Nasobiliary drainage in acute cholestatic hepatitis with pruritus

BACKGROUND/AIM

Cholestatic acute viral hepatitis may have prolonged course. Pruritus is often a prominent feature and difficult to control. Sometimes it may be accompanied by severe cough. There are no reports of endoscopic nasobiliary drainage in these patients.

METHODS

We prospectively evaluated the role of nasobiliary drainage in six patients with cholestatic acute viral hepatitis with intractable pruritus and accompanying severe cough in one patient in an uncontrolled study.

RESULTS

There were five male and one female patient with cholestatic acute viral hepatitis with intractable pruritus. One patient also had severe cough. Nasobiliary drainage relieved pruritus in all patients and patient with cough also showed marked improvement within 24h. Nasobiliary drainage also hastened the recovery in these patients.

CONCLUSIONS

Short-term nasobiliary drainage should be considered in patients with cholestatic acute viral hepatitis with intractable pruritus and cough for symptomatic relief. It may help in faster recovery in these patients. However, a larger randomized controlled study is warranted.

Endothelin receptor antagonism and cancer

The endothelin peptides have an important role in the cancer-stromal interactions that promote tumour growth. Endothelin-1 (ET-1), clinically the most investigated endothelin, is a vital agent in the growth and progression of several tumours including prostate, ovarian, colorectal, bladder, breast and lung carcinomas. ET-1 exerts its effects through the activation of two distinct receptors, ET(A) and ET(B). Once activated, these receptors transmit signals via numerous intracellular signalling pathways. The effects of ET receptor stimulation in cancer cells or cancer-associated cells include proliferation, resistance to apoptosis, angiogenesis, migration and subsequent invasion. At present, the manipulation of the endothelin axis within the pre-clinical setting is the subject of intense investigation. Recent studies into ET receptor antagonism have produced interesting results highlighting the fact that these receptors may provide novel targets for a new generation of chemotherapeutic agents in a variety of cancers.

Cardiac botryomycosis: an autopsy report

Visceral botryomycosis is rare, and documented sites are lung, brain, kidney, liver and prostate. This report describes a rare autopsy case of disseminated visceral botryomycosis, with bulky, grape-like botryomycotic vegetations in the heart, and similar abscesses in the lungs and bone marrow. This is the first such report in the literature to the best of our knowledge.

Does early medical intervention have a role in the management of intracerebral haemorrhage?

INTRODUCTION

An increasing amount of research is now being directed towards the medical treatment of patients who have suffered an intracerebral haemorrhage (ICH). Despite this, no routine drug treatment to date has been shown to be unequivocally effective in unselected patients.

TREATMENTS/DISCUSSION

Approaches to treatment are based upon our understanding of the pathophysiological sequelae following ICH. Strategies to reduce haematoma growth, subsequent oedema formation and perihaematoma ischaemia are key targets for further research. Whether these therapies become valuable tools for the future is as yet unclear. Until then, the mainstay of the medical management of ICH remains individualised care.

CONCLUSIONS

There is now a pressing need for large prospective randomised controlled trials to determine the effectiveness of pharmacological therapies for this condition.

2,4-D (ethyl ester) poisoning: experience at a tertiary care centre in northern India

2,4-Dichlorphenoxyacetic acid (2,4-D) is a selective herbicide widely used to kill broad-leaved plants in wheat cultivation. Only a few cases of documented poisoning cases with this compound have been reported from India. Since the initial manifestations are not very different from anticholinesterase poisoning, the chances of misdiagnosis are high. Anticholinesterase compounds are the most commonly used insecticides and are implicated as the commonest cause of agrochemical poisoning in India. This report aims to make physicians aware that not all cases of agrochemical poisoning are caused by anticholinesterase insecticides. Efforts must be made to correctly identify the offending compound for appropriate management.

Study of association between use of complementary and alternative medicine and non-compliance with modern medicine in patients presenting to the emergency department

CONTEXT

Complementary and alternative medicines (CAMs) are extensively used by the public. Noncompliance is an important cause of therapy failure.

AIM

This study was done to determine prevalence of emergency admission due to noncompliance with modern medicine following switching over to CAM and to identify any significant association for CAM use among noncompliers.

SETTING AND DESIGN

This cross-sectional study was conducted in the emergency unit of a tertiary healthcare institute.

MATERIALS AND METHODS

Demographic factors and system affected were compared between compliers and noncompliers. Prevalence, reasons and nature of noncompliance were determined. Age, gender, outcome, relation strength and potential preventability of noncompliance, precipitating and previous disease and noncompliant drugs were compared for significant association between CAM using and other noncompliers.

STATISTICAL ANALYSIS

Student's 't' test, Chi square test and odds ratio were used.

RESULTS

Of the 506 patients interviewed 168 (33%) were noncompliant. In 160 (95%) patients noncompliance was due to under-dosing. Lack of knowledge and CAM use constituted 144 (86%) noncompliance-related admissions. Thirty-three (7%) admissions were strongly related to noncompliance and CAM use. Age, gender, outcome, drug use and diseases except chronic obstructive pulmonary disease (COPD) and asthma showed no association while relation strength and potential preventability of emergency admission was less with CAM-using noncompliers. Noncompliance was observed for hypertension, diabetes, COPD and asthma, seizure disorder, tuberculosis and hemophilia besides hepatic and renal failure. The CAM noncompliers used CAM more for modern medicine incurable or unaffordable than curable diseases.

CONCLUSION

Advice for regular treatment and frequent monitoring can decrease CAM use-related noncompliance admissions.

A randomized controlled clinical trial to evaluate the efficacy, safety, cost-effectiveness and effect on PAI-1 levels of the three low-molecular-weight heparins--enoxaparin, nadroparin and dalteparin. The ESCAPe-END study

BACKGROUND

Comparative data for efficacy and safety between various low-molecular-weight heparins (LMWHs) in patients with unstable angina is not available. The present study was conducted to compare the efficacy, safety, cost-effectiveness and effects on plasminogen activator inhibitor-1 (PAI-1) levels of three LMWHs--enoxaparin, nadroparin and dalteparin.

METHODS

The study was a prospective, randomized, comparative, open with blinded endpoints (PROBE design) assessment with a 30-day follow-up. The primary endpoint of efficacy was a composite of cardiovascular death, myocardial infarction, recurrent angina and need for intervention. Cost-effectiveness was calculated by calculating the incremental cost-effectiveness ratio. Plasma PAI-1 levels were estimated by ELISA.

RESULTS

A total of 150 patients were available for intention-to-treat analysis. There was no significant difference at 30 days in the primary endpoint or in any of the individual components in the three groups. The secondary endpoint of silent ischemia was also not significantly different. Adverse events were similar in the three groups. The PAI-1 levels were not significantly different in the three groups. The total cost of treatment in the three groups was similar.

CONCLUSION

Any of the three LMWHs evaluated in this study were similar with respect to efficacy, safety, PAI-1 levels and cost-effectiveness.

Malarial hepatopathy

Jaundice is a common clinical presentation in severe malaria, seen in approximately 2.5% patients with falciparum infection but hepatitis is unusual. Although hepatic dysfunction is unusual and hepatic encephalopathy is almost never seen in malaria, yet, cases of hepatic dysfunction are being increasingly reported in patients with P.falciparum infection, from different parts of world. The extent of hepatocellular dysfunction varies from mild abnormalities in liver function tests to hepatic failure. Patients with hepatocellular dysfunction in malaria are more prone to develop complications, but have a favorable outcome if hepatic involvement is recognized early and managed properly. It is important to meticulously look for hepatic dysfunction in patients with severe malaria, distinguish it from fulminant hepatic failure and manage it aggressively.

HIV immunosupression and malaria: is there a correlation?

The human immunodeficiency virus (HIV) epidemic has resulted in an increase in the prevalence of many opportunistic infections and has caused re-emergence of certain diseases in the developing world. In tropical countries, immunosupression due to HIV infection has resulted in changes in the clinical presentation of endemic infections. Although the immune deficiency caused by HIV infection should presumably lead to an increased frequency of clinical malaria in areas with endemic malarial infection, like India, evidence of the association between HIV and malaria in India is scanty, with only a few studies showing a positive correlation. We hereby report a case of concurrent infection with Plasmodium falciparum malaria and human immunodeficiency virus type 1 (HIV-1) in a young male patient.

Noradrenaline and albumin in paracentesis-induced circulatory dysfunction in cirrhosis: a randomized pilot study

OBJECTIVE

Therapeutic paracentesis in patients with cirrhosis is associated with a circulatory dysfunction. Intravenous albumin has been used to prevent the circulatory dysfunction; however, the use of albumin is controversial and costly. Splanchnic vasodilation is mainly responsible for circulatory dysfunction in these patients. There are no reports of use of noradrenaline, a vasoconstrictor, on the prevention of paracentesis-induced circulatory dysfunction in patients with cirrhosis. Therefore, we studied the preventive effect of noradrenaline on paracentesis-induced circulatory dysfunction in patients with cirrhosis after therapeutic paracentesis and compared it with that of intravenous albumin in a randomized pilot study.

METHODS

Forty patients with cirrhosis and tense ascites underwent therapeutic paracentesis with albumin or noradrenaline in a randomized controlled trial at a tertiary centre. Effective arterial blood volume was assessed by measuring plasma renin activity at baseline and at 6 days after treatment.

RESULTS

Effective arterial blood volume as indicated by plasma renin activity before and 6 days after paracentesis did not differ in the two groups (20.62 +/- 10.27-22.02 +/- 10.15 ng mL(-1) h(-1); P = 0.11 in the albumin group and 19.66 +/- 8.91-20.78 +/- 9.41 ng mL(-1) h(-1); P = 0.37 in the noradrenaline group). Plasma aldosterone concentration before and 6 days after paracentesis were also similar in both groups (1196.5 +/- 434.2-1217.0 +/- 405.7 pg mL(-1); P = 0.7 in the albumin group and 1206.0 +/- 522.5-1273.5 +/- 444.8 pg mL(-1); P = 0.22 in the noradrenaline group). The cost of noradrenaline treatment was significantly lower when compared with that of albumin (P < 0.001).

CONCLUSIONS

Noradrenaline is as effective as albumin in preventing paracentesis-induced circulatory dysfunction in patients with cirrhosis after therapeutic paracentesis, but at a fraction of the cost.

Ageing and circadian variation in cardiovascular events

INTRODUCTION

Circadian variation in cardiovascular events is well recognised in vascular events. This study aims to observe any significant difference in circadian variability in geriatric patients when compared to their younger counterparts.

METHODS

This prospective study was conducted at medical emergency at the Government Medical College and Hospital, Chandigarh, India. All the patients attending medical emergency with symptoms suggestive of coronary artery disease were included. The time of occurrence of first symptom and subsequent symptoms was noted. Electrocardiography, cardiac enzymes and echocardiography were performed to establish the diagnosis of acute coronary syndrome. The 24-hour day was divided into 12 equal parts of two hours each. For the final analysis, the two-hour periods were grouped into six equal periods of four hours each and four quarters of six hours each.

RESULTS

We studied 559 patients, out of whom 459 were 65 years old or younger, and 100 patients were older than 65 years old. 459 patients had 498 episodes in all. 100 patients above the age of 65 years had 104 episodes. Both the groups had peaking of acute myocardial infarction in the early morning hours with patients older than 65 years of age having a slightly early peak. However, there was considerable variability for peaking of unstable angina and non-Q myocardial infarction. In patients older than 65 years, early morning peaking of events was noted whereas in 65 years or younger, the peaking of events was noted in the evening hours.

CONCLUSION

Circadian variability exists in occurrence of acute coronary events and is variable in geriatric patients when compared to their younger counterparts.

Toxicity of maduramicin

This report documents the first presentation of seven human cases of poisoning with a compound used in poultry feed. The clinical presentation was a toxic polyneuropathy with rhabdomyolysis and acute renal failure. We describe the protracted clinical course of one of these victims along with a tabulated description of the clinical course and relevant laboratory investigations of the others.

Comparison of the expression of human leukocyte antigen (HLA)-G and HLA-E in women with normal pregnancy and those with recurrent miscarriage

Recurrent miscarriage affects 1% of all couples attempting pregnancy. Immunological factors are postulated to play a role in the aetiology of recurrent miscarriage because the fetus and placenta are immunologically different from the mother. In particular, altered expression of the, non-classical, class I histocompatibility leukocyte antigen (HLA) molecules has been postulated to play a role in the aetiology of recurrent miscarriage as the fetus and placenta are semi-allogenic to the mother. This study was conducted to examine whether altered expression of the non-classical class I HLA molecules, HLA-G and HLA-E, by cells at the maternofetal interface could play a role in the aetiology of recurrent miscarriage. First-trimester placental and decidual biopsies were obtained from 45 women with recurrent miscarriage and 17 gestation-matched normal controls. These biopsies were screened by immunohistochemistry for HLA-G and HLA-E and isotype-matched control antibodies. Staining was analysed by light microscopy and digital image analysis. In both recurrent miscarriage and normal pregnancy, HLA-G was localised to the extravillous trophoblast. There was no difference in the pattern of HLA-G expression between women with recurrent miscarriage and those with normal pregnancies. HLA-E was localised to the syncytiotrophoblast, villous mesenchymal cells, extravillous trophoblast and several decidual cell types, but staining for HLA-E appeared to be confined primarily to the cytoplasm. There was no difference in the pattern of HLA-E expression between women with recurrent miscarriage and those with normal pregnancies.

Whom to treat? The contribution of vertebral X-rays to risk-based algorithms for fracture prediction. Results from the European Prospective Osteoporosis Study

INTRODUCTION

Vertebral fracture is a strong risk factor for future spine and hip fractures; yet recent data suggest that only 5-20% of subjects with a spine fracture are identified in primary care. We aimed to develop easily applicable algorithms predicting a high risk of future spine fracture in men and women over 50 years of age.

METHODS

Data was analysed from 5,561 men and women aged 50+ years participating in the European Prospective Osteoporosis Study (EPOS). Lateral thoracic and lumbar spine radiographs were taken at baseline and at an average of 3.8 years later. These were evaluated by an experienced radiologist. The risk of a new (incident) vertebral fracture was modelled as a function of age, number of prevalent vertebral fractures, height loss, sex and other fracture history reported by the subject, including limb fractures occurring between X-rays. Receiver Operating Characteristic (ROC) curves were used to compare the predictive ability of models.

RESULTS

In a negative binomial regression model without baseline X-ray data, the risk of incident vertebral fracture significantly increased with age [RR 1.74, 95% CI (1.44, 2.10) per decade], height loss [1.08 (1.04, 1.12) per cm decrease], female sex [1.48 (1.05, 2.09)], and recalled fracture history; [1.65 (1.15, 2.38) to 3.03 (1.66, 5.54)] according to fracture site. Baseline radiological assessment of prevalent vertebral fracture significantly improved the areas subtended by ROC curves from 0.71 (0.67, 0.74) to 0.74 (0.70, 0.77) P=0.013 for predicting 1+ incident fracture; and from 0.74 (0.67, 0.81) to 0.83 (0.76, 0.90) P=0.001 for 2+ incident fractures. Age, sex and height loss remained independently predictive. The relative risk of a new vertebral fracture increased with the number of prevalent vertebral fractures present from 3.08 (2.10, 4.52) for 1 fracture to 9.36 (5.72, 15.32) for 3+. At a specificity of 90%, the model including X-ray data improved the sensitivity for predicting 2+ and 1+ incident fractures by 6 and 4 fold respectively compared with random guessing. At 75% specificity the improvements were 3.2 and 2.4 fold respectively. With the modelling restricted to the subjects who had BMD measurements (n=2,409), the AUC for predicting 1+ vs. 0 incident vertebral fractures improved from 0.72 (0.66, 0.79) to 0.76 (0.71, 0.82) upon adding femoral neck BMD (P=0.010).

CONCLUSION

We conclude that for those with existing vertebral fractures, an accurately read spine X-ray will form a central component in future algorithms for targeting treatment, especially to the most vulnerable. The sensitivity of this approach to identifying vertebral fracture cases requiring anti-osteoporosis treatment, even when X-rays are ordered highly selectively, exceeds by a large margin the current standard of practice as recorded anywhere in the world.

Accurate blood pressure recording: is it difficult?

BACKGROUND

Blood pressure (BP) measurement is a routine procedure but errors are frequently committed during BP recording. AIMS AND SETTINGS: The aim of the study was to look at the prevalent practices in the institute regarding BP recording. The study was conducted in the Medicine Department at Government Medical College, Chandigarh, a teaching institute for MBBS students.

METHODS

A prospective, observational study was performed amongst the 80 doctors in a tertiary care hospital. All of them were observed by a single observer during the act of BP recording. The observer was well versed with the guidelines issued by British Hypertension Society (BHS) and the deviations from the standard set of guidelines issued by BHS were noted. The errors were defined as deviations from these guidelines.

STATISTICAL METHODS

The results were recorded as percentage of doctors committing these errors.

RESULTS

In our study, 90% used mercury type sphygmomanometer. Zero error of the apparatus, hand dominance was not noted by any one. Every one used the standard BP cuff for recording BP. 70% of them did not let the patient rest before recording BP. 80% did not remove the clothing from the arm. None of them recorded BP in both arms. In out patient setting, 80% recorded blood pressure in sitting position and 14% in supine position. In all the patients where BP was recorded in sitting position BP apparatus was below the level of heart and 20% did not have their arm supported. 60% did not use palpatory method for noticing systolic BP and 70% did not raise pressure 30-40 mm Hg above the systolic level before checking the BP by auscultation. 80% lowered the BP at a rate of more than 2 mm/s and 60% rounded off the BP to nearest 5-10 mm Hg. 70% recorded BP only once and 90% of the rest re inflated the cuff without completely deflating and allowing rest before a second reading was obtained.

CONCLUSION

The practice of recording BP in our hospital varies from the standard guidelines issued by the BHS.

Variations in the provision of resuscitation equipment: survey of acute hospitals

BACKGROUND

There are wide variations in survival after cardiopulmonary resuscitation. The aim of this survey was to describe how equipment provision of resuscitation trolleys was deployed in a range of clinical ward areas.

METHODS

The equipment in randomly selected resuscitation trolleys in all 14 South West Thames Region hospitals was surveyed. The gold standard for equipment provision was referenced from the document CPR Guidance for Clinical Practice and Training in Hospital.

RESULTS

There were significant differences in the provision of circulation equipment (p = 0.004) and in the rates of drug items present (p = 0.001). There was no significant difference in provision of airways equipment (p = 0.24) or immediate access items (p = 0.55).

CONCLUSIONS

There are variations in the provision of resuscitation equipment in many clinical areas. Hospitals need to review the procedures for ensuring adequate provision of resuscitation equipment in all clinical areas.