The study of clinico-pathological correlation and treatment outcome in acute allograft rejection in the immediate post renal transplant period

Background: The kidney Tx is the treatment of choice for patients with ESRD. However, episodes of AR have a negative impact on short- and long-term graft survival. In spite of immunosuppressive medications, CNI, MMF and steroid, the AR remains a crucial problem for Tx. This analysis was performed to evaluate the changing profile of early AR (during first week of transplant) and its repercussions on graft survival.Methods: This study was an observational cohort study and included 50 renal transplant patients irrespective of age, sex and race who developed bx proven AR within first week of transplant. Three groups were made according to histopathology: ACR, AMR and mixed rejection group. The patients were followed for 6 months thereafter.Results: AR within a week of renal Tx were less symptomatic except decrease in UO. ACR was more common (72%) than AMR and mixed rejections. AMR and Mixed group required more therapeutic modalities than ACR. More patients required HD during AR in AMR and mixed rejection group than ACR. The mean s.cr at 6 months was 1.3,1.5 and 1.6 in ACR, AMR and mixed group respectively. There were more incidences of BK viremia, CMV infection UTI and rejection fronts follow up in AMR and mixed group than ACR group.Conclusions: Acute rejections within a week are less symptomatic and ACR occurred more frequently than AMR and mixed rejection There were more incidences of BKV, CMV and UTI for 6 months follow up in AMR and Mixed rejection group.

Prevalence of anaemia in pregnant & lactating women in India.

BACKGROUND & OBJECTIVES: The prevalence of anaemia during pregnancy and lactation was significantly lower in the National Family Health Survey 1998-1999 (NFHS-2), using the hemocue method for haemoglobin estimation compared to earlier surveys. The present study selected seven States and used the same districts and villages studied in the NFHS-2, to see if the reported reduction in prevalence of anaemia was due to health and nutrition inputs and/or due to a different method for haemoglobin estimation. METHODS: A total of 1,751 women (1,148 pregnant and 603 lactating- exclusively breastfeeding up to 3 months of age), from seven States- Himachal Pradesh and Haryana in north; Assam and Orissa in east; Kerala and Tamil Nadu in south and Madhya Pradesh in central India, were selected. Haemoglobin was estimated by the cyanmethaemoglobin method, so that comparison was possible with earlier studies. Data on socio-demographic characteristics, pregnancy, nutritional status and dietary intakes were collected. RESULTS: Prevalence as well as severity of anaemia was significantly higher in the present study as compared to the NFHS-2 study data. The difference could be due to haemocue method, which gives higher haemoglobin values. The contributing factors found on multiple regression analysis for anaemia in pregnancy and lactation were: literacy, occupation and standard living index of the study women; their awareness about anaemia, its prevention by regular consumption of ironfolate tablets and increase in food intake. Maternal height, age of marriage, parity and foetal loss also contributed to haemoglobin level. There were interstate differences; lower fertility, higher literacy and better diet was observed in Himachal Pradesh as compared to Haryana. The literacy and nutritional status of women in Tamil Nadu was lower than Kerala. The remaining 3 states had poor fertility, lower social living index and nutritional status with >90 per cent women being anaemic in pregnancy and lactation. Low prevalence of severe anaemia in Orissa as compared to Assam was due to availability and consumption of iron folate tablets. The antenatal services in the first trimester and checkup by a doctor, along with availability and consumption of iron folate tablets over 3 months in all the States influenced haemoglobin levels. INTERPRETATION & CONCLUSION: Despite the measures taken to control anaemia in pregnancy and lactation in the last two decades, the severity of nutritional anaemia continues to remain a public health issue of great magnitude, suggesting that these measures have been largely ineffective. The present findings also showed interstate differences particularly in fertility, women education, nutrition status and occupation; availability of antenatal services and iron folate tablets as possible factors responsible for differences in prevalence of anaemia.

Peak expiratory flow rate of children working in lock factories.

Peak expiratory flow rate (PEFR) of 106 children working in different units of lock factory was measured and compared with age and sex matched control group of same socio-economic status children. All the children worked for about ten hours per day. It was observed that there was a significant decrease in PEFR of children working in the different units of lock factories i.e. Hand press, Polishing, Lock fitting, Lock packing units as compared to control group (P>0.001). The reduction percentage of PEFR was maximum in children working in polishing unit (25.48%).

Diabetic nephropathy--prevention and treatment.

Diabetic nephropathy is a major cause of end stage renal failure. Non-insulin dependent diabetes mellitus (NIDDM) is more prevalent in our country than insulin dependent diabetes mellitus (IDDM). Nephropathy can be classified in IDDM patients in 5 stages which have been elaborated here. The major intervention to prevent or reduce the rate of progress in diabetic nephropathy is control of blood sugar, control of blood pressure, use of angiotensin converting enzyme inhibitors, restricting dietary protein intake, treatment with inhibitors of the formation of advanced glycosylation end products, treatment with aldose reductase inhibitors and treatment of dyslipidaemia. Once the patient of diabetic nephropathy reaches the end stage renal disease, renal replacement therapy is needed. The different modalities of renal replacement therapy are: Haemodialysis, continuous ambulatory peritoneal dialysis, kidney transplantation and kidney and pancreas transplantation. Renal replacement therapy in diabetics has to be individualised from patient to patient. Kidney transplantation is at present the option of choice.

Birth weight patterns in rural undernourished pregnant women.

OBJECTIVE: To study the birth weight pattern in chronic as well as currently undernourished pregnant women. DESIGN: Prospective study of rural pregnant women by following eligible women. SETTING: Two adjoining blocks of rural Varanasi. METHOD: 3700 pregnant women from rural areas of Varanasi for whom data for anthropometry, hemoglobin, dietary intake, birth weight, fundal height and abdominal girth at 16 +/- 2, 28 +/- 2 and 36 +/- 2 weeks of gestation were recorded. Outcome measure was birth weight pattern of newborns. RESULTS: Of the births, 7.2% were < 2250 g and 27.4% < 2500 g. The weekly birth weight increments in gestation 36-42 weeks were 5-53 g, only. The fundal height did not increase during 35-39 weeks of gestation (lower by 5 cm as compared to normal). Nutrition supplement in the third trimester significantly increased fundal height and abdominal girth. Fundal height below 24.5 cm at 28 weeks of gestation (1368 women) was associated with higher low birth weight deliveries. CONCLUSION: Birth weight and fundal height increments during later pregnancy are low in undernourished pregnant women. Fundal height < 24.5 cm at 28 weeks of gestation identified women with higher risk for lowbirth weight infants. The prevalence of low birth weight was 27.4% and of prematurity was 6.6%.

Physical growth assessment in adolescence.

OBJECTIVE: To describe ponderosity indices body mass index--"BMI" and ponderal index "PI" and skin fold thicknesses (triceps, biceps, subscapular and suprailiac) for affluent Indian school going adolescents. DESIGN: Cross sectional. METHODS: Measurements were recorded in healthy affluent school going adolescents in public schools of 12 cities in India (boys=11,863 and girls 7,694). Means and percentiles of ponderosity indices and skinfold thicknesses at yearly intervals were derived for each sex and related to sexual maturity. RESULTS: BMI, PI and skin fold thickness (SFT) were higher in girls. There was lower variability of these parameters with sexual maturity rating (breast/genital development stages) as compared to age, suggesting use of these indices in relation to sexual maturity for assessment of adolescent growth. CONCLUSION: Pediatricians and endocrinologists can use these indices for assessment of thinness and obesity, in adolescent Indian children, in relation to sexual maturity for the age.

Impact of the integrated child development services (ICDS) on maternal nutrition and birth weight in rural Varanasi.

OBJECTIVE: To evaluate the impact of ICDS on maternal nutrition and birth weight. SETTING: 28 ICDS and 21 non-ICDS villages in two adjoining blocks of Varanasi. METHODS: 5289 pregnancies were registered during 1987-1993 in these two blocks. In the ICDS block 916 and 1453 nutrition supplemented and unsupplemented, respectively and 1748 of the non-ICDS live births with weight recorded within 48 h formed the study subjects. RESULTS: The ICDS supplemented mothers gained 100g more in pregnancy and birth weight was higher by 58 g (p < 0.05) as compared to unsupplemented ICDS mothers. Birth weight in unsupplemented ICDS areas was 25g higher as compared to non ICDS area. ICDS supplemented women had a significantly smaller proportion of low birth weight babies (14.4%) compared to ICDS unsupplemented (20.4%) and non-ICDS women (26.3%). The corresponding prevalence of preterm births was 2.0, 2.4 and 4.3%, respectively (P < 0.001). Multiple regression analysis showed that increased wight gain in pregnancy, length of gestation, caloric intake and term hemoglobin were significantly associated with birth weight. However, the length of gestation was not influenced by factors improving the birth weight. CONCLUSION: Undernourished pregnant women are benefitted by late pregnancy nutrition supplement

Pregnancy wastage in rural Varanasi: relationship with maternal nutrition and sociodemographic characteristics.

OBJECTIVE: To study the relationship between pregnancy wastage and matrnal undernutrition and other sociodemographic factors in rural Indian women. SETTING: Rural community of Varanasi. DESIGN: Longitudinal observation. METHOD: In 49 villages during 1988-92, 8111 pregnancies were registered to observe for wastage. The pregnancy outcome was correlated with various factors. RESULTS: There were 1321 abortions and 141 still births. Women's income < Rs. 250 per month, education < 10th class and protein intake < 50 g/day had significantly higher relative risks (RR) (4.1, 2.9 and 2.8, respectively) for abortions. Poor maternal nutrition was in additional important risk factor, for still births (RR 5.1 and 4.2 for maternal weight and height, respectively). A pregnancy interval over 2 years reduced both. CONCLUSION: Low socioeconomic status, chronic undernutrition and illiteracy in rural India are associated with high pregnancy wastage.

Nutritional status of rural non-pregnant non-lactating women in reproductive age.

OBJECTIVE: To find out the degree of current undernutrition in rural reproductive age women. SETTING: 49 villages of two adjoining rural blocks of Varanasi. METHODS: 6130 non-pregnant and non-lactating rural women in the age group 18-45 year were studied for sociodemographic characteristics and anthropometry, i.e., weight, height and midarm circumferance. Their percentiles for age and for weight for height were calculated by using cubic spline method. RESULTS: The women in 10th centile weighed < 38 kg and those in > 90th centile weighed 47-48 kg; 74.2% had weight < 45 kg. The 50th centile height ranged between 148-150 cm; 13.5% were < 145 cm. For mid arm circumference 50th and 90th centile values were around 22 and 24 cm, respectively. Mid arm circumference and height had significant linear correlation with weight. CONCLUSION: Around 50% rural UP women in pre-pregnancy state are undernourished. With age these rural women did not change in weight or mid-arm circumference.

Weight gain during pregnancy--a key factor in perinatal and infant mortality.

OBJECTIVE: To identify risk factors for high perinatal (PMR) and infant (IMR) mortality in a rural area. DESIGN: In 49 randomly selected villages from two adjoining blocks of rural Varanasi, all pregnant women and live births were followed for perinatal and infant mortality, during the years 1988-1992. SUBJECTS: 6790 births and their 6649 live births. RESULTS: The PMR was 90.7 per thousand births and IMR was 98.6/1000 live births. These mortalities were significantly higher if weight gain during pregnancy was less than 7.0 kg. Low weight gain during pregnancy was also associated with significantly higher low birth weight deliveries and to some extent increased still birth rate. PMR and IMR decreased with higher levels of hemoglobin in third trimester and socioeconomic index; however, the calculated RR were not significant. CONCLUSION: Low weight gain during pregnancy is an important risk factor for PMR and IMR.

Sequelae of early undernutrition on reaction time of rural children at 11-14 years.

85 undernourished rural school children at 11-14 yr of age were randomly selected on the basis of their nutritional status during first five years of life for assessment of reaction time (RT). Audio-visual RT apparatus and electromyograph were used for the study. Early life undernourished children had prolonged RT as compared to their matched control maintaining normal nutrition status in first five years of life. The total, premotor and motor RT for audio as well as visual stimuli were affected in these undernourished children. The RT increased with severity of current undernutrition; those achieving normal nutritional status at this age continued to have prolonged RT. The study suggests that the early life undernutrition affects perceptual abilities, information processing and analytical capabilities.

Relationship of manometric findings to symptomatic response after pneumatic dilation in achalasia cardia.

BACKGROUND: Achalasia cardia is usually treated by pneumatic dilation or surgical esophagomyotomy. The role of esophageal manometry for objective assessment of symptom response is controversial. AIM: To study the relationship between symptoms and manometric parameters before and after pneumatic dilation in patients with achalasia cardia. METHODS: Sixteen patients with achalasia cardia underwent esophageal manometry before and after undergoing pneumatic dilation. At each time, lower esophageal sphincter (LES) pressure and mean basal esophageal-gastric pressure gradient (MIEP-MIGP) were measured. RESULTS: Good symptom response was obtained in 12 of 16 patients. Median (range) LES pressure fell from 42 (17-51) mmHg to 18 (8-39) mmHg in those patients with a good response, and from 51 (25-68) mmHg to 29.5 (23-42) mmHg in those who responded poorly. Mean intraesophageal pressure fell below mean intragastric pressure in both the groups. CONCLUSIONS: Esophageal manometry does not correlate with symptom improvement after pneumatic dilation in achalasia cardia. Dysphagia may persist in spite of reversal of the MIEP-MIGP gradient.

Percutaneous transhepatic biliary drainage in the management of obstructive jaundice.

BACKGROUND: Percutaneous transhepatic biliary drainage (PTBD) has been employed for decompression of the obstructed biliary tract to palliate jaundice and pruritus and for the management of cholangitis. We present our data to review the indications, therapeutic results and associated mortality and complications of this procedure. We have also studied the effect of size of drainage catheters on the improvement in liver functions and procedure related complications. METHODS: PTBD was attempted in 41 patients (18 men, age 56 +/- 12 years; 23 women, age 55 +/- 11 years) with obstructive jaundice (37 malignant, 4 benign). RESULTS: PTBD was successful in 39 (95%) patients. Mean serum bilirubin and alkaline phosphatase concentration declined significantly (p < 0.000001 for both) after 1 week, however thereafter decline was slow. Complete relief of pruritus and cholangitis was noted in most patients. Major complications such as cholangitis, bile leak into the peritoneum, malfunction of drainage catheter, intraperitoneal haemorrhage and renal failure, occurred in 11 (28%) patients, 2 (5%) of whom died. Large catheters (> 10 Fr) were superior to small size catheters (< 10 Fr) in relief of jaundice and had lower catheter related cholangitis. CONCLUSIONS: We conclude that PTBD is useful for palliation of malignant obstructive jaundice with intractable symptoms and cholangitis. Catheters larger than 10 Fr should be used.

Myocarditis and hemiplegia from scorpion bite--a case report.

A 16 year old boy presenting with features of myocarditis and pulmonary oedema following scorpion sting developed hemiplegia with patchy vasculitic lesions on CT scan. The possible pathogenic mechanism is discussed.

Role of biliary scintigraphy in management of bile leak.

BACKGROUND: Endoscopic biliary drainage is effective in the management of patients with postoperative bile leak. Evidently, it cannot be used in patients with completely tied-off common bile duct (CBD). AIM: To ascertain whether biliary excretion scintigraphy could reliably detect patients with tied-off CBD so that endoscopic retrograde cholangiography (ERC), an invasive test, could be avoided. METHODS: Twelve patients with active bile leak (11 postcholecystectomy, one posttraumatic), in whom the biliary system was imaged by both 99m technetium mebrofenin biliary scintigraphy and ERC, were evaluated. RESULTS: Bile leak was demonstrated in all the 12 patients by scintigraphy. In six of these, there was no visualization of radionuclide activity in the intestines; in three of these six patients, ERC showed a patent CBD potentially amenable to endoscopic drainage, whereas in the remaining three, there was complete obstruction presumably due to CBD tie-off during surgery. CONCLUSION: Biliary excretion scintigraphy is unreliable for detecting complete biliary obstruction in patients with bile leak.

Association of digital clubbing with corrosive stricture of esophagus.

We report a young woman who developed digital clubbing following corrosive esophageal injury. The clubbing regressed with effective dilatation of the esophageal stricture.

Biliary ascariasis associated with periampullary carcinoma.

A 65 year old man presented with obstructive jaundice, biliary colics and recurrent cholangitis. Sonography revealed dilated intrahepatic biliary radicles and common bile duct. Bile duct also showed linear parallel intraluminal structures suggesting biliary ascariasis. The lower end of common bile duct and pancreatic region showed a mass which proved to be a coexistent periampullary carcinoma.