A histopathological study of liver and biliary remnants with clinical outcome in cases of extrahepatic biliary atresia.

Context: The indicators of poor prognosis in cases of extrahepatic biliary atresia (EHBA) continue to remain controversial. Aims: To correlate the histopathological findings of wedge biopsy from liver and tissue obtained from the shaving at the porta hepatis, during hepatic portoenterostomy, with the clinical outcome. Materials and Methods: All cases of EHBA surgically treated in our hospital from 1995 to 2006 have been reviewed. Wedge biopsies of the liver and biopsies from the porta hepatis were analyzed with hemotoxylin-eosin stains and immunohistochemistry. The parameters correlated with clinical outcomes were - presence of large bile ducts ( > 150μm diameter) in the portal tissue plaque, degree of fibrosis (semi-quantitative; graded as mild, moderate and severe), presence of ductal plate malformation (DPM) and age at operation. Results: The proportions of patients with small or large ductal diameter who remained clinically controlled (serum bilirubin < 1.5mg/dl with no evidence of end stage liver failure) were 39% and 66.6% respectively (P=0.44). There was a highly significant correlation between the extent of fibrosis and clinical outcome. Mild, moderate and severe fibrosis resulted in clinical control rates of 78.5%, 34.4% and 24% respectively (P=0.001). Ductal plate malformation was seen in 15% of our cases and was uniformly associated with poor outcome. A non-significant trend towards poorer outcome was seen with increasing age at surgery. Conclusions: Histopathological correl ations with clinical outcome in EHBA have been rarely reported from the Indian subcontinent. A greater degree of fibrosis at the time of hepatic portoenterostomy and presence of ductal plate malformation is associated with a significantly poorer clinical outcome.

Vertigo and dizziness--a clinical approach.

Dizziness is a term which is used to describe a variety of sensations. It is possible to group these complaints into four types: a rotational sensation (Type I dizziness), impending faint (Type II dizziness), dysequilibrium (Type III dizziness) and vague lightheadness (Type IV dizziness). Type I dizziness or vertigo is due to disease of the vestibular system--peripheral or central, and is characterized by a feeling of movement relative to one's surrounding. The majority of dizzy patients, however, belong to Types II, III and IV, collectively called the non-vestibular system disorders. The distinction is usually possible by a detailed history and clinical examination, but some special bedside tests--the dizziness simulation battery--are often required for properly distinguishing the various types of dizziness. Important causes of vertigo and the non-vestibular system disorders have been discussed with focus on benign positional vertigo, acute peripheral vestibulopathy, Menieres' disease, toxic damage to labyrinths, perilymph fistula, cerebrovascular disease, multiple sclerosis, cerebellopontine angle tumors, basilar migraine, vestibular epilepsy, cervical vertigo and phobic postural vertigo.

Squatting, blood pressure and stroke.

Most Indians still adopt squatting posture in toilets. In a group of 67 healthy volunteers, squatting produced a small (8.09 +/- 7.04 mm Hg) but significant rise in systolic blood pressure (SBP) but not in diastolic (DBP). However, in a group of randomly selected treated hypertensives (N=104) squatting produced a much greater and significant rise in both SBP (14.46 +/- 11.63 mm Hg) and DBP (9.10 +/- 9.19 mm Hg). The possible clinical significance of this rise of BP in squatting has been evaluated in 100 consecutive CT proved patients with stroke by analysing their stroke onset data in relation to time, place, posture and activity. Most strokes (52%) occurred in the morning hours (5 am-9 am) and at home (86%) and over a third (36%) while in toilets. Thirty six percent of strokes occurred when the subjects squatted, mostly during defecation. More than half of hemorrhagic strokes occurred in the squatting position. The relationship of these clinical observations with the BP changes noted above on squatting appears to be more than fortuitous. We would suggest that hypertensive subjects and those at risk of stroke should avoid squatting and urge physicians to check squatting BP while monitoring anti-hypertensive therapy.

Intraocular pressure changes and mountaineering--preliminary observations and possible application.

Measurement of intraocular pressure (IOP) has been suggested as an indirect way of assessing the intra cranial pressure (ICP) because of the anatomical relationship between the brain and the eyeball. Mountain-sickness during high altitude climbing results from acute rise in ICP. In this preliminary study, we have observed gradual increase in IOP with gain in altitude in a group of healthy mountain trekkers. Although the rise in IOP had not been steep in most climbers who did not experience any significant symptoms, the rise had been steep into two subjects who experienced symptoms of acute mountain sickness with raised IOP. While clearly further work is needed in this field with larger number of subjects, measurement of IOP appears to be a useful non-invasive screening test in high altitude climbers to avert the risk of acute mountain sickness.

Pulmonary function tests--a comparison between urban industrial and rural agricultural workers of Andhra Pradesh.

Physical parameters and pulmonary function tests (VC, FEV1, FEV1% and FEF25-75%) were collected in 112 urban industrial workers and 104 rural agricultural workers. These average values, values according to age and smoking habits were compared between urban and rural workers. Inspite of no differences in age, rural workers average height, weight, BSA is significantly lower than urban workers. A significant increase in VC value to the extent of 0.22 lit (7.1%), significantly lower FEV 1% value by 4.7% and reduce FEF25-75% value (4.7%) is demonstrated in rural than urban workers. Smoking is shown to produce airway obstruction in both urban and rural workers. A wide variation of PFT values between the present workers and other reported values in India is observed. This study indicates rural workers have better pulmonary capacity and less flow rates than their urban counterpart.

Congenital adrenal hyperplasia: experience at Calcutta.

Eight patients (7 females, 1 male) with congenital adrenal hyperplasia (CAH), were seen over a 24-month period beginning from March 1988. Seven patients had 21 hydroxylase (21-OH) deficiency while one had 11 beta hydroxylase deficiency. Of the 7 patients with 21-OH deficiency, 3 were of the salt losing (SL-CAH), and 4 were of the non-salt losing (NSL-CAH) type. The patients with NSL-CAH were diagnosed by their elevated 17-hydroxyprogesterone (17-OHP) levels. The 3 cases with SL-CAH were diagnosed on the basis of ambiguous external genitalia, typical electrolyte picture, normal female internal genitalia, sex chromatin and response to steroids. In one patient post-ACTH 17 OHP was alter measured. All 3 patients with SL-CAH were assigned the male sex. Sex reassignment was advised for two children; one accepted the advice and the child is doing well; one family did not accept sex reassignment and the child died. One patient died due to non-availability of fludrocortisone. Six patients are under follow-up. All are doing well except one patient with NSL-CAH who started treatment late. We conclude that a high index of suspicion, early diagnosis and meticulous patient education are the key features of successful management of CAH in India.

Pulmonary function status of shopkeepers of Ahmedabad exposed to autoexhaust pollutants.

The study deals with evaluation of pulmonary function status (VC, FEV1% and FEF25-75%) in Ahmedabad shopkeepers stationed near different traffic junctions and relating them with the levels of oxides of nitrogen (NOx) near these junctions categorised as Heavy, Medium and Low polluted area junctions. The pulmonary function test (PFT) values of heavy polluted and medium polluted area shopkeepers is compared with low polluted area shopkeepers. The influence of smoking habits and duration of exposure over PFT values was seen. The prevalence of airway obstruction in shopkeepers was compared with USA population. The results indicated significant impairment in FEV1% and FEF25-75% value in high polluted area shopkeepers where NOx level is much higher than TLV value. In medium polluted area, where NOx level is slightly higher than TLV value, shopkeepers demonstrated significant impairment in FEF25-75%. Smoking is found to have an additive effect. A linear increase in the prevalence of pulmonary impairment with increasing duration of exposure was evidenced. Shopkeepers exhibited higher prevalence of impairment in both smokers and non-smokers than USA population attributing it to the effect of autoexhaust pollutants. This study also denoted that FEF25-75% is an early indicator of obstruction in smaller airways which is the primary site of deposition of inhaled pollutants.

Genetics of epidermal ridges: a study in subjects with refractive errors.

The dermatoglyphic characteristics of subjects with refractive errors when compared with control group revealed significant differences in both qualitative and quantitative parameters. The loops were increased in male myopics; the whorls were increased in male hypermetropics and astigmatics and the arches were decreased in all types of refractive errors in males. However, the whorls were decreased in female hypermetropics only. The mean total ridge count was significantly higher in male astigmatics only. As regards pattern intensity (fingers) no significant difference in the mean value was observed in either sex with any type of refractive errors when compared with those of controls.