Disseminated TB in inpatient deaths at a tertiary care centre: an autopsy study over three decades.

BACKGROUND: One of the most severe forms of TB, disseminated TB (dTB) is associated with significant mortality. A retrospective study was undertaken to assess the proportion of dTB among inpatient deaths and to describe the pathological spectrum of lesions. Associated comorbidities and missed dTB cases ante-mortem were also sought.METHODS: Data on autopsy-confirmed cases of dTB from over three decades (1988-2016) obtained from the departmental archives of the Post Graduate Institute of Medical Education and Research, Chandigarh, India, were reviewed for clinical details, as well as gross and histopathological findings. The proportion of autopsy-confirmed dTB were reported.RESULTS: During this period, a total of 243 autopsy-confirmed cases were retrieved. The organs most commonly involved in these cases were the lungs (90.1%), followed by the liver (72%), spleen (44%), kidneys (37%), bone marrow (17%), adrenals (12.2%), intestine (11.4%), pancreas (8.5%) and reproductive organs (6.9%). The brain was involved in 73.3% cases. In one third of cases, the diagnosis of TB was not suspected ante-mortem. Comorbid conditions were noted in 36.2% cases.CONCLUSION: A significant burden of dTB was noted among hospital inpatient deaths. Due to multi-organ involvement, dTB has atypical symptoms and may remain undiagnosed ante-mortem. Increased awareness and robust screening of TB cases are mandatory, particularly in patients with underlying comorbidities.

Morphine Versus Loperamide with Intrasite Gel in the Treatment of Painful Dermal Ulcers: A Randomized, Crossover Study.

BACKGROUND: Topical morphine along with intrasite gel has been proven to be a simple and effective method to relieve pain. However, morphine is still not freely available in developing countries due to drug restrictions and stringent laws governing it. Loperamide has been reported to relieve pain caused by stomatitis effectively when given topically. Loperamide, being an mu receptor agonist with no systemic absorption, can serve a dual purpose here. Also loperamide being freely available as an over-the-counter drug can be a surrogate drug for topical application. OBJECTIVES: The primary aim was to compare the efficacy of loperamide and morphine in treating pain when applied topically along with intrasite gel. STUDY DESIGN: Adult patients with healthy wounds with pain on Numeric Rating Scale (NRS-11) greater than 5 with no systemic comorbid illness were divided randomly into 2 groups - group morphine or group loperamide - for 24 hours followed by a 1-day washout and crossover in the other group for 24 hours. Pain was assessed once every day. SETTING: Medical college and hospital. METHODS: The parameters assessed included: (1) characteristics of the ulcer; (2) pain was assessed by NRS-11 at 12-hour intervals for a period of 72 hours; and (3) patient satisfaction. Statistical analysis used repeated measures analysis of variance to measure change in mean NRS-11 within each group. Analysis of covariance was used to compare the mean change in NRS-11 in the 2 groups. RESULTS: Morphine and loperamide were equivocal in pain relief after 12 and 24 hours (P = 0.400 and P = 0.753); however, the patient satisfaction scores were better in the morphine group. LIMITATIONS: The earlier studies performed used injectable forms of morphine, for the sake of comparison, we used powdered morphine and powdered Loperamide diluted with saline. Confounding variables include ulcer size and aetiology, which can be a source of bias. The ulcer size was not standardized due to the paucity of sample to study. Equianalgesic doses of loperamide and morphine could not be found even after an extensive literature search. The loperamide dose used in our case was equal to the dose used orally since the same dose appears effective across a range of oral opioid analgesics. The morphine dose was standardized as 10 mg based on a mixture previously used to treat pain due to epidermolysis bullosa. CONCLUSIONS: Topical loperamide can be an efficacious and novel intervention to treat painful ulcers while avoiding systemic effects.

A Comparative Study of Analgesic Efficacy of Intrathecal Bupivacaine with Ketamine Versus Bupivacaine with Magnesium Sulphate in Parturients Undergoing Elective Caesarian Sections.

Background and Aims: Spinal anaesthesia is the most preferred technique of anaesthesia in parturient, undergoing lower segment caesarean sections (LSCS) which provides effective pain relief during intra operative and early postoperative period. However, recent studies demonstrate that about 50%-70% of patients experience moderate to severe pain after LSCS indicating that postoperative pain remains poorly managed. The aim of our study was to compare intrathecal magnesium sulphate (Mgso4) and ketamine as adjuvants to hyperbaric bupivacaine in parturients posted for elective caesarean sections under spinal anaesthesia to determine their effectiveness in extending the duration of analgesia. Materials and Methods: After institutional ethical committee approval, 82 parturient undergoing elective LSCS were enrolled into the prospective randomized double blinded study. Group BK (n = 41) received intrathecal ketamine (25 mg) as additive to hyperbaric bupivacaine and group BM (n = 41) received magnesium sulphate (75 mg) as additive to hyperbaric bupivacaine. Time of onset of sensory analgesia, motor blockade, duration of analgesia was noted down. Intraoperative hemodynamics and any adverse effects of study drugs were noted. Results: The mean duration of analgesia in group BK was significantly longer (P < 0.05) than in Group BM. The onset of sensory and motor blockade was significantly early in Group BK compared to Group BM. Hemodynamics was better maintained in Group BK with less requirement of ephedrine compared to Group BM. The visual analog scale scores were significantly lower without side effects in both the groups. Conclusion: The present study demonstrated that the duration, quality of analgesia, hemodynamic stability was better with intra thecal ketamine as an adjuvant to bupivacaine compared to intrathecal MgSo4 without any significant side effects on mother and child.