Biochemical and clinical profile after organophosphorus poisoning--a placebo-controlled trial using pralidoxime.

BACKGROUND: Organophosphorus (OP) compounds are the most common suicidal poison in developing countries and mortality continues to be high. METHODS: A study was done to see butyryl cholinesterase (BuChE) profile after OP poisoning in pralidoxime (P2AM) and placebo treated cases. Highest recommended dose of P2AM was used to study the reactivation of cholinesterase. Clinical outcomes like, correlation of BuChE and severity of poisoning, mortality and complications like Type I and II paralysis, need for ventilation and ICU stay were also studied. RESULTS: Twenty one cases of moderate and severe poisoning with OP compounds were included in the study. Mean BuChE levels came up gradually over 6-7 days, some taking up to two weeks. There was no. difference between the treatment and placebo groups. BuChE levels did not correlate with severity of poisoning nor did it correlate with Type I or II paralysis, need for ventilation, ICU stay or mortality. CONCLUSIONS: Treatment with P2AM does not make any difference in BuChE reactivation or complications of moderate and severe OP poisoning. We have not been using P2AM for OP poisoning in our medical ICU with good patient outcomes.

A comparative study on idiopathic pulmonary fibrosis and secondary diffuse parenchymal lung disease.

BACKGROUND AND AIMS: Clinical characteristics of patients diagnosed to have Diffuse parenchymal lung disease (DPLD) were evaluated in this study. DESIGN AND SETTING: Retrospective evaluation, a tertiary care center in South India. MATERIAL AND METHOD: Subjects diagnosed to have DPLD over a five-year period were included in this study. Data pertained to clinical characteristics and lab parameters were obtained. STATISTICAL CONSIDERATIONS: t- test for Mean values and chi-square test for comparing proportions were used. RESULTS: There were 73 eligible patients included for evaluation. Secondary cause for DPLD was diagnosed in 40 (55%) and idiopathic pulmonary fibrosis (IPF) was diagnosed in 33 (45%). The mean age was 45+/-11 and 53+/-10 years, of these 5 (12%) and 17 (52%) were male subjects in the secondary DPLD and IPF group respectively. The mean age, dyspnoea, cough, clubbing and crepitations were noted to be higher in patients with IPF as compared to patients with secondary DPLD. Fifty patients were followed up for a mean of 13 months (28 secondary DPLD and 18 IPF). Follow up data was available in 46 patients. Of these subjects prednisone alone was initiated in 24 subjects and combination with azathioprine in 22. Subjective improvement in symptoms was noted in 29/46 (63%), 19 with secondary DPLD and 10 with IPF. CONCLUSION: symptoms and signs were noted more frequently with IPF, subjective improvement to treatment was noted in 63% and the best response was noted among patients diagnosed to have sarcoidosis. A prospective trial is needed to study the long term prognosis and therapeutic response among Indian patients.

Clinical characteristics and treatment response among patients with multidrug-resistant tuberculosis: a retrospective study.

BACKGROUND: This retrospective study was conducted to evaluate the characteristics and therapeutic response among patients with multidrug-resistant tuberculosis (MDR TB). METHODS: One hundred subjects with isolates resistant to isoniazid and rifampicin were included over a three-year period (1997-1999). There were 82% males with a mean age of 36 years, mean duration of symptoms of 29 months, and a previous history of tuberculosis in 85% (pulmonary 96% and extrapulmonary 4%). RESULTS: HIV ELISA test was positive in two out of 28 (7%) patients while diabetes was diagnosed in 16 percent. Mean time to diagnose MDR TB was 5.5 months. Subjects had received a mean of 3.2 anti-TB drugs before the diagnosis of MDR TB was made. Forty-five patients were lost to follow-up. The rest had a median follow-up of 13.5 months (range 1-37 months). Follow-up AFB smear and culture results were available in 49 out of 55 and 26 out of 55 patients, respectively. Sputum smear became negative for AFB in 26 out of 49 (53%) and culture converison occurred in 16 out of 26 (61.5%) patients. Clinical and radiological response was noted in 31 (56%) and 13 (32.5%) out of 40 patients respectively. A mean of 5.5 drugs was used in those who achieved sputum conversion. Combination therapy containing ofloxacin in the regimen was noted to have a favourable response. CONCLUSION: Only a limited number of patients with MDR tuberculosis have a favourable response.

Prevalence of bronchial asthma among bank employees of Vellore using questionnaire-based data.

Asthma and related allergic disorders are reported to be rare in poor and developing countries and their prevalence is expected to rise with urbanisation. Investigation was carried to see the prevalence of asthma and asthma-related symptoms by using a simple questionnaire-based data collection. One hundred and twenty bank employees were studied in the age group 25-55 years in 4 centres of Vellore town. A one-page questionnaire in English regarding asthma and allergic symptoms was used to assess the prevalence and the details of medical care utilisation by those who were asthmatics. The prevalence of self-reported bronchial asthma was 8.3% and that of asthma-related symptoms 15.8%. A significant number of subjects with symptoms suggestive of asthma self-reported themselves as non-asthmatic. There was a significant association between those who had symptoms of asthma and a positive family history of asthma. Most of the asthmatic subjects using allopathic medicines reported a poor quality of life, despite treatment. The prevalence of asthma in Vellore town is more than that reported in other studies carried out at different centres in India. The prevalence may actually be higher since a significant number of subjects with symptoms suggestive of asthma reported themselves as non-asthmatic subjects. As expected, positive family history was forthcoming in subjects with asthma symptoms. Most asthmatic subjects have not experienced a significant improvement in their quality of life, which could indicate sub-optimal management. These findings can form the basis for further studies to investigate factors that lead to these variations.

Abdominal tuberculosis affecting lesser omentum.

We present a case of a young man who presented with fever and nonspecific epigastric symptoms and fluid collection in the lesser omental sac, which was proved to be of tubercular etiology.

Enthesopathy: clinical recognition and significance.

Enthesopathy is a common clinical finding denoting pathology at the 'entheses', i.e. attachment sites of muscles, tendons, joint capsules, ligaments and fascia to the bone. Inflammatory enthesopathy or enthesitis is a sine qua non of seronegative spondyloarthropathies (SSA). It can also be occupational, metabolic, drug induced, infective or degenerative. Bursitis closely mimics enthesitis. Ultrasound with high frequency transducers is a simple, cost-effective and feasible test to detect enthesopathy which is amenable to treatment with local steroid injections, physiotherapy and non-steroidal anti-inflammatory drugs, in addition to treatment of the primary disease. Unrecognized and untreated, it can lead to considerable morbidity.

Pulmonary nocardiosis in human immunodeficiency virus infection: a tuberculosis mimic.

Patients with human immunodeficiency virus (HIV) infection are prone to develop pulmonary infections like nocardiosis. It is often misdiagnosed as pulmonary tuberculosis since the manifestations are similar. A twenty-seven years old male presented with fever, cough with expectoration and weight loss for two months. Chest radiograph showed opacity in the right mid zones. Sputum smears were negative for acid fast bacilli (AFB) and revealed gram positive branching filamentous organisms resembling Nocardia species. Subsequently, Nocardia was grown on sputum culture. HIV antibody was positive by ELISA test. He was treated with co-trimoxazole. If sputum is repeatedly tested negative for AFB in the setting of radiological suspicion of tuberculosis, testing for Nocardia species should be considered in the HIV-infected patients.

Unusual association of Kikuchi's disease and dengue virus infection evolving into systemic lupus erythematosus.

Kikuchi's disease is a histologically alarming self-limiting condition typically affecting the lymph nodes of young females. A 13-year-old girl was presented with fever, skin rash and cervical lymphadenopathy. On examination she was found febrile, mild pallor was present and she had lymphadenopathy. Liver was palpable. Cervical lymph node biopsy showed histiocytic necrotising lymphadenitis (Kikuchi's disease). Dengue virus serology for IgG blot showed evidence of seroconversion in serial samples. She was treated with antibiotics and fluconazole and cyclosporin A. During hospitalisation she developed retinal vasculitis. She was reviewed after one month and showed rashes of subacute cutaneous lupus erythematosus. This case can be described to be a triggering event by dengue viral infection causing abnormal immune response leading initially to Kikuchi's disease and later on to systemic lupus erythematosus.

Randomized controlled trial on the effective dose of anti-snake venom in cases of snake bite with systemic envenomation.

Snake bite is the common cause of morbidity and mortality in India. Snake antivenom, although very effective, is expensive, scarce, and associated with side effects. The conventional dose may not be required in all cases and a smaller dose may be as effective. A randomized double blind controlled trial was conducted to compare the effect of lower versus the conventional (high) dose. Patients presenting within 24 hours of snake bite with hematological or neurological evidence of systemic envenomation were included in the study. Patients were randomized either to receive high dose (2 vials over 1 hour, followed by 2 vials over 4 hours and repeated 4 hourly until clotting parameters normalized and then 2 vials as infusion over 24 hours) or low dose (2 vials over 1 hour, followed by 1 vial over four hours, repeated 4 hourly until clotting parameters were normalized and then 1 vial as an infusion over 24 hours). Thirty one patients received high dose and 29 a low dose. The mean dose of antivenom used was significantly different in the two groups (8.9 and 4.7, respectively). There was no mortality. The duration of stay was 4.94 and 3.48 days, respectively. There was no difference in the transfusion, dialysis or ventilation requirement of the two groups. Low dose regimen is more effective and required 5 vials less than the conventional dose. Each vial costs Rs. 200, so the estimated savings is Rs. 1000 per patient.

A randomised control trial on sequential drug monotherapy versus conventional step care therapy in the treatment of mild to moderate hypertension.

OBJECTIVES: There are many studies in the literature on single drug therapy (monotherapy) for mild to moderate hypertension. These studies show comparable efficacy, side effect profile and compliance. It has not been shown yet, whether the number of patients controlled on monotherapy can be improved by systematically stopping a drug which does not adequately control blood pressure and starting another drug in a sequential manner until blood pressure is well controlled. The aim is to show that sequential drug monotherapy (SDM) is as good as step care therapy (SCT) in controlling mild to moderate hypertension. METHODS: Patients attending three medical outpatient departments of Christian Medical College and Hospital, with mild to moderate hypertension uncontrolled on single drug therapy formed the patient population. They were then randomised to the sequential drug monotherapy or step care therapy. The choice of one of the five antihypertensive drugs was left to the attending physician. RESULTS: Thirty two and 42 patients entered the study and 28 and 35 completed the study in SCT and SDM group, respectively. Follow up was for a period of three months. BP was controlled 100% each in SCT and SDM groups. Efficacy with intention to treat was 85.2% in SCT and 81.8% in SDM group. Percent controlled with second drug was 82 and 71, controlled with third drug was 18 and 14 in SCT and SDM, respectively. Mean duration of treatment for control for BP was 1.7 and 2.3 months in SCT and SDM groups respectively. Average cost in SCT was Rs 66.28 and in SDM was Rs 45.53 per month (p = 0.005). Incidence of ADR was 28.6% and 10.5% in SCT and SDM groups, respectively (p = 0.06). CONCLUSIONS: SDM is as effective as SCT, SDM offers the following advantages: less expensive, better compliance, fewer complications, drug interaction and thus improved quality of life.

Post lumbar puncture headache: is bed rest essential?

Headache following lumbar puncture is a well known and well described complication. Various manoeuvres have been tried to prevent post lumbar puncture headache--the commonest being bed rest for 4 to 24 hours following lumbar puncture, though its value is questionable. Randomised controlled clinical trial was done to evaluate the effect of 24 hours bed rest on the incidence and severity of post lumbar puncture headaches. Two hundred and eight patients were randomly allocated to either the ambulant or the bed rest group. Patients were interviewed by a single investigator on days 0, 1, 2 and 7 about the presence and nature of headache. Other relevant clinical and laboratory data pertaining to the lumbar puncture was collected. The overall incidence of post lumbar puncture headache was 17%; 15% in the ambulant and 18% in the bed rest group. Of the patients who had headaches, severe headache was observed in 57% in the ambulant and 12% in the bed rest group (p = 0.02). Other variables did not alter the outcome of headaches. Bed rest does not appear to alter the incidence of post lumbar puncture headaches, but reduces the severity in those who get headaches, after a lumbar puncture.

A randomized double-blind sham-controlled study of intrathecal human anti-tetanus immunoglobulin in the management of tetanus.

BACKGROUND: Tetanus is a major cause of mortality and morbidity in developing countries. Various modalities of treatment to prevent progression of the disease and alter its outcome have been tried. This study was designed to evaluate the role of intrathecal human anti-tetanus immunoglobulin (TIG) in the management of tetanus. METHODS: Thirty-six adult patients presenting to an university-affiliated teaching hospital were stratified based on the severity of disease into mild and severe disease, and subsequently randomly allocated to receive either 250 i.u. of TIG intrathecally or a sham procedure mimicking the lumbar puncture. RESULTS: In mild tetanus, TIG administration significantly retarded the rate of progression (p = 0.05), reduced the duration of hospital (p = 0.01) and intensive care unit stay (p = 0.05), need for tracheostomies (p = 0.03) and the dose of sedatives required for control of spasms (p = 0.01). In mild tetanus, the mortality rates were 20% and 30% in the treated and control groups, respectively. CONCLUSION: We suggest that TIG is useful in reducing the morbidity, progression of disease and mortality in patients presenting with mild tetanus.

Predictors of mortality in a medical intensive care unit.

BACKGROUND: Scoring systems to predict mortality in intensive care units have been developed in western populations. There is a need to identify and validate prognostic variables in the Indian context. We compared two scoring systems to predict the discharge outcome in patients admitted to a medical intensive care unit. METHODS: Five hundred patients admitted to a medical intensive care unit were studied prospectively. Modified acute physiology and chronic health evaluation II (APACHE II) score and modified organ system failure (OSF) score were applied on the day of admission to the intensive care unit. The scores obtained by the two systems were compared using the area under the curve approach. The likelihood ratios were calculated for predicting discharge outcome. RESULTS: The modified OSF score predicted discharge outcome better than the modified APACHE II score--receiver operating characteristic curve area (standard error-area) 0.7062 (0.0244) and 0.6068 (0.0267) for the modified OSF and the modified APACHE II scores, respectively. This was statistically significant (p < 0.001). The likelihood ratio for the modified OSF score for different cut-off points varied from 0.27 to 5.49, while the likelihood ratio for the modified APACHE II score varied from 0.11 to 2.08. This means that for an intensive care unit with a 30% overall mortality, the modified OSF score could separate patients with 10% to 70% mortality, while the modified APACHE II score could predict only 5% to 47% mortality. CONCLUSION: The modified OSF score was superior to the modified APACHE II score in predicting mortality in patients admitted to the medical intensive care unit.

Epidemiological features of acquired immunodeficiency syndrome in southern India.

AIDS was diagnosed in 187 men and 24 women (M:F = 8:1) from April 1987 till December 1994 at the Christian Medical College Hospital, Vellore. The doubling time of the occurrence of AIDS cases was 14 months; during 1987-90 there were an average of 5.7 cases per year; in 1991-93 there were 28 per year; in 1994 there were 104 cases. The mean age of patients was 33 yr for men and 31 for women. Among men, the primary mode of infection was heterosexual contact with female commercial sex workers. Among women, the most common source of infection was their husbands. There were 4 bisexuals and one homosexual subject who might have acquired infection by having sex with other men. There were 135 subjects from urban and 76 from rural communities. Most subjects belonged to the lower socio-economic classes. These data show that HIV infection had been very widespread in this region, both urban and rural.

Drug interaction: rifampicin and glibenclamide.

BACKGROUND: Rifampicin is a potent inducer of the hepatic microsomal enzyme system. However, the drug has been shown to cause clinically important interactions with many drugs. This study was designed to test the interaction of rifampicin with the oral hypoglycaemic agent glibenclamide. METHODS: Twenty-nine well-controlled diabetic patients on a combination therapy of diet and glibenclamide, and willing to participate in the trial, received a daily dose of 450 mg (body weight < 50 kg) or 600 mg (body-weight > 50kg) of rifampicin for 10 days. RESULTS: There was a significant (p < 0.001) worsening of fasting and post-prandial blood sugar after administration of rifampicin. Dose modification of glibenclamide was required in 15 of the 17 patients in whom the diabetes became uncontrolled. Blood sugar normalized by day 6 after stopping rifampicin in all patients. CONCLUSION: Rifampicin and glibenclamide interact. Therefore, necessary dose modifications should be made in order to achieve euglycaemia if these two drugs are given together.