Exploration and neurolysis for the treatment of neuropathic pain in patients with a sciatic nerve palsy after total hip replacement

The purpose of this study was to establish whether exploration and neurolysis is an effective method of treating neuropathic pain in patients with a sciatic nerve palsy after total hip replacement (THR). A total of 56 patients who had undergone this surgery at our hospital between September 1999 and September 2010 were retrospectively identified. There were 42 women and 14 men with a mean age at exploration of 61.2 years (28 to 80). The sciatic nerve palsy had been sustained by 46 of the patients during a primary THR, five during a revision THR and five patients during hip resurfacing. The mean pre-operative visual analogue scale (VAS) pain score was 7.59 (2 to 10), the mean post-operative VAS was 3.77 (0 to 10), with a resulting mean improvement of 3.82 (0 to 10). The pre- and post-neurolysis VAS scores were significantly different (p < 0.001). Based on the findings of our study, we recommend this form of surgery over conservative management in patients with neuropathic pain associated with a sciatic nerve palsy after THR.

Cite this article: Bone Joint J 2013;95-B:20–2.

HIV-1 seroprevalence and awareness of mother-to-child transmission issues among women seeking antenatal care in Tamil Nadu, India

BACKGROUND

Despite increasing availability of HIV-1 testing, education, and methods to prevent transmission, Indian women and their children remain at risk of acquiring HIV. We assessed the seroprevalence and awareness about HIV among pregnant women presenting to a private tertiary care hospital in South India.

METHODS

Seroprevalence was determined via enzyme-linked immunosorbent assay (ELISA) testing, and questionnaires were analyzed using chi-square statistics and odds ratios to look for factors associated with HIV positivity.

RESULTS

A total of 7956 women who presented for antenatal care were interviewed. Fifty-one women of the 7235 women who underwent HIV testing (0.7%) were found to be HIV positive. Awareness of mother-to-child transmission (MTCT) of HIV (64%), HIV transmission through breast milk (42%), and prevention of MTCT (13%) was low.

CONCLUSIONS

There is a need to educate South Indian women about HIV to give them information and the means to protect themselves and their unborn children from acquiring HIV.

Increase in CD4 cell counts between 2 and 3.5 years after initiation of antiretroviral therapy and determinants of CD4 progression in India

BACKGROUND

Estimation of CD4 cell count remains the primary monitoring tool in assessing efficacy or failure of Anti Retroviral Therapy (ART) under national program conditions in India.

AIMS

To study the average trajectory of CD4 cell count after two years of initiation of potent ART and to find the determinants of CD4 progression over time.

SETTINGS AND DESIGN

A prospective cohort study under program conditions. Materials and Methods : Adult ART naïve patients, receiving drug regimens consisting of two NRTIs and one NNRTI were studied for CD4 progression. Laboratory monitoring included the baseline and follow-up CD4 cell count, hemoglobin level and absolute lymphocyte count estimation. The change in CD4 cell count, hemoglobin and bodyweight was calculated from the baseline to the latest follow up measurements. Statistical Analysis : Survival curve using Life table methods was plotted. Comparison between survival curves was done using Tarone-Ware statistics. Generalized estimating equation with exchangeable correlation structure was done to find the risk factors for CD4 progression. Results : Among 7,934 HIV positive patients in the ART program, one-year cohort of 714 adult patients who had completed two consecutive follow-up CD4 values were assessed. Those with baseline CD4 < 100 had cumulative probability of survival 85%, 82%, 82% and 82% at 12, 24, 36 and 42 months respectively. Those who had baseline CD4 count between 100-199 had cumulative probability of survival 96%, 93%, 92% and 90% at 12, 24, 36 and 42 months respectively (P < 001). Lower the CD4 count ( 100) lower the hemoglobin values. Conclusions : CD4 progression continues two years after ART in patients who had base level > 100 cells. Early initiation of ART is necessary before CD4 crashing to < 100 cells for increasing the survival function.

Efficacy of antiretroviral therapy program in children in India: prognostic factors and survival analysis

The objective of this article is to study the survival pattern and the prognostic factors for HIV-infected children on antiretroviral therapy (ART) for two and half years at the Government Hospital of Thoracic Medicine, Tambaram, Chennai, India. We studied 295 children who were initiated on ART from 1 April 2004 to 30 September 2006 at a large, public tertiary care facility in Chennai, India. Weight for age Z-score was calculated. Survival curves and Cox proportional hazard models were used to identify risk factors for mortality. The mean and median follow up was 11 and 10 months, respectively. The cumulative survival probability at 6, 12, 18, 24 and 30 months was 93, 90, 89.7, 89.7 and 89.7%, respectively. Of the children who died, about 50% died within the first month. Nearly 6% of the children had adherence less than 95%. The children who had a baseline CD4 percent less than or equal to 14% had significantly (p < 0.05) higher mortality as compared to children who had 20% or more. The children who had negative or no change in weight for age Z-score and hemoglobin had 18.9 (3.7-95.7) times significantly higher mortality as compared to children who had positive change in both variables (p < 0.001). The sensitivity, specificity and likelihood ratio of the positive test for negative change or no change in HB was 65%, 85% and 4.3, respectively. Similarly, these were 80%, 73% and 3% for negative or no change in Absolute Lymphocyte Count (ALC). These findings indicate the feasibility and effectiveness of implementing an ART program in a large government hospital in India. Simple nutritional variable hemoglobin and immunologic variable ALC could be used to monitor the progression of disease in children.

Post-HAART tuberculosis in adults and adolescents with HIV in India: incidence, clinical and immunological profile

BACKGROUND

Highly Active Antiretroviral Therapy (HAART) was introduced in National AIDS Control Programme in 2004 to reduce the morbidity and mortality among those affected with HIV/AIDS. Tuberculosis, being an important coinfection, its emergence/occurrence in post-HAART period has potential implications.

OBJECTIVE

Primary objectives were to study the incidence of post-HAART tuberculosis in HIV patients and to identify the possible risk factors. It was also intended to understand the clinical and immunological profile of this important condition.

METHODOLOGY

Eligible adults and adolescents with HIV disease enrolled on HAART at Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, from April, 2004 to March, 2007, formed the study population. They were monitored and screened for the occurrence of tuberculosis after commencing HAART. Clinical details and immunological profile of these patients were analysed.

RESULTS

Two hundred and sixty-two patients (5.1%) of 5099 patients followed-up for one to four years were found to have Post HAART TB with 100-person year risk of 2.83. Post HAART TB occurred predominantly in men (67.6%) and in 31-44 years age group (69.8%) with 100-person year risk being 3.26 and 2.83 respectively. Pulmonary, Extra-pulmonary and disseminated tuberculosis were found to occur in the frequencies of 78%, 16% and 6% respectively. A total of 144 patients (54.9%) developed tuberculosis within six months and this number increased to 202 (77%) by 12 months. 230 patients (87.7%) had base level CD4 cell count < 200 / mm3.

CONCLUSION

Tuberculosis was found to occur pre-dominantly in adult male patients with HIV during the first year after the initiation of HAART. Significantly, occurrence of Post HAART TB remained almost the same (5%) among patients treated for TB prior to the initiation of HAART.

Antibiotic prescribing practices in primary and secondary health care facilities in Uttar Pradesh, India

BACKGROUND

Emerging antibiotic resistance in common pathogens is a worldwide problem known to be related to inappropriate overuse of antibiotics. Wide variability in antibiotic use throughout the world is because of various factors, including socio-cultural differences.

OBJECTIVE

To study the rate of antibiotic prescribing for common outpatient illnesses and the various disease, patient, physician and health facility characteristics, which influence this in primary and secondary healthcare settings in Uttar Pradesh.

METHODS

After sampling of health facilities - both private and government, rural and urban, a cross-sectional survey of prescriptions for patients presenting with runny or blocked nose, cough, sore throat, diarrhoea or fever without localizing symptoms was conducted. Information on disease, patient, physician and facility characteristics was collected. Outcome factors: antibiotic prescription and group of antibiotic prescribed. No intervention was made.

RESULTS

Overall antibiotic prescription rate was 81.8%. It was significantly higher in urban private than in government settings, and higher in rural than in urban settings. Presence of fever prompted antibiotic use across all strata. Lower age of patients and higher socioeconomic status were associated with higher antibiotic use. Patient requests for antibiotics were very rare. Specialist practices with staff with higher qualifications and better opportunities for updating knowledge were associated with lower antibiotic prescribing. Government health-facilities with larger staff complement and better infrastructure was associated with lower prescribing rates. The most common antimicrobial agents used were the penicillin, sulfonamides and fluoroquinolones. Injection use paralleled antibiotic use.

CONCLUSIONS

These data on overprescribing of antibiotics can be used to design educational programs for physicians working in these settings.

Pyritinol for post asphyxial encephalopathy in term babies-- a randomized double-blind controlled trial

OBJECTIVE

To evaluate the efficacy of pyritinol in improving the neurodevelopmental outcome at one year of age among term babies with post-asphyxial encephalopathy.

SETTING

Level II Neonatal Nursery and Child Development Centre, Medical College, Thiruvananthapuram.

DESIGN

Randomised placebo controlled double blind trial.

PARTICIPANTS

108 term babies with post-asphyxial encephalopathy, stratified into three grades based on clinical criteria.

INTERVENTION

The treatment group (n=54) received pyritinol and the control group (n=54) received placebo, in exactly the same increasing dosage schedule of 1 to 5 mL liquid drug (20-100 mg) from 8th postnatal day until the end of six months.

OUTCOME VARIABLES

Mean Mental Development Index (MDI) and mean Psychomotor Development Index (PDI) measured on Bayley Scales of Infant Development at one year of age.

RESULTS

No statistically significant difference was observed in MDI or PDI scores at one year between the treatment and control groups. The confidence interval for the differences ranged from -6.3 to 8.7 for MDI and from - 4.1 to 12.7 for PDI. On multiple regression analysis using one year MDI and PDI scores, even after controlling for birthweight, there was no statistically significant difference between the treatment and control groups.

CONCLUSION

Pyritinol is not useful in improving the neurodevelopmental status of babies with post-asphyxial encephalopathy at one year of age.

Validation of Home Screening Questionnaire (HSQ) against Home Observation for the Measurement of Environment (HOME)

This study was done to validate the screening tool Home Screening Questionnaire (HSQ) against the gold standard Home Observation for the Measurement of Environment (HOME) inventory, using diagnostic test evaluation. Both HOME inventory and HSQ were administered by separate observers, with children less than 3 years of age, among 200 families belonging to 14 anganwadi areas. There was a high sensitivity of 83 and a high specificity of 82 observed for a cutoff point of less than or equal to 19 on HSQ against HOME Inventory as Gold Standard, as was also observed in the Receiver Operating Characteristic (ROC) curve. The likelihood ratio (LR) for positive test was 4.6 (95 % CI, 3.3 to 6.9) which implies that the families with poor home environment are 4.6 times more likely to have the HSQ score less than or equal to 19 as compared to normal families. The results of this study imply that we can confidently apply the HSQ in developmental evaluation clinics and reserve HOME inventory for research purposes.

Effect of Child Development Centre model early stimulation among at risk babies--a randomized controlled trial

OBJECTIVE

To study the effectiveness of Child Development Centre (CDC) model early stimulation therapy done in the first year of postnatal life, in improving the developmental outcome of at-risk neonates at one and two years of age.

DESIGN

Randomized controlled trial.

SETTING AND SUBJECTS

The study participants included a consecutive sample of 800 babies discharged alive from the level II nursery of Medical College, Thiruvananthapuram.

INTERVENTION

The control group received routine postnatal check-up as per hospital practice. Intervention group in addition received CDC model early stimulation therapy (home-based).

RESULTS

The intervention group of babies had a statistically significant higher score for mental developmental index (MDI) and psychomotor developmental index (PDI) at one and two years of age. After adjusting all significant risk factors for development, the babies who had intervention had significantly higher Bayley scores, 5.8 units at one year and 2.8 units at two year, as compared to control babies.

CONCLUSION

Early stimulation therapy was effective at one year. The beneficial effect also persisted at two years, without any additional interventions in the second year.

Demographic & clinical profile of HIV infected children accessing care at Tambaram, Chennai, India

BACKGROUND & OBJECTIVE

Human immunodeficiency virus (HIV) is severely affecting the poorly educated and economically disadvantaged in Indian society. When children start developing clinical manifestations, needing treatment, they have to travel long distances for accessing care and support at tertiary institutions. This places an extra burden on patients, who are already struggling to cope with their illness. Sufficient data are needed for the government to evolve appropriate policy for providing care to the children affected with HIV. We undertook this study to present the socio-demographic characteristics, signs and symptoms, clinical profile, distance travelled and follow up pattern of HIV positive children who accessed care for the first time in a referral hospital at Chennai, India.

METHODS

Electronic medical records from patients diagnosed with HIV between 2002 and 2004 at the Government Hospital for Thoracic Medicine (GHTM) in Tambaram (Chennai) in India were analyzed to understand care-seeking behaviours. Demographic variables such as age, sex, education and occupation, data on clinical manifestations were examined together with geographic information.

RESULTS

At GHTM 1,768 new paediatric patients accessed care from 2002 to 2004. Children aged less than 5 yr were 49.9 per cent; 1115 children had (63%) tuberculosis. Significantly, 14.9 and 20.6 per cent children had extra-pulmonary TB and disseminated TB respectively. Lower respiratory infection (15.8%), Pneumocystis carinii pneumonia (15.20%), oral/oesophageal candidiasis (13.5%), wasting (6.1%) and diarrhoeal disorders (3.5%) were the common clinical manifestations. In all 47 per cent children traveled between 200-400 km from home and 14 per cent travelled over 400 km.

INTERPRETATION & CONCLUSION

Our findings showed that tuberculosis should be regarded as the indicator disease for HIV infection in children, especially when they have clinical manifestations of progressive, non pulmonary and disseminated disease. The primary and secondary health care centres should have the trained capacity to diagnose and treat HIV disease and opportunistic infections so as the children to have much needed care and support nearer to their residence.

Developmental Evaluation Clinic--CDC experience

We describe our five year experience of conducting developmental evaluation clinic at CDC. We have also assessed the prevalence of developmental delay (defined as delay in any two areas in Denver Development Screening Test II [DDST II]), documented the possible prenatal, natal, postnatal risk factors for developmental delay and, also identified the pattern of developmental disorders. A total of 2111 children were screened. DDST II results were abnormal for 953 (45.1 %) children. On multivariate analysis, delayed cry at birth, increasing age of the child, presence of feeding problems, assisted delivery, and birth injury were found to be associated with increasingly abnormal DDST II results. Nearly 50 % of referred babies had developmental delay without a specific clinical diagnosis, 13.9 % had speech problems, 9.5 % had neurological problems and 5.2 % had chromosomal anomalies. Birth related events are important risk factors for developmental delay.

Meta-analysis of 5-year outcomes of CABG vs PCI with stenting in patients with multivessel disease

AIM

The purpose of this meta-analysis was to systematically review and synthesize existing data on long term outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with multiple stenting in patients with multivessel coronary artery disease.

METHODS

Three randomized control trials of CABG versus stenting with a 5-year follow-up and a total number of 2 063 patients were included in the meta-analysis. The primary end-point of the study was freedom from major adverse cardiovascular events at 5 years.

RESULTS

After 5 years of follow-up, 42.81% of patients randomized to PCI with stenting versus 20.81% of patients randomized to CABG reached the primary clinical end-point(relative risk [RR] 2.16, 95% confidence interval [CI] 1.38-3.38). Repeat revascularization procedures occurred more frequently in patients allocated to PCI with multiple stenting compared with CABG (30.29% versus 7.45%, RR 4.47 and 95% CI 2.75-7.29). Non fatal myocardial infarction (MI) (6.6% versus 6.2%, RR 1.00 and 95% CI 0.58-1.70) was nearly equal in the two groups while deaths (9.3% versus 7.4%, RR 1.50 and 95% CI 0.61-3.66) were slightly higher in patients treated by PCI as compared to CABG.

CONCLUSION

Five years after the initial procedure, there is no survival benefit for CABG over PCI, but major adverse cardiovascular events and repeat revascularization procedures are high after PCI.

Funding agencies in low- and middle-income countries: support for knowledge translation

OBJECTIVE

The aim was to describe how selected health research funding agencies active in low- and middle-income countries promote the translation of their funded research into policy and practice.

METHODS

We conducted inductive analysis of semi-structured interviews with key informants from a purposive sample of 23 national and international funding agencies that fund health research in Brazil, Colombia, India, the Philippines, South Africa and Thailand. We also surveyed web sites.

FINDINGS

We found a commitment to knowledge translation in the mandate of 18 of 23 agencies. However, there was a lack of common terminology. Most of the activities were traditional efforts to disseminate to a broad audience, for example using web sites and publications. In addition, more than half (13 of 23) of the agencies encouraged linkage/exchange between researchers and potential users, and 6 of 23 agencies described "pull" activities to generate interest in research from decision-makers. One-third (9 of 23) of funding agencies described a mandate to enhance health equity through improving knowledge translation. Only 3 of 23 agencies were able to describe evaluation of knowledge translation activities. Furthermore, we found national funding agencies made greater knowledge translation efforts when compared to international agencies.

CONCLUSION

Funding agencies are engaged in a wide range of creative knowledge translation activities. They might consider their role as knowledge brokers, with an ability to promote research syntheses and a focus on health equity. There is an urgent need to evaluate the knowledge translation activities of funding agencies.

Antimicrobial prescription patterns for common acute infections in some rural & urban health facilities of India

BACKGROUND & OBJECTIVES

Irrational use of antimicrobials is a key factor behind rapidly spreading antimicrobial resistance in microorganisms. This study was undertaken to determine the rate and pattern of antimicrobial prescribing in patients with uncomplicated acute respiratory infections, fever and diarrhoea attending a few rural and urban health settings.

METHODS

The study was done in primary and secondary health care facilities of public/government and private settings at four sites in India. Patients with fever, cough, diarrhoea or ear, nose or throat infections of < 7 days were included. Pregnant women, lactating mothers, infants, seriously ill patients and patients with bloody diarrhoea or purulent nasal or ear discharge were excluded.

RESULTS

Overall antimicrobial prescription rate was 69.4 per cent (95% CI 67.1, 71.7). Wide variation was observed (Thiruvananthapuram 47.6%, Lucknow 81.8%, Chennai 73.1% and Vellore 76.5%). Physicians practicing in rural and public/government settings prescribed antimicrobials more frequently than those in urban and private settings (83.8, 81.9, 68.3 and 68.2% respectively). Antimicrobials were more frequently prescribed for patients presenting with fever. Highest rate was noticed for children aged between 6 and 18 yr. Patients of the high-income group received antimicrobials more frequently (72.7%). In both public/ government and private settings, for patients who purchased medicines, the rate was higher (82.4 and 68.9% respectively), vs. those receiving free medicines (70.2 and 46.2% respectively). Two third of all antimicrobials prescribed were penicillins and co-trimoxazole, and > 40 per cent of prescriptions from private sector were quinolones and cephalosporins.

INTERPRETATION & CONCLUSIONS

Our findings showed that prescription of antimicrobials for acute respiratory infections and diarrhoea was extremely common and warrants interventional strategies.

Physical spousal violence against women in India: some risk factors

Domestic spousal violence against women in developing countries like India, is now beginning to be recognized as a widespread health problem impeding development. This study aimed to explore the risk and protective factors for lifetime spousal physical violence. A cross-sectional household survey was carried out in rural, urban and urban-slum areas across seven sites in India, among women aged 15-49 years, living with a child less than 18 years of age. The sample was selected using the probability proportionate to size method. Trained field workers administered a structured questionnaire to elicit information on spousal physical violence. The main hypothesized variables were social support, witnessed father beating mother and experience of harsh physical violence during childhood, alcohol abuse by spouse and socioeconomic variables. The outcome variables included three physical violence behaviours of hit, kick and beat. Odds ratios were calculated for risk and protective factors of violence using logistic regression. Of 9938 women surveyed, 26% reported experiencing spousal physical violence during the lifetime of their marriage. Adjusted odds ratios calculated using multiple logistic regression analysis suggest that women whose husbands regularly consumed alcohol (OR 5.6; 95% CI 4.7-6.6); who experienced dowry harassment (OR 3.2; 95% CI 2.7-3.8); had reported experiencing harsh physical punishment during childhood (OR 1.6; 95% CI 1.4-1.8) and had witnessed their fathers beat their mothers (OR 1.9; 95% CI 1.6-2.1), were at increased risk of spousal physical violence (beat, hit and kick). Higher socioeconomic status and good social support acted as protective buffers against spousal physical violence. The findings provide compelling evidence of the potential risk factors for spousal physical violence, which in turn could help in planning interventions.

Predictors of mortality in mechanically ventilated patients

OBJECTIVES

There are scarce data from India validating scoring systems used to predict outcome in patients requiring mechanical ventilation. This study prospectively compared the organ system failure (OSF), the acute physiology and chronic health evaluation (APACHE) II, and the APACHE III, scores on patients requiring mechanical ventilation in the medical intensive care unit, to predict outcome.

METHODS

200 consecutive patients requiring mechanical ventilation in a medical intensive care unit were recruited. OSF, APACHE II, and APCHE III scores were calculated at admission and daily for one week or until discharge in all patients. Other variables recorded include age, sex, diagnosis, oxygen therapy before ventilation, complications on ventilation, duration in hospital before ventilation, duration of ventilation, type of respiratory failure, alveolar arterial oxygen gradient, P/F ratio, use of tracheostomy, time on ventilator before tracheostomy, muscle relaxant used, fluid balance, inotrope support. Logistic regression analysis and area under the curve were computed to determine which variables independently predict outcome.

RESULTS

Of the 200 patients, at discharge 143 patients (71.5%) had died. The factors that independently predicted outcome among these patients on mechanical ventilation were the type of respiratory failure (type I) OR = 2.7 (p = 0.02), the use of inotropes OR 2.4 (p = 0.04), and the APACHE II score OR = 1.8 (p = 0.008) for every five point increase in APACHE II score.

CONCLUSIONS

Type 1 respiratory failure, the use of inotropes, and the APACHE II score measured at admission are significant independent predictors of mortality in the patients on mechanical ventilation.

Fine needle aspiration in chronic tonsillitis: reliable and valid diagnostic test

Fine needle aspiration (FNA) of the tonsil as a diagnostic tool in evaluating the microflora in chronic tonsillitis has not been popularized. A prospective study of 30 patients with chronic tonsillitis undergoing tonsillectomy was undertaken. FNA of the tonsil core was done under local/general anaesthesia. The reliability of the culture by FNA of the tonsil core was then validated with the reference (gold) standard which is the dissected tonsil core. The sensitivity of FNA culture as compared to core culture was 100 per cent and 93 per cent under general and local anaesthesia respectively. The positive predictive value of FNA culture as compared to core culture was 92 per centand 82 per cent for general and local anaesthesia respectively. These factors indicate that FNA of the tonsil core is reliable and valid. It can safely be performed as an out-patient procedure under local anaesthesia. This is reported for the first time. Identifying the bacterial organism within the infected tonsil for appropriate antibiotic therapy could revolutionize the management of chronic tonsillitis.

World studies of abuse in the family environment--risk factors for physical intimate partner violence

OBJECTIVES

To identify risk factors for physical intimate partner violence against women in Chile, India, Egypt and the Philippines.

DESIGN

Population-based household survey.

SETTINGS

Selected urban communities in Temuco, Chile; ISmailia, Egypt; Lucknow, Trivandrum and Vellore in India and Metro Manila, Philippines.

PARTICIPANTS

Women aged 15-49 years of age who care for at least one child younger than 18 years of age. The number of participants was 442 in Chile, 631 in Egypt, 506 in Lucknow, 700 in Trivandrum, 716 in Vellore and 1000 in the Philippines.

MAIN OUTCOME MEASURE

Risk of and protective factors against lifetime physical IPV.

RESULTS

Significant associations were found between several risk factors like regular alcohol consumption of the husband/partner, past witnessing of father beating mother, the woman's poor mental health and poor family work status, with any lifetime physical IPV. Woman's poor mental health and witnessing father beat mother were statistically significant only in a few sites. Poor family work status, differences in employment between husband and wife and experiencing harsh physical punishment during childhood, were not found to be statistically significant across all sites. Protective factors, like higher levels of husband's and wife's education, were only found to be significantly associated with any lifetime physical IPV in Trivandrum, India. Social support was not significantly associated with any lifetime physical IPV across all sites.

CONCLUSIONS

These large population-based household surveys have provided empirical evidence of the widespread nature of domestic violence and the relative commonality of risk factors across sites.

Biochemical and clinical profile after organophosphorus poisoning--a placebo-controlled trial using pralidoxime

BACKGROUND

Organophosphorus (OP) compounds are the most common suicidal poison in developing countries and mortality continues to be high.

METHODS

A study was done to see butyryl cholinesterase (BuChE) profile after OP poisoning in pralidoxime (P2AM) and placebo treated cases. Highest recommended dose of P2AM was used to study the reactivation of cholinesterase. Clinical outcomes like, correlation of BuChE and severity of poisoning, mortality and complications like Type I and II paralysis, need for ventilation and ICU stay were also studied.

RESULTS

Twenty one cases of moderate and severe poisoning with OP compounds were included in the study. Mean BuChE levels came up gradually over 6-7 days, some taking up to two weeks. There was no. difference between the treatment and placebo groups. BuChE levels did not correlate with severity of poisoning nor did it correlate with Type I or II paralysis, need for ventilation, ICU stay or mortality.

CONCLUSIONS

Treatment with P2AM does not make any difference in BuChE reactivation or complications of moderate and severe OP poisoning. We have not been using P2AM for OP poisoning in our medical ICU with good patient outcomes.

Community prevalence of hepatitis B infection and modes of transmission in Tamil Nadu, India

BACKGROUND AND OBJECTIVE

There have been very few community based studies on prevalence of hepatitis B virus (HBV) infection in India. We undertook this study to determine the prevalence of HBV infection in a southern State of India, Tamil Nadu and to describe the important factors related to transmission of the virus in the community.

METHODS

Analysis of stored blood samples from a representative population of Tamil Nadu from an earlier community cluster survey on sexually transmitted diseases (STD) prevalence using proportionate to population size (PPS) technique was done. Serum markers of HBV viz., hapatitis B surface antigen (HBsAg), hepatitis B e antigen (HBe Ag) and antibody to surface antigen (anti-HBs) were performed.

RESULTS

1981 subjects were screened in the study. HBsAg prevalence was 5.7 per cent (CI 4.6- 6.8) with 23.5 per cent (25/106) of these having positive HBe-antigen. Community seroprevalence (HbsAg + anti-HBs) of hepatitis B infection was 27.4 per cent (CI: 25.3-29.5) with the highest prevalence of 32.7 per cent (CI: 30.2-35.2) noted in the 15-20 yr age group. Significant independent association (OR 1.4; P=0.006) was detected with family history of exposure to HBV infection by logistic modeling. Other risk factors noted to have significant association were use of disposable needles during injection (OR 0.5; P=0.02) in men, smoking (OR 3; P=0.04) and use of condom (OR 0.6; P=0.08) in women.

INTERPRETATION AND CONCLUSION

This community based study shows a high prevalence of hepatitis B infection in the state of Tamil Nadu with the highest prevalence being in the younger (15-20 yr) age group. High prevalence rate in childhood with e-antigenemia seen in 23.5 per cent of HBsAg positive subjects suggest childhood transmission. Poor injection practices and high-risk sexual behavior were found to be additional risk factors for transmission of the disease in the community.

Segmental colonoscopic biopsies in the differentiation of ileocolic tuberculosis from Crohn's disease

BACKGROUND AND AIM

The differentiation between Crohn's disease (CD) and tuberculosis (TB) of the intestine can be difficult in areas where both diseases occur. The present study examined histological criteria that would enable the diagnosis in mucosal biopsies.

METHODS

Colonoscopic biopsies from 33 patients with TB and 31 patients with CD were examined for several specific histological features and their distribution.

RESULTS

The salient distinguishing features of TB were granulomas larger than 400 microm in maximum dimension, more than four sites of granulomatous inflammation per site, cessation, a band of epithelioid histiocytes in ulcer bases and location of granulomas in the caecum. The salient features of CD were granulomas not showing any of the above features, focally enhanced colitis, pericryptal granulomatous inflammation, and the presence of architectural alteration/activity/chronic inflammation/deep ulceration at sites that did not show granulomatous response in the same or adjacent segments. Although granulomas in CD were distributed throughout the colon, they were more frequent in the rectosigmoid than in TB. All biopsies from endoscopically abnormal sites did not show distinguishing features of TB or CD, emphasizing the need for multiple biopsies. There was an accrual in the number of diagnoses made with increasing numbers of biopsies from rectum to ileum.

CONCLUSIONS

Histology of mucosal biopsies can aid in the differentiation of TB from CD, but multiple biopsies from different colonic segments are important for complete evaluation.

Pre-trial evaluation of the potential for unblinding in drug trials: a prototype example

Blinding is an important design feature of randomised trials that may reduce bias in the results, compared to the situation where blinding is not possible or is not maintained. The literature provides some guidance for the evaluation of blinding in ongoing or completed studies, but the question of pre-trial assessment of the potential for unblinding has not been addressed. This paper describes the design and analysis of a prototype experiment for the pre-trial assessment of blinding in a drug trial. This work was motivated by a trial using antibiotic therapy, in which the investigators were concerned about the possibility of subjects being able to differentiate active medication from placebo, and thus become unblinded to their treatment assignment. A small experiment was mounted in which participants had to divide a random mixture of tablets into two groups. Statistical methods were developed to calculate the probability of a given number of similar tablets being classified into the same group by chance, with a modification to allow for some participants having constrained their responses to have equal numbers of tablets in each group. Differentiation of tablets by taste (the initial concern of the investigators) was not statistically different from chance. A smaller set of data on differentiation by appearance (a possibility not originally considered) had borderline statistical significance. After reviewing all these results, the investigators decided to proceed with the study without modifying the tablets, in part because subjects in the study would be unlikely to compare the two types of medication side-by-side. Our results suggest that blinding might sometimes be compromised in unexpected ways. Whenever possible, we suggest that similar and larger such experiments be carried out before the trial to assess whether blinding might be compromised. The methods proposed here could easily be adapted to evaluate the results of such experiments.

X-Rays in the evaluation of adenoid hypertrophy: It's role in the endoscopic era

OBJECTIVES

To evaluate the reliability of X-rays in the diagnosis of adenoid hypertrophy and to validate this with flexible nasopharyngoscopy which is the existing gold standard.

METHOD

Lateral radiograph of the neck and a flexible nasopharyngeal endoscopy was done to evaluate adenoid enlargement in children aged 3-12 years who were included in a S week randomized double-blind placebo controlled study for the effect of beclomethasone in adenoid hypertrophy. These were graded independently by both the co-investigor and investigator X-ray and nasal endoscopy for reevaluation of adenoid size was done at the completion of the study. Variables of both the procedures were scored at the beginning and end of the study. The agreement between the two groups was assessed using weighted kappa statistic.

RESULTS

There were 26 patients in the study, 17 of them had complete correlation between the X-ray and endoscopy findings. The agreement between these findings was statistically significant (p<01) with the weighted kappa 0.51.

CONCLUSION

This study shows that lateral X-rays of the neck, besides being a noninvasive procedure, still remains a very reliable and valid diagnostic test in the evaluation of hypertrophied adenoids.

Effect of potassium channel modulators on toxicity of Cleistanthus collinus

The study was conducted to determine the effects of boiled extract of Cleistanthus collinus on rats by observing ECG changes and electrolyte levels in serum and urine. Influence of minoxidil and glibenclamide on Cleistanthus collinus induced toxicity was determined. ED50 for arrhythmia, changes in contractility and heart rate were recorded using the isolated frog heart. Cleistanthus at low doses caused transient tachycardia and increase in contractility and at high dose caused arrhythmia and cardiac arrest in rat. LD50 was found to be 1690 mg/kg. Minoxidil potentiated cardiac toxicity, whereas glibenclamide did not produce any significant change. High concentration of potassium in Cleistanthus extract hindered comparison of its levels. There was excretion of sodium even in the presence of hyponatraemia. Cleistanthus at low dose caused transient tachycardia and increase in contractility and at high dose caused arrhythmia and cardiac arrest in isolated frog heart. ED50 for arrhythmia was found to be 1406 mg/kg. Acute toxicity was mainly due to depressive cardiac activity of Cleistanthus. It also caused renal failure. Potassium channel modulators did not have important role in acute cardiac toxicity treatment. Probably in chronic toxicity, electrolyte level changes are involved and potassium channel modulators might have a role.