Predictors of outcome in fulminant hepatic failure in children

OBJECTIVE

To identify the predictors of outcome in fulminant hepatic failure (FHF) in children.

STUDY DESIGN

Prospective cohort study.

METHODS

41 children with FHF were studied. Patient characteristics and findings on examination at the time of hospitalization were noted. Serum biochemistry and screening for hepatotropic viruses (A, B and C) were done in each patient. Patients were treated using a predefined protocol and followed up till death or discharge. Univariate and multivariate analysis was done to find the predictors of outcome.

RESULTS

Hepatitis B was the commonest cause of FHF (11 children; 26.9%). Markers for hepatitis A and C viruses were present in one and two patients, respectively. Serology was negative in 27 children (65.9%), of whom two had history of ingestion of hepatotoxins (antitubercular drugs). The overall mortality was 61%. Irrespective of etiology, the following factors were associated with poor outcome on univariate analysis: presence of gastrointestinal (GI) hemorrhage, serum bilirubin more than 10 mg/dL, age 6 years or less, coma of grade 3 or more, presence of infection, prolongation of prothrombin time > 8 s over control, prothrombin concentration < 50%, hypoglycemia (blood glucose < 45 mg/dL), hyponatremia (serum sodium < 125 mEq/L) and hyperkalemia (serum potassium > 5.5 mEq/L). On multiple logistic regression analysis, presence of GI hemorrhage (p = 0.005), degree of coma (p = 0.02) and serum bilirubin level (p = 0.025) were identified as independent predictors of mortality.

Hemifacial microsomia

Congenital abnormalities of face emerge as a constellation of malformation of structures which arise from the first and the second branchial arch and the intervening first pharyngeal pouch and the primordia of the temporal bone. When fully expressed, a patient with hemifacial microsomia [Syn: otomandibular dysostosis] exhibits usually unilaterally under developed external or middle ear, mandible, zygoma, maxilla, temporal bone, facial muscles, muscles of masticiation. Many cases however, have been reported where the syndrom is not fully expressed (Crabb 1965).

Fractionation of mycobacterial integral membrane proteins by continuous elution SDS-PAGE reveals the immunodominance of low molecular weight subunits for human T cells

Integral membrane proteins (IMP) represent a serologically distinct class of mycobacterial antigens which are potent stimulators of human T cells (Mehrotra et al., Clin Exp Immunol 1995; 102:626). The range of IMP from Mycobacterium fortuitum was resolved by continuous elution SDS-PAGE to recover 31 discrete fractions covering bands up to approximately 58 kD. The fractions, after removal of SDS, were subjected to human T cell proliferation assays for the identification of immunodominant molecule(s). A low molecular weight (<20kD) fraction was able to stimulate T cells from 11 out of 12 donors comprising mainly tuberculoid leprosy patients. The described protocol is well suited to situations where large quantities of antigenic protein mixtures must be processed in order to get the purified molecules/fractions in amounts required for immunoepidemiological studies.

Methotrexate : Side effects and the role of folic acid supplementation in psoriasis - A study

In 50 patients of psoriasis, side effects observed with methotrexate pulse were studied. Folic acid ameliorated majority of the side effects without compromising with the therapeutic efficacy of methotrexate.

Favus in a non-endemic area

A typical case of favus of scalp in a 60-year-old female, resident of a village in district Udaipur (Rajasthan) is being reported for its rarity and occurrence in non-endemic zone. Some of the nails were also involved. Fungal hyphae were demonstrated in KOH examination from scalp and nails. Culture on Sabourauds agar medium grew Trichophyton violaceum.

Secondary fungal infections in chronic suppurative otitis media

A clinical, bacteriological and mycological study of 103 cases of 'safe' chronic suppurative otitis media with intractable otorrhoea was conducted to observe the role of fungi in the pathogenesis and perpetuation of the disease process. Mycotic otitis media was found in 42 cases (40.77%).45 patients with draining ears which grew pure bacterial growth were treated with ear drops. Fifteen of these patients were treated with topical antibiotics (polymyxin, Neomycin & Gramicidin). Other 15 patients were put on antibiotic steroid (Polymxin, Neomycin and Hydrocortisone) ear drops. The remaining 15 patients acted as controls with dry mopping treatment only.It was noted that prolonged exposure to antibiotic ear drops and antibiotic-steroid ear drops led to the growth of pathogenic fungi in 5 patients (33.33%) each from two study subgroups while the third control subgroup of 15 patients grew fungi of low virulence in 3 cases (20%).It was concluded that the routine and prolonged use of topical antibiotics or antibiotics-steroids in cases of wet 'safe' chronic suppurative otitis media, from the onset is not justified.

Thickening of peripheral nerves in neurofibromatosis

A 14-year-old boy presented with multiple asymptomatic swellings all over the body. Cutaneous findings were classical for neurofibromatosis. Interesting and unusual finding was generalised thickening of peripheral nerve trunks. Biopsy from thickened nerve had features of neurofibromatosis.

Host immune response in chlamydial cervicitis

In order to study host immune responses to Chlamydia trachomatis infection in patients with chlamydial cervicitis, lymphoproliferative responses to purified protein derivative (PPD) and Chlamydia trachomatis antigen (elementary bodies) were studied in 15 patients and 10 normal control subjects. A significant lymphoproliferation of peripheral blood mononuclear cells (PBMC) was obtained with PPD and C. trachomatis antigen (P < 0.001) as compared to unstimulated PBMC showing that antigen-reactive T-cells are present in patients. There was no significant difference in the lymphoproliferation response to C. trachomatis in patients as compared to control subjects suggesting that the cell-mediated immune (CMI) response in peripheral blood is not altered in chlamydial cervicitis. Inhibition of IL-2 production in cervical secretions ranged from 44 to 84% in patients with chlamydial cervicitis while supernatants derived from PBMC stimulated with PPD failed to show inhibition. However, there was no inhibition of IL-2 production in secretion or supernatants stimulated with PPD in control subjects, thereby showing that local cell-mediated immunity is impaired in patients. Significant C. trachomatis specific IgA antibodies, in cervical secretions, were present in only three of 15 patients. C. trachomatis specific IgG, IgM and IgA were detected in the serum of most patients, suggesting that serum antibodies do not confer immunity at the local site. We conclude that although circulating antigen-reactive T-cells are present in chlamydial cervicitis patients, absence of protective antibody as well as impairment of local cell-mediated immunity may be responsible for alteration of the mucosal defence mechanism against chlamydial infection.

A piebald family

Piebaldism is an uncommon congenital hypomelanotic disorder characterized by a white forelock and vitiligo like amelanotic macules. We report a family with piebaldism affecting four successive generations. The disease was present in 16 members of the family.

Low-dose intravenous diltiazem--efficacy and safety in supraventricular tachyarrhythmias

Intravenous diltiazem has been used to rapidly reduce ventricular rate in patients with supraventricular tachyarrhythmias (SVTs). This study assesses the efficacy and safety of a low-dose (0.1 mg/kg) intravenous bolus of diltiazem on the heart rate and blood pressure. Fifteen consecutive patients were treated for 21 episodes of atrial fibrillation, sinus tachycardia or ectopic atrial tachycardia. The bolus dose reduced the heart rate significantly in all patients with atrial fibrillation within 5 min (173 +/- 21 to 144 +/- 27 beats/min, p < 0.05) with the maximum response seen at 10 min (128 +/- 26.7 beats/min, p < 0.05). However, patients with sinus tachycardia showed a significant decrease in heart rate only at 15 min (147 +/- 12 to 123 +/- 15 beats/min, p < 0.05). One patient with ectopic atrial tachycardia required maintenance infusion of diltiazem. Conversion to sinus rhythm was observed in another patient with atrial fibrillation. The drug was well tolerated with no significant hypotension, bradyarrhythmia or aggravation of pre-existing congestive heart failure. It is concluded that Indian patients require a lower dose of intravenous diltiazem as compared to Western ones (0.1 mg/kg versus 0.25-0.33 mg/kg) which gives a prompt, effective and safe response in patients with SVTs.

Interaction of a rat intestinal brush border membrane glycoprotein with type-1 fimbriae of Salmonella typhimurium

Type-1 fimbriated Salmonella typhimurium was found to adhere to rat intestinal brush border membrane in a mannose sensitive manner. The maximum binding of the purified fimbriae observed with the rat illeal enterocytes was inhibited by 69.2% in presence of D-mannose. Brush border membrane from rat illeum was isolated, delipidified, solubilised and fractionated by affinity chromatography on type-1 fimbriae coupled Sepharose CL 4B column. Sodium dodecyl sulphate polyacrylamide gel electrophoresis of the material eluted from the column with D-mannose revealed a single band of molecular weight 60 kDa. The direct binding of this affinity eluted glycoprotein to the purified type-1 fimbriae was demonstrated by a modified Western blot experiment. Our findings suggest that the 60 kDa glycoprotein may serve as a receptor for the type-1 fimbriae in the rat intestinal brush border membrane and thereby may help in mediating bacterial adherence to the host epithelium.

Magnesium status and parenteral magnesium sulphate therapy in acute aluminum phosphide intoxication

The results of an open randomized study on magnesium status and parenteral magnesium sulphate therapy in acute aluminium phosphide intoxication are presented. The study was conducted on 105 patients divided into two group (I & II). Patients of Group I did not receive parenteral magnesium and acted as blank. Magnesium levels were monitored every 6 h for 24 h. Patients of group II received magnesium sulphate therapy. It was administered as 1.0 g (8.1 mEq or 4.05 mmol) magnesium sulphate dissolved in 100 ml of 5 per cent dextrose intravenously as a bolus dose followed by 1.0 g every hour for three successive hours, then 1.0 g every 6 h as a maintenance dose for the next 24 h as intravenous infusion in 5 per cent dextrose. The total dose of magnesium sulphate infused was 30.0 mmol over a period of 24 h (initial dose), then 16.0 mmol (4.0 g) daily till final outcome or a maximum of five days. All the vital parameters were monitored. All the patients were followed till final outcome. The resuscitation methods used were the same in both groups. At the end of the study, mortality rates were calculated in both groups. Hypomagnesaemia was observed as the constant finding in patients of Group I. It was transient and reversed itself without MgSO4. The mortality rate was 52 per cent. On the other hand, magnesium levels rose immediately after parenteral MgSO4 administration in patients of group II and they remained persistently above normal during the observed period.(ABSTRACT TRUNCATED AT 250 WORDS)

Purification and characterization of distinct type of mannose-sensitive fimbriae from Salmonella typhimurium

The fimbriae (E4) of a virulent strain of Salmonella typhimurium were purified by ion exchange chromatography in an FPLC system. They had a channelled appearance under transmission electron microscope and showed a major structural subunit of 17-kDa on sodium dodecyl sulphate-polyacrylamide gel electrophoresis. The purified fimbriae were found to agglutinate guinea pig erythrocytes, but this effect was inhibited in presence of D-mannose. Immune sera raised against the Mono-Q purified fimbriae (E4) showed cross-reactivity with the type-1 fimbriae (F1) composed of 21-kDa fimbrin subunit, purified by a different method from the same strain.