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Congenital anomalies in children are not infrequent and the birth defects of cardiovascular and digestive systems are the most common. Congenital spinal defects have prevalence and incidence of about 2.74% and 1-3 per 1000 live births respectively. The range of spinal defects may vary from a tuft of hair with an underlying spina bida to various types of spinal dysraphism. This observational study was undertaken to study the spectrum of neural tube defects among children attending the pediatric outpatient of a tertiary care hospital. Twenty-one children were included in the study. Fourteen infants were less than 1-year old and seven were between 2-7 years of age. Fourteen children had meningomyelocele (MMC). The commonest site was in the lumbosacral region. Seven patients of MMC had associated hydrocephalus, and seven had talipes deformity. Other accompanying defects included pes cavus, pectus carinatum, polydactyly and congenital heart defects, seen in one case each. Soft uctuant swelling over the spine, kyphoscoliosis, accid paralysis of lower extremities, and incontinence of urine were the cardinal symptoms. CT Scan and MRI in these children helped us to assess the quantum of decit involving the vertebra and spinal cord. This paper highlights the range of spinal abnormality seen in children with the similar clinical presentation, and therefore the need for neuroimaging in all cases with suspected neural tube defect (NTD) for proper management and prognostication.

A critical part of planning and managing road infrastructures in mountainous regions is thepragmatic assessment of the prevailing and credible landslides hazard. Such assessments assumegreater significance for the Himalayan region, where seismically induced landslides present agreater threat than commonly recognized, and require a robust comprehension of two hazards:earthquake and the landslides induced by the former. However, the traditional practice oflandslide hazard assessment often neglects seismic factor due to paucity of pertinent data, whichmay further be ascribed to the rarity of an extreme event. In this context, an endeavor has beenmade in this study to evaluate the seismically induced landslide hazard for a scenario earthquakeof 10% exceedance probability in 50 years for an important road corridor in the lower IndianHimalayas using Fuzzy algorithms. Probabilistic Seismic Hazard Assessment (PSHA) has beencarried out for the study area to calculate the Peak Ground Acceleration (PGA) of the scenarioearthquake, which is then used as a landslide triggering factor. PGA is integrated with eightdifferent landslide controlling factors viz. lithology, slope angle, aspect, elevation profile,distance form fault, distance from drainage, distance from road, and land-use-land-cover patternsin a Geographical Information System (GIS). 232 numbers of landslides are mapped for thestudy area using high resolution Google earth imagery platform. The Fuzzy Cosine Amplitudemethod is used to define the degree of similarity (strength of correlation) between the observedlandslides (dependent variable) and the landslide causative factors (independent variable(s)).Expectedly, the probability of landslide occurrence correlates (degree of similarity) to the PGAin a linear pattern (goodness of fit = 0.9954). The result of the study is discussed in terms of aseismically induced Landslide Hazard Zonation (LHZ) map for the study, which is generatedusing three Fuzzy operators (AND, OR and GAMMA). The prepared LHZ map demarcates morethan 40% of the study area as the zones of high to very high landslide hazard under the scenarioearthquake, with a prediction accuracy of 80%. The study shows that probabilistically generatedPGA can be included as seismic parameter for a more comprehensive assessment of the landslidehazard in seismically active regions.Keywords: Fuzzy Cosine Amplitude, Probabilistic Seismic Hazard Assessment (PSHA), PeakGround Acceleration (PGA), Landslide Hazard Zonation (LHZ), the Himalayas

The evaluation of the vulnerability of society aroused to landslide-related tragedy is an enlargedtopic. Few studies talk about this issue and limited research has been carried out on therelationship between landslides and their potential impact on buildings and infrastructure.Uttarakhand Province in India is a highly landslide-prone area in the Himalayan region. Thepresent study focused on assessing the building vulnerability for the landslide susceptibility zonein the Champawat district of Uttarakhand state. The building footprint areas are identified byusing an image segmentation algorithm in artificial intelligence. Moreover, the landslide-pronezone was identified based on the historical and recent information collected from variousauthenticated sources and the field investigations made on the recent landslides whereas, morethan ten landslide causative parameters/landslide conditioning factors (LCF) have been used togenerate a susceptibility map. The frequency ratio method has been applied to carry out thesusceptibility zone in the entire study area. Most buildings are found in dangerous areas that arehighly correlated by using published and in-situ datasets.Keywords: Landslide Susceptibility Zone, Artificial Intelligence, Vulnerability, Building Footprints

Snakebites, including poisonous ones, are common occurrence in tropical countries and are endemic during summer months.However, snake bite remains a neglected public health problem in resource limited countries like India. The snake venom may cause local cytotoxicity, hemotoxicity, neurotoxicity and myotoxicity. Cardiac involvement is not usually encountered and has not been extensively discussed. It is however reflected in ECG changes, echocardiographic changes, raised cardiac enzymes and new unexplained cardiac events.We recently managed case of cobra envenomation who presented with features of cytotoxicity leading to extensive cellulitis, coagulopathy and neuroparalysis. He was managed with polyvalent anti-snake venom (ASV) administration and supportive treatment. He recovered from neuroparalysis and was successfully weaned off the ventilator. Three days later, he developed ischemic cerebral infarction and left ventricular failure (LVF). Electrocardiography showed fresh ST-T changes in anterior and inferior leads. Echocardiography revealed features of severe, left ventricular (LV) dysfunction, markedly reduced ejection fraction (LVEF 20-25%) and mid-basal to apical akinesia. The patients LVF was managed with diuretic and resolved over next 48 h. Repeat echo after three days showed marked improvement in LVEF to 50% and only mild hypokinesia of akinetic segments.The transient LVF and echo findings were suggestive of the diagnosis of stress (Takotsubo) cardiomyopathy. We report this case for its unusual complications and review the relevant literature. &nbsp

INTRODUCTION Currently, ischemic heart diseases and stroke are the leading causes of morbidity and mortality worldwide and more than 80% of deaths occurring in the low and the middle-income countries. There are a number of risk factors associated with ischemic stroke; the important ones being hypertension, diabetes mellitus, tobacco use and hyperlipidemia. All the risk factors also contribute towards atherogenesis. Change in the carotid artery intima–media thickness (CIMT) is an indicator of generalized atherosclerosis. This study was conducted to find out correlation between risk factors and CIMT in the stroke patients of western Maharashtra. AIMS AND OBJECTIVES This observational study was conducted in department of medicine from February 2013 to June 2014 to study the risk factors and their association with CIMT if any, in patients of stroke. Fifty stroke patients admitted in the medical ICU were studied. RESULTS Thirty-five patients out of 50 studied had ischemic stroke. Tobacco use (82%) and hypertension (80%) were the commonest risk factors for stroke followed by, dyslipidemia, obesity, metabolic syndrome and diabetes mellitus. Twenty-four (68.5%) out of 35 ischemic stroke patients had CIMT value more than 1.00 mm. Out of 35 ischemic stroke patients 15 had carotid stenosis; four severe (>70%), five moderate (50% - 70%) and six patients had mild (

Creutzfeldt-Jakob Disease (CJD) is a rare invariably fatal neurodegenerative disease believed to be caused by an abnormal isoform of cellular infectious glycoprotein called prion protein. Though it is arare disease; yet it is the most common among prion diseases. Clinical presentation consists of rapidly progressive loss of memory, cognitive & visual disturbance, lack of coordination, myoclonus, cerebellar, pyramidal and extra pyramidal signs, akineticmutism & with progression of disease deterioration in higher mental functions become more pronounced. Periodic sharp triphasic wave complexes on EEG, high signal abnormalities in caudate nucleus and putamen on diffusion weighted (DW) or FLAIR MRI of Brain and positive 14-3-3 protein in CSF substantiate the diagnosis of CJD but definitive diagnosis is established by brain biopsy or autopsy materials. We report a case of 58-year old female patient who was admitted with complaints of rapidly progressive dementia, cognitive disturbance, blurring of vision and myoclonic jerks. Initial MRI brain and CSF findings were normal. Differential diagnoses that can present with rapidly progressive dementia and thereby mimic sporadic Creutzfeldt-Jakob disease were considered after review of literature. In EEG triphasic wave complexes were seen, repeat DWMRI after two weeks showed bilateral hyper-intensities in basal ganglia involving caudate nucleus and putamen, suggesting a diagnosis of probable CJD on the basis of center for disease control and prevention (CDC) criteria. The case is reported because of its rarity and also to emphasise that patients with rapidly progressive dementia, associated visual and cognitive disturbances and myoclonus should be investigated with DW MRI, EEG&CSF for diagnosis of CJD.

Background:Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide. Despite advanced diagnostic modalities and treatment options, CAP is the fourth leading cause of death in developing countries.Several severity scores have been proposed to guide initial decision making on hospitalization and to predict the outcome. Pneumonia Severity Index (PSI) and CURB 65 are the two most widely used scoring systems to prognosticate pneumonia. Aim: To compare the efficacy of PSI and CURB 65 scoring systems inprognosticating the ICU admission and outcome in cases of CAP. Methodology: This wasan observational study conducted at a tertiary care hospital in westernMaharashtra.A hundred patients of CAP fulfilling the inclusion criteria were enrolled in the study, classified as per CURB 65 and PSI system and their outcome compared. Result: The study subjects comprised of 100 patients (64 men and 36 women) of CAP. Twenty-four patients needed ICU admission.In both PSI and CURB-65 risk scoring systems, the need for intensive care unit (ICU) admission and mortality rates increased progressively with increasing scores.PSI class ≥IV and CURB 65 ≥III had 77.52% and 40.24% sensitivity and 88.46% and 69.48% specificity respectively in predicting ICU admissions. The PSI class ≥IV had more sensitivity and specificity in predicting ICU admission than CURB-65.CURB 65 class III and IV had sensitivity86.59% and 89.64% and specificity 89.64% and 97.54% respectivelyin predicting mortality, while PSI class IV and Vhadsensitivity68.92% and 72.58% and specificity 24.74% and 54.86% respectively. CURB 65 had more sensitivity and specificity than PSI in predicting mortality. Conclusion: The PSI is better in predicting the need for ICU admission and CURB 65 is a better predictor of mortality in cases of community-acquired pneumonia.

Introduction:Spontaneous Bacterial Peritonitis (SBP) is recognized as a severe complication in patients of ascites. In recent years, it has also been diagnosed in patients without liver disease. SBP is commonly reported in patients of ascites due to cirrhosis of liver. If untreated, SBP could be a fatal complication in patients of ascites. Objective:To study the ascitic fluid biochemical parameters and causative micro-organisms in patients suffering from SBP. Materials and Methods:A prospective study was performed on 100 patients of ascites out of which 68 were males and 32 were females. After admission all patients were interviewed and detailed history and complete physical examination was performed. Results:In this study 86.7% patients had increased serum bilirubin levels, 73.4% patients had decreased serum albumin, 46.7% and 40% patients had increased blood levels of urea and creatinine respectively. 60% patients had ascitic fluid pH 250 polymorphonuclear cells/µL and 80% patients had >500 polymorphonuclear cells/ µL in ascitic fluid. 46.7% cases of SBP were culture positive and 53.3% were culture negative.Gram staining of ascitic fluid was positive in one case. Conclusion:Hypoalbuminemia, hyperbilirubinemia, low ascitic fluid pH, low ascitic fluid proteins, increased blood urea and creatinine levels are risk factors related with development of SBP in patients of ascites.The commonest micro-organism identified on culture were E-coli.

Hanging is the suspension of a person by a noose or ligature around the neck and has been a common method of capital punishmentsince medieval times. Hanging is also a common method of suicide/homicide worldwide as also in India. We report a case ofattempted suicidal hanging admitted in our intensive care unit. The patient, a 32-year old male, presented with poor clinical status,in gasping condition, hypoxemic and required immediate intubation, resuscitation, assisted ventilation and intensive care treatment.He received standard supportive intensive care and made a full clinical recovery without any neurological deficit. The purpose of thecase report is to emphasize that the cases of near-hanging need to be aggressively resuscitated and managed irrespective of dismalinitial presentation.

Background: Health problems of veterans have not been studied extensively. Obesity though not a major problem while in service, could be a major factor leading to morbidity and mortality due to lifestyle diseases seen among overweight/obese people.Methods: Status of overweight and hypertension was studied among ex-servicemen population of a military station in the age group of primarily 50-70 years.Results: More than 35% veterans were found to be overweight/obese. Underweight was a more serious problem than overweight among those above 70 years of age. Prevalence of hypertension was also high (25%). There was weak association of overweight with hypertension among ex-servicemen because the problem seems to appear late in life. This association was stronger upto 60 years of age after which it starts decreasing.Conclusions: The problems of overweight and obesity and hypertension constitute considerable health burden among the veterans. However, a significant causal association could not be established between overweight and hypertension.

Introduction: Chest pain is amongst the commonest causes of visits to the emergency department. A rapid assessment with a prompt evaluation with an electrocardiogram clinches the diagnosis in most cases. However, with ever increasing strain on our limited resources, patient reported symptoms are central to initial assessment and must decide the course of action. Although considered ominous signs requiring further, often emergent, assessment, data on correlation of symptoms of angina with ST segment elevation is limited in contemporary literature. Methodology: 230 patients with biomarker proven ST segment elevation myocardial infarction (STEMI) were studied and assessed for frequency of the four, patient reported, cardinal symptoms of angina, namely retrosternal chest discomfort, diaphoresis, palpitations and radiation. We assessed the relative presence or absence of these supposedly cardinal symptoms of angina and set out to classify the most important symptoms of angina. Results: Our study shows that presence of three or more above symptoms is associated with a much higher possibility of an actual STEMI as opposed to only one symptom. Furthermore, a measurable increase in the probability of MI exists, when the number of patient reported symptoms increases from none to all four, as mentioned above. Though the study also reaffirmed the association between hypertension and Type 2 Diabetes Mellitus with acute coronary syndromes, our study was neither powered, nor designed to study this association. Conclusions: Patient reported symptoms have a direct and additive correlation with STEMI. A quick but detailed history in the emergency department is of paramount importance to identify high risk patients.

A 42-year-old female was admitted to tertiary care teaching hospital with history of headache, vertigo, difficulty in swallowing both liquids and solids, vomiting, gait ataxia, drooping of left eyelid, inability to feel hot and cold on right side of body and diplopia of forty-fivedays’ duration. Clinical examination and neuroimaging were suggestive a posterior circulation stroke, with lateral medullary syndrome.The patient had selective thermoanaesthesia on the right side, including the face, which is an atypical finding, given the clinical setting.

Uncertainty is the inherent to the medical profession. Medical profession incorporates science and the scientific method with the art of being a physician. Every decision a clinician makes has some degree of uncertainty in it. There are several factors which result in medical uncertainty during clinical practice, and this could arise from physicians as well as patient factors, from test and treatment characteristics and practice environment. The inability to come at a conclusion, despite a thorough and reasonable evaluation generates anxiety amongst patients and physicians and the relationship between them may become strained and unproductive. Personal tolerance to ambiguity and uncertainty also plays a significant role in medical students when it comes to career choice. Medical Uncertainty may be technical, personal or conceptual. In the era of information overload and ‘evidence based medicine’ where guidelines, protocols and algorithms are available for every symptom complex and disease, one would expect medical uncertainty to be less if not totally eliminated but that is actually not the case. In fact, the protocols also threaten to depersonalize the relationship between the doctor and the patient. This article reviews the underlying mechanisms, causes and effects of medical uncertainty and also some methods to reduce uncertainty in today’s clinical practice.

Anaemia is an important clinical problem in patients with HIV infection and those with AIDS. The causes of anaemia in HIV infection are multifactorial. HIV per se causes decrease in production of RBCs and other bone marrow elements, as it has direct effect on bone marrow stromal cells and cause cytokine secretion. The elevated level of cytokines and Tumour necrosis factor further inhibit haematopoiesis in HIV. There is also evidence of increased risk of anaemia in association with zidovudine use, CD4 cell counts of < 200 cells/μl. The patients not on ART had higher prevalence of anemia than those who were receiving ART, regardless of whether the regimen was AZT containing or not. The study highlights that advanced disease, low CD+ count and non-exposure to ART are adverse risk factors for development of anemia among HIV patients.

Introduction: Stroke is the third commonest cause of death in India and there is a higher incidence of stroke in young in India than in the developed countries. With an increasing aging population, the stroke burden in India can be expected to reach epidemic proportions. Ischemic stroke accounts for 70-85% of all strokes. The present study was conducted in a tertiary level large neurological centre between 2007-2009 to study the risk factors associated with ischemic stroke and its correlation with angiographic profile. Material & Methods: In this study group of 161 patients, patients were between 15-70 years of age and all cases included were those who presented with first ever ischemic stroke. Patients who had documented cardiovascular causes like RHD, Atrial fibrillation & mechanical heart valves were excluded. Other category who were not included were those with hypercoagulable states like pregnancy, postpartum state and malignancies. Patients were assessed for conventional risk factors for stroke and also procoagulant factors. All patients underwent a DSA of neck and intracranial vessels. The DSA profile was then correlated with their risk factors. Results: Angiographic abnormalities were found in 36% of patients, most of the abnormalities were in extracranial vasculature. Intracranial vascular lesions were seen in 14% of patients which is much higher than western literature where intracranial disease was in 4-6% of cases. Patients were divided in two groups those who had risk factors and angiographic abnormalities vs those who had angiographic abnormalities and no risk factors. Conclusion: There was no significant statistical difference between the two groups who had risk factors and angiographic abnormalities vs those who did not have risk factors and angiographic abnormalities disease, thus risk factors do not predict the likelihood og angiographic abnormality. Other significant conclusion was that stroke in young (17-45yrs) had more procoagulant abnormalities and those in the middle aged and elderly had more of conventional risk factors.

Acute Kidney Injury (AKI), earlier termed Acute Renal Failure, is a very common entity affecting patients suffering from a wide variety of illnesses. It refers to a clinical entity characterized by a rapid decrease in renal excretory function with increase in levels of urea and creatinine and decreased urine output. In the initial stages of aki these patients can be easily managed. However, AKI in the setting of multiple co-morbidities is very difficult to manage and is a potentially fatal complication. This study was conducted to analyse the incidence, types, etiological factors, management protocol and mortality secondary to AKI in a in tertiary care hospital. 172 patients admitted in the hospital were included in the study. Patients were selected if their serum creatinine level on the day of admission was more than 1.5 times of the baseline serum creatinine or the urine output was less than 0.5 ml/kg/h for 6 h or the GFR was less than 25 % from the baseline. Patients were classified as pre-renal, renal or post-renal AKI based on history, clinical findings and investigation results. Out of 172 patients with AKI, 35 patients had chronic kidney disease. Infection accounted for 48.8% of all cases followed by volume loss (17.4%) and drugs (12%). Other important causes were altered renal hemodynamics (6.3%), and obstructive uropathy (4%). Pre-renal cause accounted for 84 cases, Renal cause for 79 cases and Post-renal cause for 7 cases. Out of 172 patients, 83 belonged to the Risk category, 57 developed Kidney Injury and 32 developed kidney failure. A total of 52 (30.5%) patients required renal replacement therapy. Out of these 35 underwent hemodialysis, 12 underwent peritoneal dialysis and 5 required CVVHD.

This is a case report of a 29 years old primigravida who at 32 weeks of gestation presented with severe pain abdomen and backache. She had a massive concealed placental abruption that led intrauterine fetal death. Due to the progressively deteriorating maternal condition a cesarean section was performed under general anesthesia to deliver the dead fetus. After five days the patient developed acute respiratory failure and needed mechanical ventilation. The common causes of respiratory failure associated with pregnancy are discussed.