Localized lepromatous leprosy presenting as a painful nodule in a muscle.

Lepromatous leprosy is a generalized disease usually presenting with numerous macules, papules, nodules or plaques involving wide areas of the skin. It is generally believed that in India lepromatous leprosy often originates from the borderline spectrum (Jha et al, 1991). Localized lepromatous or borderline lepromatous disease is a rare variant of multibacillary leprosy (Yoder et al, 1985; Jha et al, 1991; Pfaltzgraff & Ramu, 1994; Vijaikumar et al, 2001). This variant usually presents as a single nodule or a localized area of nodules and papules, while most of the body surface appears normal (Pfaltzgraff & Ramu, 1994; Vijaikumar et al, 2001). Its occurrence in our case as a single painful nodule in the bicep muscle of left forearm was indeed intriguing, such presentation being rarely reported in the literature.

Betamethasone in plus phenobarbitone prior to hepatobiliary scintigraphy increases diagnostic accuracy in infants with jaundice.

OBJECTIVE: In the diagnostic work up of the child with neonatal obstructive cholangiopathy (NOC), hepatobiliary scintigraphy (HBS) determines the need for peroperative cholangiography (POC). Traditionally, phenobarbitone is recommended to prime the liver to HBS. This retrospective study was designed to evaluate whether addition of the betamethasone (BM) alters the diagnostic accuracy of the HBS in distinguishing neonatal hepatitis (NH) from extra hepatic biliary atresia (EHBA). METHODS: Between 1993-1999, 202 patients presented with NOC and this study was not designed as a prospective randomized clinical trial. Of these, 126 patients had received Phenobarbitone (Group I) and the remaining 76 (Group II) had received BM in addition to the PB in a dose of 5 mg/k/d and 2.2 mg/k/d respectively for 7 days prior to HBS. RESULTS: Retrospective analysis revealed that, in the Group I, 41 showed excretion and 85 did not show any excretion of the radiopharmaceutical and the latter underwent POC which revealed that 31 patients (36%) of them showed patent biliary tract. In group II, 32 patients revealed excretion and 44 did not show any excretion of the radiopharmaceutical and the latter had undergone POC, which revealed that only 8 patients (18%) showed patent biliary tract. The percentages of false positives (36% vs 18%) was statistically significant (p < 0.03). CONCLUSION: Addition of BM increases the diagnostic accuracy of the HBS and this would lead to decreased need for POC to distinguish NH from EHBA.

Evaluation of transplanted hepatocytes using HIDA scintigraphy.

BACKGROUND: Hepatocyte transplantation has generated interest because of potential clinical application in enzyme deficiency disorders and acute hepatic failure. Ex-vivo HIDA scintigraphy has been used to assess graft survival after hepatocyte transplantation. The present study evaluates in-vivo99mTc-HIDA scintigraphy to assess graft function after hepatocyte transplantation. METHODS: Rat hepatocytes were isolated by a modified collagenase digestion technique and injected intrasplenically into 6 syngenic rats; 4 control rats received intrasplenic saline injections. In-vivo HIDA scintigraphy and histological evaluation were done 90 days after transplantation. RESULTS: Five of the six rats in the study group showed prompt and progressive accumulation of HIDA in the spleen. Histological examination showed presence of hepatocytes in the splenic red pulp. None of the control group animals had splenic uptake of HIDA. CONCLUSION: HIDA scintigraphy may be a useful modality for assessment of graft function after intrasplenic hepatocyte transplantation.

Advanced biliary atresia: is portoenterostomy justified in all infants?

During 1989-98, of the 127 patients with biliary atresia, 23 were seen with advanced biliary atresia (ABA) presenting with (i) at more than 120 days of age (ii) established cirrhosis and (iii) features of portal hypertension. Sixteen of these underwent exploratory laparotomy, dissection at the porta hepatis and hepatico-portoenterostomy (HPE) (group I). The remaining 7 infants underwent portal dissection and sump drainage only (instead of HPE). The drainage if any was evaluated for any change in colour, volume and concentration in the post-operative period (group II). Age and presentation were the same in both the groups. In group-II, HPE was considered only if the bile flow was noted after portal dissection. Bile flow was seen in 3/16 in group I and 0/7 in group II. The fall in serum bilirubin during the first seven post operative days was noted in 2/16 in group I and 0/7 in group II. No drain output was recorded in any of the group II infants. The incidence of complications and the duration of hospital stay was significantly higher in group I patients. The sump drainage as an alternative procedure to HPE not only served the purpose of evaluating the patients with ABA for the possible bile flow in the post operative period but also avoided the need for a major operative procedure like HPE.

Hepatocyte isolation and transplantation in syngenic rats.

Refinement of techniques to isolate viable hepatocytes began in the late 1960's. It was established that perfusion of the intact liver as opposed to incubation of liver slices or chopped tissue increased the yield of cells. The present study aims to establish a simple, two-step, collagenase digestion method for hepatocyte isolation. A single inbred Fisher rat was used for hepatocyte isolation. The liver was perfused in-situ with perfusion buffer containing ethylene glycol bis N, N1, tetra acetic acid (EGTA), followed by the collagenase buffer. The liver was excised and gently minced. The tissue was resuspended in the collagenase buffer to complete dissociation. The cell suspension obtained was washed, centrifuged and filtered to complete the isolation procedure. The trypan blue exclusion test showed 80-85% cell viability. The isolated cells were transplanted into the splenic parenchyma of syngenic rats. Survival of the transplanted hepatocytes was confirmed by histological examination at the end of 90 days. This two step technique of in-situ liver perfusion gives a high yield of viable hepatocytes which show long term survival after transplantation.

Sprengels deformity: anaesthesia management.

A 28 years old lady presented with Sprengels deformity and hemivertebrae for Fothergills surgery. Clinically there were no anomalies of the nervous, renal or the cardiovascular systems. She had a short neck and score on modified Mallapati test was grade 2. She was successfully anaesthetised using injection Propofol as a total intravenous anaesthetic agent after adequate premedication with injection Midazolam and injection Pentazocine. Patient had an uneventful intraoperative and postoperative course.

Surgery in tuberculosis.

Tuberculosis in children involves many organs and systems including lymphatics, lungs, CNS, GIT and genitourinary. Although the mainstay of treatment is medical, surgery has a definite role under specific circumstances. It is important to differentiate atypical mycobacterial infection wherein surgery is the primary modality of treatment. The lung is most commonly involved in tuberculosis and besides bronchoscopy, thoracic procedures range from tube thoracostomy to decortication and lung resection. Neurotuberculosis constitutes almost half the cases of extrapulmonary tuberculosis and tuberculous meningitis (TBM) is the commonest type of CNS involvement. Hydrocephalus is a late complication of TBM and shunt surgery is indicated when signs and symptoms of raised intracranial pressure persist despite adequate medical therapy. Abdominal tuberculosis could be peritoneal or gastrointestinal. Either form can complicate the other and each can present in acute, subacute or chronic form. Surgical therapy is reserved for complications like strictures, fistulae and GI bleed. Genitourinary tuberculosis constitutes 15-20% of all extrapulmonary disease and epididymitis is the most common manifestation in the males. Surgery is generally reserved for management of complications such as ureteral strictures, perinephric abscesses and nonfunctioning kidneys.

Esophageal atresia and tracheo-esophageal fistula: a review.

The improved survival of neonates with esophageal atresia and tracheo-esophageal fistula reflects the advancement in neonatal care and anaesthesia over the years. Chick embryo studies have given new insights in the embryopathy of esophageal atresia. It is now apparent that the various types of esophageal atresia could be explained due to selective discrepancy in the growth of the 3 folds in the region of tracheo-esophageal separation. The early disturbances in organogenesis which result in esophageal atresia also lead to other associated anomalies, the incidence of which varies from 40 to 55%. These anomalies have an important bearing on the survival outcome. The physiological aspects of esophageal atresia such as esophageal dysmotility and gastro-esophageal reflux are also vital in the long term and proper treatment of the associated defects. The criteria for an ideal esophageal substitute in long gap esophageal atresia have been determined and several options are now available with good results, such as: gastric transposition, colon, gastric tube and small intestine. IN developing countries, however, a high mortality is still attributed to late referrals, low birth weight, hypothermia and chest infection.

Management of hydrocephalus.

The present study is an analysis of 747 patients with hydrocephalus, treated and followed up in the Hydrocephalus Clinic run by the department of Paediatric Surgery at the All India Institute of Medical Sciences, New Delhi. The distribution of patients was: congenital-46%, post-meningomyelocoele excision-28%, post-meningitic-21% and others-5% (including post haemorrhagic and post encephalocoele excision hydrocephalus. The average age was 7 months in the shunted group and 10 months in the medical group with overall male to female ratio of 2.3:1. The data were analysed to study the effect of treatment on ventriculomegaly and mental development with special reference to the type of treatment (shunt versus medical) and age at starting treatment. The probability of shunt failure was also studied. A comparison of ventricular size in US/CAT scans between the time of starting treatment and last follow-up revealed improvement in ventriculomegaly in 60% of the shunted patients but only 30% of the medically treated patients. A significant difference was particularly noted in patients with severe hydrocephalus, 72% and 22%, respectively. Comparison of the mean Mental Performance Quotient (MPQ) scores in the shunted & medically treated patients also revealed significantly better MPQ scores in the shunted group (p = < 0.001). Probability of shunt survival, as depicted by the Kaplan-Meier survival curve, revealed that there is a high rate of shunt failure in the first 12 months, followed by a dramatic slowing down. Our observations support the contention that CSF shunt surgery offers better outcome than medical management even when ventriculomegaly is severe at the time of presentation.

The relation of exposure to asbestos and smoking habit with pulmonary function tests and chest radiograph.

Environmental cum medical study was conducted in asbestos cement factory. The environment was evaluated for asbestos fiber by the methods recommended by BIS. Total 355 exposed and 312 suitably matched control workers were investigated by spirometer, Wright's peak flow meter and full sized postero-anterior chest radiograph. The levels of asbestos fiber were 2 to 3 times higher than TLV i.e. 2 f/ml in pipe cutting dept., crude fiber grinding inlet count was more than the ACGIH recommended limit i.e. 5 mpccf of air in pipe cutting dept. and silica mill. In the rest of the department, fiber level as well as dust particle count were below prescribed limit. The comparison of mean values of PFT parameters of workers with 16-20 years exposure history with control one was showing statistically significant decline in mean values of FVC only suggesting restrictive type of PFT impairment in this group of workers. But in workers with more than 20 years exposure, the mean values of all the parameters studied were reduced as compared to control one suggesting combined type of PFT impairment. When the mean values of PFT parameters of exposed smokers were compared with exposed non-smokers there was statistically no significant difference. This can be due to marginal contribution of smoking habit in impairment of PFT parameters of exposed smokers. The percentages of workers with parenchymal and pleural changes due to asbestos exposure were nearly two times more in more than 20 years exposure groups as compared to 11-20 years exposure groups. The parenchymal and pleural changes due to asbestos exposure were more common in exposed smokers as compared exposed non-smokers. However the detailed analysis revealed that if smoking contributes to the development of interstitial fibrosis, the contribution is a marginal one in comparison to the effect of asbestos dust exposure.

The correlation of chest radiograph and pulmonary function tests in asbestos miners and millers.

An environmental-cum-medical survey was carried out in asbestos mines and milling units at Pullivendalla, Cuddaph (A.P.) India. This was done in two mines and six milling units with 95% of the total work force being surveyed. Out of a total of 633 registered workers, 329 (52%, all males) were employed in mines while 135 (21.4%) workers of whom 114 (84%, all females) were employed in the milling units. All subjects underwent limited medical examination, spirometry and chest radiographs. The levels of asbestos fiber concentration was much below threshold limit value (TLV) in underground mines but several times higher than TLV in milling units. The percentage of workers with abnormal pulmonary function tests (PFT) and chest radiographs increased with duration of exposure in smokers as well as non-smokers. Restrictive pattern of lung functions (159 workers-16.27%) was more common than obstructive (33 workers-5.21%) and combined type (22 workers-3.4%). Similarly, the parenchymal changes (156 workers-24.6%) were more common than pleural (27 workers-4.3%). As most of the males were employed in mines, where the fiber levels were much below TLV, the number of male workers with normal PFT and chest radiographs were ten times (61.3%) more than male workers with both the parameters abnormal (6.3%). As most of the females (114 our of 120--95%) were employed in milling units, where the levels of fibers were several times higher than TLV, the number of females having both the parameters normal 29 (24.1%) or abnormal 35 (29.2%) were similar.

Professional freedom of government leprosy personnel.

BACKGROUND. Government employment in India is known for its lack of flexibility. We studied whether this also involved professional freedom among health personnel working for the National Leprosy Eradication Programme. METHODS. The sample population consisted of National Leprosy Eradication Programme employees from Tamil Nadu and Andhra Pradesh and 8 health professional groups. A questionnaire was developed for each of them to elicit information on 5 aspects of their autonomy. They were studied individually and as homogeneous groups so that comparisons were possible both within and between groups in different regions who were conducting similar health programmes. RESULTS. National Leprosy Eradication Programme personnel enjoy a high degree of autonomy within the organization. This autonomy was evident in both states investigated, despite different administrations and it was not connected with the professional positions they held. Professional freedom correlated with the training activities, promotional prospects and commitment to the organization. CONCLUSIONS. The National Leprosy Eradication Programme job is not rigid because the organization is small and the intellectual needs of the professionals are met within it.

Humoral immunological profile of workers exposed to asbestos in asbestos mines.

Humoral immunological profile including immunoglobulins IgG, IgA, IgM, C-reactive protein, rheumatoid factor, antinuclear antibodies and circulating immune complexes were studied in a representative sample of 36 workers suffering from asbestosis (group A), 35 workers who are exposed to asbestos but not having evidence of asbestosis (group B) and 28 control workers (group C). Mean IgG and IgA levels were found to be significantly higher in the two exposed groups than in the controls. Circulating immune complexes of IgG, IgA and IgM class were detected in a significant percentage of cases in exposed groups than in controls. In groups A and B, the percentage of positive ANF cases was much higher than in the controls. The results suggest that immunological changes are associated with exposure to asbestos and these may play an important role in the pathogenesis of the disease process.

Impact of multidrug therapy on health personnel in their level of job satisfaction.

This study examines the "service" factors of the health professionals working in the National Leprosy Eradication Programme (NLEP) resulting from the introduction of multidrug therapy (MDT) technology, and their impact on their job satisfaction. The findings show that both among physicians and paramedicals, the significant chemotherapeutic dissatisfaction observed before the introduction of multidrug therapy has been replaced by a moderately positive satisfaction. This was much higher than the other incentives like pay, promotional prospect and job significance within NLEP and the community. It was also consistent over five years which was not the case with hydnocarpus and monotherapy technologies. Intercorrelation matrix test revealed three positive intercorrelations. First, personnel associated technology with personal progress which provided a sense of accomplishment while also satisfying their economic needs; second, they saw it as a mode of developing relationships with their clients; and third, it improved their self-image in the community. However, this satisfaction may not be static when there is a reduction of work load, or, the leprosy programme is integrated into general health services. Therefore, while planning these changes, care must be taken that the present level of technological satisfaction is maintained or further improved.

Systolic time intervals in rheumatic mitral stenosis.

Thirty two patients with pure mitral stenosis and twenty normal subjects were studied by M-Mode Echocardiography and systolic time intervals. Preejection period (PEP) was increased in 62 percent of patients in New York Heart Association (NYHA) Class III and IV, compared to 42.9 percent of cases in NYHA class I and II. Left ventricular ejection time (LVET) was abbreviated in 87.5 percent cases in NYHA class III and IV, and in 58.3 percent of cases in NYHA class I and II. PEP/LVET ratio was significantly increased (p less than 0.01) in mitral stenosis (0.42) compared to normal subjects (0.33) while calculated left ventricular ejection fraction (EF) was significantly lower (p less than 0.01) in mitral stenosis (60%) compared to normal subjects (71.55%). It is hypothesized that a rigid "mitral complex" immobilises the posterobasal area of the left ventricle in mitral stenosis thereby impairing left ventricular contraction.