Hepatic calcification following dengue virus-induced fulminant hepatic failure

Hepatic calcification can be seen with various infectious and neoplastic conditions. We report a 32-year- old man who developed massive calcification in the right lobe of liver following recovery from dengue virus-associated fulminant liver failure.

An epidemiological study of road traffic accident cases attending emergency department of teaching hospital

Several studies have shown that road traffic injuries are a major cause of death and disability globally, with a disproportionate number occurring in developing countries. The growth in numbers of motor vehicles is a major contributing factor in the rising toll of fatalities and injuries from road traffic crashes in poor countries. In this study, we reviewed medical records of all the victims of road traffic accidents attending the emergency department of Kathmandu Medical College Teaching Hospital within a year. A total of 757 road traffic victims were reported which accounted for 6.66% of all the cases attending the emergency. 49.93% cases belonged to 21-40 years age group. The most common victim group comprised the pedestrians (56.54%) with motorcycle (55.09%) being the most commonly involved vehicle. 44.65% accidents occurred in evening (12-6 pm). The lower limbs (in 42.0% cases) were the most common body region injured with superficial injuries (bruise/abrasion) accounting for the most common injury pattern followed by soft tissue injuries, incised/lacerated wounds and fractures and dislocations. Most accidents occurred in the April-June trimester.

Patterns of organophosphorous poisoning attending a teaching hospital

The objective of this was to study the pattern of patients of organophosphorous (OP) poisoning attending Kathmandu Medical College Teaching Hospital (KMCTH). This is a retrospective study of OP poisoning from hospital records were analyzed meticulously and data extracted. Data collected were: patient's demographics, motive for poisoning, type of OP poison, arrival time, time since ingestion, patient's vitals, predisposing factors, serum cholinesterase levels, treatment given, duration of hospital stay and mortality. A total of 47 patients of OP poisoning attended KMCTH from Aug 2003 to July 2005. 22(46.8%) cases were male and 25(53.2%) were female. The maximum number of patients were between the age of 20-40 (33-70.2%). Married patients outnumbered the unmarried (35/74.5% vs 12/25.5%). The most common motive for poisoning was suicidal, 41 cases (87.2%). Metacid (methyl-parathion) was the most commonly used OP compounds in 32 (68%) patients. Interpersonal marital relationship seemed to be the commonest predisposing factor, 23 cases (48.9%). The commonest time of presentation was between 6 pm-12 midnight. 7(57.4%) cases presented within 2 hours of ingestion of the poison. Serum cholinesterase level measured after full atropinisation was >50% of normal level in 17 cases (36.2%). 10 cases (21.3%) required respiratory support. Intermediate syndrome (IMS) was observed in 3 cases. Overall mortality occurred in 3 cases (6.4%). This study highlights the problem of OP poisoning in our region. Establishment of strict policies against the sale and availability of insecticides and pesticides which are freely available in the market is an effective way to control OP poisoning.

Two cases of severe falciparum malaria in KMCTH

Malaria is the most important parasitic disease of man. It is the protozoan infection of RBCs transmitted by bite of blood feeding female anopheline mosquito. Until the 19th century malaria was found throughout Europe, North America and Russia. Since then, it has been eradicated from these areas but in tropics though initial efforts of eradication had been successful, there has been resurgence of disease accompanied by increasing resistance of the anopheline vector to insecticide and of the parasite to antimalarial drugs. We report two cases of falciparum malaria in which there was co-existent vivax malarial infection. These two cases were both exposed to highly endemic zone for malaria.

Study of clinical profile and antibiotic sensitivity pattern in culture positive typhoid fever cases

OBJECTIVES

The present study was designed to analyze the clinical profile and antibiotic sensitivity pattern in the cases of culture positive typhoid fever.

METHOD

The study was conducted over a period of 1 year. Total of 46 culture positive cases of Typhoid fever were included in the study. The sensitivity pattern of isolates from blood culture was recorded. The modes of presentation, clinical course, lab investigation reports were also recorded.

RESULTS

Out of 46 cases, 33 (71.7%) were males and 13 (28.3%) were females. Average age of presentation was 26.17 years. Fever was present in all patients. Resistance of S .typhi to amoxycillin, chloramphenicol and co-trimoxazole were significantly high. Ciprofloxacin showed resistance in 2 (4.3%) cases. Sensitivity to ceftriaxone was 100% in our study.

CONCLUSION

Typhoid fever is one of the most common health problem in Nepal. Various drugs are being used in the treatment of typhoid fever, in the mean time resistance to many of them are emerging. An appropriate antibiotic has to be initiated only after culture sensitivity in typhoid fever.

Experience with aspiration in cases of amebic liver abscess in an endemic area

The study presented here was performed to evaluate the need for aspiration in patients with amebic liver abscess (ALA). Patients older than 12 years with a diagnosis of ALA based on clinical features, ultrasound results, and positive amebic serology were included in the study (n=144). Serological testing was performed to detect the presence of immunoglobin G antibody against Entamoeba histolytica, and a value of more than 0.4 optical density units was considered positive. All patients were given intravenous metronidazole (500 mg every 8 h) and their clinical progress and need for abscess aspiration was documented. Fever, pain in the upper abdomen, and tender hepatomegaly was seen in 133 (92.3%), 128 (88.8%), and 144 (100%) patients, respectively. Multiple abscesses were seen in 40 (27.7%) patients. Six (4.1%) patients died. Seventy-one (49.3%) patients responded to metronidazole alone. A total of 73 (50.69%) patients required aspiration of the abscess. This study shows that almost 50% of the patients with amebic liver abscess failed to respond to metronidazole and required aspiration.

Arthroscopic reconstruction of the anterior cruciate ligament using bone-patellar tendon-bone autograft: experience of the first 100 cases

PURPOSE

To review the results of patients who underwent arthroscopic reconstruction of the anterior cruciate ligament (ACL) via a single incision technique using a bone-patellar tendon-bone autograft.

METHODS

Patients with ACL-deficient knees who were symptomatic and wanted to maintain an active lifestyle or continue sporting activities were included. ACL reconstruction using the bone-patellar tendon-bone graft was performed on 100 patients. One-year follow-up was completed in 78 patients who were then reviewed. The mean age of patients reviewed was 26.8 years (range, 21-39 years), of whom 35 (44.9%) were aged between 26 and 30 years. There were 73 men and 5 women (ratio, 14.6:1). Injuries on the right side outnumbered those on the left (44 versus 34). Sports injuries accounted for 66.7% (n = 52) of patients, motor vehicle accidents and household injuries accounted for 30.8% (n = 24) and 2.6% (n = 2), respectively.

RESULTS

Excellent and good-to-excellent results were achieved in 7 (9%) and 61 (78.2%) of patients. Residual anterior knee pain (n = 18) was the most common complication, followed by difficulty in regaining full range of motion (n = 10) and divergence of femoral screw (n = 9).

CONCLUSION

This procedure provides consistent and reproducible results in carefully selected patients and allows them an early return to sporting activities with minimal residual morbidity.

Prevalence of tobacco use among school going youth in North Indian States

BACKGROUND

Tobacco use, which is the cause of several respiratory diseases, generally starts in the teens. Global Youth Tobacco Survey (GYTS) is an international initiative to investigate the tobacco use in school going youth of 13 to 15 years of age. This report describes the GYTS findings in the North Indian region.

METHODS

A two-stage cluster sample was used with selection of schools on probability proportional to enrollment size followed by systematic equal probability sampling with a random start of classes from each school. The 85-item questionnaire included 'core GYTS' and other additional questions. Data analysis was performed using EpiInfo 3.2 software and the results accounted for the complex sampling design and weighting factors in the data set.

RESULTS

The sample consisted of 9319 students out of the total eligible population of 30488 from 100 schools. The prevalence of ever-use of tobacco varied between 2.9 to 8.5% in boys and 1.5 to 9.8% in girls. The prevalence was highest in Chandigarh and lowest in Punjab. Between 16 to 46% of students were exposed to the habit of tobacco among parents or friends. There were 10 to 34% students who were passively exposed to environmental tobacco smoke.

CONCLUSION

Tobacco use is present in up to 10 percent of school going youth in the region. A majority of them had desired to quit. Tobacco control and cessation programmes therefore, remain important health issues.

Ancient cystic pelvic schwannoma presenting as a right iliac fossa mass

Schwannoma is rare in pelvis. Ancient schwannoma is rarer histological subtype of schwannoma. We report a very rare case of pelvic schwannoma presenting with right sciatica and right iliac fossa pain. Clinical and imaging findings were suggestive of Peritoneal Hydatid cyst. The tumour was resected completely with marked clinical improvement. Histopathological examination showed Ancient cystic schwannoma.

Omental torsion: a case report

Omental torsion is a rare cause of acute abdomen. Most often it presents with sign and symptoms of acute appendicitis. It is seldom considered in the differential diagnosis preoperatively based on clinical findings and the diagnosis is only established during surgery. We present a case of omental torsion in a middle aged male patient who presented with findings suggestive of appendicular perforation and underwent emergency laparotomy.

Intra abdominal abscess presenting as a thigh abscess

Secondary thigh abscesses are rare, and their cause is often obscure. We report a case of an elderly diabetic who presented with thigh abscess secondary to tuberculous sacroilitis. Key words: Secondary thigh abscess, retroperitoneal abscess, tuberculous sacroilitis.

Anthropometry and body composition in northern Asian Indian patients with type 2 diabetes: receiver operating characteristics (ROC) curve analysis of body mass index with percentage body fat as standard

AIMS

To determine the anthropometric profile and appropriate cut off of body mass index (BMI) to define obesity in Asian Indians with Type 2 diabetes mellitus (T2DM).

METHODS

Three hundred and eighty T2DM patients (213 males and 167 females) in northern India were subjected to anthropometric and body fat analysis (derived from skinfold thickness). The latter was considered as "standard" for defining obesity. Receiver Operating Characteristics (ROC) curves were drawn for males and females to determine the appropriate limits of BMI to define obesity.

RESULTS

Mean values of percentage of body fat (%BF) were 40.2 +/- 6.2% and 29.4 +/- 7.1% in females and males, respectively. Of particular note, substantial percentage of patients had high values of waist-hip ratio (W-HR) [males > 0.95 (53.9%), and females > 0.80 (88.6%)] indicating significant abdominal obesity, and high % BF [males > 25 % BF (73.2%), females > 30% BF (92.2%)] indicating generalized obesity as well. Significantly higher prevalence of obesity was observed in both males (p < 0.001) and females (p < 0.001) when estimated by %BF (males > 25%, females > 30%), as compared to BMI (> 25 kg/m2 in both males and females). ROC curve analysis showed that with %BF taken as the 'standard' for determining obesity, sensitivity and specificity of BMI of > 25 kg/m2 were low. For BMI > 22 kg/m2 in males and > 23 kg/m2 in females, sensitivity increased and there was decrease in overall misclassification.

CONCLUSIONS

The data of current study suggest strikingly high prevalence of abdominal obesity, and generalized obesity as determined by %BF in T2DM patients, and that cut offs for defining obesity by BMI are lower than the suggested limit of 25 kg/m2. Revised definition of obesity using lower cut off of BMI, or based on %BF in northern Asian Indian T2DM patients will lead to a more rational application of dietary restriction, lifestyle measures, and use of metformin.

Pneumocystis carinii pneumonia in a patient with active untreated systemic lupus erythematosus

Pneumonias due to Pneumocystis carinii (PCP) commonly occur in immunocompromised hosts. Although a treatable infection, it is associated with high mortality. A case of PCP presenting in an untreated case of systemic lupus erythematosus is reported, in view of the rarity of this association.

PD-L2 is a second ligand for PD-1 and inhibits T cell activation

Programmed death I (PD-I)-deficient mice develop a variety of autoimmune-like diseases, which suggests that this immunoinhibitory receptor plays an important role in tolerance. We identify here PD-1 ligand 2 (PD-L2) as a second ligand for PD-1 and compare the function and expression of PD-L1 and PD-L2. Engagement of PD-1 by PD-L2 dramatically inhibits T cell receptor (TCR)-mediated proliferation and cytokine production by CD4+ T cells. At low antigen concentrations, PD-L2-PD-1 interactions inhibit strong B7-CD28 signals. In contrast, at high antigen concentrations, PD-L2-PD-1 interactions reduce cytokine production but do not inhibit T cell proliferation. PD-L-PD-1 interactions lead to cell cycle arrest in G0/G1 but do not increase cell death. In addition, ligation of PD-1 + TCR leads to rapid phosphorylation of SHP-2, as compared to TCR ligation alone. PD-L expression was up-regulated on antigen-presenting cells by interferon gamma treatment and was also present on some normal tissues and tumor cell lines. Taken together, these studies show overlapping functions of PD-L1 and PD-L2 and indicate a key role for the PD-L-PD-1 pathway in regulatingT cell responses.

Relation between plasma leptin and anthropometric and metabolic covariates in lean and obese diabetic and hyperlipidaemic Asian Northern Indian subjects

This study investigated the relationship of plasma leptin to obesity, diabetes and hyperlipidaemia in Asian Northern Indian subjects, considered to have a predisposition to abdominal obesity and metabolic syndrome. A total of 72 subjects, subcategorised into lean and obese healthy subjects, lean and obese Type 2 diabetic and lean and obese non-diabetic hyperlipidaemic subjects were recruited. High leptin values were observed in all obese groups, and obese diabetic patients showed the highest levels. In lean and obese diabetic subjects, plasma leptin did not show any correlation to any index of glycaemia. When all lean and all obese subjects were analysed in two separate groups, body mass index (BMI), percent total body fat, and body density significantly correlated with the plasma leptin levels (p<0.05). Leptin values, when correlated to all variables in all patients taken together, showed the greatest magnitude of correlation with BMI (r=0.64), percent total body fat (r=0.67), and waist circumference (r=0.51). Strong inverse correlation was seen with body density (r=-0.67). Levels of serum insulin did not show any correlation with leptin levels in all subjects combined, and separately in various groups. Multiple linear regression analysis performed in obese, non-diabetic and normolipidaemic subjects, all Type 2 diabetic and all non-diabetic hyperlipidaemic subjects separately showed that percent total body fat is the only significant predictor of plasma leptin concentration in all the 3 groups. The present study suggests that plasma leptin has a strong positive correlation with percent total body fat in Asian Northern Indian subjects. Among other components of metabolic syndrome, only abdominal obesity is weakly correlated to serum leptin levels.

Plasma plasminogen activator inhibitor-1 activity in normoglycemic hypertriglyceridemic north Asian Indian subjects: a preliminary case-control study

BACKGROUND

Recent evidence suggests that increased activity of plasma plasminogen activator inhibitor-1, an important component of the insulin resistance syndrome, plays a crucial role in the pathogenesis of atherosclerosis.

METHODS AND RESULTS

In this case-control study, relationships between plasma plasminogen activator inhibitor-1 activity, serum triglyceride levels and hyperinsulinemia were explored in 40 non-diabetic patients with primary hypertriglyceridemia (Group 1) and 40 non-diabetic normotriglyceridemic controls (Group 2) matched for potential confounders like smoking and physical activity. Mean values of fasting serum insulin levels were increased in Group 1 (p>0.05). Hyperinsulinemia was observed in 14 (17.5%) individuals in Group 1 and 11 (13.8%) individuals in Group 2. Mean plasma plasminogen activator inhibitor-I activity in Group 1 (9.8+/-8.4 IU) was higher than in Group 2 (7.0+/-7.7 IU), though the difference was not significant (p>0.05). However, when only subjects with elevated levels of plasma plasminogen activator inhibitor-1 activity were taken into account, mean values were significantly higher in Group 1 (p<0.05). The plasma plasminogen activator inhibitor-1 activity was higher in subjects with body mass index >25 in both the groups, significantly so in males (p=0.05). Hyperinsulinemic subjects with a body mass index >25 and raised serum triglyceride levels had higher mean values of plasma plasminogen activator inhibitor-1 activity (18.42+/-11.15 IU) than subjects with similar characteristics and normal triglyceride levels (14.22+/-8.20 IU, p<0.05).

CONCLUSIONS

Though in the current study a trend for hyperinsulinemia and high plasma plasminogen activator inhibitor-1 activity was observed in hypertriglyceridemic subjects, a larger study is needed to achieve significant differences and correlations. Obese male subjects, irrespective of their lipid profile, are at risk for thrombotic events in view of their significantly higher plasma plasminogen activator inhibitor-1 values. Procoagulant tendency is further enhanced if hypertriglyceridemia and hyperinsulinemia are added on to obesity.

Comparative evaluation of the inflammatory mediators in patients undergoing laparoscopic versus conventional cholecystectomy

BACKGROUND

Injury induces systemic inflammatory response. The degree of response is proportionate to the trauma.

METHODS

Patients with ultrasound-proven gall stones posted for operation were randomized into two groups. Laparoscopic cholecystectomy was performed in one group while the other group underwent conventional cholecystectomy. Peripheral venous blood samples for inflammatory mediators, namely tumour necrosis factor, C-reactive protein, oxygen release from monocytes and polymorphonuclear leucocytes were drawn 1 day before surgery and repeated on the first and third days after surgery. Partial pressure of arterial oxygen was also measured in both groups. Only patients who met selection criteria and had uncomplicated postoperative courses were included in the study. There was a total of 40 patients for the final analysis, 20 in each group.

RESULTS

There was no significant difference (P > 0.1) in age, sex or body mass index in both groups of patients. The level of all of the inflammatory mediators was elevated on the first postoperative day; however, the elevation was significantly less following laparoscopic cholecystectomy compared to conventional cholecystectomy (P < 0.01). Although the values came down on the third postoperative day, they remained above the respective controls. Postoperative hypoxaemia was significantly more in patients of conventional than laparoscopic cholecystectomy (P < 0.001).

CONCLUSIONS

Trauma-induced inflammatory response is significantly less following laparoscopic cholecystectomy compared to conventional cholecystectomy. It appears to be related to degree of trauma.

The death inhibitory molecules CED-9 and CED-4L use a common mechanism to inhibit the CED-3 death protease

The apoptotic machinery of Caenorhabditis elegans includes three core interacting components: CED-3, CED-4, and CED-9. CED-3 is a death protease composed of a prodomain and a protease domain. CED-4 is a P-loop-containing, nucleotide-binding molecule that complexes with the single polypeptide zymogen form of CED-3, promoting its activation by autoprocessing. CED-9 blocks death by complexing with CED-4 and suppressing its ability to promote CED-3 activation. A naturally occurring alternatively spliced form of CED-4 that contains an insertion within the nucleotide-binding region (CED-4L) functions as a dominant negative inhibitor of CED-3 processing and attenuates cell death. Domain mapping studies revealed that distinct regions within CED-4 bind to the CED-3 prodomain and protease domain. Importantly, the CED-4 P-loop was involved in prodomain binding. Disruption of P-loop geometry because of mutation of a critical lysine (K165R) or insertional inactivation (CED-4L) abolished prodomain binding. Regardless, K165R and CED-4L still retained CED-3 binding through the protease domain but were unable to initiate CED-3 processing. Therefore, the P-loop-prodomain interaction is critical for triggering CED-4-mediated CED-3 processing. Underscoring the importance of this interaction was the finding that CED-9 contacted the P-loop and selectively inhibited its interaction with the CED-3 prodomain. These results provide a simple mechanism for how CED-9 functions to block CED-4-mediated CED-3 processing and cell death.

Hyperhomocysteinemia confers an independent increased risk of atherosclerosis in end-stage renal disease and is closely linked to plasma folate and pyridoxine concentrations

BACKGROUND

A high level of total plasma homocysteine is a risk factor for atherosclerosis, which is an important cause of death in renal failure. We evaluated the role of this as a risk factor for vascular complications of end-stage renal disease.

METHODS AND RESULTS

Total fasting plasma homocysteine and other risk factors were documented in 176 dialysis patients (97 men, 79 women; mean age, 56.3 +/- 14.8 years). Folate, vitamin B12, and pyridoxal phosphate concentrations were also determined. The prevalence of high total homocysteine values was determined by comparison with a normal reference population, and the risk of associated vascular complications was estimated by multiple logistic regression. Total homocysteine concentration was higher in patients than in the normal population (26.6 +/- 1.5 versus 10.1 +/- 1.7 mumol/L; P < .01). Abnormally high concentrations (> 95th percentile for control subjects, 16.3 mumol/L) were seen in 149 patients (85%) with end-stage renal disease (P < .001). Patients with a homocysteine concentration in the upper two quintiles (> 27.8 mumol/L) had an independent odds ratio of 2.9 (CI, 1.4 to 5.8; P = .007) of vascular complications. B vitamin levels were lower in patients with vascular complications than in those without. Vitamin B6 deficiency was more frequent in patients than in the normal reference population (18% versus 2%; P < .01).

CONCLUSIONS

A high total plasma homocysteine concentration is an independent risk factor for atherosclerotic complications of end-stage renal disease. Such patients may benefit from higher doses of B vitamins than those currently recommended.

Hypomelanosis of Ito

A two-year-old male child presented with bizarre hypopigmented skin lesions, severe mental retardation and generalized tonic-clonic seizures. Examination showed hypopigmented patterned whorls and irregular patches over the trunk and linear streaks over the flexor aspects of upper and lower limbs. He also had generalized hypertonia and brisk tendon reflexes. Other systems were normal.