Complete congenital sternal cleft in an adult: repair by autogenous tissues

We are reporting here a rare case of congenital complete sternal cleft in an adult of 25 years of age, with absent anterior pericardium and "diastasis recti." Successful surgical repair was achieved along with the preservation of the already existing anatomic and mechanical sanctity of thoracic cage, sternal reconstruction, and protection of the underlying heart and great vessels with a good cosmetic result using autogenous tissue i.e., iliac bone and "V-Y" myoplasty of pectoralis major muscles with their functional preservation and correction of associated anomalies.

Current status of Takayasu arteritis in India

The clinical features of 106 patients of Takayasu arteritis (TA) seen over a period of 16 years are documented (65 females and 41 males). The mean age was 27.3 +/- 9.2 years. Hypertension was the commonest mode of presentation (51.3%) and was detected in 82 patients (77.4%) at the time of presentation. Vascular bruits were heard in 72 patients (67.9%) and 13 patients (12.3%) were in congestive heart failure. Aortography was performed in 95 patients. Based on the extent of involvement, Type I (branches of aortic arch) was seen in 7 (6.6%) patients, Type II (aortic arch, its branches and descending thoracic aorta) in 7 (6.6%) patients, Type III (descending thoracic aorta and abdominal aorta) in 4 (3.8%) patients, Type IV (abdominal aorta only) in 29 (27.3%) patients and Type V (aortic arch, descending thoracic aorta and abdominal aorta) in 59 (55.7%) patients. Therapeutic modalities included antihypertensive drug therapy in 81 patients, antitubercular drugs in 8 patients, steroids in 16 patients and cyclophosphamide in one patient. Response to steroids was satisfactory in 5 of these 16 patients while the lesions of vasculitis healed in the patient who was treated with cyclophosphamide. Surgical interventions included nephrectomy and autotransplantation of kidney in 3 patients each and revascularization in 4 patients and angioplasty in 4 patients. In the area of pathogenesis of this disease, a high activity of protein kinase C(PKC), an increased intracellular calcium and inositol 1,4,5 triphosphate in both unstimulated and stimulated T cells of TA was observed. These findings suggest an activation of PKC-calcium pathway in TA.

Comparison of two substrates in determination of plasma cholinesterase activity & genetic variability

Two substrates, acetyl thiocholine iodide ATCI and benzoylcholine chloride BCC were compared for the determination of plasma cholinesterase ChE levels and after incorporation of dibucaine and sodium fluoride in the assay, their usefulness in determining plasma ChE genetic variability was assessed in 64 healthy subjects. With both substrates, plasma ChE levels were found to be in the reference range. However, ATCI could detect only two variants with the usual phenotype UU in 60 of 64 [93.75%] subjects whereas with BCC 6 different groups could be determined. Though both substrates are of equal value in estimation of plasma ChE levels, BCC is definitely superior in determining its genetic variants.

Diagnostic criteria for Takayasu arteritis

Diagnosis of Takayasu arteritis (TA) is often delayed because of a non-specific clinical presentation. Ishikawa's criteria (1988) has been widely used for the diagnosis of this disease. Few modifications have been proposed in Ishikawa's criteria for the diagnosis of TA. The proposed modifications include: (a) removal of the obligatory criteria of age less than 40 years; (b) inclusion of characteristic signs and symptoms as a major criteria; (c) removal of age in defining hypertension; (d) deletion of the absence of aorto-iliac lesion, in defining abdominal aortic lesion; and (e) an addition of coronary artery lesion in absence of risk factors. The criteria proposed consists of three major criteria including left and right mid subclavian artery lesions and characteristic signs and symptoms of at least one month duration and ten minor criteria-a high erythrocyte sedimentation rate, carotid artery tenderness, hypertension, aortic regurgitation or annuloaortic ectasia, pulmonary artery lesion, left mid common carotid lesion, distal brachiocephalic trunk lesion, descending thoracic aorta lesion, abdominal aorta lesion and coronary artery lesion. Presence of two major or one major and two minor criteria or four minor criteria suggests a high probability of TA. When applied to 106 Indian patients of angiographically proven TA and 20 control subjects, it had a sensitivity of 92.5% and specificity of 95% that was higher than that of Ishikawa's criteria (sensitivity 60.4%, specificity 95%) and American college of Rheumatology criteria (sensitivity 77.4%, specificity 95%). Similarly, this criteria had a 96% sensitivity and 96% specificity in 79 Japanese patients of TA and 79 control subjects. Adoption of these criteria is expected to prevent the possibility of an under diagnosis of TA.

Systemic manifestations of Takayasu arteritis: the expanding spectrum

Takayasu arteritis (TA) is a chronic inflammatory and obliterative disease of large vessels particularly the aorta and its major branches. Recently, the disease has been shown to involve the parenchyma of various organs. Specific glomerular lesions reported in patients with TA are mesangial proliferative, membrano-proliferative, crescentic glomerulonephritis and amyloidosis. Dermatological manifestations of this disease are erythema nodosum, facial lupus rash and erythema induratum. Dilated cardiomyopathy, myocarditis and pericarditis have been reported in TA. Rarely, interstitial lung disease, pneumonic consolidation, idiopathic ulcerative colitis, rheumatoid arthritis and polymyositis have been described in association with TA. In this report, five patients of TA with primary parenchymatous involvement of kidneys, skin, heart and gastrointestinal tract have been described. An association of primary parenchymatous organ involvement and TA suggests an autosensitization to an unidentified antigen in the pathogenesis of TA.

Alteration of peripheral blood lymphocyte subsets in essential hypertension

OBJECTIVE

To assess lymphocytic subpopulation by labelled monoclonal antibody technique in a small group of patients with untreated essential hypertension (EH) and to detect any alteration with control of blood pressure.

DESIGN

Prospective study with phenotypic estimation of lymphocytes at presentation and a minimum of two weeks after the control of blood pressure.

SETTING

Referral, tertiary care hospital.

PATIENTS

Group 1, normotensive controls (n = 10); group 2, mild to moderate essential hypertension (n = 10); group 3, severe (accelerated/malignant) hypertension (n = 10). All the secondary causes of hypertension were ruled out by a thorough history, physical examination and appropriate radiological and biochemical investigations.

TESTS

Venous blood samples, taken at entry and a minimum of two weeks after control of blood pressure, were analyzed by alkaline phosphatase antialkaline phosphatase (APAAP) antibody technique for CD4, CD3, CD8 and CD22. Peripheral lymphocytes were separated and cocultured with phytohemagglutinin (PHA) for 72 h and assayed for CD25 by the APAAP technique.

MAIN RESULTS

In untreated patients with EH (groups 2 and 3), there was a significant down regulation of CD3, and CD4 lymphocytes whereas the proportion of mature CD22 cells increased. In group 3 there was a significant down regulation of CD25 with PHA stimulation. A negative correlation was observed between CD25 and diastolic pressure upon pooling the results of groups 2 and 3. No significant alteration in these parameters was observed following control of blood pressure with drugs for up to two weeks.

CONCLUSION

In this small group of patients with untreated EH, a significant alteration in the lymphocytic repertoire was observed. Whether this will be found in large groups of hypertensives remains to be seen.

Normal spirometry in healthy natives of Bhutan

We performed spirometry on 333 healthy Bhutanese men and women at Thimpu. Prediction equations were derived using age and height as regression coefficients. Age had a significant negative correlation while both height and weight had positive linear correlation with spirometric indices. The relationship of weight with FVC was explained largely on the basis of the "muscularity" effect of weight. Bhutanese have lower ventilatory parameters than the Europeans and the North Indians. The difference is likely to be ethnic in origin.

Prevalence of serum antibodies to synthetic peptides to HPV16 epitopes among Indian women with cervical neoplasia

Serum samples from 38 Indian women with cervical intraepithelial neoplasia (CIN) and cancer along with 20 control women were analysed for IgG antibodies against a panel of four synthetic peptides derived from early and late gene open reading frames of HPV16. The cervical tissue samples from these patients were also subjected to PCR in order to detect the presence of human papilloma viruses (HPVs) type 6, 11 and 16 DNA, using a set of primers for the E6 open reading frames in order to establish the acquisition of HPV infection. E2, E6 and L1 peptides of HPV16 were found to be highly reactive with the patients' sera, and a significant prevalence of antibodies to E6, E2 and L1 (P < 0.01) was observed among women with CIN, while antibodies to E6 peptide were only significantly elevated (P < 0.01) among women with cervical invasive carcinoma. Furthermore, there was good agreement between the development of the E6 antibody response and the presence of HPV16 E6 DNA among women with CIN and cervical invasive carcinoma as shown by high values of the kappa coefficient (0.7-1.0). The study clearly revealed a strong agreement between two assay methods defining unambiguous immunogenic B-cell epitopes on synthetic peptides to early and late gene open reading frames of HPV16 which could be used in HPV peptide serology. As such, single or combination of peptides in HPV peptide serology can be used as a screening tool to identify HPV-associated cervical lesions.

Platelet calcium pump activity in essential hypertensives and their first-degree relatives

Intracellular free Ca2+ concentration has been shown to be elevated in platelets of patients with essential hypertension. This study was designed to characterize Ca(2+)-pump activity of the platelet membranes (surface and intracellular) in these patients A double-blind study was carried out. Untreated and treated (on beta-blockers) essential hypertensives were studied in comparison with normotensive control subjects. First degree blood relatives of essential hypertensives were also studied. The Ca2+ activation kinetics of the enzyme showed a significant decrease in the Vmax (for the plasma- and intracellular membranes) and Km (for the intracellular membranes) in the essential hypertensive patients. Increased platelet membrane cholesterol content was observed in these patients. Lowered Ca2(+)-efflux by Ca2(+)-ATPase may lead to elevated intracellular free Ca2(+)-levels in platelet of essential hypertensives. A lowered Ca2(+) -ATPase activity may emerge as a marker for essential hypertension.

Oxygen-dependent and -independent mechanisms of renal injury in experimental ascending pyelonephritis

Pyelonephritis is the most common urinary tract infection affecting females of all age groups. Despite concerted efforts the mechanism of renal injury in pyelonephritis is not clearly understood. In the present study we have made an attempt to characterise the mediators of inflammatory insult in an experimental model of ascending pyelonephritis. Mice infected with Escherichia coli O6:K13:H1 were sacrificed at 2, 7 and 14 days post-infection. Luminol-dependent chemiluminescence response, NADPH oxidase, acid phosphatase, beta-glucuronidase and N-acetyl-beta-D-glucosaminidase activities were monitored in circulating as well as renal phagocytic cells in order to determine the role of reactive oxygen species and lysosomal enzymes in genesis of renal injury. We have demonstrated that reactive oxygen species are generated at the initiation of infection and the levels increase progressively during the course of infection. While intracellular release of lysosomal enzymes was seen in all groups, extracellular release was primarily observed at 7 and 14 days post-infection only. The results indicate that while reactive oxygen species play a significant role in tissue injury during all stages of infection, lysosomal enzyme release in extracellular milieu augments tissue destruction at later stages only.

Aluminum phosphide ingestion--a clinico-pathologic study

BACKGROUND

Aluminum phosphide is widely used in India as a fumigant to protect stored grain from pests and rodents. It is marketed in India as 3 g tablets under several brand names as Celphos, Phostek, Quickphos, and Phosphume. If ingested, it is acutely toxic with a high mortality. The present study was undertaken to define any factors which could predict the outcome after an ingestion.

METHODS

Between March 1989 and March 1994, 195 patients with aluminum phosphide ingestion were admitted to Nehru Hospital of the Postgraduate Institute of Medical Education and Research, Chandigarh in Northwest India. The information regarding demography, time elapsed between ingestion and arrival in the hospital, nature of ingestion, dose ingested, symptoms and signs at admission and course during hospital stay was recorded on a proforma.

RESULTS

Of 195 patients, 115 died. The deaths could be related to the dose ingested but not to the time elapsed between ingestion and arrival at the hospital. The nonsurvivors had more severe hypotension and metabolic acidosis than the survivors who had more severe vomiting. Autopsies conducted in 115 subjects revealed congestion of liver, spleen, kidneys, adrenals, gastrointestinal tract and brain that correlated with the severity of hypotension. Histopathology did not reveal any specific changes beyond visceral congestion and patchy necrosis of the liver.

CONCLUSION

Aluminum phosphide when ingested is highly toxic with fatal dose as low as 1.5 g. The dominant clinical feature is severe hypotension refractory to dopamine.

Reactive oxygen species-mediated tissue injury in experimental ascending pyelonephritis

Pyelonephritis is the most common urinary tract infection in females, but the pathogenetic mechanisms are not well understood. Reactive oxygen species (ROS) have been implicated as cause of injury in several renal diseases. In this study, we have demonstrated the role of ROS in pathogenesis of pyelonephritis in Balb/c mice. A clear correlation between extent of ROS generation and subsequent lipid peroxidation and DNA damage in kidneys was observed during the course of infection, from 2 to 14 days. Activities of brush border membrane marker enzymes were also significantly altered. Administration of antioxidants, superoxide dismutase, catalase and dimethylsulfoxide significantly reversed the histopathological changes, reduced the extent of lipid peroxidation in renal brush border membrane, and also reversed the altered enzyme activities to near normal situation. These results clearly suggest that interaction of ROS with various cellular organelles in kidneys has a significant deleterious effect, and this could be the underlying mechanism for renal dysfunction in pyelonephritis.

Is atropine alone sufficient in acute severe organophosphorus poisoning?: experience of a North West Indian Hospital

Between January 1990 and December 1992, 18 patients with severe organophosphate poisoning (OPP) were admitted to our respiratory intensive care unit (RICU). Suicidal ingestion was the commonest cause of poisoning (15/18). The treatment comprised of atropine in bolus doses. 2-PAM in conventional dose and mechanical ventilation (MV) with positive end expiratory pressure (PEEP) wherever indicated. The mean dose of atropine on day 1 was 178.9 mg (range 60-480 mg) and then gradually reduced. The mean duration of treatment with atropine was 9.6 days (range 1-24 days). We felt that aggressive atropinization and MV with PEEP is adequate and the role of 2-PAM given in 3 gm dose in 12 h is not clear. There is a need for controlled study to assess the efficacy of atropine and MV alone vs. atropine, 2-PAM in suggested doses and MV in severe OPP patients.

Comparison of growth hormone-releasing factor and somatotropin: the somatotropic axis in lactating primiparous cows

Our objective was to compare the effects of recombinant bovine growth hormone-releasing factor and recombinant bST on the somatotropic cascade in lactating dairy cows. Primiparous cows were killed after 63 d of continuous daily infusion with 12 mg of releasing factor or 29 mg of bST or no infusion (controls). Both hormone infusions similarly increased mean concentration of somatotropin in serum, but pulsatility of somatotropin in serum was greater for cows given releasing factor. Both hormone infusions increased the amounts of IGF-I in serum, IGF-I mRNA in liver, and IGF-binding protein-3 in serum and decreased IGF binding protein-2 in serum, but these effects were less for cows given releasing factor than for those given bST. Both infusions decreased the number of free binding sites for IGF-I in mammary tissue. In liver, treatment did not alter the abundance of mRNA for the somatotropin receptor or the number of free binding sites for somatotropin. Results suggest that endogenous somatotropin is less effective as an IGF-I secretagogue than is exogenous bST infused continuously, yet the releasing factor and bST increased milk yield similarly. We conclude that growth hormone-releasing factor stimulates milk synthesis mostly through the same mechanisms as bST, but that serum IGF-I alone is not a good indicator of the galactopoietic potency of the two hormones.

Long-term somatotropic and galactopoietic effects of a (1-30) ethyl amide analog of growth hormone-releasing factor

Thirty-five lactating Holstein cows (165 +/- 8 DIM) received the following treatments for 96 d: uninfused controls; i.v. infusion of .9, 2.7, or 8.1 mg/d of Ile2, Ser8.28, Ala15, Leu27, Hse30-bovine growth hormone-releasing factor (1-30) ethyl amide; or i.v. infusion of 12 mg/d of recombinant Leu27, Hse45-bovine growth hormone-releasing factor (1-45) lactone. Concentrations of somatotropin in serum and SCM yield of cows infused with 1-30 releasing factor increased quadratically as the dose increased. Responses for somatotropin and SCM yield were quantitatively similar for cows infused with 2.7 and 8.1 mg of 1-30 or 12 mg of 1-45. While concurrently infused with the 1-30 or 1-45 as described, cows retained their ability to release somatotropin following an acute i.v. injection of 10 nmol/100 kg of BW of either growth hormone-releasing factor 1-30 or 1-45. Mean concentrations of IGF-I in serum increased similarly in magnitude for cows infused at all doses of 1-30 or 1-45. The 1-30 releasing factor generally increased IGF-binding protein-3, but had little effect on IGF-binding protein-2. The 1-45 releasing factor did not significantly affect either binding protein. Yield of SCM was correlated with serum concentrations of somatotropin, but not with IGF-I. Concentrations of NEFA in serum were elevated through 36 and 50 d in response to the highest doses of 1-30 and 1-45, respectively. Treatment did not affect DMI, BW, or body condition score.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of calcium and protein kinase C in the activation of T cells in Takayasu's arteritis

The roles of protein kinase C and calcium in the T cells of patients suffering from Takayasu's arteritis (TA) in response to the mitogens phorbol-myristate acetate (PMA) and streptococcal antigens have been studied. In TA there was an increased basal activity of protein kinase C (1.074 +/- 0.223 nmoles/mg protein/min) as compared with that of controls (0.570 +/- .12) (p < 0.001). There was 75% translocation from the cytosol to membrane fraction in response to PMA. Intracellular calcium levels showed increased basal levels in TA (177.07 +/- 12.56 nmoles) compared with the controls (112.83 +/- 10.6 nmoles) (p < 0.001) and there was a further rise on stimulation, indicating the T cells were in an activated state. There was a positive correlation between the calcium levels and the activity of protein kinase C (r = 0.71, p < 0.05). Unlike the situation in patients with rheumatic fever, T cells in TA showed no stimulation in response to streptococcal antigens. The low level of cAMP (1.12 +/- 0.169 pmoles/million cells) compared with that of controls (1.4 +/- 0.03) further supports the role of PKC-calcium in the T cell activation process. These findings suggest activation of the PKC-calcium pathway in TA.

Effect of dietary energy restriction on the expression of insulin-like growth factor-I in liver and corpus luteum of heifers

The effects of energy balance on the corpus luteum may be mediated by IGF-I. Our objective was to determine whether negative energy balance decreases expression of IGF-I mRNA in the liver or corpus luteum of heifers. For four consecutive estrous cycles, 14 Holstein heifers were maintained in negative or positive energy balance to lose 510 g/d of BW or gain 560 g/d of BW, respectively. The liver was biopsied and the corpus luteum was collected 7 d after fourth estrus. Heifers fed below maintenance had a smaller corpus luteum than did control heifers. Compared with that of controls, negative energy balance increased growth hormone in serum but decreased IGF-I in serum and the abundance of mRNA for growth hormone receptor and IGF-I in liver. In contrast, diet did not affect the abundance of mRNA for the growth hormone receptor or IGF-I in luteal tissue. Negative energy balance increased IGF binding protein-2 in serum but did not affect IGF binding protein-3. We conclude that negative energy balance of cattle decreases IGF-I mRNA abundance in the liver but not in the 7-d corpus luteum. If decreased IGF-I mediates the adverse effect of negative energy balance on luteal growth, the mode of action is likely endocrine, not autocrine or paracrine.

Takayasu arteritis may be underdiagnosed in North America

OBJECTIVES

To summarize some of the literature about Takayasu arteritis, a nonspecific chronic inflammatory disease involving the aorta and its main branches, and to analyze the criteria for its diagnosis. The pulmonary artery and its branches, as well as the coronary arteries, may also be involved.

DATA ANALYSIS

Although Takayasu arteritis has been commonly reported in Asian countries such as Japan, India, China and Korea, case reports from other parts of the world describing symptoms of this disease are also available. Because of nonspecific pathology, a rather nonspecific initial clinical presentation and an obligatory criterion of age (40 years or younger) it is possible that the disease may be underdiagnosed in Europe and North America. The cause of this disease remains obscure. Various infections have been blamed but genetic and immunological disturbances seem to play a major role in bringing Takayasu arteritis into the list of autoimmune disease.

INTERVENTIONS

Takayasu arteritis responds well to glucocorticoids/cyclophosphamide in the acute (prepulseless) phase. In the chronic fibrotic phase, treatment of hypertension and various angioplastic and surgical interventions are required.

CONCLUSIONS

Adoption of improved diagnostic criteria may change the prevailing view that Takayasu arteritis is an Asian disease. Understanding of the pathogenesis at cellular and molecular levels is needed. Creation of an animal model would be a desirable tool in that direction.

Malignant hypertension in north west India. A hospital based study

One hundred and thirty-five patients with malignant hypertension seen over a period of 11 years (1979 to 1989) at a referral hospital were analyzed to characterize the clinical features and etiology of this disease. Ninety male and 45 female patients with an average age of 38.2 +/- 1.4 years were studied. Malignant hypertension was the presenting feature in 68 patients. The etiology included essential hypertension in 88 patients and a secondary cause in 47 patients. Secondary causes included a renovascular etiology in 20 patients, renal parenchymal disease in 19, pheochromocytoma in 6 and Conn's syndrome and adrenal carcinoma in one patient each. Among the 20 patients with renovascular hypertension, Takayasu's arteritis was seen in 15 (75%). The mean age of patients with essential hypertension was 41.7 + 1.14 years while the mean age in patients with secondary hypertension was 33.2 + 1.96 years. Duration of preexisting hypertension was longer in essential hypertensives (2.42 + 0.45 years) than in patients with secondary hypertension (1.27 + 0.41 years, p < 0.05). Raised serum creatinine was seen in 93 patients. Seventy-seven patients had left ventricular hypertrophy on ECG. Ninety-six patients were followed for a period ranging from 18 months to 10 years (mean 32 months). Sixteen patients died during hospital stay while 6 patients died during the follow-up period. The deaths were related to the effects of uncontrolled hypertension including, renal failure (11), stroke (6), congestive cardiac failure (3) and myocardial infarction (1).(ABSTRACT TRUNCATED AT 250 WORDS)

Expression of insulin-like growth factor-I in cows at different stages of lactation and in late lactation cows treated with somatotropin

Relative amounts of IGF-I mRNA were measured in livers of Holstein cows at different stages of lactation (6 early, 6 mid, 6 late lactation, 6 dry) and 6 late lactation cows treated with bST for 1 wk. Milk yield was greater for early lactation cows than for mid and late lactation controls. All cows except those in early lactation were in positive energy balance. Serum IGF-I increased as lactation progressed and was greatest during the dry period. Liver IGF-I mRNA was less in cows in early than in late lactation but greater in lactating than in dry cows. Treatment with bST increased milk yield and concentrations of serum IGF-I, hepatic IGF-I mRNA, and serum IGF-binding protein-3, decreased concentration of serum IGF-binding protein-2, and did not alter abundance of mammary IGF-I mRNA. These parallel changes in serum IGF-I and hepatic IGF-I mRNA suggest that exogenous bST increases IGF-I synthesis in liver of cows during late lactation and that IGF-I synthesis is depressed during early lactation when cows are in negative energy balance. We conclude that IGF-I may play an endocrine role in mediating galactopoietic effects of exogenous bST during late lactation. However, the role of IGF-I during early lactation remains unclear.

Stimulation of macrophage oxygen free radical production and lymphocyte blastogenic response by immunization with porins

Porins were prepared from smooth strain of Salmonella typhi 0-901 and chemotype rough mutant of S. typhimurium Ra-30. Porins could significantly stimulate the immune systems of mice. Immunization of mice with the porins provoked synthesis of anti-porin antibodies. Macrophages from the immunized mice showed increased capacity to generate oxygen free radicals, and lymphocytes from these mice showed proliferative response to the porins. Thus porins may play a role in providing protection from salmonellosis by stimulating the antibody production and increasing the capacity of macrophages to generate oxygen free radicals along with stimulation of lymphocytes.

Evaluation of Salmonella porins as a broad spectrum vaccine candidate

Porins were prepared from smooth strain of Salmonella typhi 0-901 and chemotype of rough mutant of S. typhimurium Ra-30. Mice were immunized with both the porin preparations in different groups and challenged with S. typhimurium LT2-71 and S. enteritidis SH-1269. Porin immunized mice showed significant protection (P < 0.01) against challenge with homologous as well as heterologous strains. Hence, the use of porins may be attempted in future to protect against salmonellosis.

Evaluation of three serological tests for detection of anti-candidal antibodies in diagnosis of invasive candidiasis

Immunoblot detection of antibody against 47 KD cytoplasmic antigen of Candida albicans was evaluated in diagnosis of invasive candidiasis and compared to whole cell agglutination and gel diffusion tests for detection of anticandidal antibody in 64 patients. The patients included 17 with culture proved candidemia, 34 with significant candiduria (more than 10,000 colony forming units per ml of urine) and 13 with nonsignificant candiduria. Antibody against 47 KD antigen was found to be the best indicator for diagnosis of invasive candidiasis even in patients with malignancy. The sensitivity of this procedure was 82.4%, specificity 86.7%, positive predictive value 77.8%, negative predictive value 89.7% and efficacy 85.1%. The gel diffusion procedure lacked in sensitivity whereas whole cell agglutination lacked in specificity. Detection of antibody against 47 KD antigen proved to be a valuable adjunct in the diagnosis of invasive candidiasis.

Pneumocystis carinii pneumonia complicating Hodgkin's disease: a case report

A case of Hodgkin's disease who developed Pneumocystis carinii pneumonia (PCP) is described. The diagnosis of P. carinii was confirmed on post-mortem lung biopsy. The rarity of its occurrence in our country is emphasised as is the need for high degree of suspicion and early institution of treatment.

Non-surgery related aspergillus native valvular endocarditis: report of two cases

Two unusual cases of aspergillus valvular endocarditis without any history of cardiovascular surgery found at autopsy are reported. As there is a chance of dissemination, early diagnosis is important. Clinical awareness can lead to early recognition and effective treatment of this potentially lethal condition.

Is a hypertensive always a hypertensive?

Forty two patients of uncomplicated essential hypertension with well controlled and stable blood pressure for the last six months have been followed up for 2 years after withdrawal of therapy. Drug therapy was reinstituted if they became hypertensive again. Thirty four (89.9%) and 33 patients remained normotensive at 4 and 8 weeks respectively. At the end of 6 months, 26 (61.9%) patients were drug free, 9 (21.4%) were back on therapy and 7 (16.5%) were lost to follow up. At the end of one year, 18 (42.8%) were drug free, 14 (33.3%) were on drugs and 10 (23.8%) had dropped out. At the end of 2 years, the figures were 14 (drug free), 15 (on drugs) and 13 (drop-outs). No cardiovascular or any other complication was recorded during the period. These observations suggest that there may be a subgroup of mild or moderate hypertensives in whom it may be possible to withdraw therapy under observation. However, there is a risk of substantial drop out rate possibly under a false sense of security. Considering the large number of hypertensives in our country and the world over, its economic and therapeutic implications are obvious.

Ca2+ transport in unstimulated platelets of essential hypertensives and their blood relatives

OBJECTIVE

Intracellular free Ca2+ concentration has been shown to be elevated in platelets from essential hypertensive patients. This study was designed to characterize Ca2+ homeostasis in platelets of essential hypertensives.

DESIGN

A double-blind study was carried out. Untreated and treated (propranolol therapy) essential hypertensives were studied in comparison with normotensive control subjects. First-degree blood relatives of essential hypertensives were also studied. The various procedures used in the study were already standardized and well-established methods.

METHOD

For Ca2+ uptake and efflux studies, 45Ca was used. For intracellular free Ca2+ concentration studies the fluorescent Ca2+ chelator dye fura-2/acetoxymethyl ester (fura-2/AM) was used.

RESULTS

The uptake of 45Ca by unstimulated platelets of untreated essential hypertensives and their relatives was significantly higher than for controls. However, essential hypertensives treated with a beta-blocker drug showed no significant difference in Ca2+ uptake compared with controls. A significantly decreased Ca2+ efflux was observed in essential hypertensives (both untreated and treated) compared with controls. Relatives also showed a depressed Ca2+ efflux compared with controls.

CONCLUSIONS

It appears that the elevated intracellular free Ca2+ concentration levels in platelets (also observed by us) may be due to both an enhanced uptake into, and decreased efflux of Ca2+ from, the cell. Beta-blocker therapy may help to normalize the elevated intracellular free Ca2+ concentration levels observed in essential hypertensives. Relatives exhibit a state predisposed towards the development of hypertension.

Fluorescein angiography in systemic hypertension

This study evaluates the role of fluorescein angiography (FA) in detecting changes in the retinal and choroidal capillary bed in hypertension and defines its advantages over direct ophthalmoscopy. 37 patients with varying degree of severity of hypertension were studied. Direct ophthalmoscopy and FA was done in all cases. No significant difference was found in documenting vessel calibre and arteriovenous crossing changes with either of the methods. Hard exudates were not visualized on FA. Capillary bed and choroidal abnormalities could be better studied on FA which can be employed in selected patients of hypertension but its use is not advocated as a routine in all hypertensives.

Coarctation repair in neonates with subclavian-sparing advancement flap

A modification of the technique of using the subclavian-sparing advancement flap for severe coarctation of the aorta was successfully used in 7 neonates ranging in age from 3 to 30 days (mean age, 12 days). Four of the 7 patients had associated cardiac defects with congestive heart failure. The procedure was performed through a left thoracotomy incision, and the coarctation repair was performed by advancing the origin of the left subclavian artery as a flap while preserving flow to the left arm. No deaths occurred, and there was patency of the repair in all patients at follow-up ranging from 1 1/2 to 2 1/4 years (mean, 2 years). In 7 of the 8 patients there was no clinically significant gradient either by examination or Doppler echocardiography at follow-up. One patient underwent balloon angioplasty at the time of catheterization to evaluate other cardiac defects 1 year postoperatively, at which time he was noted to have a peak systolic gradient of 30 mm Hg across the repair site. The technique of subclavian-sparing advancement is a reasonable addition to the surgical armamentarium for coarctation repair in neonates. It provides the advantages of subclavian flap aortoplasty without sacrificing the blood supply to the left arm. Because of the unique anatomic variations associated with coarctation of the aorta, we suggest that the choice of repair be individualized for patients with this condition.

Domiciliary mechanical ventilation in a patient with severe chronic obstructive lung disease and respiratory failure

A patient of chronic obstructive pulmonary disease (COPD) with cor-pulmonale and chronic respiratory failure, who was given intermittent positive pressure ventilation at home, is reported. The patient did remarkably well on home mechanical ventilatory support. We believe this to be the first case report of domiciliary mechanical ventilation in a patient of COPD from India.

Cytodiagnosis of granulocytic sarcoma presenting as superior vena cava syndrome in acute myeloblastic leukemia. A case report

We describe a rare case of acute myeloblastic leukemia presenting with superior vena cava syndrome due to a mediastinal granulocytic sarcoma. The morphologic diagnosis of granulocytic sarcoma was obtained from computed tomography-guided fine needle aspiration cytology. This is the second such case described in the world literature.

Oxygen free radicals in essential hypertension

Membrane abnormalities in essential hypertensives (EH) are well known. The respiratory burst enzyme, NADPH oxidase is located in the cell membrane of the neutrophil (PMNLs) and its activity is important in generation of oxygen derived free radical (OFR). Recently OFR have been implicated in vascular changes in variety of conditions. An attempt was made to delineate the status of OFR and antioxidants in EH. Ten, age and sex-matched, healthy controls (GpI) and 26 untreated EH (Gp IIA mild-8, Gp IIB Moderate-8, Gp IIC Severe-10) were studied. After clinical examination and basic laboratory evaluation of subjects, neutrophils isolated from their blood were studied. Chemiluminescence (CL) emitted by PMNLs after stimulation was measured (counts/min) in a luminometer and was taken as measure of OFR production and thereby of NADPH oxidase activity. The levels of antioxidants, superoxide dismutase (SOD) and reduced glutathione (GSH), were also estimated. Chemiluminescence was increased significantly (p less than 0.01) in Gp IIC (243.04 +/- 24.9 x 10(3) counts per minute) as compared to Gp IIA (2.80 +/- 1.87), Gp IIB (34.54 +/- 30.24) and Gp I (0.52 +/- 0.15) and SOD was reduced significantly (p less than 0.05) in all EH (Gp IIA 3.9 +/- 0.3 units per mg protein, Gp IIB 3.5 +/- 0.3 and Gp IIC 3.12 +/- 0.3) as compared to controls (4.1 +/- 0.2). Similarly GSH was reduced (p less than 0.05) in EH (Gp IIA 11.2 +/- 1.7 mg per gm protein, Gp IIB 8.5 +/- 1.1 and Gp IIC 6.6 +/- 0.3) as compared to Gp I (13.5 +/- 2.5).(ABSTRACT TRUNCATED AT 250 WORDS)

Immunopathogenesis of Takayasu arteritis

Takayasu arteritis is a common cause of renovascular hypertension in India. Sensitization to infective agents, particularly mycobacterium tuberculosis or autoimmune disturbances have been incriminated in its pathogenesis. Twenty patients of Takayasu arteritis along with groups of normal individuals, patients of essential hypertension, autoimmune disorders, tuberculosis, and healthy tuberculin reactors were studied. Besides detailed immunological profiles including LE cell phenomenon, serum complement C3 levels, antibodies to single (SS) and double stranded (DS) DNA, rheumatoid factor, lymphocyte subsets, blast transformation to antigens including, phytohemagglutinin, PPD, pokeweed, and purified human aortal antigen (PHAA) were examined. Soluble protein from human aorta was fractionated into 9 peaks by DEASE-52 and Sephadex G-75 chromatography, and 25 micrograms of major protein fraction-II was used for blast transformation study. Blast transformation by PHAA was higher in Takayasu arteritis as compared to all other groups (P < 0.05). Blast transformation to PPD showed wide variation in all the groups, and was significantly higher only in tuberculin reactors as compared to controls. These observations support aortal sensitization to PHAA playing a role in pathogenesis of Takayasu arteritis and do not relate tuberculosis to Takayasu arteritis, at least immunologically. In addition, the ratio of CD-4 positive to CD-8 positive lymphocytes changing in favor of the former and the concomitant increase in B lymphocytes favor the presence of autoimmune disturbances in Takayasu arteritis.

Takayasu arteritis in India

Takayasu arteritis is the commonest cause of renovascular hypertension in India. The clinical and radiological features, complications and course of 83 patients (51 females, 32 males) seen during the period from 1972-1990 are described in this study. The age of the patients ranged from 5 to 53 years with the mean +/- SD of 26.9 +/- 9.7. Hypertension (n = 50) and the related symptom of headache (n = 40), dyspnea (n = 24), and giddiness (n = 20) were common at presentation. Twelve patients were in congestive cardiac failure. The symptoms of activity with fever and arthralgia were present in only 16% contrary to reports from Japan and Mexico. Abnormal arterial pulses and bruit over abdominal (37%) or extra abdominal great arteries (25%) were useful clinical clues to suspect Takayasu arteritis. Rapid sequence intravenous urography was a sensitive screening procedure and predicted correctly the presence of renovascular disease in 80% of the patients. The diagnosis was confirmed on aortography in 72. In the rest, the clinical features and autopsy findings confirmed the same. The four patterns of the disease based on the anatomical extent of involvement were recognised. These were: type I (n = 8) with involvement of aortic arch and its branches, type II (n = 25) descending thoracic and abdominal aorta type III (n = 46) combination of I and II and type IV (n = 4) pulmonary artery in addition to any of the above.(ABSTRACT TRUNCATED AT 250 WORDS)

Visceral larva migrans in an adult

Visceral larva migrans is rare in adults. An adult male in whom the diagnosis was made by suggestive clinical features and muscle biopsy and who responded to thiabendazole is described.

Chemiluminescence response of phagocytes in E. coli induced experimental ascending pyelonephritis

The mechanism of tissue injury at the cellular level by following the chemiluminescence response of various phagocytes in E. coli induced experimental pyelonephritis in mice was investigated. There was a marked increase in the capacity of various phagocytic cells viz; renal neutrophils and macrophages peritoneal macrophages, blood monocytes and neutrophils to produce reactive oxygens species through the respiratory burst activity as monitored by the chemiluminescence response. The chemiluminescence response was observed to be increased significantly (p less than 0.001) with increasing days post infection in all phagocytic cells. However, the quantity of total reactive oxygen species produced per million cells was much more in the renal and peritoneal macrophages as compared to blood monocytes and neutrophils. The peak chemiluminescence response time was observed to be decreased from 4 to 2 minutes with the progression of the diseases. The implications of these findings have been discussed.

Extrathoracic Castleman's disease

Castleman's disease is an uncommon clinical entity. We report two cases of this disease with a brief review of literature. Both of them had extrathoracic disease which is relatively infrequent. One of them presented with localized hyaline vascular type of the disease and the other with the multicentric plasmacytic variety. The patient with the latter form of Castleman's disease had sclerodactyly, which has not been reported earlier in association with this disease.

Prolonged undiagnosed fever in northern India

A prospective study for five years along with a retrospective analysis of all patients admitted over 10 years with the diagnosis of prolonged undiagnosed fever was carried out in a referral hospital of North India to determine the specific disorders responsible for it. One hundred and fifty patients (80 prospective and 70 retrospective) were included in the study. Infections, especially tuberculosis, was the most dominant cause (50%), followed by lymphoreticular and haematological disorders (21.32%), collagen vascular disorders and neoplasms (8.67%) each. Miscellaneous causes were responsible in 6.67% and in 4.67% the cause of fever remained undiagnosed.

Blood pressure in schoolchildren in northwest India

Blood pressure was determined among 2,453 schoolchildren aged between 7 and 16 years in the northwest Indian town of Chandigarh to establish the norms. The percentiles were calculated for each age group in both sexes. Both systolic and diastolic blood pressure had a positive correlation with age, weight, height, and body surface area (r = 0.112-0.178, p less than 0.01). There was no difference in the systolic and diastolic pressures of boys compared with girls of corresponding age. The upper limits of normal (90th percentile) systolic/diastolic pressure were 113/74, 119/76, and 126/79 in children aged 7-9 years, children aged 10-12 years, and adolescents aged 13-16 years, respectively. The lower limits of hypertension (95th percentile) for systolic/diastolic pressure were 119/80, 124/81, and 132/82 in each of these groups, respectively. The 99th percentile values indicative of severe hypertension for systolic/diastolic pressure in these groups were 128/88, 135/88, and 149/89, respectively. The 90th percentile of height and weight shown in the percentile table should be taken into consideration whenever blood pressure exceeds the 90th percentile for age and sex while planning the management of an individual.

Patients' attitude towards health care at a teaching hospital in India

Using a questionnaire, 362 patients attending the outpatients services of Internal Medicine of Nehru Hospital attached to our institution were randomly interviewed. Seventy per cent of the patients were in the 21-50 years age range; 50% came from rural and 50% from urban areas. Forty per cent travelled more than 30 Km; 72% used a public transport to reach hospital. Most patients had an income less than Rs. 1000/-. Ninety per cent had already consulted another medical practitioner earlier. The largest number of complaints related to the gastrointestinal, cardiovascular and respiratory systems. On an average 1-2 drugs were prescribed per patient; only 13% of these were available at the hospital dispensary. Most patients were willing to purchase the prescribed drugs from the market.