Role of drains in cases of peptic ulcer perforations: comparison between single drain versus no drain

Background: Peptic ulcer perforation is one of the commonest causes of peritonitis and needs immediate surgical intervention after prompt resuscitation if mortality and morbidity are to be contained. Aims and objectives of the study was to compare role of Intra-abdominal drains prophylactically after plugging of these perforations single drain or no drain.Methods: In this study, we compared the relative safety and efficacy of putting single drain prophylactically near operation site or in natural abdominal fossae (hepato-renal pouch or sub hepatic) and no drain in cases of peritonitis due to peptic ulcer perforation. Study was done on 60 patients (one drain put in 30 patients Group A and no drain was put in other 30 patients of Group B). We handle the perforation after thorough peritoneal lavage with warm saline and metrogyl. All the perforation was closed by Grahm’s Patch.Results: No significant difference between drain and non-drain group as far age and sex concerned. Significant difference was seen in operative duration, hospital stay, wound dehiscence and post-operative fever, intraperitoneal collection or abscess formation. So use of drains are not effective in preventing post-operative infection rather there are chances of its blockage due to debris, intestine or omentum and tubes itself are source of infection as foreign body and there are chances of migration of bacteria from exterior to peritoneal cavity via these drains.Conclusions: Non drainage of peritoneal cavity after peptic ulcer perforation surgery is an effective method to reduce operative duration, hospital stay and wound dehiscence and post-operative pyrexia.

Frequency & predictors of pancreatitis in symptomatic primary hyperparathyroidism

Background & objectives: The frequency and predictors of pancreatitis in primary hyperparathyroidism (PHPT) are not well understood. The objective of the present study was to evaluate the frequency of pancreatitis in patients with PHPT and its association with clinical and biochemical parameters of the disease. Methods: In this retrospective study all consecutive patients with PHPT registered in the PHPT registry (www.indianphptregistry.com) from the year 2004 to 2013 were included. The clinical, biochemical and radiological parameters related to pancreatitis were evaluated in histologically proven PHPT patients. Results: A total of 218 patients (63 men; mean age: 40.6±14.4 yr) underwent surgery for PHPT during the study. Pancreatitis occurred in 35 [16%, 18 acute and 17 chronic pancreatitis (CP)] patients and male:female ratio was 1:0.94. Skeletal manifestations were seen less frequently in PHPT with pancreatitis as compared to that of PHPT without pancreatitis. PHPT with pancreatitis had significantly higher serum calcium (12.4±2.0 vs. 11.7±1.5 mg/dl, P <0.05) in comparison to PHPT without pancreatitis. PHPT with acute pancreatitis (AP) had higher serum calcium (P <0.05) and parathyroid hormone (PTH) (P <0.05) levels than PHPT with CP. Curative parathyroidectomy improved the symptoms associated with pancreatitis as there was no recurrence in AP group, whereas recurrence was observed only in about 10 per cent patients of the CP group. Interpretation & conclusions: Pancreatitis was observed in 16 per cent of PHPT patients with male predominance in the study population. No recurrence of AP was observed after curative surgery. It may be proposed that serum amylase with calcium and PTH should be measured in all patients of PHPT with pain abdomen to rule out pancreatitis.

Comparative evaluation of Metoprolol and Telmisartan in hypertensive patients.

Background: Epidemiological studies and clinical trials have shown that meticulous control of blood pressure is required in patients with hypertension to ensure decreased cardiovascular morbidity and mortality. Objective: To compare the effect of Metoprolol and Telmisartan on blood pressure reduction and heart rate in patients of Stage I Hypertension. Material and Methods: This was a prospective, randomized, open, parallel study conducted at the outpatient department of Medicine. Patients of either sex with Grade I Hypertension according to JNC VII, aged between 18-60 years were enrolled and followed up every 2 weeks from baseline till 12 weeks. Patients were randomly divided into two groups to receive tablet Metoprolol 50 mg (Group A, n=30) and Telmisartan 40 mg (Group B, n=30) once a day. Response to study treatments was evaluated in terms of decrease in Blood pressure and heart rate. Results were analysed using Student’s ‘t’ test. Results: Baseline characters of both the groups were well balanced. Systolic Blood Pressure was reduced by 7.5 % from Metoprolol and 12.9% by Telmisartan and Diastolic Blood Pressure was reduced by 8.2% in group A and 13.6% in group B. Both the drugs leads to significant reductions (i.e. P <0.05) in systolic as wel as diastolic BP. Heart rate reduction was significant and was observed to be more with the Metoprolol group i.e. 15.2% reduction as compared to 9.1% reduction with Telmisartan. Conclusion: Telmisartan is a better choice than Metoprolol in Indian Population for treating Grade I hypertension as it leads to greater reduction in Blood Pressure and less effect on Heart rate.

Cardiodepressant activity of 90% alcoholic extract of Terminalia arjuna and its probable mechanism of action.

Background: Terminalia arjuna is being used in various cardiovascular diseases as cardiotonic, diuretic & in hypercholesterolemia. Studies conflict each other for its mechanism of action. This study aims to investigate effect of 90% alcoholic extract of Terminalia arjuna on in vitro isolated rabbit’s heart & to find its probable mechanism of action. Objective: To study the preliminary pharmacological effects of 90% alcoholic extract of Terminalia arjuna in-vitro on isolated heart, coronary blood flow, and to study its probable mechanism of action. Material & Methods: Effect of Terminalia arjuna was observed on heart rate, coronary blood flow, amplitude on in vitro isolated perfused rabbit’s heart mounted on langendorff apparatus & further cholinergic & adrenergic blockers were used to study the mechanism of action. Six experiments were conducted for each parameter & data was analysed using Student’s t test. Results: Terminalia arjuna causes mean percentage decrease of 7.26%, 9.31% & 20.51% in heart rate, decrease of 10.34%, 16.64%, 20.51% in coronary blood flow & decrease of 15.11%, 12.61%, 11.65% in amplitude at 25μg, 50μg & 100μg doses respectively. The decrease in heart rate, coronary blood flow & amplitude persists even after cholinergic & adrenergic blockers suggesting that cholinergic & adrenergic receptors are not involved in mechanism of Terminalia arjuna. Conclusion: Terminalia arjuna cardiodepressant effect does not involve cholinergic & adrenergic receptors.

Efficacy of cabergoline on rapid escalation of dose in men with macroprolactinomas.

Background & objectives: Since cabergoline has a long half-life and sustained occupancy of dopamine (D2) receptors in lactotrophs, its doses are slowly built up either monthly or two monthly. This possibly results in delayed normalization of serum prolactin and slow reduction in tumour size. This study was planned to assess the efficacy and safety of rapid escalation of cabergoline doses in men with macroprolactinomas. Materials: Fifteen consecutive men with macroprolactinomas underwent evaluation for anterior pituitary functions, visual fields, quality of life (QOL) score and magnetic resonance imaging (MRI), at baseline and after 6 months of cabergoline therapy. Serum prolactin and testosterone levels were assessed at monthly intervals. Cabergoline was started at a dosage of 0.5 mg twice per week and increased to 1.5 mg twice per week (3 mg ) by the third week, as 3 mg is usually considered as effective dose. Subsequent increase in doses was done as per protocol. Results: The mean age of patients at presentation was 31.7 ± 3.3 yr and duration of symptoms was 25.0 ± 3.6 months. Serum prolactin at baseline was 6249.3 ± 3259.2 μg/l with a tumour volume of 28.9 ± 8.3 cm3. Eighty six per cent of the patients had visual field defects while 53 per cent had decreased visual acuity. The mean dose of cabergoline required was 3.2 mg/wk. Symptoms improved in majority (93%) of patients after four weeks of cabergoline therapy with a dramatic fall in serum prolactin by 99 per cent from 6249.3 ± 3259.2 to 46.9 ± 14.9 μg/l and it was normalized in 93 per cent of the patients by 8.2 wk. Improvement in visual field defects was noted in all but one, after one month and there was further improvement at 6 months. All patients had >25 per cent reduction in tumour size, and 73 per cent had > 50 per cent reduction after six months of cabergoline therapy. Basal circulating testosterone levels were low in 11 (73%) patients and started improving from first month of cabergoline therapy and became normal in around half of the patients after 6 months. No major side effects were observed requiring discontinuation of cabergoline therapy. Interpretation & conclusions: Our preliminary findings show that rapid build-up of cabergoline doses increases its efficacy as well as rapidity of response in terms clinical improvement, normalization of serum prolactin and gonadal functions and reduction in tumour size, without compromising its safety in men with macroprolactinomas. Further studies with a larger sample size and control group for comparison need to be done to confirm these findings.

Radioactive iodine therapy in Graves' hyperthyroidism: a prospective study from a tertiary referral centre in north India.

BACKGROUND: Radioactive iodine has gained widespread acceptance as the first-line therapy for Graves' hyperthyroidism and is the preferred treatment option in most situations. OBJECTIVE: A prospective study was conducted to look at the therapeutic practice of use of radioactive iodine in the treatment of Graves' hyperthyroidism, to determine whether the expected or desired therapeutic outcome is achieved. SETTINGS: A tertiary referral centre in north India, Delhi that caters to patients with thyroid disorders. METHODS: One hundred and seventy four consecutive subjects with Graves' hyperthyroidism, who were given radioactive iodine were followed up. RESULTS: There were 59 (33.9%) males and 115 (66.1%) females. The mean age was 41.8 +/- 9 years. The dose of radioactive iodine ranged from 2 mCi to 15 mCi and the mean dose administered was 5.2 +/- 1.9 mCi. After one year following radioactive iodine therapy, 29 (16.7%) subjects were euthyroid, 51 (29.3%) were hypothyroid and the remaining 94 (54%) had persisting hyperthyroidism. Those subjects with persisting hyperthyroidism at one year after radioactive iodine had received a significantly lower dose compared to the groups who had achieved cure (either euthyroidism or hypothyroidism). CONCLUSION: The study shows that the current practice of empirical low dose radioactive iodine therapy to avoid hypothyroidism results in majority of patients having persisting hyperthyroidism. There is a need to take a new look at the current practice to increase the cure rate.

Comparative immunological and histopathological study in fifty cases of mucosal/nonmucosal lichen planus.

Lichen planus is a common disorder and 40-50% of LP patients also reveal mucosal lesions. It is well known that mucosal LP lesions take very long to heal in comparison to cutaneous lesions. Rarely erosive mucosal LP can turn malignant. Both CMI and humoral immunity may play role in aetiopathogenesis of LP. Present study was conducted to study and compare CMI, Humoral Immunity, histopathology in mucosal and nonmucosal LP.

Clinico-histopathological study of subacute cutaneous lupus erythematous.

Fourteen cases of sub acute cutaneous lupus erythematosus (SCLE) were selected from Dermato-Venereology outpatients during the last 2(1/2) years. Clinically all patients revealed photosensitivity and annular plaques either covered with peripheral collarette of scale or EM--like or DLE--like lesions. Systemic associations were arthralgia in 4, hypertension in I. rheumatoid arthritis in I and pulmonary tuberculosis in L Histopathologically epidermal atrophy, interface dermatitis, basal cell degeneration, colloid bodies and mononuclear infiltrate of dermis were salient features. Good response to 15 mg prednisolonc, medium potency topical steroids and sunscreens was seen in all cases.

Clinical, biochemical and cytomorphological observations in juvenile chronic lymphocytic thyroiditis.

OBJECTIVE: To determine the clinical, biochemical, ultrasonological and cytomorphological features in goitrous juvenile chronic lymphocytic thyroiditis(CLT). SETTING: Tertiary referral center for thyroid disorders. SUBJECTS: A total of 455 children were evaluated for goiter. Of these 122 children had features of CLT in FNAC and were further studied. METHODS: All subjects were subjected to detailed clinical examination. The thyroid functional status was assessed by estimation of serum concentration of thyroid hormones (thyroxine and triiodothyronine) and thyrotropin (TSH). In addition the antithyroid antibody titers were measured. Ultrasonological and cytomorphological characteristics in these patients were also evaluated. RESULTS: The mean age at presentation was 12.5 years (SD 3.93). The male: female ratio was 1:7.7. Thyroid functional status as assessed by serum thyroxine and thyrotropin levels revealed, euthyroidism in 67 (54.9%), hypothyroidism in 30 (24.6%), subclinical hypothyroidism in 22 (18%) and hyperthyroidism in 3 (2.5%). Thyroid antimicrosomal antibodies were detected in significant titers in 90 (73.8%) and antithyroglobulin was positive in 71 (58.2%). The positivity of the antimicrosomal and antithyroglobulin antibodies were much higher in subjects with hypothyroidism and was detected in 86.5% and 69.2%, respectively. The mean urinary iodine excretion was 74.1 micrograms/g of creatinine (SD 31.4) indicating mild iodine deficiency. Fine needle aspiration cytoloty (FNAC) revealed features of chronic lymphocytic thyroiditis. Hurthle cell changes was seen in only 12% of the cases. The epithelium was more often hyperplastic and vacuolation of the cytoplasm and peripheral vacuolations were seen frequently. Giant cells and epithelioid cells were seen in many cases. CONCLUSIONS: In any child presenting with firm goiter, a diagnosis of CLT should be excluded. Many subjects with juvenile CLT have biochemical evidence of hypothyroidism but only few symptoms or clinical features.

Effect of attachment surface on the growth and differentiation of breast cells.

This experimental work was undertaken to study the difference in cell growth due to different attachment surface. Three types of attachment surface were studied (i) collagenized surface (ii) glass surface and (iii) plastic surface. Rat tail collagen suspension was prepared and coated on culture flasks. Human breast epithelial cells and breast carcinoma cells were cultured for three weeks. Cell counts were made before and after one, two and three weeks of culture. Out of five cases only two survived for more than a week. The best survival was observed on plastic surface. Collagenized and glass surfaces had similar results. Thus plastic surface is probably the best compared to glass and collagenized surface, possibly because the plastic surface provides better adhesion to malignant cells. It was also seen that in plastic surface the cells get lined up around a basement membrane like structure growing a resemblance to ductal structure. This is contradictory to the prevalent view that collagenized surface is best for in vitro growth and differentiation.

Thyrotoxicosis--treatment by I131 therapy and early prediction of hypothyroidism following this therapy.

This study was undertaken in 68 thyrotoxic patients to assess the predictive value of various post treatment biochemical and immunological tests for early hypothyroidism after I131 therapy and to determine whether pretreatment with carbimazole protects against post I131 therapy hypothyroidism. Early changes observed in serum T3, T4, TSH, thyroid microsomal and thyroglobulin antibody levels were found to be of no predictive value. A sharp increase in TRAb levels around 3 months following I131 therapy indicated that hypothyroidism was likely to occur as this rise reflected a greater degree of thyroid damage. Lower levels of thyroglobulin in patients who became hypothyroid by 12 months after treatment would support this view. Carbimazole pretreatment for eight weeks did not appear to protect against hypothyroidism, in our study.