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Objectives: Factors responsible for causing complications in venomous snakebites are unknown. The present study was planned to identify such factors. Material and Methods: This was a prospective and observational study. All patients presenting to the emergency department between April 2016 and August 2017 with venomous snakebites and meeting inclusion/exclusion criteria were enrolled. Patients were divided into two groups based on the presence/absence of complications. Risk factors associated with complications were analyzed. Results: Out of 236 patients screened, 156 were eligible. Mean age was 39.5 ± 15.6; majority (n = 122, 78.2%) were in the age group of 20–59 years; 119 (76.3%) were males. Eighty-eight patients (56.4%) developed complications, of which, cellulitis/compartment syndrome (n = 54, 34.6%) was most common, followed by acute kidney injury (n = 18, 11.5%), coagulopathy/disseminated intravascular coagulation (n = 17, 10.9%), neuroparalysis needing ventilator (n = 12, 7.7%), shock (n = 8, 5.1%), acute respiratory distress syndrome (three patients, 1.9%), and sepsis (one patient, 0.6%). The mortality rate was 1.92%. On univariate analysis, low hemoglobin, elevated neutrophil count, lower lymphocyte count, serum creatinine, initial/total dose of anti-snake venom, and prolonged hospital stay had a statistically significant association with complications. On multivariate analysis, elevated neutrophil count (OR 1.084; 95% CI 0.997, 1.179) and prolonged hospital stay (OR 1.975; 95% CI 1.393, 2.800) were associated with complications. Bite-to-needle time was associated with mortality. Conclusion: The nature of complications depends on composition of venom, and thus varies with geographical region. The Association of neutrophil and lymphocyte counts points to an inflammatory hypothesis. The Association of bite-to-needle time with mortality highlights the early use of antivenom. Awareness of risk factors may guide in predicting complications.

BackgroundHypertension in children is often under recognized, especially in developing countries. Data from rural areas of developing countries is particularly lacking.ObjectivesTo study prevalence of hypertension and its determinants in apparently health school children from predominantly rural populations of India.MethodsApparently healthy schoolchildren ( n = 14,957) aged 5–15 years (mean (standard deviation) age 10.8 (2.8) years; 55.5% boys) at four predominantly rural sites in separate states of India were studied. Systolic and diastolic blood pressures were recorded by trained staff in addition to age, gender, height, weight, type of school and season. Waist circumference was also recorded in 12,068 children. Geographic location and type of school (government, government-aided or private) were used to determine socio-economic status.ResultsSystolic and/or diastolic hypertension was present in 3443 (23%) children. Systolic hypertension was present in 13.6%, diastolic hypertension in 15.3% and both in 5.9%. Isolated systolic hypertension was present in 7.7% while isolated diastolic hypertension was present in 9.4%. On univariate analysis, age, gender, geographical location, socio-economic status, season and anthropometric parameters (z-scores of height, weight and waist circumference, waist/height ratio and body mass index) were all significantly related to risk of hypertension ( p ConclusionThere is a high prevalence of hypertension in apparently healthy schoolchildren even in predominantly rural areas of India. Screening and management programs targeted to high risk groups identified may prove cost-effective.

Objectives Rheumatic heart disease (RHD) continues to be major public health burden in developing world. Echocardiographic screening in school children has shown that subclinical RHD cases are several times more than clinical cases. Recent reports have used World Heart Federation (WHF) criteria. Objective of present study was to determine RHD prevalence using WHF criteria in Indian children. Methods Children (5–15years) from randomly selected schools across four sites were included. After focused clinical evaluation, echocardiography was performed using WHF criteria in all children. Images/loops of abnormal cases were analyzed independently by an additional experienced cardiologist. Children with murmur and confirmatory echocardiography were categorized ‘clinical RHD'; those with abnormal echocardiography alone were labeled ‘subclinical RHD'. Results Among 16,294 children included, mean age was 10.8 ± 2.9years; 55.1% were males; 11,405 (70%) were from rural areas and 3978 (24.4%) were from government schools. We detected RHD by echocardiography in 125 children [prevalence: 7.7/1000 (95% CI 6.3, 9.0)]. Borderline RHD was present in 93 children (5.7/1000, 95% CI 4.6, 6.9), definite RHD in 32 (2/1000, 95% CI 1.2, 2.6), and clinical RHD in six [0.36/1000, 95% CI: 0.1–0.7]. On univariate analysis, older age, female gender, and higher waist circumference were associated while on multivariate analysis, older age (OR 1.18, 95% CI: 1.09, 1.26) and female gender (OR 1.61, 95% CI: 1.13, 2.3) were associated with RHD. Conclusion RHD prevalence varies in different parts of India. Echocardiographic prevalence is several times higher than clinical and underscores importance of echocardiographic screening in community.

Used primarily as a fumigant or as a substrate in chemical processes, methyl bromide is a highly toxic gas. The gas is usually absorbed by inhalation and effects on the lungs, gastrointestinal tract, skin, and brain are seen. Numerous instances of acute and chronic neurologic injury have been reported: acute poisoning results in seizures, myoclonus, ataxia or cerebral oedema beginning as early as 30 min after exposure while subacute or chronic intoxication presents with diverse slowly progressive neurological and neurobehavioral symptoms. Serum bromide levels may be elevated, but often return rapidly to normal. Electroencephalography may show frontally-predominant slow waves or polyspikes with following slow wave, and MRI reveals characteristic involvement in the dentate nucleus of the cerebellum, the brainstem, and the splenium of the corpus callosum. Symmetric and selective lesions in characteristic sites are observed on imaging and on histopathological examination. These are likely produced by methylation of intracellular lipids, protein and glutathione; production of toxic metabolites; defective neurotransmitter function; and abnormal oxidative phosphorylation. This article reviews the toxic effects of this gas, the pathophysiology and symptoms of its effects on the nervous system, and characteristic findings on MRI; and presents an illustrative case of methyl bromide intoxication due to exposure at a factory producing the compound commercially.

The neurotoxicity of lead to the adult brain is less well-known than that seen in children. It may present as acute severe encephalopathy or as chronic cognitive and behavioural symptoms, either in isolation or with systemic features of lead intoxication. Magnetic resonance imaging findings in lead encephalopathy vary. The pathogenesis of lead encephalopathy and its effects on cognition both during development and in the adult are discussed. That encephalopathic symptoms do not correlate with blood lead levels and that they may persist after chelation are highlighted. As an illustration, we describe a patient with chronic cumulative lead intoxication, who presented with peripheral neuropathy, anaemia, and a 'lead line' on the gingiva. She had cognitive dysfunction with extensive subcortical and cerebellar white matter lesions on magnetic resonance imaging. An area of restricted diffusion in both frontal regions is likely to be due to active ongoing demyelinating at the 'leading edge' of the lesion. Although systemic features and the peripheral neuropathy improved with chelation, the encephalopathy showed only marginal change, with later appearance of a symmetric akinetic-rigid state.

Shone's complex is a rare congenital heart disease consisting of multiple levels of left sided obstructive lesions including supravalvar mitral ring, parachute mitral valve, subaortic stenosis and coarctation of aorta. The present case report describes a case of complete form of Shone's complex that was incidentally detected in an adult.