A study on the clinical, epidemiological profile and the outcome of the snake bite victims in kashmir valley.

Background: India is estimated to have the highest snakebite mortality in the world. In India, around 250,000 incidents of snake bite are reported annually with 50,000 deaths. There are about 236 species of snakes in India, most of which are nonpoisonous. Most snakes found in Kashmir valley are nonvenomous of colubridae family (ptyas mucosus or grass snake). Materials and Methods: This Hospital-based retrospective and prospective study was conducted at Sher-i-kashmir Institute Of Medical Sciences Srinagar, a multispeciality teaching hospital having clinics for various medical and surgical specialities. All snake bite patients admitted in department of Emergency Medicine, other specialities, and critical care medicine were taken in this study over a period of 3 years. Results: Among a total of 108 cases of snake bite, majority were males (57.40%) and mostly 20 to 50 years of age (68.51%).Majority of victims were from rural areas (93.5%) and most of the bites occurred during day time (87.96%) mainly on the lower limbs (63.88%). Highest number of cases occurred from May to October (98.14%). Most of the victims were farmers. Bleeding was present in 13.88% patients and coagulopathy ( International normalized ratio (INR)>1.2) in 63.88% of patients. Neuroparalytic features were present in 8.33% patients. Mortality in our study was 2.8%. Conclusion: Snake bite in our valley is an occupational hazard affecting working class engaged in farming in fields, fruit orchards, and forests in rural areas. There is seasonal variation with most envenomations occurring in peak months of agricultural activities. Non recommended first aid measures like tourniquet and incision are commonly encountered. Regular public health programmes regarding prevention, prehospital management (first aid), and immediate transfer to hospital should be emphasized.

Combination of vitamin C, thiamine and hydrocortisone added to standard treatment in the management of sepsis: results from an open label randomised controlled clinical trial and a review of the literature.

Background: Combination of vitamin C, hydrocortisone and thiamine have recently been used in sepsis but data of efficacy are conflicting and no data are available from developing countries. We sought to study the effect of addition of this combination to standard care in patients with sepsis/septic shock in a north Indian setting.Methods: In a prospective, open label, randomised fashion, 100 patients with sepsis/septic shock were recruited to receive either standard therapy alone (control group, n = 50) or a combination of vitamin C, thiamine and hydrocortisone (treatment group, n = 50) in addition. The patients were followed for various clinical and laboratory parameters, in-hospital and 30-day mortality, duration of vasopressor use, lactate clearance, duration of hospital stay, and change in serum lactate and the SOFA score over the first 4 days.Results: The 2 groups were matched for basic characteristics. The in-hospital mortality (28% in controls and 24% in treatment group, p = .82) and 30-day mortality (42% in controls and 40% in treatment group, p = 1.00) was not significantly different in the 2 groups. However, there was a significant difference in duration of vasopressor use (96.13 ± 40.50 h in control group v/s 75.72 ± 30.29 h in treatment group, p value = .010) and lactate clearance (control group: 41.81% v/s treatment group: 56.83%, p value =.031) between 2 groups.Conclusions: Addition of vitamin C, hydrocortisone, and thiamine into standard care of sepsis does not improve in-hospital or 30 day mortality. However lower vasopressor use and faster lactate clearance is observed with treatment.

Intrathoracic gossypiboma causing intractable cough.

A 45-year old woman presented with a 5-month history of coughing, eight months after surgery for post-tubercular fibrosis with bronchiectasis. Upon computerized tomography (CT) scanning, a sponge-like structure was seen in the pneumonectomy cavity near the stump of the right main bronchus. Bronchoscopic examination revealed a whitish mass blocking the right main bronchial stump which, upon attempted retrieval, yielded long threads of cotton fibres from a retained surgical gauze. The gossypiboma was removed surgically and the patient became symptom-free. Although rare after thoracic surgery, gossypibomas need to be considered in symptoms following surgery.

Nontraumatic massive right-sided Bochdalek hernia in an adult: an unusual presentation.

Diaphragmatic hernias in adults usually pose a diagnostic challenge; the presentations are varied and range from acute abdominal pain with features of gut obstruction, pleuritic chest pain, breathlessness, to a pregnant woman with pain abdomen. The usual cause in adults is posttraumatic. Because of varied presentations, the diagnosis is often delayed. We present a case of a young woman who presented with sudden-onset breathlessness with similar episodes in the past and no history of trauma, who proved to be having a right-sided diaphragmatic hernia. This case is reported not only because of rarity of nontraumatic right-sided Bochdalek hernias in adults, but also because of peculiar presentation and history.

A "Near-Miss Lethal Accident Case" in MR Suit of a Tertiary Care Hospital.

A "near miss" is an unpleasant event that did not result in injury, illness, or damage but had the potential to do so, but for a fortunate break in the chain of events. We present a near-miss case which occurred in the MR suite of a tertiary care hospital. Although the MR is considered a very safe procedure, if MR safety guidelines are not adhered to, adverse and catastrophic events to the extent of patient deaths are known to have occurred. It is hoped that this incident will prompt hospitals to document and follow MR safety protocols for patient and staff safety. Although MRI is an extremely safe procedure rarely MR adverse incidents have resulted in serious physical injury or even death. The incident is an eye opener regarding potential adverse events lurking in the relatively safe MR environment and provides an opportunity to rectify the inadequacies in MR safety.

Lamotrigine-induced toxic epidermal necrolysis in a young epileptic.

A 20-year-old young female presented with extensive skin rashes with bullae and extensive epidermal necrolysis about 20 days after the addition of lamotrigine (LTG) to her anticonvulsant medication. The patient was managed by stopping LTG and supportive treatment. The seizures were controlled with increase in the doses of carbamazepine. The report emphasises exercising of caution once LTG is added to a regimen containing valproic acid.

Kaposi Sarcoma in a Non HIV Patient.

We report a case of a 45 year old non HIV infected female, who presented with multiple painful, livid reddish brown plaques, papules and nodules on both lower limbs and left index finger. The cutaneous nodular lesions on biopsy showed characteristic features of Kaposi's sarcoma. This case is reported due to paucity of Kapsi's sarcoma in non HIV Persons. It is typically a disease of older men from European and Mediterranean region. Here we present a case report of classic Kaposi's Sarcoma in a young Indian female.