Captopril in the treatment of cardiovascular manifestations of indian red scorpion (Mesobuthus tamulus concanesis Pocock) envenomation.

OBJECTIVES: To study outcome of patients with scorpion envenomation treated with oral captopril in the ICU of a Tertiary Care, University Hospital in Mumbai. METHODS: Retrospective analysis of all patients with scorpion sting admitted to Medical Intensive Care Unit of a tertiary care university hospital in Mumbai between 1993 and 2003. RESULTS: Of 38 patients with cardiovascular manifestations, six had tachycardia alone and 8 had hypertension; these patients received oral captopril 12.5-25 mg thrice daily with no deaths. Pulmonary oedema with normal blood pressure and high central venous pressure (CVP) was seen in 10 patients. Five patients had hypotension, low CVP but no pulmonary oedema; with fluid infusion, these patients had correction of low CVP and hypotension, but developed pulmonary oedema. Pulmonary oedema resolved in all 15 patients with captopril (6.25-25 mg thrice daily): one patient died of ventricular tachycardia. Nine patients had cardiogenic shock; 6 patients, whose blood pressure improved with dopamine received, captopril; 1 of these 6 died. The other three patients did not respond to maximum vasopressor therapy and could not be given captopril; all three died. Four of the 5 deaths occurred in patients weighing < 25 kg suggesting that severity of cardiovascvlar manifestations also depends on body weight of the victim. CONCLUSION : Afterload reduction with oral captopril is safe and effective in scorpion envenomation with cardiovascular manifestations. Results are similar to those with other vasodilators.

Diagnostic and prognostic utility of rapid strip (OptiMal and Paracheck) versus conventional smear microscopy in adult patients of acute, uncomplicated P. falciparum malaria in Mumbai, India.

OBJECTIVES: The present study compared the diagnostic and prognostic utility of two rapid tests the (Paracheck and OptiMal) versus conventional smear microscopy. METHODS: Using two independent microscopists we carried out the three tests in 31 adult cases of smear positive, acute, uncomplicated Plasmodium falciparum malaria. All three tests were done pretreatment, and on Days 8, 15 and 29. RESULTS: Compared to microscopy, the Paracheck had a sensitivity of 100%, while the OptiMal had a sensitivity of 83.7%. The lower sensitivity of OptiMal resulted from misidentification by both microscopists of 6/31 cases as Plasmodium vivax. As a follow up tool, the OptiMal was better than Paracheck, due to the earlier disappearance of the parasite LDH. Also in the Paracheck, between microscopists, there was a significant difference in reading the tests, on Days 8 and 15. CONCLUSION: Our study reiterates, the continued utility of conventional smear microscopy.

Human immunodeficiency virus type 1 infection in patients with severe falciparum malaria in urban India.

BACKGROUND: CD4+ T cells restrict parasitaemia during the first attack of falciparum malaria; humoral immunity, develops weeks later and protects against reinfection. HIV infection may affect severity of falciparum malaria and development of protective immunity. AIMS: To study the prevalence of HIV infection in Indian patients with severe falciparum malaria and its effect on severity of illness and recurrences of and mortality related to malarial infection. PATIENTS: Consecutive patients with severe falciparum malaria and voluntary blood donors. SETTING AND DESIGN: Prospective cohort study in a university hospital in Mumbai. RESULTS: Five (11.6%) of 43 patients and 521 (1.8%) of 28749 blood donors had HIV infection (OR 7.1, 95% CI = 2.8 to 18.2, p=0.001). Clinical features, APACHE II score, number of organs affected, parasite index and mortality in patients with and without HIV infection were comparable. CD4+ counts were < 500 cells/ microl in 2 patients and normal in 3. Opportunistic infections including pulmonary tuberculosis in one patient (CD4+ counts > 500 cells/ microl), and oral candidiasis in two (CD4+ counts 275 and 250 cells/ microl) were noted. One patient developed fatal Pneumocystis carinii pneumonia two weeks after recovering from malaria. P. falciparum infection recurred in 2 of the 4 HIV infected survivors and in none of 31 survivors without HIV infection (RR 38.8, 95% CI 2.2 to 671, p=0.01). CONCLUSIONS: HIV infection is associated with increased risk of severe malaria even with normal CD4+ counts; severity of disease and mortality are not increased. However, prior HIV infection impairs protective immune response to Plasmodium falciparum in residents of hypoendemic areas.

Ascitic fluid filtration and intravenous infusion versus total-volume paracentesis with infusion of plasma expander in cirrhosis with tense or intractable ascites.

BACKGROUND: Patients with cirrhotic ascites have low serum albumin levels, and paracentesis of ascitic fluid could compromise them further. AIM: We compared the therapeutic efficacy of ascitic fluid filtration and concentrate infusion (AFI) versus total-volume paracentesis (TVP) with colloid infusion in control of tense or intractable cirrhotic ascites. METHODS: Ten patients underwent AFI; their ascitic fluid was filtered repeatedly through hollow-fiber hemodialyzer, and the concentrate reinfused intravenously. In ten patients TVP was done with simultaneous intravenous colloid infusion. Follow-up was done weekly and the study terminated if the patient needed diuretics or developed complications. RESULTS: Pre-study parameters were similar in the two groups. In the AFI and TVP groups, the duration of procedure was median 12 hours and 5.5 hours; fluid removed by paracentesis was 10.2 L and 8.0 L, respectively; and fluid infused intravenously was 0.5 L [with mean (SD) protein content 5.7 (1.3) g/dl] and 1.1 L, respectively. Glomerular filtration rates were lower than normal in the two groups but did not change significantly with the procedure; body weight remained significantly lower up to week 3 and week 2, respectively. The study was terminated at median week 3 (range 1-8) and week 2 (1-4), respectively. Fever was an accompaniment of AFI and one patient developed peritonitis. CONCLUSION: Patients undergoing AFI remained diuretic-free longer; the procedure is cost-effective but needs to be further evaluated to minimize the side-effects.

Randomized double-blind trial of metronidazole versus secnidazole in amebic liver abscess.

OBJECTIVE: To compare the efficacy of secnidazole with metronidazole in the treatment of amebic liver abscess. METHODS: Thirty two patients with uncomplicated liver abscesses were studied in a randomized, double-blind trial. Fifteen received metronidazole (400 mg t.i.d. for 7 days) and 17 secnidazole (500 mg t.i.d. for 5 days). All abscesses were aspirated on day 1 and laboratory tests and ultrasonographic examination were done on days 1 and 10. RESULTS: One patient in the metronidazole group developed intraperitoneal rupture. The other 31 patients had 40 abscesses (19 in metronidazole group, 21 in secnidazole group). Complete resolution of signs occurred by day 10 in 10 patients on metronidazole and 12 on secnidazole, and in all others by day 28. On day 10 ultrasonography in the metronidazole group showed complete disappearance of abscess in one patient, decrease in 8 and increase in 5 (versus 2, 12 and 3, respectively in the secnidazole group). After 6 months, four asymptomatic patients (two from each group) had small abscess cavities on ultrasonography; there were no recurrences. CONCLUSIONS: Secnidazole is as effective in the treatment of amebic liver abscess as metronidazole; it is equally well tolerated.

Metronidazole relieves symptoms in irritable bowel syndrome: the confusion with so-called 'chronic amebiasis'.

BACKGROUND: Metronidazole is often administered to patients with irritable bowel syndrome with an erroneous diagnosis of 'chronic amebiasis'. AIMS: To assess how patients with irritable bowel syndrome respond to metronidazole in the absence of amebae in their stools. METHODS: We randomly allocated 45 patients (35 men; aged 15-59 years) with irritable bowel syndrome to receive isapghul (10 g bid x 60 days), metronidazole (400 mg tid X 10 days, followed by placebo x 50 days), or placebo (1 capsule bid x 60 days). Symptoms were evaluated and scored on days 0, 15, 30, 45 and 60. Rectosigmoid manometry was performed in 5 of 15 patients in each group on days 0 and 60. RESULTS: There was a significant time effect and treatment effect on the symptom scores in all groups (isapghul > metronidazole > placebo); total score decreased from mean 25.8, 24.0 and 24.6 on day 0 to 7.2, 10.9 and 18.1 on day 60, respectively. Severity, duration and frequency of pain; and mucus in stool were all significantly reduced in all treatment groups (p < 0.001 for each). Treatment with isapghul increased the mean amplitude of propagated activity from 26.2 mmHg to 30.1 mmHg at 20 cm (p < 0.025) and from 23.1 mmHg to 27.4 mmHg at 10 cm (p < 0.05) from the anal verge, as well as the total duration of propagated activity at both sites (p < 0.05), with decrease in number of propagated contractions per 10 min (p < 0.025). Metronidazole and placebo had no effect on manometric findings. CONCLUSIONS: Metronidazole provides symptom relief in irritable bowel syndrome, without affecting rectosigmoid motility. This symptom response may be misinterpreted as supporting a diagnosis of 'chronic amebiasis'.

Effect of venous hypercarbia and hyperventilation on myocardial contractility in canine haemorrhagic shock.

To study the effect of venous hypercarbia on myocardial contractility, haemorrhagic shock was produced in six healthy mongrel dogs by ex-sanguination of 15 ml of blood/kg body weight every 20 minutes till a loss of 45 ml/kg was achieved. After recording haemodynamic and respiratory parameters, the dogs were hyperventilated by positive pressure ventilation for 30 minutes and haemodynamic and blood gas parameters reassessed. During haemorrhagic shock, mean cardiac output decreased from 4.23 l min to 0.98 l min (p < 0.01), stroke index from 2.25 to 0.35 ml/kg (p < 0.05) and left ventricular stroke work index from 3.72 to 0.19 g. m/kg. The mean mixed venous pCO2 increased from 35 mmHg to 56.7 mmHg (p < 0.05). During hypoventilation, mixed venous pCO2 decreased to 40 mmHg (p < 0.05) and without any volume replacement, mean cardiac output increased 2.5 l min (P < 0.05), stroke index to 1.13 ml/kg (p < 0.05) and left ventricular stroke work index, and index of myocardial contractility, increased to 0.78 g.m/kg (p < 0.05). Thus, although hypovolaemia is the major cause of low cardiac output in haemorrhagic shock, this study shows that venous hypercarbia (which probably indicates tissue respiratory acidosis) further worsens circulatory failure by decreasing myocardial contractility. Hyperventilation improves cardiac functions and increases output by relieving tissue hypercarbia in spite of persistent hypovolaemia.

Tense ascites redefined: renal consequences of tense ascites in decompensated cirrhotics.

Cirrhotics with tense ascites fail to achieve increased diuresis in the supine position. To assess the role of inferior vena cava compression in this phenomenon, we studied cirrhotics with mild to moderate (n = 11) and tense (n = 2) ascites, and patients with membranous inferior vena cava obstruction (n = 2) before and after balloon dilatation, in the sitting, supine and 10 degrees head down tilted positions for 2 hours each. Urinary output (p < 0.005), creatinine clearance (p < 0.025) and sodium excretion (p < 0.025) increased in cirrhotics with mild to moderate ascites in the supine position, and further in the head down position. Similar changes occurred in patients with inferior vena cava membrane. In cirrhotics with tense ascites, these parameters did not change significantly in the supine position, but increased in the head down position. We conclude that failure to augment diuresis in the supine position in cirrhotics with tense ascites is not due to inferior vena cava obstruction alone but is probably also due to compression of the collateral vessels. This clinical observation may serve as a criterion for diagnosing tense ascites.

A scoring system to differentiate cirrhotic from non-cirrhotic portal hypertension.

When it is not possible to perform a liver biopsy in cirrhosis, one has to rely on suggestive clinical and biochemical parameters and imaging procedures to arrive at a presumptive diagnosis. Based on the statistical method described by Spiegelhalter and Knill-Jones, we have devised a scoring system to reliably differentiate cirrhotic from non-cirrhotic portal hypertension without a liver biopsy. Age, presence of ascites, liver scan result and serum albumin, taken together, could confirm or rule out the diagnosis of cirrhosis in two-thirds of patients with portal hypertension. A score of 5 or more suggested cirrhosis (sensitivity 78%), and of 5 or more suggested cirrhosis (sensitivity 78%), and a score of -6 or less suggested a non-cirrhotic cause (sensitivity 64%) for portal hypertension, both with 100% specificity. Eliminating liver scan result reduced both sensitivity and specificity, suggesting that liver scan is an important component of the score. This score may be useful not only in the management of individual patients but also to classify them in clinical trials.