An unusual cause of acute abdomen and acute renal failure: Djenkolism

@#Te djenkol bean (Archidendron pauciforum) is a native delicacy in Southeast Asia, though consumption can sometimes lead to djenkolism. Clinical features of djenkolism include acute abdominal pain, hematuria, urinary retention, and acute kidney injury (AKI). Te pain can be severe, which often leads to a misdiagnosis of acute abdomen. In this paper, we report the case of an Indonesian migrant with djenkolism. Due to the short history and severity of the abdominal pain, medical professionals suspected acute abdomen and proceeded with a negative exploratory laparotomy. However, djenkolism was suspected once relatives informed the professionals that the patient had consumed djenkol beans hours earlier. Te patient recovered through aggressive hydration and urine alkalinization with bicarbonate infusion. We highlight the importance of being aware of this rare cause of AKI, especially in Southeast Asia, in order to provide early diagnoses and prompt treatments.

Oral Involvement In Pemphigus Vulgaris : An Epidemiological Profile.

Abstract: Background and Objectives: Pemphigus vulgaris is a chronic autoimmune disease characterized by the formation of intraepithelial blisters in skin and mucosa. In majority of the patients the initial manifestations of pemphigus vulgaris appears in the oral mucosa followed at a later date by cutaneous lesions. Detection of the oral lesions can result in an earlier diagnosis and early treatment thereby decreasing the hospital stay of the patients. Objective: We review the clinical and epidemiological aspects of oral pemphigus vulgaris in patients attending tertiary care centre. Methodology: All patients diagnosed as having Pemphigus in the department of skin during last 6 years were included in the study and data analysed. Results : Out of 91 patients diagnosed as having pemphigus during the period of 6 years, pemphigus vulgaris was the most common type ( 91.2 % ) . The mean age of onset was 45 years . Male to female ratio in the patients with pemphigus vulgaris was 1:1.5 . Oral lesions were found in 84 % of patients and it was the first manifestation in 66% of cases. Results & Conclusion: Pemphigus vulgaris was the most common condition seen, oral cavity being the initial site of disease presentation.

Drug utilization study of antimicrobial agents in patients of neonatal sepsis in neonatal intensive care unit at a tertiary care hospital in western part of India.

Background: Neonatal sepsis is one of the major causes of death and morbidity among neonates in India; however, studies related to neonatal sepsis are somewhat in limited numbers. Furthermore, time to time sensitivity and efficacy of various antimicrobial agents (AMA) change which necessitates studies related to antimicrobial drug utilization in hospitals. The objective of present study was to evaluate the pattern of use of AMAs in neonatal sepsis at the neonatal intensive care unit (NICU) at a tertiary care hospital in western part of India. Methods: It was a prospective cross-sectional study conducted over a period of 6-month duration in NICU at tertiary care hospital. Data were collected and analyzed. Results: It has been observed that 57.67% patients were pre-term, 42.32% full term; 23.28% were of normal birth weight, 58.73% low birth weight and 15.34% were very low birth weight. In 48.7% of patients, two different antibiotics were prescribed while in 40.1% of patients three different antibiotics were prescribed. A total number of antibiotics prescribed were 499, per patient 2.78 antibiotics were prescribed. Amikacin was used in 73.01% cases while cefotaxime was used in 64.55% of cases. Piperacilin + tazobactam combination was used in 41.26% cases. In 50.9% cases, antibiotics were prescribed by generic name. Conclusion: Antibiotic resistance is increasing due to the irrational prescribing habits of physicians, leading to increasing morbidity, mortality and treatment costs. Therefore, the medical professionals as well as government personnel who are related to the health sector need to understand that antibiotics are precious and finite resources. The remedy of this situation requires that regular educational awareness programs should be conducted in hospitals at a regular basis.

Role of glipizide therapy on oxidative stress parameters in the patient with Type-II diabetes mellitus.

Background: Oxidative stress has an important role in the pathophysiology of diabetes mellitus (DM) Type-II. Oxidative stress has an important role in the progression of DM Type-II and its related complications such as retinopathy, neuropathy and many others. The present study was carried out to evaluate the effect of glipizide therapy on oxidative stress parameters in Type-II DM. Methods: Thirty newly diagnosed diabetes patients were given glipizide therapy on 1st day and continue for 3 months. 30 non-diabetic healthy volunteers served as a control. Plasma malondialdehyde (MDA), superoxide dismutase (SOD) and catalase levels were measured at the time of enrollment and at the end of 3 months of glipizide treatment. Result: The results are analyzed using paired t-test. Plasma MDA was significantly increased, whereas SOD and catalase were significantly reduced in newly diagnosed diabetic patients as compared to control. After 3 months of glipizide therapy, plasma MDA was significantly reduced, whereas SOD and catalase were significantly increased. Conclusion: Glipizide therapy significantly reduced oxidative free radicals and increased antioxidant mechanism, which reduced oxidative stress, progression DM-II and its related complication.

Bilateral reversed palmaris longus muscle with trifid insertion, a rare variation.

Normally the palmaris longus muscle originates from the medial epicondyle of the humerus from common flexor origin. In the middle of the forearm, the muscle belly forms a tendon which is inserted into the flexor retinaculum and the palmar aponeurosis. In our study after dissection of both forearms of a 45-year-old male cadaver we found a reversed palmaris longus muscle. This means that the palmaris longus muscle was tendinous in its proximal part and muscular in its distal part. The fleshy belly of muscle was passing over flexor retinaculum, was ensheathed by separate fascia. The muscle belly was spreading on both the sides of each palm for insertion which was trifid, that is centrally into palmar aponeurosis, laterally continuous with the fascia covering the thenar muscles and medially with Abductor digit minimi. It was having tendinous interconnection with the muscle mass of both the sides. Bilateral reversed palmaris longus muscle mentioned in the literature, was a surgical finding in a patient who suffered from edema and pain in the wrist. The overuse of the reversed palmaris longus muscle can lead to the muscle’s local hypertrophy. As per the literature a reversed palmaris longus muscle may cause a compartment syndrome with pain and edema in the wrist area, the carpal tunnel syndrome and Guyon’s syndrome. The variation is also useful to the hand surgeon, as the palmaris longus muscle is an anatomical landmark for operations in this area.

Event related potential (ERP) P300 after 6 months residence at 4115 meter.

Background & objectives: The P300 wave is an event related potential (ERP) elicited by infrequent, task-relevant stimuli and appeared at about 300 ms, represents higher cognitive function of information processing, working memory or stimulus categorization. Hypobaric hypoxia deteriorates the cognitive function during the short term stay (days to few weeks) at high altitude. The present study was carried out to evaluate the P300 responses during long duration stay (1 month and 6 months) at high altitude (HA, 4115 m) in a sample of Indian lowlanders. Methods: The study was carried out on 18 healthy male volunteers at sea level (SL). The volunteers were stage inducted to 4115 m altitude in the Eastern Himalayas. The P300 was recorded after 1 and 6 months of their stay at HA. Results: The latencies of peaks N100, P200 and N200 waves did not show any significant changes after 1 and 6 months of stay at HA as compared to SL. The P300 latency was significantly delayed after 1 month and further delayed after 6 month of residence at 4115 m. The P200 and P300 amplitudes did not show any changes. Interpretation & conclusions: The increase in P300 latency indicated that long duration of stay at high altitude slows the stimulus evaluation processes. The observations suggest that hypoxia causes slowing of the signal processing at HA. The magnitude of the effects of hypobaric hypoxia may be dependent upon the duration of residence at high altitude.

Effect of simulated ascent to 3500 meter on neuro-endocrine functions.

Ascent to extreme High Altitude (HA) is in steps and it entails acclimatization at moderately HA locations. In terms of acclimatization, it is pertinent to understand the physiological changes, which occur on immediate ascent to moderate HA. The study aimed to evaluate the effect of ascent to 3500 m on neuro-endocrine responses in the first hour of induction. The plasma levels of catecholamines and cortisol were measured before and after one hour of ascent to high altitude. The peripheral oxygen saturation (SpO2), Galvanic Skin Resistance (GSR), Heart Rate (HR) and Blood Pressure (BP) were simultaneously monitored. The plasma epinephrine, norepinephrine, dopamine and cortisol were increased after one-hour exposure to 3500 m altitude as compared to before exposure. The SpO2 showed a significant decrease during and after high altitude induction. The heart rate and diastolic BP increased at 3500 m whereas the GSR did not show significant changes. There are changes in neuroendocrine responses, which reflect a sympathetic over activity in the first hour of exposure to 3500 m.

Effect of hypobaric hypoxia on visual evoked potential at high altitude.

The effect of hypobaric hypoxia on visual evoked potential (VEP) was studied in 27 male volunteers at sea level (SL), during the 1st and 3rd weeks of their stay at high altitude (HA) of 3,500 m and in the 1st week of their return to the sea level (RSL). Exposure to high altitude (HA) led to significant changes in VEP. The N1 wave latency of both right and left eye was significantly increased (P<0.05) during 3rd week of stay at the altitude which persisted even after the return to the sea level. The latency of P1 wave of both right and left eye was higher in 3rd week at high altitude but not significant statistically. But the delay in P1 latency persisted in 1st week of their return to sea level which was significant (p<0.05) statistically as compared to sea level. The latency of N2 wave was significantly decreased (P<0.05) during the 1st week of stay at HA and returned back to basal value in the 3rd week of stay at HA in both right and left eye. However, the changes observed in NPN complex in terms of wave latencies were within the physiological limits. The amplitude of wave N1-P1 of both the right and left eye did not show any change. The changes observed reflect the process of acclimatisation to 3500m high altitude.

Laparoscopic intervention in resistant hepatosplenic tuberculosis presenting as pyrexia of unknown origin.

Hepatosplenic tuberculosis (HST), rarely encountered in surgical practice, is seen in-patients with disseminated tuberculosis. A 20-year-old female presenting with pyrexia of unknown origin (PUO) was subsequently diagnosed to have lymph-nodal tuberculosis with involvement of liver and spleen. Despite anti-tuberculosis treatment (ATT) for 3 months, clinical improvement did not occur and fever persisted. Laparoscopic splenectomy and drainage of the hepatic cold abscess were done with favorable results. Smear for acid fast bacilli (AFB), culture for Mycobacterium tuberculosis and histopathological examination (HPE) established the diagnosis of tuberculosis (TB).

Changes in visual evoked potentials on acute induction to high altitude.

BACKGROUND & OBJECTIVES: Induction to high altitude leads to altered central nervous system (CNS) functions induced by hypobaric hypoxia. The sensory systems like visual and auditory systems are reported to be affected by hypoxia. The present study was undertaken to assess the effects of hypobaric hypoxia on visual evoked potentials (VEPs) at 3200 m and 4300 m. METHODS: The VEP of 30 human volunteers were recorded at sea level (SL) and then at high altitude (HA) of 3200 m (HA I) and 4300 m (HA II) in eastern Himalayas and on return to sea level (RSL). The absolute latencies and amplitude of positive and negative waves were recorded. RESULTS: High altitude of 3200 m did not alter the latency of major wave N1, P1 and N2 of the VEPs. At HA II (4300 m), there was a statistically significant increase (P < 0.01) in the latency of NI wave as compared to the SL value and HA I (3200 m) in both left and right eye. There was a slight increase in latenty of P1 wave in both left and right eye at HA II. INTERPRETATION & CONCLUSION: From these results it may be concluded that induction to HA causes increase in latency of N1 wave at 4300 m which is still within physiological limits. This increase in wave latency of N1 wave in both eyes may be due to synaptic delay and/or altered neuronal processing at HA.

Auditory evoked functions in ground crew working in high noise environment of Mumbai airport.

The continuous exposure to the relatively high level of noise in the surroundings of an airport is likely to affect the central pathway of the auditory system as well as the cognitive functions of the people working in that environment. The Brainstem Auditory Evoked Responses (BAER), Mid Latency Response (MLR) and P300 response of the ground crew employees working in Mumbai airport were studied to evaluate the effects of continuous exposure to high level of noise of the surroundings of the airport on these responses. BAER, P300 and MLR were recorded by using a Nicolet Compact-4 (USA) instrument. Audiometry was also monitored with the help of GSI-16 Audiometer. There was a significant increase in the peak III latency of the BAER in the subjects exposed to noise compared to controls with no change in their P300 values. The exposed group showed hearing loss at different frequencies. The exposure to the high level of noise caused a considerable decline in the auditory conduction upto the level of the brainstem with no significant change in conduction in the midbrain, subcortical areas, auditory cortex and associated areas. There was also no significant change in cognitive function as measured by P300 response.

Effect of chronic hypobaric hypoxia on components of the human event related potential.

BACKGROUND & OBJECTIVES: Induction to high altitude (HA) leads to deterioration in cognitive functions. The event related potentials (ERPs) like P300 are reported to be affected by hypoxia and bring about impairments in cognitive performance. The aim of the study was to investigate the effect of hypobaric hypoxia on event related potentials at two different altitudes i.e., 3200 m (HA I) and 4300 m (HA II) in ascending order to see how ERPs change with increasing altitude. METHODS: The study was carried out on 20 healthy male volunteers at sea level (SL) and thereafter at high altitude (HA) in Eastern Himalayas and on return to sea level (RSL). The P300 was recorded by using standard auditory odd ball paradigm with compact -4 (Nicolet, USA). RESULTS: The N1, N2 and P2 latencies were not significantly affected at HA I and HA II in comparison with SL indicating no effect of hypobaric hypoxia on sensory conduction. However, at HA II, most of the subjects showed an increase in latency of P3 component reflecting sensory discrimination and delay in evaluation process at 4300 m. At HA I, only 10 out of 20 subjects showed an increase in P3 wave latency and 3 did not show any change in N2-P3 components. INTERPRETATION & CONCLUSION: The results of the present study showed an increase in P300 wave latency at 3200 and 4300 m of high altitude. The observations suggest that hypoxia causes slowing of the signal processing at 4300 m, and magnitudes of the effects are altitude dependent with higher level of decline observed with increasing altitude.

Effect of high altitude on human auditory brainstem responses.

The effect of hypobaric hypoxia on Brain Stem Auditory evoked potentials (BAERs) were studied. BAERs were recorded in 30 volunteers at sea level (SL) and then at high altitude (HA) of 3200 m (HA I) and 4300 m (HA II) in Eastern Himalayas and on return to sea level (RSL). The BAERs were recorded using Nicolet Compact - 4 (USA) in response to monaural auditory stimuli consisting of clicks of 100 ps square pulse at a rate of 15/sec. The BAERs were recorded on day 4 of their stay at 3200 m and 4300 m respectively. Findings indicated an increase in absolute peak latencies of wave V at 3200 m, which was statistically significant. On further ascent to 4300 m there was an increase in absolute peak latencies of wave I and III indicating delay in sensory conduction at the medullo-pontine auditory pathways.

Inadvertent choledochotomy during Frey's procedure: management options.

We report the occurrence of inadvertent injury to the intra-pancreatic common bile duct in 3 of 9 patients undergoing Frey's procedure for chronic pancreatitis with inflammatory mass in the head. In one case, the choledochotomy was extended and anastomosed to the cored-out parenchyma. In the other two, after lateral pancreatico-jejunostomy, hepatico-jejunostomy was performed using the same Roux loop.

Brainstem auditory evoked responses in young urban and rural boys--a comparison.

Brainstem auditory evoked responses (BAER) were studied in a total of 194 boys in the age group between 10-15 yrs taken from a busy metropolitan city and also from a relatively quiet town in order to compare their values and to look into the probable cause of the difference between them, if any. BAER were tested with the help of Compact-4 (Nicolet, USA) instrument using the standard technique. In general, the BAER values of the two sample populations were found to be almost similar with no gross differences in terms of peak latency and inter peak latencies. The values were found to be comparable to adult male values as reported earlier.

Effect of high altitude (HA) on event related brain potentials.

Event Related brain potentials (ERPs) were recorded in 15 subjects using standard auditory odd ball paradigm, in which subjects were presented a sequence of two distinguishable sound stimuli of that occurred frequently (frequently (frequent stimulus-non target) and the other infrequently (rare stimulus-target). These recordings were made at sea level (SL) and then the subjects were air lifted to 3500 m altitude (HA), where they stayed for 3 weeks. Their ERPs were recorded during the first and third week of stay at HA and on return to sea level (RSL). Data indicated impairment in cognitive function as a result of exposure to HA as depicted by increase in the latency of P3 which was significant during the 1st week of stay at HA compared to sea level. The P3 wave latency during the 3rd week of stay at HA showed an increase compared to SL but was not statistically significant. From the results it may be concluded that high altitude hypoxia induced slow processing of stimulus evaluation, may be responsible for increase in P3 latency. The difference in the latent period of P3 waves during the first and third week of stay at HA may be due to continuous stay at HA which might lead to the time dependent adaptive processes occurring with increasing duration of exposure to HA which may induce learning effects.

Effect of sojourn at altitude of 3,500 m on auditory evoked potential in man.

Auditory evoked potentials were studied on 27 male subjects to evaluate the effect of sojourn at high altitude (HA). They were initially studied at Delhi (260 m) for their auditory evoked potentials and were then flown to an altitude of 3,500 m. During their stay at HA the same parameter was tested twice, once on the second day of arrival at HA and another on 21st day of stay. Then they were flown back to sea level (SL) and were retested on the third day of return. The results showed a significant delay in the peak latency of wave I of both the right and left ears on the second day of arrival at HA with a persistent delay in wave V even after 3 days of return to SL. The results suggest that HA stress caused a delay in sensory conduction at the cochlear level during the first week of induction, which was normalised during further stay.