Intermediate syndrome in organophosphorous poisoning--a case report.

A case of organophosphorous poisoning in a 29 year old male who developed intermediate syndrome manifested by features of respiratory depression as evidenced by marked weakness of the respiratory muscles, tachypnoea, and drop in oxygen saturation despite reversal of nicotinic and muscarinic effects of organophosphorous poisoning. The case highlights its early recognition and prompt institution of mechanical ventilation with continuation of anticholinergic drugs. The mechanical ventilation had to be continued for 9 days with successful outcome.

The circadian pattern of ischaemic heart disease events in Indian population.

A circadian variation of the onset of almost all ischaemic heart disease (IHD) manifestations with an increased incidence between 6:00 a.m. to 12:00 noon has been reported in several publications during the last decade. This study included 605 patients of various IHD subgroups, i.e., acute Q-wave myocardial infarction (n = 174), unstable angina (n = 266), non-Q myocardial infarction (n = 67), acute pulmonary oedema (n = 35) and sudden cardiac death (n = 63) proven to be due to IHD by electrocardiogram and/or autopsy. In overall, 33.55% (p < 0.0001) of patients had the IHD events with an increased frequency between 6:00 a.m. To 12:00 noon (2nd quarter of the day.) The distribution in the remaining, 1st 3rd and 4th quarters was 22.64%, 20.99% and 22.80%, respectively. Similar circadian rhythm (2nd quarter peak) was seen in males (n = 486), females (n = 119), patients ages < 60 years (n = 388), patients without past history of IHD (n = 434) and in those not on any medications (n = 359). However in patients with past history of IHD and diabetics, the circadian distribution did not differ from the random and the cases were distributed almost evenly in all the four quarters of the day. 39.08% of all the acute Q wave myocardial infarction (A-QMI), 33.45% of unstable angina and 36.5% of sudden cardiac deaths also occurred between 6:00 a.m. and 12:00 noon. However 51.42% cases of acute pulmonary oedema were encountered in the 4th quarter of the day and patients with non Q-myocardial infarction (non-QMI) did not show any particular pattern in relation to circadian rhythm. Thus it was inferred that in Indian population too the circadian pattern of IHD manifestations are similar to other population studies and morning appears to be the time, when the triggers (transient precipitating risk factors) that lead to these events are likely to be prominent. Study of these triggers and/or early morning pathophysiological changes may go a long way in understanding ischaemic heart disease and suggesting possible means of prevention.

Renal failure in acute pancreatitis.

Twenty six (7.3%) of a total of 356 patients with acute renal failure were found to have acute pancreatitis as the primary disease. Seventeen (65.4%) of them were males. Their mean age was 35.6 years. Clinically epigastric pain and tenderness were seen in all (100%); nausea vomiting (73%), low grade fever (50%), left sided pleural effusion (38.4%), haemopericardium (26.9%), shock (26.9%), pseudocyst (19.3%) and adult respiratory distress syndrome (7.6%) were the other major presenting features. Serum amnylase (100%), lipase (53.8%), triglycerides (53.8%) and blood sugar (38.5%) were raised in majority whereas serum calcium was detected to be below normal in 46.2% patients. Blood urea and serum creatinine were raised in all and hyperkalacmia was found in 50% patients. CT scan and USG abdomen showed bilateral enlarged kidneys (100%), pancreatic oedema (80.7%), necrosis of pancreas (19.3%) and pseudocyst (19.3%). Management included repeated peritoneal dialysis in all (100%) and surgical intervention in 53.8% patients with severe necrotising and haemorrhagic pancreatitis. All patients recovered from acute renal failure, but 26.9% patients expired due to complications of acute pancreatitis other than acute renal failure.

Prolactin and cortisol levels in seizure disorders.

Levels of prolactin (PRL) and cortisol were estimated to find out the acute effects of generalised tonic clonic seizures (GTCS), partial seizures and pseudoseizures in 60, 18 and 9 patients respectively. Prolactin levels were estimated at 20, 60 and 120 minutes whereas, cortisol was estimated at 20, 60, and 120 minutes postictally. Cortisol and PRL estimation was also done in 10 healthy controls and 11 patients of epilepsy during interictal phase. Serum PRL levels were elevated (> 25 ng/ml) in 68.33% of GTCS and 11.11% of partial seizure cases. The peak levels were achieved in first 30 minutes after the seizures with a gradual return to base line during subsequent one hour. None of the patients with pseudoseizure showed any rise in serum PRL levels. The interictal PRL levels were normal in all the epileptics. Plasma cortisol levels were elevated during 60 to 120 minute postictal period in 45% of GTCS, 55.55% of partial seizures and 66.66% of pseudoseizure patients. Cortisol appears to be non-selectively triggered by all stressful events but postictal PRL estimation can help in differentiating pseudoseizures from GTCS. While an elevated PRL indicates the occurrence of grandmal seizure, a normal postictal PRL level does not always exclude epileptic seizure, specially a partial seizure.

Low grade pyrexia: is it chronic fatigue syndrome?

Eighty seven consecutive patients presenting with prolonged low grade pyrexia (99 degrees-101 +/- F) during 1984-93 were followed up for a mean duration of 2.9 years. Mean age was 37.55 years (SD + 10.16) and 66 (75.8%) were females. Onset of pyrexia was acute in 57 patients and was associated with chilly sensation (42), Fatigue (69), Arthralgias (61), myalgias (55) and several other non specific symptoms. Clinical examination showed paucity of physical signs with 7 patients showing tender lymphadenopathy, 7 showing splenomegaly, 5 hepatomegaly, and 1 phylctenular conjunctivitis. Psychiatric examination was within normal limits. Extensive investigations for any viral or other infection, autoimmune disorder or malignancy were unrewarding. Patients were followed up for an average of 2.9 (2 to 5 years). Thirteen patients had become asymptomatic within one year of onset of symptoms, 38 by two years and 45 by the end of three years. This syndrome may be a variant of chronic fatigue syndrome.

Significance of minor electrocardiographic repolarisation changes in asymptomatic subjects.

3000 routine ECGs were screened during a 2 year period in Armed Forces personnel reporting for annual medical examination. 90 asymptomatic men with minor ST segment and T wave changes at rest were assessed by exercise ECG. 33 responded abnormally. They were subjected to coronary arteriography. 14 subjects were confirmed to have coronary artery disease (CAD). 19 subjects had a false positive response and assuming a false negative response of 2%, a sensitivity of 87.5%, specificity of 74.3% and a positive predictive value of 42.4% is obtained for exercise ECG. A positive predictive value of 15.5% is obtained for the resting ECG.

Systemic manifestations of systemic lupus erythematosus.

Twenty five cases with systemic lupus erythematosus admitted to a referral service hospital over a period of 6 years have been studied to analyse the pattern of multisystem involvement. Febrile polyarthritis, renal involvement and skin changes dominated the clinical picture. Important serological abnormalities included the presence of antinuclear antibody and anti ds DNA. Renal biopsy carried out in all cases helped to reveal lupus nephritis in subclinical cases. The pattern of renal involvement varied, with diffuse proliferative glomerulonephritis being the commonest. Oral steroids was given to all cases and cyclophosphamide was given to severe and resistant cases. The severity of system involvement, especially renal, influenced the response to treatment. Changes in presentation between Indian and Western patients are highlighted.

Nuclear, biological and chemical warfare. Part I: Medical aspects of nuclear warfare.

Casualties in earlier wars were due much more to diseases than to weapons. Mention has been made in history of the use of biological agents in warfare, to deny the enemy food and water and to cause disease. In the first world war chemical agents were used to cause mass casualties. Nuclear weapons were introduced in the second world war. Several countries are now involved in developing nuclear, biological and chemical weapon systems, for the mass annihilation of human beings, animals and plants, and to destroy the economy of their enemies. Recently, natural calamities and accidents in nuclear, chemical and biological laboratories and industries have caused mass instantaneous deaths in civilian population. The effects of future wars will not be restricted to uniformed persons. It is time that physicians become aware of the destructive potential of these weapons. Awareness, immediate protective measures and first aid will save a large number of persons. This series of articles will outline the medical aspects of nuclear, biological and chemical weapon systems in three parts. Part I will deal with the biological effects of a nuclear explosion. The short and long term effects due to blast, heat and associated radiation are highlighted. In Part II, the role of biological agents which cause commoner or new disease patterns is mentioned. Some of the accidents from biological warfare laboratories are a testimony to its potential deleterious effects. Part III deals with medical aspects of chemical warfare agents, which in view of their mass effects can overwhelm the existing medical resources, both civilian and military.(ABSTRACT TRUNCATED AT 250 WORDS)