Acute renal failure in the intensive care unit.

BACKGROUND: Acute renal failure (ARF) in the intensive care unit (ICU) is associated with high mortality. A thorough understanding of the clinical spectrum of the disease is needed in order to devise methods to improve the final outcome due to this problem. AIMS AND OBJECTIVES: The aim of the present study was to analyze the clinical spectrum, causes, risk and prognostic factors and final outcome of ARF in the setting of ICU. METHOD: This prospective study involved patients admitted to ICU during the period between September 2003 to January 2005 (17 months). Patients who developed ARF during the ICU stay were included in the study. The clinical and laboratory data were collected at admission and then on daily basis. Data recorded included; patient characteristics, underlying medical conditions responsible for ICU admission, dialytic status, need for ventilation, total duration of ICU stay, APACHE-III score and final outcome, and these data were analyzed for predicting survival using univariate and multivariate analysis. RESULTS: Twelve hundred and fifteen (1215) patients were admitted to ICU from September 2003 to January, 2005 and 46 (3.79%) patients developed ARF after admission to ICU. Mean age of patients was 44.9 +/- 17 years and 56.5% were males. Comorbidity was seen in 24 (52%) patients; hypertension (34.7%), diabetes mellitus (28.3%), coronary artery disease (30.4%) and chronic kidney disease (13%). ARF had developed complicating medical and surgical conditions in 33 (71.7%) and 11 (23.7%) patients respectively. The etiology of ARF was multifactorial and included; hypotension (71.74%), volume depletion (17.4%), nephrotoxic drugs (67.39%), and sepsis (69.5%). Multiple organ system failure (MOSF) was noted in 63% of cases and dialysis was required in 25 (54.3%) patients. Mortality occurred in 63% of patients. MOSF and sepsis were found to be significant adverse prognostic factors when multiple logistic regression analysis was done. CONCLUSIONS: ARF was seen in 3.79% of cases in our ICU and associated with poor prognosis. Presence of sepsis, MOSF, higher APACHE--III scores and ventilation need were correlated with higher mortality in ARF patients in the intensive care unit.

Dhanwantari: the God of Hindu medicine.

The original conception of Ayurveda in its entirety is essentially linked to Dhanwantari who is considered as God of Hindu Medicine. Dhanwantari is considered a mythical deity born with ambrosia in one hand and Ayurveda on the other at the end of the churning of milk ocean. He reincarnated himself in the Chandra dynasty. He was born to King Dhanwa, learnt Ayurveda from Bharadwaja. His great grandson Divodasa was also known as Dhanwantari, but was specialised only in surgical branch of Ayurveda. Sushruta, is said to have learnt the art of science of surgery from Divodasa Dhanwantara.

Monoclonal gammopathies in asymptomatic HIV-seropositive donors.

Twenty two HIV antibody ELISA reactive serum samples from blood donors were subjected to Western blot (WB) test, out of which 12 sera were found WB positive, five were WB-indeterminate and five were WB-negative. Electrophoresis on agar gel and polyacrylamide gel (PAG) was done in all ELISA reactive sera. Two of the 12 WB-positive and one of the five WB-indeterminate donors showed presence of monoclonal (M) immunoglobulin component and which was identified as of IgG isotype on immunoelectrophoresis (IEP). Sera with 'M' component demonstrated decreased levels of IgA and IgM whereas other sera showed polyclonal increase of immunoglobulins. The paraproteins observed in these patients are possibly a reflection of B-cell overactivation.

Endodermal sinus tumor: report of 12 cases.

Twelve cases of endodermal sinus tumor were reviewed. There were 10 females and 2 males with a median age at presentation of 3 years. The primary site was sacrococcygeal in 4 patients, vaginal in 3, retroperitoneal in 2, and testicular, ovarian and left chest wall in one each. The diagnosis rested on histopathological examination and elevation of serum alfa feto protein levels (median 46,200 ng/ml). Two patients had Stage I disease, 9 had Stage III and one had Stage IV disease. Patients were managed by surgery and chemotherapy (BVP regime). All patients on BVP (even those lost at later stages), had achieved clinical remission with the first cycle of treatment.

Adenoid cystic carcinoma of the cervix.

Adenoid cystic carcinoma constitute around 0.4 to 1.7% of all carcinomas of cervix. It generally presents in elderly age group, however few cases in younger age have also been reported. Majority of cases present in early stage. Though concluding statement regarding the results cannot be made from the cases accumulated from the various reported series, nonetheless this review shows that radiotherapy too is effective in early stage and even in stage I results with radiotherapy appear better than surgery. In advanced stage outcome is invariably poor. In early stage main pattern of failure is distant metastasis. Both local and distant failure are observed in stage III and IV. Though lung is the commonest site of metastases (51%), abdominal cavity and brain are also found to be involved in some cases. Limited experience shows effectiveness of high doses of cisplatin and multiagent chemotherapy. Cases of early stage disease having risk for metastases and local failure should be identified and managed with multimodality treatment using surgery for bulky disease with post-operative radiotherapy and chemotherapy. In advanced stages combination of chemotherapy and radiotherapy is required. Exenterative surgery for central failure has been used effectively. Overall no evidence of disease rate is found to be about 48%, with mean follow-up of 39 months.

Neonatal gastrointestinal perforations.

Fourteen neonates presented with clinical and radiological evidence of gastrointestinal perforation, of which 13 were treated by operative intervention. No infant was formula fed, had rectal bleeding or radiological evidence of pneumatosis intestinalis. Operative findings revealed localized perforation in ten of which three were gastric, two distal ileal, three cecal and two in sigmoid colon. Gangrene with extensive perforation of jejunum, ascending colon and transverse colon were seen in one each. Blood cultures were positive in four, one grew E. coli and three Klebsiella while peritoneal cultures were positive in six, one grew E. coli and five Klebsiella. Ten neonates survived and are being followed up. Three of the four cases who died had white blood cell count greater than 25 x 109/L and grew Klebsiella on peritoneal culture. Factors predisposing to gastrointestinal perforations in neonates are discussed, emphasis is made on the cautious use of umbilical, gastric and rectal catheters, and the need for early surgical intervention.

Peripheral nerve sheath tumours: an ultrastructural study of 30 cases.

This report deals with the ultrastructural observations of 30 peripheral nerve sheath tumours [PNST], which include 25 schwannomas of acoustic nerve, one schwannoma of cauda equina, one neurofibroma from a case of Von Recklinghausen's disease, one pigmented neurofibroma of spinal nerve root and a malignant schwannoma of frontal region. Interdigitating slender cytoplasmic processes covered with a continuous layer of basal lamina constitute the single most important ultrastructural attribute of Schwann cells. Myelin formation was encountered in the cell processes of four out of 25 acoustic schwannomas. In four cases Microtubular arrays identical to that in an axon were seen in Schwann cells. These two observations require further support by additional cases of PNST studies by electron microscopy. The neurofibroma consisted only of Schwann cells and no ultrastructurally identifiable perineurial cells or fibroblasts were detected. The cells in the pigmented neurofibroma revealed submicroscopic features of both Schwann cell and melanocyte, indicating their common ancestry. A unique case of malignant schwannoma arising from frontal meninges is illustrated and it is emphasized that electron microscopy is mandatory for a correct histogenetic diagnosis of malignant tumours which occur at unexpected anatomical sites.

Von Hippel-Lindau disease without Lindau's tumour.

A case of Von Hippel-Lindau's disease lacking the classical Lindau's tumour is reported. The uncommon features of this case are highlighted and the relevant literature is briefly outlined.

Hexokinase isoenzymes in diabetes.

Hexokinase is present in the tissues in four isoenzymic forms. Cerebral tissue contains predominantly Type I hexokinase which is believed to be insulin-insensitive. In cerebral tissue about 60 to 70% of the hexokinase is bound to the particulate fraction. The changes in the distribution of hexokinase Type I and Type II together with the bound and free hexokinase have been studied in control, diabetic and diabetic animals treated with insulin. The results indicate that the presence of insulin is essential for the normal binding of the hexokinase to the particulate fraction. In heart tissue, Type II hexokinase bound to the pellet shows a significant decrease in diabetes, which is reversed on insulin administration.