Effect of low dose hydrocortisone on duration of vasopressor therapy in septic shock.

Background & objectives:Severe sepsis and septic shock are major health problems. Stress dose of hydrocortisone infusion reduces the time of cessation of vasopressor therapy in septic shock. This study was planned to see the role of low dose corticosteroids on duration of vasopressor therapy in patients with septic shock along with their outcome. Methods: The study was carried out in 40 patients of septic shock. The patients were randomized into two groups i.e. treatment (Group A) and the placebo (Group B) groups of 20 each. Both groups received antibiotics, vasopressors i.e. Dopamine and Norepinephrine and IV fluids along with low dose hydrocortisone being administered only to Group A. Mean values were compared statistically using t-test and z-test. Results: The mean time spent in shock (hours) in survivors was 44.00 ± 11.2 (p< 0.001) while in group B was 72.00 ± 0.00 (p< 0.05). Also, the number of survivors in group A was more with cortisol levels of 5-25 mcg/ml. Interpretation & conclusion:Low dose hydrocortisone reduced the time spent in shock in survivors of group A, thereby reducing duration of vasopressor therapy. It also reduced mortality in subgroup of patients with serum cortisol levels of 5-25 mcg/ml proving that moderately low cortisol levels are benefitted more with hydrocortisone therapy than those with relatively high cortisol levels.

Pulmonary Manifestations in HIV Seropositive Patients and Their Correlation with CD4 Counts in a Tertiary Care Centre of North India.

The prolonged course of human immunodeficiency virus (HIV) infection is marked by a decrease in the number of circulating CD4+ T helper cells and persistent viral replication, resulting in immunologic decline and death from opportunistic infections. The study was conducted in HIV Seropositive Patients admitted in our hospital. Demographic profile of the patient was recorded along with history, examination, investigations and evaluated for pulmonary manifestations and correlated with the CD4 counts. Age of HIV positive cases ranged from 21 to 74 years, male: female ratio was 3:1. Commonest mode of transmission was heterosexual sex (77%) followed by IV drug abusers (13.3%). Commonest X- ray finding was Infiltrates (33.3%) followed by pleural effusion (8%) and miliary mottling (5.3%). Commonest pulmonary diagnosis was pulmonary tuberculosis in 22.6% cases, followed by pyogenic pneumonia in 14.67% and pneumocystis carinii pneumonia (PCP) in 5.3% cases. Extrapulmonary tuberculosis was present in 16% of the cases. Pulmonary tuberculosis and pyogenic pneumonia was present in over wide range of CD4 count but their incidence has increased as the CD4 count declined. The knowledge of the CD4 count level in HIV patients is extremely useful in making differential diagnosis and suggesting a diagnostic and therapeutic plan.

Maternal Heart Disease and Pregnancy Outcomes.

This study was conducted to assess the presence of various types of cardiac lesions in pregnant females admitted to a tertiary care hospital of Punjab. 97 women having pregnancy and heart disease were assessed for the various etiologies, cardiac lesions, maternal and perinatal outcomes. Rheumatic heart disease (RHD) with isolated mitral stenosis was the commonest acquired lesion while mitral valve prolapse was the predominant lesion among the congenital heart disease. In the miscellaneous group, cardiomyopathy was the leading cause. Multiple cardiac lesions were diagnosed in 36 women. Majority delivered by caesarean section and some had spontaneous vaginal delivery while few required induction of labour. 19 women had cardiac complications. There were three maternal deaths.This study concluded that rheumatic heart disease in pregnancy is still predominant though acquired cardiac lesions are rising. A careful observation and management during pregnancy can improve the maternal & fetal outcomes.

Efficacy and safety of pegylated IFN alfa 2b alone or in combination with ribavirin in thalassemia major with chronic hepatitis C.

Background Treatment of HCV infection in patients with thalassemia major (TM) is limited by the lack of large clinical trials and concerns about ribavirin-induced hemolysis. Methods We conducted a prospective, randomized, openlabel study to determine efficacy and tolerability of pegylatedinterferon alfa 2b (1.5 μg/kg/week) alone (group A) or with ribavirin (12–15 mg/kg/day; group B) in patients with TM and chronic HCV infection. Patients with genotype 1 or 4 HCV were treated for 48 weeks and those with genotype 3 or 2 HCV for 24 weeks. Early viral response (EVR; after 12 weeks of treatment), end-of-treatment virological response (ETR) and sustained virological response (SVR; 6 months after stopping therapy) were assessed. Results Of 40 patients, 20 each were allocated to the two treatment groups. EVR rates in group A and B were 15 (75%) and 18 (90%), respectively. ETR occurred in 17/20 (85%) patients in each group. SVR occurred in 8 (40%) patients in group A and 14 (70%) in group B. Blood transfusion requirements increased in one patient in group A and four patients in group B. One patient in group A had severe sepsis and one in group B had nephrotic syndrome. Two patients in each group required reduction in drug dose. Conclusions In patients with TM and chronic HCV infection, pegylated interferon alfa 2b and ribavirin combination therapy achieves a higher SVR rate than pegylated interferon alone, and is well tolerated except for an increase in blood transfusion requirement.

Cyclosporine in the treatment of severe steroid refractory ulcerative colitis: a retrospective analysis of 24 cases.

BACKGROUND: Cyclosporine A (CsA) has been found to be the first successful therapy used in the recovery of patients with steroid-refractory ulcerative colitis (UC). However, the long-term benefits of cyclosporine remain questionable. We report our results on the use of CsA in patients with severe steroid-refractory UC. METHODS: The records of all patients with steroid refractory UC treated with CsA from January 2003 to December 2007 were reviewed. Demographics, clinical characteristics of the disease, responsiveness to CsA, complications arising from the treatment and the need for surgery were recorded for all patients. RESULTS: Of 146 admissions of severe UC, 24 patients who were steroid refractory (mean age 41.7 years; 11 men) received intravenous cyclosporine (4 mg/kg/day) for mean of 6.63 days (range 1-7), followed by oral CsA for a period of 3 months. All patients had failed to respond to intravenous hydrocortisone given for 7 days. Four patients required a colectomy immediately, three of whom failed to respond to CsA, and one had convulsions following drug administration. Nineteen of the 24 patients (79%), in whom a colectomy was avoided during the early stages of their treatment, were followed up for a mean of approximately 38 months (range 12-62 months). Three patients required surgery on follow up; one was operated at day 94, another in the second year and one in the third year. Overall, 16 of 24 patients (67%) remained colectomy-free. The main side-effects observed included infections, tremors, paresthesias, headache, hypertension, hypertrichosis and peripheral neuropathy. Three of seven patients who had to undergo surgery died within 2 weeks. CONCLUSIONS: Our study shows that surgery can be avoided in two-thirds of patients with steroid refractive severe UC. However, the drug toxicity and mortality are significant.

Landry-Guillaine-Barré syndrome as presentation of celiac disease.

Celiac disease has been associated with a variety of neurological illnesses, most frequently cerebellar ataxia and peripheral neuropathy. We report presentation as Landry-Guillaine-Barré syndrome in a 28-year-old woman with previously unsuspected celiac disease.