Knowledge and practice of clinical ethics among healthcare providers in a government hospital, Chennai.

The growing public concern about the ethical conduct of healthcare professionals highlights the need to incorporate clinical ethics in medical education. This study examined the knowledge and practice of clinical ethics among healthcare providers in a government hospital in Chennai. A sample of 51 treating physicians and 58 other non-physician service providers from the hospital answered a self-administered, semi-structured questionnaire on their knowledge of and adherence to ethical principles, and the problems they faced related to healthcare ethics. More than 30% did not give a definition of healthcare ethics, and 40% did not name a single ethical principle. 51% stated that they witnessed ethical problems in their settings and named patient dissatisfaction, gender bias by provider, and not maintaining confidentiality. The responses of healthcare providers to various ethical scenarios are reported.

Pancreatic mucinous cystadenoma.

We report here the case of a 75-year-old lady who presented to us with a 4-month history of abdominal symptoms. The computed tomography scan revealed a cystic lesion in the tail of the pancreas. Distal pancreatectomy was done and biopsy showed a benign mucinous neoplasm. Because this is potentially malignant it is vital to diagnose it before it becomes malignant; identification of this entity remains a diagnostic and therapeutic challenge.

Intravenous immunoglobulin reduces serum tumor necrosis factor alpha in patients with Guillain-Barre syndrome.

BACKGROUND: Tumor necrosis factor a TNF-alpha has a possible role in the pathogenesis of the Guillain-Barre syndrome (GBS). AIMS: To study the effect of intravenous immunoglobulin (IVIg) on serum TNF-alpha concentrations in patients with GBS. MATERIAL AND METHODS: The effect of IVIg on TNF-alpha was evaluated in 36 patients with GBS. Serum TNF-alpha concentration was measured by enzyme-linked immunosorbent assay (ELISA). The sera of 22 (61%) patients with GBS showed elevated concentrations of TNF-alpha (35-182 pg/ml) and these sera were individually incubated in vitro with IVIg (0.25 mg/ml) at 37 degrees C for 24 hours. RESULTS: The serum TNF-alpha concentrations in the 22 GBS patients with elevated levels showed a steady decline (60.34-19.78 pg/ml) following incubation with IVIg. These 22 patients also received IVIg therapy, and serum TNF-alpha concentrations showed a significant decline (65.5-9.75 pg/ml) at the end of the therapy. At the time of discharge from the hospital, there was a positive correlation between neurological recovery and decline in TNF-alpha concentrations in these 22 GBS patients. CONCLUSIONS: The results of this study indicate that elevated levels of TNF-alpha occur in a proportion of patients with GBS and in these patients elevated serum TNF-alpha levels decline with IVIg therapy.

Circulating tumour necrosis factor alpha & soluble TNF receptors in patients with Guillain-Barre syndrome.

BACKGROUND & OBJECTIVES: Tumour necrosis factor-alpha (TNF-alpha) is regarded as one of the immune factors that can induce demyelination of peripheral nerves in patients with Guillian-Barre syndrome (GBS). This present study was undertaken to find out the role of TNF-alpha and soluble TNF receptors in the pathogenesis of GBS; and to study the effect of intravenous immunoglobulin (ivIg) therapy on the serum TNF-alpha and soluble TNF receptors in patients with GBS. METHODS: Thirty six patients with GBS in progressive stages of motor weakness were included in this study. The serum TNF-alpha and soluble TNF receptors (TNF-RI, TNF-RII) were measured in the serum samples of these patients before and after ivIg therapy by a sandwich ELISA. RESULTS: Of the 36 patients with GBS, 26 (72.2%) showed elevated serum TNF-alpha levels prior to ivIg therapy. Following a complete course of ivIg therapy there was a progressive decrease in the serum TNF-alpha concentrations in these 26 patients. On the other hand, the soluble TNF receptors, particularly TNF-RII showed an increase in the serum of GBS patients following ivIg therapy. INTERPRETATION & CONCLUSION: The results indicate that ivIg reduces the serum TNF-alpha concentrations in the GBS patients having elevated levels prior to ivIg therapy. Elevated serum levels of soluble TNF receptors following ivIg therapy may play a protective role by inhibiting the demyelinating effect of TNF-alpha in the peripheral nerves of patients with GBS.

Detection of heat stable mycobacterial antigen in cerebrospinal fluid by Dot-Immunobinding assay.

BACKGROUND: Isolation of Mycobacterium tuberculosis in cerebrospinal fluid (CSF) specimen in patients with tuberculous meningitis (TBM) is infrequent and carries low sensitivity. Thus development of an alternative laboratory diagnostic test is essential for the early diagnosis and treatment of TBM. OBJECTIVE: A simple, rapid Dot immunobinding assay (Dot-Iba), for the laboratory diagnosis of TBM is devised. This method minimizes the risk of handling infectious material in the laboratory. METHOD: The Dot-Iba was standardized with heat-inactivated M tuberculosis antigen (PPD). The heat-inactivated CSF from TBM and non-TBM patients was similarly assayed and it can detect antigen upto 1ng/ml in CSF. RESULT: A positive result was obtained in all the five culture positive patients with TBM and in 20/25 probable TBM. A negative result was obtained in 38/40 CSF from disease control group. The overall sensitivity and specificity of Dot-Iba was 83.3% and 95% respectively. CONCLUSION: Dot-Iba can be used as an adjunct for the laboratory diagnosis of TBM, particularly in culture negative TBM patients and also in those clinical situations where no laboratory tests are available to distinguish between TBM and partially treated pyogenic meningitis.

A dot-immunobinding assay (dot-Iba) for rapid diagnosis of pulmonary tuberculosis.

IgG antibody to Mycobacterium tuberculosis from the sera of patients with 'definite' pulmonary tuberculosis (PT) was isolated and coupled with Cyanogen bromide-Sepharose 4B. Using an immunoabsorbent affinity chromatography, 14 kDa antigen was recovered from the culture filtrates of M. tuberculosis. With this mycobacterial antigen, a dot immunobinding assay (Dot-Iba) was developed for the detection of specific antibody to M. tuberculosis in the sera of patients with PT and controls. The assay gave positive results in all the 12 sputum-smear positive [acid fast bacilli (AFB)] patients with PT and gave negative results in the 50 sera from control groups. The Dot-Iba as described in this study, is simple, rapid and specific for laboratory diagnosis of PT.

Significance of serum antibody to GD1b ganglioside in patients with Guillain-Barré syndrome.

BACKGROUND & OBJECTIVES: The precise etiological factors in Guillain-Barré syndrome (GBS) are still unknown. However, humoral and cellular immune factors may have a role in the pathogenesis of GBS. The present study was undertaken to evaluate the clinical significance of circulating serum IgG antibody to GD1b ganglioside in patients with GBS. METHODS: Serial samples of serum were collected from 18 patients with GBS undergoing plasma exchange (PE) during their hospital stay. Serum IgG antibody titers to GD1b, before, during as well as following PE were measured by an indirect enzyme-linked immunosorbent assay (ELISA). RESULTS: In 10 of 18 patients with GBS the antibody to GD1b was present in high titers (1:640-1:5120) prior to PE and the antibody titers in these 10 patients decreased following PE. At the time of completion of the study, the anti GD1b antibody titers declined in relation to clinical recovery in 7 of 10 patients with GBS. INTERPRETATION & CONCLUSION: The findings of the present study show that antibody to GD1b gangliosides may be one of the immunological factors in the pathogenesis of GBS and PE decreases the anti GD1b antibody titers in these patients.

Significance of circulating immune complexes in myasthenia gravis.

In this study, circulating immune complexes (CICs) were isolated and characterized in the sera of myasthenia gravis (MG) patients with thymoma and MG patients without any thymic lesions. High titres of antistriational antibodies in the CICs were demonstrated by an indirect immunofluorescence (IF) method in 60 per cent (15/25) MG patients with thymoma. The CICs showed a steady decrease in these 15 patients during the post thymectomy period. Antistriational antibodies in the CICs of MG patients without thymic lesions were not detected by IF method. The results of this study emphasised the usefulness of estimation of CICs in the overall management of MG patients with thymoma.

Incidence and management of posteriorly dislocated nuclear fragments following phacoemulsification.

PURPOSE: To report the incidence, management and complications of nucleus dislocation into the vitreous during phacoemulsification. METHODS: Retrospective review of 1250 consecutive phacoemulsification performed by consultants and residents in a teaching hospital. RESULTS: The incidence of nucleus drops was 0.8% (10 out of 1250). Loss of nuclear fragments occurred during phacoemulsification in 9 patients. In one, the dislocation was caused by hydro-dissection. All except one patient (who refused further intervention) underwent pars plana vitrectomy with removal of nuclear fragments. Eight of them had intraocular lens (IOL) inserted at the time of cataract surgery or at vitrectomy; one patient was scheduled for a secondary IOL. Postoperative best corrected visual acuity ranged from 6/24-6/6; 8 patients achieved a vision of 6/12 or better. Complications included cystoid macular oedema (5 patients), retinal break (1 patient) and retinal detachment (1 patient). CONCLUSION: Appropriate management of posteriorly dislocated nucleus can restore good visual acuity. The use of phacoemulsification mandates availability of referral facilities for management of complications.

VISTECH contrast sensitivity testing in primary open angle glaucoma.

Contrast sensitivity has been recommended as a screening and diagnostic test in primary open angle glaucoma (POAG). We tested contrast sensitivity (CS) using Vistech charts in 184 eyes of 95 patients. Three groups were examined--established primary open angle glaucoma, glaucoma suspects and age matched controls. The distribution of contrast sensitivities amongst the three groups were similar. The median contrast sensitivity of glaucoma suspects and controls were well within normal limits while that of the POAG group fell along the lower limit of normal. In all three groups the younger subjects scored better than the older, indicating a depression of contrast sensitivity with increasing age. Even if depression of any one spatial frequency was considered abnormal, the test yielded a sensitivity of 55.4% and specificity of 69.5%. Similarly contrast sensitivity testing was found to be of little use in detecting field defects a maximum sensitivity of 47.3% and specificity of 73.3%. Vistech contrast sensitivity testing is not a useful test in POAG screening or diagnosis.

Characterization of mycobacterial antigens by Elisa and immunoblot methods.

Antibodies to two mycobacterial antigens viz - culture filtrate antigen (CFA) and Mycobacterium tuberculosis antigen 5 were raised in rabbits. Enzyme-linked immuno sorbent assay (ELISA) and immunoblot methods were used for the evaluation of the specificity of the rabbit antibodies to M. tuberculosis. Immunoblot method is more sensitive than ELISA for the detection of antibodies to M. tuberculosis in the rabbit sera. It is being emphasised that characterisation of the mycobacterial antigens and evaluation of the specificity of the antimycobacterial antibodies are essential prior to their applications as an adjunct in the laboratory diagnosis of human mycobacterial disease.

Diagnosis of tuberculous meningitis by enzyme-linked immuno-sorbent assay (ELISA), using an affinity chromatography purified mycobacterial antigen.

Using an immunoabsorbent affinity chromatography, a mycobacterial antigen was isolated from culture filtrate of H37Ra Mycobacterium tuberculosis (MTB). The immunoabsorbents were prepared by coupling cynogen bromide-activated Sepharose-4B with human IgG antibody to MTB. Cerebrospinal fluids (CSF) from 10 culture positive, 30 culture negative patients with tuberculous meningitis (TBM) were assayed, for IgG antibody to this mycobacterial antigen by ELISA. CSFs from 50 patients with non-tuberculous neurological diseases were selected as control group. At a selected 'cut off' titre of 1:80, 21 out of 30 CSFs from culture negative patients gave positive results. No false negative result was observed in CSF from 10 culture positive patients with TBM. No false positive results were recorded in CSFs of 50 patients with non-tuberculous neurological diseases. Technical aspects involved in the isolation of this myobacterial antigen and its potential applications in the laboratory diagnosis of TBM have been emphasised in this study.

Correlation between the isolation of Mycobacterium tuberculosis and estimation of mycobacterial antigen in cisternal, ventricular and lumbar cerebrospinal fluids of patients with tuberculous meningitis.

In the study Mycobacterium tuberculosis was isolated in the cerebrospinal fluid (CSF) specimens of patients with tuberculous meningitis (TBM) by the conventional bacteriological technique. The isolation rate of M. tuberculosis was found to be 11.5% in lumbar, 75% in ventricular and 87.5% in cisternal CSFs. Low isolation rate of M. tuberculosis in lumbar CSF is due the low density of tubercle bacilli in lumbar CSF than in cisternal CSF. However M. tuberculosis antigen 5 is present in significant concentration in CSFs. The antigen concentration in CSF was estimated by an inhibition enzyme-linked immunosorbent assay (ELISA). Since CSF specimens can not be collected from ventricular or cisternal routes for the routine bacteriological investigations in patients with TBM, estimation of M. tuberculosis antigen 5 concentration in lumbar CSF by an inhibition ELISA may be considered as an adjunct in the laboratory diagnosis of TBM. This is particularly relevant in those patients in whom bacteriological methods fail to demonstrate M. tuberculosis in CSF specimens.

Botulinum toxin in the treatment of paralytic strabismus and essential blepharospasm.

As an alternative to conventional medical and surgical modalities that have met little success in the treatment of paralytic strabismus and essential blepharospasm, we explored the use of botulinum toxin as a treatment of choice in these two disorders. We used botulinum toxin in three patients with paralytic strabismus and in nine patients with essential blepharospasm. In three patients with paralytic strabismus, the botulinum toxin was injected into the ipsilateral antagonist of the paralysed muscle. The preinjection deviations ranged from 18 to 60 prism diopters. Two of these three patients achieved orthotropia around the thirtieth day and thereafter maintained it. The third patient became orthotropic on the eighteenth day, but deviation recurred and therefore required another injection of toxin. In nine patients with essential blepharospasm, botulinum toxin was injected into the orbicularis oculi muscles. Both objective and subjective improvement occurred in all nine patients within seven days and the effect lasted 12 to 15 weeks. Further injection of the toxin produced extremely beneficial results. However, the only significant complication that we encountered in both groups of strabismus and blepharospasm was ptosis, which was usually partial and temporary. From our experience, we advocate the use of botulinum toxin in the treatment of essential blepharospasm.

Releasable suture technique for trabeculectomy.

We studied the effect of the releasable suture technique on immediate postoperative intraocular pressure (IOP). Nine eyes of nine patients with glaucoma had trabeculectomy with a releasable suture. In the six eyes that did not receive antimitotics, the suture was released by the fifth postoperative day; in the others suture release was delayed up to the fourteenth day. Of the nine patients, one had an acceptable postoperative IOP and did not need suture release; in another the suture broke and could not be released. In the remaining seven patients, the difference between the pre-release and post-release IOP was statistically significant (p < 0.001). The complications of this technique include failed suture release, subconjunctival hematoma and a distinctive "windshield wiper" keratopathy.

Evaluation of purified protein derivative in the laboratory diagnosis of tuberculous meningitis.

An enzyme-linked immunosorbent assay (ELISA) was standardised for the quantitation of IgG antibody in cerebrospinal fluid (CSF) specimens of patients with tuberculous meningitis (TBM). Purified protein derivative (PPD1) from H37Ra M tuberculosis was used as the antigen in the assay. The sensitivity of the ELISA with this antigen was evaluated in the CSF of 10 culture positive and 40 culture negative patients with TBM. The specificity of the assay was evaluated in the CSF of 50 patients with non-tuberculous neurological diseases (control group). The results obtained with this antigen were compared with commercially available tuberculin purified protein derivative (PPD2) and BCG antigens. PPD2 gave false negative results (50%) in culture positive patients with TBM, and BCG antigen gave false positive results in 32% of non-tuberculous subjects. PPD1 gave a sensitivity of 60% in culture negative patients with TBM and no false positive reactions in the non-tuberculous group. PPD1 antigen, in contrast to other mycobacterial antigens, can be very easily prepared in any routine laboratory, and this antigen is recommended for use as an aid in the laboratory diagnosis of TBM, particularly in culture negative patients with TBM.

Circulating immune complexes in cerebrospinal fluid of patients with tuberculous meningitis.

Circulating immune complexes (ICs) were isolated from cerebrospinal fluids (CSFs) of patients with tuberculous meningitis (TBM), non-tuberculous neurological diseases by a polyethylene glycol (PEG) precipitation method. Mycobacterium tuberculosis antigen 5 was detected in CICs of 30% patients with TBM, by sandwich ELISA. CIC level decreases during antituberculosis chemotherapy and therefore its detection can provide a method to monitor the therapeutic schedule in patients with TBM.

Humoral immune reactions in tuberculous meningitis.

Humoral immune reactions as reflected in sera and cerebrospinal fluid (CSF) of 50 patients with Tuberculous meningitis (TBM) were studied. CSFs and sera from 50 patients with nontuberculous neurological diseases were selected as controls. CSFs of patients with TBM showed high titres of circulating antimycobacterial antibodies than in nontuberculous subjects. The CSF-IgG index is significantly higher in patients with TBM. Humoral immune reaction could be applied in the laboratory diagnosis of TBM, particularly when repeated bacteriological methods are negative for M. tuberculosis in CSFs.

Correlation between culture of Mycobacterium tuberculosis and antimycobacterial antibody in lumbar, ventricular and cisternal cerebrospinal fluids of patients with tuberculous meningitis.

In this study positive culture for M. tuberculosis were obtained, 20% in lumbar cerebrospinal fluid (CSF), 75% in ventricular CSF and 87.5% in cisternal CSFs of patients with tuberculous meningitis. Low culture positivity in lumbar CSF is due to the low density of circulating tubercle bacilli in lumbar CSF than in cisternal or ventricular CSFs. However antimycobacterial antibody in lumbar, cisternal and ventricular CSFs circulate in significant titres and are not statistically different from one another. Since specimens of CSF can not be obtained from cisternal or ventricular routes for the routine bacteriological investigations in patients with tuberculous meningitis, detection of antimycobacterial antibody of M. tuberculosis antigen 5 in lumbar CSF by an indirect ELISA may be considered as an aid for the diagnosis of tuberculous meningitis, particularly when repeated CSF cultures are negative for M. tuberculosis.