Kasturba Medical College Hospital

Records and 2,634 pairs of radiographs (anteroposterior and lateral) of 610 patients with Perthes disease were reviewed. The evolution of the disease was divided into seven stages (stages Ia, Ib, IIa, IIb, IIIa, IIIb, and IV) based on plain radiographic appearances. Intraobserver and interobserver reproducibility of this new classification system was assessed. The duration of each stage of the disease was noted. The stages at which epiphyseal extrusion and widening of the metaphysis occurred and the stages at which metaphyseal and acetabular changes appeared were identified. The shape and the size of the femoral head, the extent of trochanteric overgrowth, and the radius of the acetabulum were assessed in hips that had healed. The new classification system of the evolution of Perthes disease was reproducible and helped to identify when crucial events occur during the course of the disease. The median duration of each stage varied between 95 and 335 days. Epiphyseal extrusion and metaphyseal widening was modest in stages Ia, Ib, and IIa but increased dramatically after stage IIb. More than 20% extrusion occurred in 70% of the hips by stage IIIa. Metaphyseal changes were most frequently encountered in stage IIb, while acetabular changes were most prevalent in stage IIIa. At healing, only 24% of untreated patients had spherical femoral heads, while 52% had irregular femoral heads. The timing of epiphyseal extrusion, metaphyseal widening, and the appearance of adverse metaphyseal and acetabular changes suggest that femoral head deformation occurs by stage IIIa in untreated hips. Hence, if containment were to succeed, it should be achieved before this stage.

OBJECTIVES: (1) To determine the frequency of maternal near miss, maternal near miss incidence ratio (MNMR), maternal near miss to mortality ratio and mortality index. (2) To compare the nature of near miss events with that of maternal mortality. (3) To see the trend of near miss events. DESIGN: Audit. SETTING: Kasturba Hospital, Manipal University, Manipal, India. POPULATION: Near miss cases & maternal deaths. METHODS: Cases were defined based on WHO criteria 2009. MAIN OUTCOME MEASURES: Severe acute maternal morbidity and maternal deaths. RESULTS: There were 7390 deliveries and 131 "near miss" cases during the study period. The Maternal near miss incidence ratio was 17.8/1000 live births, maternal near miss to mortality ratio was 5.6 : 1, and mortality index was 14.9%. A total of 126 cases were referred, while 5 cases were booked at our hospital. Hemorrhage was the leading cause (44.2%), followed by hypertensive disorders (23.6%) and sepsis (16.3%). Maternal mortality ratio (MMR) was 313/100000 live births. CONCLUSION: Hemorrhage and hypertensive disorders are the leading causes of near miss events. New-onset viral infections have emerged as the leading cause of maternal mortality. As near miss analysis indicates the quality of health care, it is worth presenting in national indices.

Non-obstetric surgery during pregnancy posts additional concerns to anaesthesiologists. The chief goals are to preserve maternal safety, maintain the pregnant state and achieve the best possible foetal outcome. The choice of anaesthetic technique and the selection of appropriate anaesthetic drugs should be guided by indication for surgery, nature, and site of the surgical procedure. Anaesthesiologist must consider the effects of the disease process itself and inhibit uterine contractions and avoid preterm labour and delivery. Foetal safety requires avoidance of potentially dangerous drugs and assurance of continuation of adequate uteroplacental perfusion. Until date, no anaesthetic drug has been shown to be clearly dangerous to the human foetus. The decision on proceeding with surgery should be made by multidisciplinary team involving anaesthesiologists, obstetricians, surgeons and perinatologists. This review describes the general anaesthetic principles, concerns regarding anaesthetic drugs and outlines some specific conditions of non-obstetric surgeries.

We report a series of 18 patients with pain in the thumb or finger tips who were diagnosed as having glomus tumour. Fourteen patients were found to have histopathologically proven glomus tumours, one had a neuroma and three had haemangioma. The duration of symptoms before treatment averaged 1.9 years. Cold-sensitivity and Hildreth's tests have sensitivities of 100% and 77.4% respectively and specificity of 100%. Love's pin test had a sensitivity of 100%. Love's and Hildreth's tests showed 78% accuracy, whereas the cold-sensitivity test was 100% accurate. We used a double-tourniquet technique during dissection and excision of the tumour. None of our patients experienced recurrence of symptoms during the post-operative follow up.

The number of suicide attempts in developing countries has been increasing progressively, as in the West. It is important to note that much of the data on suicidal behaviour is based on information obtained from developed Western societies. All such data need to be evaluated within their specific cultural context as well as cross-culturally. The present study explored the various socio-demographic, clinical characteristics of suicide attempters in a general hospital unit in India. There were certain findings that contrasted markedly with those observed in the West. Male suicides tended to predominate here, as in many Indian studies. None of them were living alone, separated or deserted by their partner. Some suicide attempters continued to live with their extended family. There was virtually no alcohol consumption by female suicide attempters. The commonest agents used were organophosphates and other household poisons. Several cross-cultural variations in the suicidal act emerged compared to the West. The 'suicide potential' in the Indian culture is discussed.

Background: serovar Typhi (Typhi) genomic data to inform public health action. This analysis, which marks 22 years since the publication of the first Typhi genome, represents the largest Typhi genome sequence collection to date (n=13,000). Methods: This is a meta-analysis of global genotype and antimicrobial resistance (AMR) determinants extracted from previously sequenced genome data and analysed using consistent methods implemented in open analysis platforms GenoTyphi and Pathogenwatch. Results: Compared with previous global snapshots, the data highlight that genotype 4.3.1 (H58) has not spread beyond Asia and Eastern/Southern Africa; in other regions, distinct genotypes dominate and have independently evolved AMR. Data gaps remain in many parts of the world, and we show the potential of travel-associated sequences to provide informal 'sentinel' surveillance for such locations. The data indicate that ciprofloxacin non-susceptibility (>1 resistance determinant) is widespread across geographies and genotypes, with high-level ciprofloxacin resistance (≥3 determinants) reaching 20% prevalence in South Asia. Extensively drug-resistant (XDR) typhoid has become dominant in Pakistan (70% in 2020) but has not yet become established elsewhere. Ceftriaxone resistance has emerged in eight non-XDR genotypes, including a ciprofloxacin-resistant lineage (4.3.1.2.1) in India. Azithromycin resistance mutations were detected at low prevalence in South Asia, including in two common ciprofloxacin-resistant genotypes. Conclusions: The consortium's aim is to encourage continued data sharing and collaboration to monitor the emergence and global spread of AMR Typhi, and to inform decision-making around the introduction of typhoid conjugate vaccines (TCVs) and other prevention and control strategies. Funding: No specific funding was awarded for this meta-analysis. Coordinators were supported by fellowships from the European Union (ZAD received funding from the European Union's Horizon 2020 research and innovation programme under the Marie Sklodowska-Curie grant agreement No 845681), the Wellcome Trust (SB, Wellcome Trust Senior Fellowship), and the National Health and Medical Research Council (DJI is supported by an NHMRC Investigator Grant [GNT1195210]).

BACKGROUND: Drug related admissions have significantly increased over the past few decades. According to various studies on drug related hospital admissions, it was estimated that around 5-10% of hospital admissions were due to drug related problems (DRP), in which 50% of them are avoidable. OBJECTIVE: The objective of the study was to derive results from various studies conducted on drug related hospital admissions and have an overall view about the incidence, frequency, cost of treatment, major causative drugs, problems for drug related hospital admissions, and preventable drug related admissions and summarize the factors responsible for the occurrence of DRP. METHOD: Relevant literatures related to 'drug related hospital admissions' were obtained from PubMed database. Articles that were published from October 2007 to September 2012 were collected. All the studies being shown in the search results were considered for the study irrespective of the specialty department. RESULTS: A total of 366 articles were found based on the keyword 'drug related hospital admission', 'drug related problem admission', and 'adverse drug event admissions' search. Out of which 49 articles were identified to be showing relevance to the study. Non-English, abstract-only articles, and out-patient adverse drug reaction (ADR) studies were filtered from 49 articles. Finally 15 articles were taken up for the study. Systemic analysis was made on these articles and the results were summarized. CONCLUSION: Most of DRP studies were retrospective, multicenter studies conducted in general populations in Europe. The main objective of the studies was to estimate DRP frequency, incidence, risk factors and trends of DRP hospital admissions. Anti-neoplastic agents, CVS drugs and CNS drugs were related to most of the drug related problems. These studies concluded polypharmacy and older age were the major risk factors for developing drug related problems. It was found that the cost for the management of DRP was directly proportional to severity.

To identify the optimal timing for containment surgery for Perthes disease, the outcomes following femoral osteotomy of 97 children were analyzed. Univariate and multivariate analyses were employed to identify variables that influenced the shape and size of the femoral head at healing. The timing of surgery was an important variable that had a bearing on the outcome. The chances of retaining a spherical femoral head were much higher in children operated on either during the stage of avascular necrosis or in the early part of the fragmentation stage than in those operated later. The authors conclude that containment surgery aimed at preventing femoral head deformation in Perthes disease should be performed before the advanced stage of fragmentation. Further, any study on the outcome of containment treatment of Perthes disease must consider the timing of containment as a variable that influences the outcome while interpreting the results.

BACKGROUND: World Health Organization estimated that people with diabetes (DM) are at 2-3 times higher risk for tuberculosis (TB). Studies have shown that DM not only increases the risk of active TB, but also puts co-affected persons at increased risk of poor outcomes. OBJECTIVES: To determine the protective effect of metformin against TB in DM patients and also, to investigate the relationship between poor glycemic control and TB. METHODS: A case-control study was conducted over 8 months, where cases and controls were selected based on the inclusion and exclusion criteria of the study. The diabetics diagnosed with TB were selected as study group (SG=152) and without TB were as control group (CG=299). Exposure status of metformin in both groups were analyzed. RESULTS: The mean (SD) age of both CG and SG were 55.54±11.82 and 52.80±11.75, respectively. Majority of the subjects in the study were males. The mean hospital stay of SG and CG were 7 days and 6 days, respectively. Poor glycemic control (HbA1c>8) observed in SG (51.7%) vs CG (31.4%). HbA1c value <7 is associated protective factor for TB occurrence [OR=0.52 (95% CI 0.29-0.93)]. The protective effect of metformin against TB was 3.9-fold in diabetics (OR=0.256, 0.16-0.40). CONCLUSION: Poor glycemic control among diabetics is a risk factor for TB occurrence. The result shows metformin use is a protective agent against TB infection in diabetics. Hence, incorporation of metformin into standard clinical care would offer a therapeutic option for the prevention of TB.

BACKGROUND: The prevalence of malnutrition among children in developing countries is very high. As a step towards reducing the prevalence of malnutrition, there is a need to identify the important determinants of malnutrition in the specific population so that preventive and control measures can be implemented. The objective of the study is to determine the risk factors for malnutrition among preschool children in Rural Karnataka, South India. METHODS: A case-control study was carried out among preschool children, aged between three to six years, attending the Anganwadi centers and their mothers' in Udupi district of Karnataka, India. A total of 570 children (190 cases and 380 controls) were selected by multistage cluster sampling technique. A semi-structured risk factors questionnaire was used to identify the risk factors for malnutrition among children. RESULTS: The majority (45.8 and 45.5%) of the children in the study were in the age group of 3.0 to 4.0 years in case and control groups respectively. There was a slight preponderance of illiterate parents among cases in comparison to the controls. Largely, 87.4% of the children belonged to poor socio-economic status in the case groups compared to 82.4% in the control group. After adjusting for the confounders, underweight was significantly associated with socio-economic status of the parents (aOR: 2.05, 95% CI: 1.06, 3.96), birth weight < 2000 g (aOR: 25, 95% CI: 0.10, 0.59), recurrent diarrhoea (aOR: 2.74, 95% CI: 1.56, 4.83), recurrent cold and cough (aOR: 3.88, 95% CI: 1.96, 7.67), worm infestation (aOR: 2.0, 95% CI: 1.19, 3.38) and prelacteal feed given (aOR: 3.64, 95% CI: 2.27, 5.86). CONCLUSION: Parental education, childhood illness, short birth interval, open defecation, type of weaning and complimentary food given to children were some of the significant determinants of underweight that were found in the study. Information, Education and Communication (IEC) campaigns alleviating food habits and taboos and promoting birth spacing is the need of the hour for preventing the occurrence of undernutrition among preschool children.

OBJECTIVE: To compare the use of metformin with that of insulin for the treatment of gestational diabetes mellitus (GDM) and type 2 diabetes mellitus (T2DM) unresponsive to diet therapy. MATERIALS AND METHODS: In this prospective observational study, maternal glycemic control and perinatal outcome in diabetic pregnancies were compared between 2 obstetric units, one using insulin therapy and the other using metformin therapy. Baseline pretreatment glycemic profile was done and then repeated weekly throughout pregnancy. The outcome measures studied were glycemic control, maternal complications and perinatal outcome. RESULTS: Sixty women with gestational and type 2 diabetes were enrolled, 30 each for metformin and insulin. Both groups were comparable with respect to age, body mass index (BMI), parity and pretreatment plasma glucose levels. Glycemic control was better with metformin after 1 week of therapy and also throughout gestation (P = 0.03-0.007). There were no major complications or perinatal deaths in this study. Mean gestational age and birth weight (2.9 +/- 0.4 kg versus 3.1 +/- 0.4 kg, P = 0.30) were comparable. However, there was a significant increase in neonatal intensive care unit (NICU) admission and stay for babies born in the insulin group. The cost of treatment was tenfold higher in thethe insulin group. CONCLUSION: Metformin is clinically effective, cheap and a safe alternative to insulin therapy in pregnant diabetic women.

Radiographs of 155 Indian children were examined to identify the acetabular changes which occur in Perthes' disease. These changes included osteoporosis of the acetabular roof, irregularity of contour, premature fusion of the triradiate cartilage, hypertrophy of articular cartilage and changes in dimensions. These changes tended to be more marked in older children and when more than half of the femoral epiphysis was involved. Comparison with 25 cases of Perthes' disease from Liverpool showed the same picture. Several of the acetabular changes noted during the active stages were also seen in a series of 24 adult hips after Perthes' disease. Radio-isotope scans of the hips of 27 children with Perthes' disease showed a consistently increased uptake in the acetabulum on the affected side, indicative of a local increase in vascularity and metabolic activity. It was possible to postulate a working model for the pathogenesis of all the acetabular changes. A number of statistical correlations suggest that most of the changes have a bearing on the final outcome.

OBJECTIVE: The objective of this study was to evaluate the applicability of the discrimination parameters Mahalanobis distance, spectral residuals, and limit tests, developed by this group to differentiate normal from malignant colon tissues. BACKGROUND DATA: Colon cancers are diagnosed using fiberoptic endoscopic localization and a subsequent histopathological examination of biopsied tissue, which is highly dependent on the skill and experience of the investigator. There exists a risk of missing significant lesions, especially with carcinoma in situ lesions. Raman spectroscopy, which is sensitive to biochemical variations in the samples and amenable to multivariate statistical tools, can lead to rapid and objective detection of colon cancer. METHODS: A total of 102 spectra from 11 normal and 11 malignant ex vivo colon tissues were recorded by conventional near infrared (NIR) Raman spectroscopy (excitation wavelength of 785 nm). Spectral data were analyzed by principal components analysis (PCA) and other discriminating parameters, namely Mahalanobis distance, spectral residuals, and a multiparametric limit test approach. RESULTS: Mean malignant spectra exhibit relatively stronger bands, suggesting the presence of additional biomolecules such as protein (stronger amide III and I), lipids (1,100, 1,300 cm(1)), and DNA (1,340, 1,470 cm(1)) versus those seen in normal tissue. Mean normal spectra indicate the presence of disordered structures (hump at 1,247 cm(1)). Scores of factor 1 gave good discrimination, and this is further fine-tuned by employing Mahalanobis distance and spectral residuals as discriminating parameters. A limit test approach provided unambiguous objective discrimination. CONCLUSION: This study further supports the efficacy of Raman spectroscopy, in combination with a limit test, for discrimination of normal and malignant colon tissues. The multiparametric limit test approach is user-friendly, and a clinician or minimally trained individual could directly compare the unknown spectra against the available standard sets to make the decision instantly, objectively, and unambiguously.

BACKGROUND: Oxidative stress is involved in the pathophysiology of diabetes mellitus. METHODS: In the present study, 68 patients with type 2 diabetes mellitus and 31 clinically healthy individuals were evaluated. The patients were divided into two groups. Group 1 included 29 patients without diabetic complications and group 2 consisted of 39 patients with diabetic complications. Erythrocyte glutathione, superoxide dismutase, and thiobarbituric acid-reactive substance levels as well as plasma antioxidant vitamins C and E, and serum total glutathione-S-transferase, ceruloplasmin, and protein thiols were estimated by using spectro-photometer. RESULTS: A significant decrease of erythrocyte glutathione was observed in group 1 when compared with the controls. Thiols decreased in group 2. An increase in glutathione-S-transferase, ceruloplasmin, superoxide dismutase, and vitamins C and E levels was noted in patients with diabetes mellitus. Thiobarbituric acid-reactive substance levels decreased in group 1 but increased in group 2 when compared with the controls. CONCLUSION: In the present study, tendency of most of the antioxidants to rise in diabetes could probably be due to an adaptive response to the pro-oxidant milieu of the diabetic state. Hence, we suggest that supplementation with dietary antioxidants especially antioxidant vitamins accompanied by change in lifestyle might help to reduce damage brought about by free radical toxicity in diabetes mellitus.

Genital tuberculosis is an important cause of infertility in developing countries and hysterosalpingography (HSG) is the initial procedure performed for the evaluation. Reviewing 37 cases of female genital tuberculosis, we encountered various appearances on HSG. Of 579 HSGs performed over a period of 4 years, 492 (85%) were performed as part of infertility work up. Genital tuberculosis was found in 6.3% of all the patients who underwent HSGs and 7.5% of all patients investigated for infertility. The various features of proven tuberculosis cases are illustrated in this pictorial review. We briefly discuss the pathology and these appearances along with radiopathological correlation.

PURPOSE: To establish the common clinical and radiologic features of discoid lateral meniscus in a setting where magnetic resonance imaging was not routinely possible because of cost and access. Arthroscopy was used to confirm the diagnosis. Type of Study: Retrospective study of group of patients with discoid lateral meniscus as the diagnosis. METHODS: Of 1,643 arthroscopies of the knee performed between January 1993 and January 1999, 87 patients (95 knees) with discoid lateral meniscus were studied with regard to their clinical presentation and radiologic features. Arthroscopy was used for confirmation of diagnosis, classification of types of discoid lateral meniscus and pattern of tears, and for treatment. RESULTS: Of all the knee arthroscopies, 5.8% involved patients with discoid lateral meniscus. The average age of patients at presentation (24.7 years), contributed to a 67.3% incidence of associated tears. Tears were more frequently associated with patients older than 15 years, which was statistically significant (P =.0005). The most common clinical features were pain and joint-line tenderness. In this series, the incidence of radiologic findings was high (53.9%). CONCLUSIONS: The high incidence of tears is attributable to the late presentation. The incidence of radiologic findings in this series is high.

OBJECTIVES: We aim to illustrate the multimodal imaging spectrum of hepatic involvement in tuberculosis (TB). Whilst disseminated tuberculosis on imaging typically manifests as multiple small nodular lesions scattered in the liver parenchyma, isolated hepatic tuberculosis remains a rare and intriguing entity. METHODS: Indubitably, imaging is the mainstay for detection of tubercular hepatic lesions which display a broad spectrum of imaging manifestations on different modalities. While sonography and computed tomography (CT) findings have been described in some detail, there is a paucity of literature on magnetic resonance imaging (MRI) features. Due to a significant overlap with other commoner and similar appearing hepatic lesions, hepatic tuberculosis is often either misdiagnosed or labelled as indeterminate lesions. This article is a compendium of cases highlighting the spectrum of imaging patterns that can be encountered in patients with isolated primary hepatic tuberculosis as well as disseminated (secondary) disease. Rare patterns of primary disease such as tubercular cholangitis, hypervascular liver masses, and those with vascular complications are also illustrated and discussed. CONCLUSIONS: Imaging plays a valuable role in the detection of tubercular hepatic lesions. Also, imaging can be helpful in their characterisation and for assessing associated complications. TEACHING POINTS: • Hepatic TB has myriad imaging manifestations and is often confounded with neoplastic lesions. • Imaging patterns include miliary TB, macronodular TB, serohepatic TB and tubercular cholangitis. • Concurrent splenic, nodal or pulmonary involvements are helpful pointers towards the diagnosis. • Miliary calcifications along the bile ducts are characteristic of tubercular cholangitis. • Histological/microbiological confirmation is often necessary to confirm the diagnosis.

BACKGROUND: Diabetic foot infections (DFIs) are major public health problems and knowledge of microbes that cause infections are helpful to determine proper antibiotic therapy. AIMS: The aim was to investigate the antimicrobial susceptibility pattern of microbes in DFIs. SUBJECTS AND METHODS: A cross-sectional study was conducted for a period of 6 months at the Department of General Surgery, KMC hospital, Manipal University, Manipal, India. During this period, 108 patients having DFIs admitted in the general surgery wards were tracked from the hospital data management system. These patients' pus samples were examined as Gram-stained smear and cultured aerobically on blood agar and MacConkey agar plates. Antimicrobial susceptibility test was performed by disc diffusion techniques according to Clinical and Laboratory Standards Institute guidelines. RESULTS: Of the 108 specimens of the diabetic foot lesions, culture showed polymicrobial growth in 44.4% (48/108). Prevalence of Gram-negative organisms (56%, 84/150) was found to be more than Gram-positive organisms (44%, 66/150). However, Staphylococcus aureus was the most frequent pathogen (28%, 42/150). All Gram-positive aerobes were sensitive to doxycycline. All Gram-negative isolates, including extended spectrum beta lactamase producing strains of Proteus mirabilis and Klebsiella oxytoca except Acinetobacter were highly sensitive to amikacin, cefoperazone/sulbactam, and meropenem. Acinetobacter was completely resistant to all the common antibiotics tested. CONCLUSION: Prevalence showed Gram-negative bacteria was slightly more than Gram-positive bacteria in diabetic foot ulcers. This study recommends doxycycline should be empirical treatment of choice for Gram-positive isolates and amikacin, cefoperazone/sulbactam, and meropenem should be considered for most of the Gram-negatives aerobes.

The authors have used the nasal endoscope for the precise identification of pathological abnormalities of the nasal septum in relation to the lateral nasal wall including the osteo-metal complex and in its ultraconservative management. The aim of the study was to compare the efficacies of endoscope-aided septoplasty (EAS) over traditional septoplasty (TS) in treating the pathological septum and turbinates, performed in 30 cases each. The subjective assessment was carried out by visual analogue scores and objective assessment by nasal endoscopy. This study demonstrates the superiority and limitations of the endoscopic approach in managing a deviated nasal septum and the turbinates. The endoscope-aided technique was found to be more effective in relieving the contact areas and nasal obstruction (p = < or = 0.05). The authors advocate a combined approach--an endoscopic approach for inaccessible posterior deviation and the conservative traditional technique for accessible anterior deviation of the nasal septum.

BACKGROUND: Dyslipidemia, diabetes and obesity are all potent cardiovascular risk factors that tend to cluster in women with polycystic ovary syndrome (PCOS).Metabolic disorders in patients with PCOS cannot be explained solely by the presence of obesity.OBJECTIVE: To study the correlation between insulin resistance and serum lipid profile in Indian women with PCOS.SETTING: Gynecology clinic of a tertiary care hospital.MATERIALS AND METHODS: In this prospective study done from April 2004 to December 2004, 65 women with PCOS had their body mass index (BMI) and waist hip ratio calculated.Fasting glucose, insulin and lipid profiles were also estimated in each case.Insulin resistance was defined by fasting glucose-to-insulin ratio ≤ 4.5.The association of obesity markers and insulin resistance with lipid parameters was then studied.Statistical analysis using student 't' and Mann Whitney U tests was done as indicated.RESULTS: Insulin resistance was seen in 50 of the 65 PCOS women.There was no correlation seen between markers of obesity such as BMI and waist/hip ratio with various lipid parameters.But in PCOS women with insulin resistance, the lipid profile was significantly different [high triglycerides, total cholesterol and lower high-density lipoprotein (HDL)] compared to insulin-sensitive women.The difference between the two groups for total cholesterol (P = 0.002), triglycerides (P = <0.001) and HDL (P = <0.001) was statistically significant but that for low-density lipoprotein (LDL) (P = 0.07) was not statistically significant.CONCLUSION: Insulin resistance is associated with dyslipidemia in women with PCOS, independent of obesity.