus along with the underlying revealed a caseous rib with histopathological features of a caseating granuloma. The patient was put on antitubercular therapy and is doing well on follow-up.