Hemarthrosis as a major complication after arthroscopic subcutaneous lateral retinacular release: a prospective study

The use of arthroscopic lateral release and medial imbrication of the vastus medialis obliquus for recurrent dislocation of the patella was evaluated prospectively in 31 patients. Patients were examined clinically as well as radiologically; the average length of follow-up was 34.4 months. Seventy-one percent of the patients were satisfied with the operative result. Seven patients experienced redislocation of the patella. Postoperative effusion occurred in 13 (42%) patients, with 4 patients requiring aspiration and 3 patients requiring open revision because of hemarthrosis. Seven patients developed a long-lasting stiffness of the joint following a 3-week period of immobilization with a dorsal plaster splint of the whole leg.

Atorvastatin does not alter the anticoagulant activity of warfarin

Twelve patients chronically maintained on warfarin were administered 80 mg atorvastatin for 2 weeks. Mean prothrombin times decreased slightly, but only for the first few days of the two-week treatment period. Thus atorvastatin had no consistent effect on the anticoagulant activity of warfarin and adjustment in warfarin dosing should not be necessary.

Meta-analysis of steady-state pharmacokinetics of troglitazone and its metabolites

The object of this study is to evaluate the effects of age, gender, age-by-gender interaction, Type II diabetes, body weight, race, smoking, and formulation on steady-state pharmacokinetics of troglitazone, Metabolite 1 (sulfate conjugate), and Metabolite 3 (quinone metabolite) following multiple-dose oral administration of troglitazone. Pharmacokinetic parameter estimates [Cl/F (apparent oral clearance), AUC0-24 (area under plasma concentration-time curve), and ratio of AUC for troglitazone to Metabolite 1 and to Metabolite 3] obtained from 84 healthy volunteers and 171 patients with Type II diabetes in 8 studies were analyzed using a graphical method (for race and smoking) or a weighted ANCOVA model incorporating gender, health status (healthy vs Type II diabetes), and formulation as main effects; age, age-by-gender interaction, and body weight as continuous covariates. Ratio of AUC for troglitazone to metabolites was also examined by inspection of log-probit plots. Age, gender, age-by-gender, Type II diabetes, and formulation had negligible effects on troglitazone Cl/F, AUC0-24 (all analytes), and AUC ratio of troglitazone to metabolites. Race and smoking did not appear to influence steady-state pharmacokinetics of troglitazone and its metabolites. Although body weight was a significant covariate for AUC0-24 and Cl/F, the explanatory power of the overall model was weak (R2 < 0.2). Log-probit plots did not reveal a polymorphic distribution in AUC ratio of troglitazone to Metabolite 1 or Metabolite 3. Based on pharmacokinetics, dose adjustment for troglitazone in relation to the demographic factors examined is not required due to their poor predictive ability on steady-state pharmacokinetics of troglitazone and its metabolites.

Resection of heterotopic ossification of the hip in spinal cord injured patients

Twenty nine spinal cord injury patients were treated by resection of heterotopic ossification in 41 hips. The average follow-up period after surgery was 4.2 years. The mean time to surgery after injury was 82.1 months. The indications for surgery were seating problems, loss of function, pressure sores and pain. The average preoperative motion in flexion and extension was 21.95 degrees, the average intraoperative motion was 94.51 degrees. The average motion at follow-up evaluation was 82.68 degrees. Clinical relevant recurrence occurred in three patients. Complications excluding recurrence occurred in 10 hips, including deep and superficial wound infections, fracture, aneurysm and pressure ulcer. The operation was followed by a specific regime of physiotherapy and radiation therapy.

Perioperative antibiotic, steroid, and nonsteroidal anti-inflammatory agents in cataract intraocular lens surgery

Ophthalmologists continue to choose topical antibiotics and corticosteroids more frequently than injectable agents for their current cataract surgical techniques. The preoperative use of povidone-iodine 5% and the postoperative use of impregnated soft contact lenses have helped augment our therapeutic armamentarium. NSAIDs play an important role in decreasing postoperative convalescence with fewer side effects. The intracameral administration of heparin and antibiotic solutions is discussed.

Morbidity pattern, health care utilization and per capita health expenditure in a rural population of Tamil Nadu

BACKGROUND

Information on the existing morbidity pattern, pattern of health care utilization and the per capita health expenditure is essential to provide need-based health care delivery to a rural population. To obtain this information we performed a study in the K.V. Kuppam Block, North Arcot Ambedkar District, Tamil Nadu.

METHODS

We did a cross-sectional study, interviewing respondents from 300 households, from 3 panchayats using a multistage sampling technique. Information relating to 1440 persons was collected. The morbidity data was obtained initially for the week prior to the day of interview, followed by one week to one month and then for two months to one year.

RESULTS

During 1990-91, 825 of the 1440 persons (57.3%) did not have any illness. Sex had no bearing on the number of illnesses. Of the 60 children less than 2 years of age, 42 (70%) had one or two illnesses. The period prevalence of infective and parasitic diseases was found to be 21.9% with an average of 3 episodes. Services rendered by private practitioners (registered, non-registered and indigenous) were utilized by 59% of the households and 79% of the households had used allopathic treatment at some time. The average per capita per annum health expenditure was Rs 89.9 (Rs 449 per household). This increased significantly with increase in the household size (p < 0.001) and per capita income (p < 0.01).

CONCLUSION

The health-seeking behaviour of this population can be changed if efficient services are rendered through government primary health centres and subcentres. This would allow the existing voluntary agency to withdraw without much change in the per capita health expenditure.

Perioperative antibiotic, steroidal, and nonsteroidal anti-inflammatory agents in cataract intraocular lens surgery

Ophthalmologists are choosing topical antibiotics and corticosteroids more frequently than injectable agents for their current cataract surgical techniques. The preoperative use of povidone-iodine 5%, dilute intracameral antibiotics (via the balanced saline solution infusion), and postoperative impregnated collagen shields or soft contact lenses augment the therapeutic armamentarium. Nonsteroidal anti-inflammatory drugs, especially diclofenac 0.1%, have played an important role in decreasing postoperative convalescence through maintaining preoperative mydriasis, reducing anterior chamber reactions, and inhibiting cystoid macular edema. With fewer side effects, nonsteroidal anti-inflammatory drugs are minimizing the role of topical steroids.

Incidence of smear-positive pulmonary tuberculosis from 1981-83 in a rural area under an active health care programme in south India

SETTING

Four villages in the K V Kuppam Block of North Arcot Ambedkar District, Tamil Nadu, south India.

OBJECTIVE

To determine the prevalence and incidence of microscopy positive patients with pulmonary tuberculosis.

DESIGN

The entire population of 22,847 was covered prospectively; the prevalence survey in 1981 was conducted through house to house interviews followed by collecting and examining sputum specimens by microscopy from symptomatic patients (cough for more than 2 weeks duration or other respiratory or systemic symptoms compatible with tuberculosis). The prevalence survey was followed by monthly visits for two consecutive years to obtain an accurate estimate of the incidence.

RESULTS

The prevalence in the population among persons aged 10 years and above was 2.41 per 1000, the average annual incidence during 1981-83 was 1.11 per 1000 or 46% of the prevalence. The male:female ratio in the prevalence survey was 2.6:1, while in the incidence assessment it was 2.4:1.

CONCLUSION

The results of the study provide valuable information on the relation between prevalence and incidence of sputum smear-positive cases which should help to better our understanding of the epidemiology of tuberculosis in a disadvantaged part of the world. The reliable estimate of incidence of the microscopy positive cases provided by the study should be very useful for assessing the efficacy of case finding in the District Tuberculosis Programme in India.

Vitamin A supplementation and morbidity among preschool children in south India

A randomized, double-blind, placebo-controlled trial was conducted in an ongoing Growth Monitoring Research project in TamilNadu, India, to assess the impact of high-dose vitamin A supplementation on morbidity among mildly to moderately malnourished children aged < 3 y. Every 4 mo, the treatment group received 60 mg vitamin A (200,000 IU) whereas the control group received a placebo. Cases of xerophthalmia and severe malnutrition were excluded. Anthropometric measurements and serum retinol determinations were made at baseline and at the end of 1 y. Morbidity data were collected by trained village-level workers throughout the study period by using the weekly recall method. The two groups had similar nutritional status, serum retinol concentrations, age-sex composition, and other sociodemographic indicators at baseline. The mean number of episodes per child-year was 2.62 +/- 2.95 and 2.56 +/- 2.5 for respiratory illness and 1.9 +/- 2.2 and 1.77 +/- 1.77 for diarrhea for the vitamin A (n = 309) and placebo (n = 274) groups, respectively. The differences in respiratory and diarrheal morbidity between the two groups were not statistically significant and these findings remained unaltered after multivariate analysis in which the effects of age, sex, socioeconomic status, sanitation, etc, were considered. These findings are similar to other recent findings and indicate that vitamin A supplementation does not reduce common morbidity in children with mild-to-moderate vitamin A deficiency in areas where access to health care and immunization are good.

A 5-yr prospective epidemiological study of chronic obstructive pulmonary disease in rural south India

In a prospective epidemiological study from 1981 to 1986 in four villages belonging to the KV Kuppam block of North Arcot Ambedkar district in Tamil Nadu, we detected 328 patients of chronic obstructive pulmonary disease (COPD) amongst the 9946 inhabitants who were aged 30 yr or more. Majority of the population was from the lower income group and they were agricultural workers residing in these villages which were generally free from atmospheric pollution. Of the 328 patients with COPD, 198 were males and 130 were females showing an overall age specific prevalence of 33.0/1,000 with a prevalence of 40.8/1,000 for males and 25.5/1,000 for females, respectively. In nearly half of the patients who had chest radiography, changes consistent with COPD were observed; only one patient had clinical, radiological and electrocardiographic evidence of cor-pulmonale. Peak expiratory flow rate (PEFR) along with height (cm) were measured in 258 patients and compared to the predicted normal values. Most of those tested showed evidence of airways obstruction; severe defect was observed in 106 patients. Among the males, 122 gave a history of smoking; majority of the heavy smokers amongst them had severe impairment of PEFR. Females from these villages denied any history of smoking. Cooking for long hours using firewood and cowdung cakes could have contributed to the development of COPD in these village women.

Vitamin A supplementation does not improve growth of preschool children: a randomized, double-blind field trial in south India

A randomized, double-blind, placebo-controlled trial was conducted in an ongoing growth monitoring research project in TamilNadu, India, to assess the role of high dose vitamin A supplementation on the growth of mild to moderately malnourished children < 3 y old. The treatment group received 60 mg of vitamin A and the control group received a placebo every 4 mo. Infants 6-11 mo of age received only 30 mg of vitamin A Cases of xerophthalmia and severe malnutrition were excluded. Anthropometric measurements and serum retinol determinations were made at baseline and at the end of 1 y. The two groups were similar at baseline in nutritional status, serum retinol, age-sex composition and other socio-demographic indicators. The mean height increments were 9.20 +/- 3.51 and 9.01 +/- 3.41 cm/y for the vitamin A-treated (n = 310) and placebo (n = 282) groups, respectively, and the mean weight increments were 2.02 +/- 0.83 and 1.99 +/- 0.81 kg/y, respectively. The differences in growth increments between the two groups were not statistically significant. These findings remain unaltered following multivariate analysis and suggest the lack of an effect of vitamin A supplementation on growth in young children where access to health care and immunization are good.

Management of alimentary tract duplication in children

Duplication of the alimentary tract is rare but potentially dangerous. Five of 72 children with alimentary tract duplication treated between 1973 and 1992 died from postoperative complications; a further ten required more than one operation. Ileal duplications were the commonest, occurring in 16 patients (22 per cent). Thoracoabdominal duplications were the most complicated and responsible for much of the overall morbidity and mortality. Surgical complications were related to the size and location of the duplication, communication with the gastrointestinal tract or vertebral canal, presence of heterotopic gastric mucosa and involvement of mesenteric vessels. Complete excision of the duplication should be possible in most cases.

Hypereosinophilia in association with pulmonary tuberculosis in a rural population in south India

In a prospective study conducted in four villages of North Arcot Ambedkar district of Tamil Nadu in south India over a 5 yr period from 1981-86, 279 patients were detected to have pulmonary tuberculosis (PTB). Thirty one of them were found to have associated hypereosinophilia (HE) with total blood eosinophil level of > or = 2000 per cumm; besides cough with expectoration they also complained of dyspnoea and wheeze. Twelve of the 18 patients with intestinal parasites had remission with deworming agents alone. The other 6 non responsive patients like the 13 who did not have parasitic infestation, needed treatment with diethylcarbamazine for eosinopenic remission and thus could be classified as patients of tropical pulmonary eosinophilia (TPE). The association of hypereosinopilic state as a whole as well as TPE with tuberculosis as compared to that prevalent in the general population was found to be highly significant (P < 0.001). The frequent association of TPE with tuberculosis as observed by us suggests the possibility of an early hypersensitivity reaction to mycobacterial antigens triggering a florid TPE state in susceptible patients from an area endemic for filariasis. A similar mechanism may also operate in cases of pulmonary eosinophilia induced by other helminths in areas where they are endemic.

[Single dose prevention with cefuroxime in plastic surgery. Control of serum level, efficacy and tolerance]

Clinical efficacy and drug safety of single-shot prophylaxis with Cefuroxime was investigated in a series of 50 elective plastic surgical operations. Serum and tissue concentrations at one hour after application were determined in ten patients undergoing breast reduction. Levels far above the minimum inhibitory concentrations for possible pathogenic bacteria were obtained. No infection occurred. Wound complications not related to wound infection occurred in 12%.

Impaired glucose tolerance and diabetes mellitus in a rural population in south India

In the present study the prevalence of impaired glucose tolerance and non-insulin dependent diabetes mellitus in a rural population in South India was assessed and its associations with body mass index and a family history of diabetes mellitus. Data were obtained from inhabitants of two villages located in the North Arcot District of Tamil Nadu. After an overnight fast, 467 randomly selected subjects, aged 40 years or over, were given 75 g glucose orally. After two hours the capillary glucose level was determined. The prevalence of impaired glucose tolerance (2 h value > or = 7.8 mmol/l and < 11.1 mmol/l) was 6.6% (31 subjects). Non-insulin dependent diabetes mellitus (2 h value > or = 11.1 mmol/l) was found in 23 subjects (4.9%). Of these, 53% were previously unknown. Age and sex adjusted mean body mass index was significantly higher among subjects with impaired glucose tolerance compared to subjects without glucose intolerance, with a mean difference of 1.4 kg/m2 (95% confidence interval (CI) 0.2, 2.6). A positive family history of diabetes was non-significantly higher in subjects with impaired glucose tolerance. Subjects with non-insulin-dependent diabetes mellitus had a higher mean body mass index compared to subjects with normal glucose levels with a mean difference of 1.9 kg/m2 (95% CI 0.5, 3.3). A positive family history of diabetes was more common among diabetics with a difference of 20% (95% CI 10, 30). Our findings suggest that in a considerable proportion (11.5%) of the rural South Indian population aged 40 years or over glucose intolerance is present.(ABSTRACT TRUNCATED AT 250 WORDS)

[Preoperative prevention of infection with cefuroxime in hand surgery emergencies. Efficacy, control of concentration, follow-up]

Clinical efficacy and drug safety of Cefuroxime for preoperative prophylaxis of wound infection was investigated in 20 cases of acute open hand injuries. Ten minutes before filling of the tourniquet, Cefuroxime was given. Tissue and serum levels of ten patients were determined 10 and 70 minutes later. Levels far above the minimum inhibitory concentrations of possible pathogenic bacteria were obtained. No serious infection occurred. Wound complications not related to infection occurred in 15%.

Pulmonary eosinophilia in children: report of a school survey in rural Tamil Nadu in India

During the period of 1981-82 in a survey of 21 schools in four villages of North Arcot Ambedkar District of Tamil Nadu, amongst a population of 4282 children we detected 92 with respiratory symptoms and blood eosinophilia greater than 1000 per cumm. Sixty-eight students had associated worn infestation, majority with hookworm followed by giardia. Altogether 37 children had blood eosinophilia above 2000 per cumm and had symptoms of cough, dyspnoea, and wheeze consistent with pulmonary eosinophilia. Fourteen of the children with pulmonary eosinophilia had eosinopenic remission with deworming alone. Six of them, on the other hand, responded to diethyl carbamazine (DEC) alone and 17 others, following deworming, required further DEC therapy for successful eosinopenic remission, thus warranting a diagnosis of Tropical Pulmonary Eosinophilia (TPE).

Epidemiology of pulmonary eosinophilia in rural south India--a prospective study, 1981-86

STUDY OBJECTIVE

The study aimed to determine the prevalence and incidence of pulmonary eosinophilia, with special reference to tropical pulmonary eosinophilia, in a rural community.

DESIGN

This was a five year prospective study from 1981-86.

SETTING

The study was conducted in four villages of Tamil Nadu in south India.

SUBJECTS

The study population consisted of 24,950 subjects.

MEASUREMENTS AND MAIN RESULTS

After being questioned about pulmonary symptoms, the selected subjects had peripheral blood examined for total leukocyte and eosinophil counts; stools for ova, cysts, and parasites; sputum for acid-fast bacilli, and chest radiography. Subjects with blood eosinophilia of > or = 2000/mm3 were classified as having pulmonary eosinophilia. One of the 200 asymptomatic control subjects had blood eosinophilia > 2000/mm3. Twenty two (7.7%) of a further 286 subjects selected at random were found to have microfilaraemia. Between 1981 and 1984 the annual incidences of pulmonary eosinophilia were estimated at 4.1, 3.1, and 2.7/1000 while the prevalence rates were 6.4, 9.3, and 11.9/1000 respectively. This rising prevalence over time occurring simultaneously with a falling incidence suggests that the final incidence rate (2.7/1000) was likely to be the most accurate of the three estimated. At resurvey in 1986, 314 cases were classified as pulmonary eosinophilia giving a prevalence rate of 12.6/1000. Altogether 214 of them also had intestinal worm infestations, including 58 in whom eosinopenic remission was recorded after deworming alone. Eosinopenic remission was documented in 135 of 182 cooperative patients who were considered to have tropical pulmonary eosinophilia and agreed to be treated with diethylcarbamazine.

CONCLUSIONS

This study found that tropical pulmonary eosinophilia, either alone or with worm infestation, was a major cause or morbidity in this rural population.

Evaluation of effectiveness of good growth monitoring in south Indian villages

We conducted a community intervention trial in 12 villages in Tamil Nadu, India to evaluate the benefits of growth monitoring. The villages were divided into 6 "growth-monitoring package" of intervention villages (GMP) and 6 "non-growth-monitoring package" of intervention villages (NGM). A functioning primary health care system was in place in all 12 villages implemented a set of interventions including health and nutritional education. About 550 children under the age of 60 months were studied over 4 years in GMP villages and a similar number of children in NGM villages. The interventions were identical in the two sets of villages except for the use of growth charts in education in the 6 GMP villages. The nutrition worker in the NGM villages had the same contact time as in the GMP villages but advised mothers without the benefit of growth charts. The research team, independently of the nutrition worker, did anthropometric studies on children in all villages every 4 to 5 months. Comparisons were done by calculating monthly gains in stature, and weight, and the significance of differences observed was adjusted for age and sex. After 30 months of interventions, similar improvements in growth were seen in GMP and NGM children. The interventions seemed to have improved the nutritional status of young children in both groups of villages. In view of the lack of additional benefit from growth monitoring over other educational interventions, we question its use as part of child survival programmes in India.

Maternal risk factors associated with low birth weight

Maternal factors comprising of social, obstetric and anthropometric are found to influence LBW. The present study had found association between obstetric risk factors like age of the mother, parity and gravida with LBW. Similar association was also observed between maternal height, and maternal weight with LBW. However, social factors were not found to be associated with LBW. This could probably be due to RUHSA's intervention which requires a further inquiry.

F reticulocyte response in sickle cell anemia treated with recombinant human erythropoietin: a double-blind study

Studies on baboons and preliminary observations in three patients with sickle cell anemia (SS) suggested that high doses of pulse administered recombinant human erythropoietin (rHuEPO) stimulate F-reticulocyte production. We now report on the administration of rHuEPO in a double-blind format to ascertain frequency of response and potential precipitation of side effects. Ten patients were enrolled, but one was discontinued due to the indication of a blood transfusion. Of the other nine, five received rHuEPO in escalating doses (from 400 to 1,500 U per kg twice daily [BID] per week), alternating with a placebo, in blinded fashion. The second group, consisting of four patients, followed an identical protocol (except starting dose was 1,000 U/Kg, BID per week) and were iron supplemented during treatment. The criterion of response was a transient doubling (as a minimum) of the steady-state F-reticulocyte level. We found that none of the five patients in the first group responded to rHuEPO, and two of them became iron deficient, as judged by a significant decrease in ferritin. Of the second group, four patients responded with F-reticulocyte increases. In three patients, open label administration of rHuEPO confirmed the effect. We observed seven painful episodes during this study, two during the EPO administration and five during the placebo arm. Three patients were phlebotomized because the hemoglobin level increased 1.5 g/dL more than steady-state levels. Of the six patients followed-up by percent dense cell determinations, one exhibited increased levels during periods of the treatment, whereas the other five showed no change. No anti-rHuEPO antibodies were detected. We conclude that rHuEPO can stimulate F-reticulocyte response in some patients with sickle cell anemia, without apparent negative clinical side effects. The state of iron stores may be critical. Whether higher doses of rHuEPO and/or a different regimen might induce sustained F cells and fetal hemoglobin increases remains to be determined.