Does preoperative biliary stenting affect the outcome of pancreatico-duodenectomy?

BACKGROUND: Controversy exists whether preoperative endoscopic biliary stenting to reduce serum bilirubin level affects the outcome of pancreaticoduodenectomy. AIM: To determine whether preoperative endoscopic biliary stenting is associated with altered morbidity or mortality after pancreaticoduodenectomy. METHODS: In 37 consecutive patients with periampullary lesion undergoing pancreaticoduodenectomy over a 6-year period, frequency of septic complications, occurrence of pancreatic leak or bleeding, duration of hospital stay, and mortality were studied; of these, 15 had preoperative biliary stenting and 22 had not. RESULTS: Postoperative infective complications occurred more often in the patients with biliary stent than in those without (26% vs 0%, p=0.04). Postoperative recovery time, hospital stay and mortality were similar in the two groups. CONCLUSION: Preoperative biliary stenting is associated with septic complications, but this does not affect postoperative recovery after pancreaticoduodenectomy.

Intranasal administration of fusidic acid cream in leprosy.

The effect of local treatment of nostrils with fusidic acid cream was investigated in 30 previously untreated lepromatous leprosy patients. The cream was applied in the nostrils after flushing the nostrils with normal saline, twice a day for a period of four weeks. It was found that 20 mg/gm of sodium fusidate was effective in reducing the morphological index of the nose-blow smear to zero in two weeks in majority of the patients. No untoward side effect was seen in any of the patients. Such nasal treatment along with multidrug therapy may help in reducing the patient's level of infectiousness to their contacts, since the nose is recognized to be an important portal of exit of M. leprae.

Comparative efficacy of three measles vaccines in Indian children.

A Comparative study of three types of measles vaccines was undertaken among 1005 children. Of these 527 were vaccinated with the Serum Institute of India (SII) vaccine, 230 with Schwarz (SC) and 248 were vaccinated with Edmonston-Zegreb (EZ) vaccine (imported from Zegreb). Though the majority of children reacted favourably with all the three vaccines (SII: 98.43%; SC: 93.40%; EZ: 93.0%) with a rise in titre, but the percentage of seroconversion was significantly higher with the SII vaccine (p < 0.01). The Schwarz and Edmonston Zagreb vaccines showed significantly less GM titre as compared with the other age group i.e. 9-12 months (p < 0.05). With Serum Institute of India (SII) vaccine the GM titres were almost similar in the different age groups. The overall GM titre obtained with the SII vaccine was significantly higher than the SC vaccine (p > 0.001) as well as the EZ vaccine (p > 0.001). It is of interest to note that among the infants, 22.5% children had measles antibody in them before vaccination.

A study of pure neuritic leprosy: clinical experience.

Pure neuritic leprosy is a well-recognized clinical entity. Manifestations of leprosy in pure neuritic form accounted for 179 patients out of the total 3853 leprosy patients (4.6%) attending our Poona Urban Leprosy Investigation Centre clinics. Patients with pure neuritic leprosy are prone to develop nerve damage. Eight-seven (48.6%) of our pure neuritic patients presented with deformities. Involvement of upper extremity and right ulnar nerve in particular was the most common clinical feature. Patients presenting with involvement of two nerves of the same extremity was also quite common. None of our patients developed skin lesions while on anti-leprosy treatment. It is important to recognize neuritic symptoms early and suspect leprosy even in the absence of skin lesions.

Study of deformities in children with leprosy: an urban experience.

A study was conducted to assess the deformities in children with leprosy. Eyes, hands and feet were examined for leprosy-related deformities. The influence of age, sex, duration of disease, type of disease, occurrence of leprosy reactions and anti-leprosy treatment on the occurrence of deformities was studied. In our urban leprosy project the percentage of children (0-14 years) suffering from leprosy is 7% of the total number of leprosy patients. The response to multidrug therapy, health education and physiotherapy was good.

Wax therapy for dry feet in leprosy.

A comparative study of the effect of wax therapy and foot soaks on dry plantar skin was conducted in patients with leprosy. Thirty patients with varying grades of fissures and callosities were given wax therapy for feet, and 20 similar patients were given foot soaks. Patients given wax therapy felt subjectively much better than those who had soaking. Healing of cracks and fissures and softening of callosities was observed more frequently in patients with wax therapy. These differences are statistically significant. As an institutional method wax therapy has definite advantages for treating patients with fissures and callosities, whereas soaking of the feet is easy and readily available in patients' homes to restore the dry skin to normal.

Oral zinc therapy in recurrent erythema nodosum leprosum: a clinical study.

Effect of oral zinc as an immunomodulator was studied clinically in patients with recurrent ENL over a period of one year. In this study, 40 leprosy patients with chronic ENL, requiring more than 30-40 mg of prednisolone/day for the control of their reactions, were given oral zinc sulphate for a period of four months, and, marked improvement in the frequency, duration and severity of reactions was observed after zinc therapy. Also evident was marked reduction in the steroid requirement after oral zinc therapy. It appears that zinc may be a good substitute for the present day anti-reaction treatment which is not free from disadvantages. Further investigations to know the precise action of zinc on immune-system may help to understand the role of zinc therapy and its optimum duration.

Gelatin particle agglutination assay to detect anti-PGL-I antibodies in leprosy patients and in household contacts: a preliminary study.

A preliminary study of anti-phenolic glycolipid-I (PGL-I) IgM antibody detection using M. leprae gelatin particle agglutination (MLPA) test kit is described. Antibodies were demonstrated in 70% of our leprosy patients taking antileprosy treatment. The percentage of positivity of multibacillary cases was 86.0, whereas that of paucibacillary cases was 30.0. Good correlation was found between bacteriological index and the presence of antibodies. Antibodies were detected in 28% of our patients released from treatment. Fourteen out of 27 household contacts were found to have antibodies but none of the normal controls were seropositive. These preliminary data demonstrate that MLPA test is not applicable as sero-diagnostic test or as a test of cure, but may be useful for epidemiological studies and as a research tool.

Comparison of two multidrug regimens in multibacillary leprosy.

One of the technical problems relating to the multidrug therapy of leprosy is the slow decrease in the bacteriological index (BI) in multibacillary patients. In this study we have compared a regimen containing rifampicin given daily for 9 months with the standard WHO multidrug regimen for multibacillary leprosy. We have found, at the end of two years, a significantly greater fall of BI in patients who had received the regimen containing daily rifampicin as compared to those who had received pulsed doses of rifampicin. The doses of dapsone and clofazimine were similar in these two groups. It appears that daily administration of rifampicin may be useful in treating multibacillary patients in whom reduction in the BI is slower than expected. However, in view of its high cost and the very much increased incidence of type-2 lepra reactions and hepatitis, daily rifampicin therapy cannot be recommended for a control programme.

Hyperkeratotic and verrucous skin lesions on lower extremities of leprosy patients.

Three morphological varieties of hyperkeratotic and verrucous skin lesions on the anterior aspect of ankle joints in patients with leprosy are described: (i) verrucous lesions with thread-like horny projections similar to filiform warts; (ii) irregular compact hyperkeratotic lesions with deep fissures in between; and (iii) hyperkeratotic lesions with linear fissures corresponding to the transverse creases on the anterior aspect of the ankle. Chemical cautery was useful for the treatment of the first two varieties, and a potent topical corticosteroid with salicylic acid was useful for the third.

Vibration sense and tarsal disintegration.

The extent of loss of vibration and pressure sensations was assessed in 21 leprosy patients with disintegration of the tarsus. Feet which had and did not have tarsal disintegration both showed severe impairment of pressure sensation, but the loss of vibration sense was more severe in feet which had undergone the destructive process. It appears that loss of deep sensation is an important factor in the process of tarsal disintegration in feet which are already anaesthetic. Measurement of vibration sense using a biosthesiometer may be a valuable clinical test in the investigation and follow-up of the patient with the insensitive foot to identify those at risk of developing tarsal disintegration.

Newer designs in foot-wear for leprosy patients.

Micro-cellular rubber (MCR) foot-wear has been used widely over the past several years for the anaesthetic feet of leprosy. Although MCR has got good shock absorbing and moulding qualities, many tend to reject the foot-wear because of the stigma of the disease which it carries. Two newer models of foot-wear which would meet the demands of anaesthetic sole and avoid the stigma because of their resemblance to foot-wear available in the market were tried. Model mark II fulfilled the needs and was acceptable to the patients. Such models must be tried and acceptable and effective foot-wear need to be made available.

Thalidomide in type-2 lepra reaction--a clinical experience.

A clinical experience of using thalidomide in type-2 lepra reaction (ENL) in 90 male patients--57 with lepromatous leprosy (LL) and 33 with borderline lepromatous leprosy (BL)--is described. All the patients responded well although some took a longer time to improve. No major side effects were observed except for giddiness in 10 and gastrointestinal upsets in 7 patients. Thalidomide thus appears to be a very effective drug in the treatment of severe type-2 lepra reaction and apart from its historically well-documented embryopathic effects, does not seem to have any other serious side effects in the patients under study.

A study of dermatological conditions in leprosy in-patients.

Three hundred and sixty six in-patients in a leprosy hospital were examined for other dermatological conditions. Eighty eight of them displayed ichthyosiform changes. A peculiar condition of a verrucous hyperkeratotic growth on the anterior aspect of ankle, not described previously, was observed in four patients. It was noted that 11 out of 12 patients with scabies did not have the classical lesions in web spaces of the hands.

Malignant transformation in trophic ulcers in leprosy: a study of 12 cases.

Twelve cases of carcinomata arising in Trophic ulcers of Leprosy are presented. Out of these, 10 were on the plantar surface more commonly on the proximal part of foot, one on lower leg and dorsum of foot, and one in an ulcer over the lateral malleolus. Almost all presented with infected growths and regional lymphadenopathy. Three cases presented with advanced disease with fungating inguinal nodes and were fatal. Nine cases underwent below knee amputation under antibiotic cover as a definitive treatment and the lymph nodes were kept under observation. Histologically, all were low grade squamous cell carcinomas. In most cases lymph nodes regressed after removal of primary and in one case lymph nodes were positive for malignancy. This study was conducted at Dr. Bandorawalla Leprosy Hospital, Kondhawa, Pune 22 from the year 1981 to 1987.

'Flu' syndrome on once monthly rifampicin.

Two cases of 'flu' syndrome on once monthly rifampicin are reported. The symptoms were reproduced in one patient with the next supervised dose. In the second patient they did not recur probably because she was receiving systemic steroids for left ulnar neuritis.