Post lumbar puncture headache: is bed rest essential?

Headache following lumbar puncture is a well known and well described complication. Various manoeuvres have been tried to prevent post lumbar puncture headache--the commonest being bed rest for 4 to 24 hours following lumbar puncture, though its value is questionable. Randomised controlled clinical trial was done to evaluate the effect of 24 hours bed rest on the incidence and severity of post lumbar puncture headaches. Two hundred and eight patients were randomly allocated to either the ambulant or the bed rest group. Patients were interviewed by a single investigator on days 0, 1, 2 and 7 about the presence and nature of headache. Other relevant clinical and laboratory data pertaining to the lumbar puncture was collected. The overall incidence of post lumbar puncture headache was 17%; 15% in the ambulant and 18% in the bed rest group. Of the patients who had headaches, severe headache was observed in 57% in the ambulant and 12% in the bed rest group (p = 0.02). Other variables did not alter the outcome of headaches. Bed rest does not appear to alter the incidence of post lumbar puncture headaches, but reduces the severity in those who get headaches, after a lumbar puncture.

A randomized double-blind sham-controlled study of intrathecal human anti-tetanus immunoglobulin in the management of tetanus

BACKGROUND

Tetanus is a major cause of mortality and morbidity in developing countries. Various modalities of treatment to prevent progression of the disease and alter its outcome have been tried. This study was designed to evaluate the role of intrathecal human anti-tetanus immunoglobulin (TIG) in the management of tetanus.

METHODS

Thirty-six adult patients presenting to an university-affiliated teaching hospital were stratified based on the severity of disease into mild and severe disease, and subsequently randomly allocated to receive either 250 i.u. of TIG intrathecally or a sham procedure mimicking the lumbar puncture.

RESULTS

In mild tetanus, TIG administration significantly retarded the rate of progression (p = 0.05), reduced the duration of hospital (p = 0.01) and intensive care unit stay (p = 0.05), need for tracheostomies (p = 0.03) and the dose of sedatives required for control of spasms (p = 0.01). In mild tetanus, the mortality rates were 20% and 30% in the treated and control groups, respectively.

CONCLUSION

We suggest that TIG is useful in reducing the morbidity, progression of disease and mortality in patients presenting with mild tetanus.

Blind pleural biopsy using a Tru-cut needle in moderate to large pleural effusion--an experience

BACKGROUND

Pleural biopsy is invaluable for the etiological diagnosis of pleural diseases in the presence of an exudative pleural effusion. Conventionally, pleural biopsy is either performed with the Cope's or the Abrams pleural biopsy needles. A few investigators have used the Tru-cut biopsy needle with or without ultrasound guidance. We report our experience in performing closed pleural biopsy using a Tru-cut needle without ultrasound guidance in moderate to large exudative pleural effusion. We used a perpendicular approach to biopsy the pleura instead of the tangential approach described earlier.

METHODS

Closed Tru-cut biopsy was performed in 27 consecutive patients with exudative pleural effusion who volunteered to undergo the procedure. The biopsy specimen was sent for histopathology. Pleural fluid analysis and other relevant investigations required to obtain a specific diagnosis were carried out.

RESULTS

A specific diagnosis of tuberculosis was obtained on histopathology of pleural tissue in 12 out of 16 patients (diagnostic yield 75%) and in 5 out of 7 patients with malignancy (diagnostic yield 71%). Among the other 4 patients, other causes of exudative pleural effusion were detected in 3 and in 1 patient, no specific diagnosis could be made, despite extensive investigation.

CONCLUSION

Closed pleural biopsy using a Tru-cut needle is effective for the specific diagnosis of exudative pleural effusion. The use of a perpendicular approach to biopsy the pleura does not seem to increase the complication in moderate to large pleural effusion.

Predictors of mortality in a medical intensive care unit

BACKGROUND

Scoring systems to predict mortality in intensive care units have been developed in western populations. There is a need to identify and validate prognostic variables in the Indian context. We compared two scoring systems to predict the discharge outcome in patients admitted to a medical intensive care unit.

METHODS

Five hundred patients admitted to a medical intensive care unit were studied prospectively. Modified acute physiology and chronic health evaluation II (APACHE II) score and modified organ system failure (OSF) score were applied on the day of admission to the intensive care unit. The scores obtained by the two systems were compared using the area under the curve approach. The likelihood ratios were calculated for predicting discharge outcome.

RESULTS

The modified OSF score predicted discharge outcome better than the modified APACHE II score--receiver operating characteristic curve area (standard error-area) 0.7062 (0.0244) and 0.6068 (0.0267) for the modified OSF and the modified APACHE II scores, respectively. This was statistically significant (p < 0.001). The likelihood ratio for the modified OSF score for different cut-off points varied from 0.27 to 5.49, while the likelihood ratio for the modified APACHE II score varied from 0.11 to 2.08. This means that for an intensive care unit with a 30% overall mortality, the modified OSF score could separate patients with 10% to 70% mortality, while the modified APACHE II score could predict only 5% to 47% mortality.

CONCLUSION

The modified OSF score was superior to the modified APACHE II score in predicting mortality in patients admitted to the medical intensive care unit.

Measuring the impact of focused workshops on rational drug use

Rational drug use workshops were conducted in various centres in India. The effects of these workshops on some of the indicators for rational drug use are discussed. An evaluation based on responses to questionnaires does not permit the measurement of the effects on practice changes, and only perceived changes by the respondents are indicated. Within the short period of evaluation, drug use skills and awareness about various aspects of rational drug use are perceived to have improved. There is a need to re-emphasize through personal interaction and workshops the concept of rational drug use.

Epidemiological features of acquired immunodeficiency syndrome in southern India

AIDS was diagnosed in 187 men and 24 women (M:F = 8:1) from April 1987 till December 1994 at the Christian Medical College Hospital, Vellore. The doubling time of the occurrence of AIDS cases was 14 months; during 1987-90 there were an average of 5.7 cases per year; in 1991-93 there were 28 per year; in 1994 there were 104 cases. The mean age of patients was 33 yr for men and 31 for women. Among men, the primary mode of infection was heterosexual contact with female commercial sex workers. Among women, the most common source of infection was their husbands. There were 4 bisexuals and one homosexual subject who might have acquired infection by having sex with other men. There were 135 subjects from urban and 76 from rural communities. Most subjects belonged to the lower socio-economic classes. These data show that HIV infection had been very widespread in this region, both urban and rural.

Drug interaction: rifampicin and glibenclamide

BACKGROUND

Rifampicin is a potent inducer of the hepatic microsomal enzyme system. However, the drug has been shown to cause clinically important interactions with many drugs. This study was designed to test the interaction of rifampicin with the oral hypoglycaemic agent glibenclamide.

METHODS

Twenty-nine well-controlled diabetic patients on a combination therapy of diet and glibenclamide, and willing to participate in the trial, received a daily dose of 450 mg (body weight < 50 kg) or 600 mg (body-weight > 50kg) of rifampicin for 10 days.

RESULTS

There was a significant (p < 0.001) worsening of fasting and post-prandial blood sugar after administration of rifampicin. Dose modification of glibenclamide was required in 15 of the 17 patients in whom the diabetes became uncontrolled. Blood sugar normalized by day 6 after stopping rifampicin in all patients.

CONCLUSION

Rifampicin and glibenclamide interact. Therefore, necessary dose modifications should be made in order to achieve euglycaemia if these two drugs are given together.

Evaluation of two treatment regimens of pralidoxime (1 gm single bolus dose vs 12 gm infusion) in the management of organophosphorus poisoning

Organophosphorus (OP) poisoning is most frequently encountered among our community. Treatment of poisoning is primarily aimed at reversing the effects of the compound by administration of atropine. Oximes have been shown to be efficacious in case reports. The dose of this drug in these reports varies from 1 gm which is a very low dose and physiologically no dose, to doses upto 16 gm. This is also a very expensive imported drug which causes the nation considerable loss of foreign exchange. We report our experience with the use of two treatment regimens of Pralidoxime (P2AM) in the management of patients with OP poisoning in a prospective trial. Seventy-two adult patients presenting to a large university affiliated teaching institution with a history of consumption of OP compounds and requiring intensive care were entered into the trial. Patients were randomized using a block randomisation to receive either a single bolus dose of 1 gm P2AM at admission (Low dose group) followed by placebo infusion over the next 4 days or a single placebo bolus at admission followed by P2AM 12 gm as a continuous infusion over the next 4 days. Outcome measures analyzed were mortality, duration of ICU stay, need for ventilation and duration of ventilation, time to recovery of consciousness, development of intermediate syndrome and infections. A higher prevalence of intermediate syndrome (p = 0.08) was observed in the high dose group. Ventilatory requirement was also more in the high dose group (p = 0.09). Since this was an equivalence study designed to show that the low dose was as effective as the high dose, these results attain greater significance as the low dose group fared better than the high dose group, even though the pre-test hypothesis was in the reverse direction. Subgroup analysis of patients who received at least 1 gm of P2AM within 12 hours of ingestion of the OP poison with those who received P2AM after 12 hours, showed that there was a significant reduction of intermediate syndrome (p = 0.05) but no significant difference was noted in number ventilated. High dose P2AM infusion has no role in the routine management of patients with OP poisoning. These results also suggest that the time of administration of P2AM after the ingestion of the poison mabe a crucial factor which determines response to therapy. A prospective double blind placebo controlled trial is now justified in the light of the above findings.

Cost-effectiveness of inhaled beta-agonists v. oral salbutamol in asthma: a randomized double-blind cross-over study

BACKGROUND

Oral beta-stimulants are widely used in the management of chronic asthma in India, in spite of evidence suggesting the superiority of inhaled medication in achieving maximum bronchodilatation. An economic evaluation was performed in a randomized double-blind cross-over trial to evaluate the role of adjuvant oral beta-stimulants in the treatment of asthma.

METHODS

Patients who had seasonal or perennial asthma and were using metered dose inhalers for control of symptoms were randomly selected for the study. They received either 4 mg of oral salbutamol or placebo as adjuvant treatment. During the study they controlled their symptoms by adjusting the dose of the inhaler medication. A cost minimization technique was used to assess the economic impact of this intervention in the treatment and control periods. A sensitivity analysis was performed to assess the robustness of the conclusions.

RESULTS

The mean cost was significantly greater in the treatment period and a patient lost approximately Rs 20 per month (CI: 13 to 27; p = 0.001) as a result of the adjuvant treatment. There was no significant difference in the quality of life or peak expiratory flow rate during the two periods. The patients also noted mild but significantly increased tremors (p = 0.01) and palpitations (p = 0.001) during the treatment period. There was no treatment-to-period interaction.

CONCLUSION

Adjuvant oral beta-agonists do not improve the quality of life or bronchodilatation in asthmatics using an inhaled beta-agonist for control of symptoms.

Hyponatraemia and hiccups

BACKGROUND

Hiccups are observed in many patients with hypohatraemia. We performed a case-control study to evaluate their association in a referral teaching hospital in South India.

METHODS

Fifty consecutive patients who developed hiccups during an 18-month period were studied. They were categorized according to age group and diagnosis and controls matched for age and sex were selected from patients admitted on the same day in the medical wards. Hiccups were graded on a four-point severity scale at recruitment and every day till day 7 or till hiccups subsided.

RESULTS

The step-wise logistic regression analysis done to establish independent association showed that for every 10 mEq/L reduction in serum sodium, patients were 17 times (p = 0.001; confidence interval: 4-87) at risk of developing hiccups. The only other significant determinant of the symptom was the diagnostic category of renal failure (odds ratio = 128; confidence interval: 1-1420). The number of patients who had hyponatraemia with varying severity of hiccups showed a dose-response relationship. The crude odds ratios were 7, 58 and 320 for mild, moderate and severe hiccups.

CONCLUSION

There is a strong and independent association between hyponatraemia and hiccups in hospitalized patients. A causative association is suggested by the dose-response relationship demonstrated in the study. In many hospitals in developing countries where measurement of serum sodium is difficult and unreliable, it is important to be aware of this association since it can be easily corrected.

Outcomes in the Guillain Barre syndrome: the role of steroids

Guillain-Barre Syndrome (GBS) is one of the commonest demyelinating diseases of the peripheral nervous system. This retrospective cohort study reports the outcomes of 97 patients in a large teaching hospital in South India. Fifty patients were treated with steroids and 47 had no steroids. Twenty one of the 41 evaluable patients in the steroid group had functional improvement at discharge as compared to 20 of 42 evaluable patients in the non-steroid group. Six patients in each group had worsening of their weakness. Steroids did not show any significant beneficial effect in either improving the disability scores at discharge (steroid-0.42 vs. non-steroid-0.29) or in reducing the duration of ICU stay (4 vs. 8 median days). A higher proportion of patients on steroids developed complications (p = 0.02). The median duration of hospital stay was 16 days in the steroid group as opposed to 14 days in the group not treated with steroids. The mortality was 6 in the steroid treated group and 5 in the non-steroid group. Steroids have no significant benefit on the outcome of GBS.

Study on the effectiveness of enalapril as a monotherapy in mild to moderate hypertension

This study highlights our experience with 53 patients with mild to moderate hypertension who had monotherapy with Enalapril, one of the newer Angiotensin Converting Enzyme inhibitors. Enalapril was found to be effective in controlling blood pressure in 41 patients (77%). In 12 patients (23%) addition of one more drug was necessary for control of hypertension. Side effects were noted in 9 patients (17%). In two patients the adverse reactions were severe enough to warrant withdrawal of the drug.

Comparison of disease-specific and a generic quality of life measure in patients with bronchial asthma

BACKGROUND

Quality of life is being increasingly recognized as an important outcome in chronic and terminal illnesses. There are few publications from India on the characteristics of the instrument that measures quality of life in clinical trials. We describe a method for choosing an appropriate instrument in a randomized trial.

METHODS

We selected thirty-two patients with bronchial asthma randomly and evaluated them to compare the validity and responsiveness of the disease-specific quality of life instrument in asthma (AQL) and the generic quality of life instrument, 'Sickness impact profile' (SIP), to detect changes in their health status. Validity was determined by a priori constructs (construct validation) and the responsive coefficient was calculated by determining the relationship to the 'minimal significant change in asthma score' and the 'variability' seen in this change in stable patients.

RESULTS

The constructs used in validating the scores were that the change in quality of life score would correlate (i) highly with change in self-assessment of the disease (r > 0.7), (ii) moderately with change in physician assessment of the disease (r > 0.5), and (iii) minimally with change in peak flow reading (r > 0.3). We found both instruments to have good construct validity. The responsiveness coefficients noted for AQL and SIP were 1.8 (CI 0.65-3) and 0.7 (CI 0.3-1.2), respectively.

CONCLUSIONS

Though both AQL and SIP were valid measures of quality of life, AQL is likely to be more capable of detecting smaller changes in the health status of patients with bronchial asthma and hence was chosen as the instrument in the proposed clinical trial.

Significance of Salmonella typhi bacteriuria

Bacteriuria due to Salmonella typhi usually occurs following recent typhoid fever or in chronic carrier states. Data from 18 patients with S. typhi bacteriuria, seen during 5 years, were analyzed. Fourteen patients had localized urinary tract infection due to S. typhi. Four others had bacteriuria, probably associated with typhoid fever. Localized abnormalities of the urinary tract and kidneys and also systemic diseases were found to predispose patients to S. typhi bacteriuria. Local abnormalities encountered included urolithiasis (n = 3), prostatic hypertrophy (n = 1), and tuberculosis (n = 1). One renal transplant recipient and another with lupus nephritis had S. typhi bacteriuria. One had associated strongyloidosis, and another was pregnant.

Incidence of intermediate syndrome in organophosphorous poisoning

Seventy two patients admitted to the Intensive Care Unit following ingestion of organophosphorus compounds were studied prospectively with two different doses of pralidoxime (PAM). One group received 1 gm immediately after admission and no further PAM and the other group received infusion of PAM, 1 gm 8 hourly for four days (total 12 gms). The incidence of type II paralysis or intermediate syndrome was 47%. We observed a higher incidence in the 4 days of infusion of PAM group (61%) (20 patients) as compared to the single Bolus dose group (39%) (13 patients). Relative risk 1.48 (confidence interval = 0.9-2.4).

Osteomalacia--fifty five patients seen in a teaching institution over a 4 year period

A retrospective analysis of 55 cases of osteomalacia shows that poor calcium intake and poor sunlight exposure are the most common causes for osteomalacia. However, in patients with normal nutritional history, other disorders such as renal tubular acidosis and tumour induced osteomalacia should be looked for. A careful drug history, particularly anticonvulsant use is essential. In 4 patients there was an association between anti-tuberculous drug use and osteomalacia. Further prospective studies are needed to determine the relationship between Rifamicin use and osteomalacia.

Hyperprolactinemia in women--a series of 71 cases

Seventy one cases of hyperproloactinemia (HPRL) in women were seen over five years. Of these, twenty five had pituitary tumors, thirty three had functional HPRL, five had drug induced HPRL and four had hypothyroidism. Surgery was undertaken in fifteen women, rest were treated with bromocriptine. There were thirteen pregnancies in patients with tumor after treatment. Seven of thirty three patients with functional HPRL conceived. No patient had tumor expansion or recurrence during pregnancy. Bromocriptine was required for most patients.

Primary hyperaldosteronism--diagnostic approach and management

Primary hyperaldosteronism was detected in 1% of patients evaluated for secondary hypertension in a referral hospital in Southern India. The presence of hypokalemia with inappropriate kaliuresis (24 hr. urine K > 20mEq) was an important diagnostic clue. High resolution CT scans were found to be useful for localising the tumour. Preoperatively nifedipine and spironolactone were employed to correct hypertension and hypokalemia. The same drugs were also found to be excellent for long-term control of hypertension and hypokalemia in patients who had bilateral adrenal hyperplasia and aldosteronism.