Hypomagnesemia in the ICU - Does Correction Matter?

BACKGROUND

Magnesium is a cation that is constantly being rediscovered. A number of studies have linked low magnesium levels to poor outcome of critically ill patients. Despite this hypomagnesemia continues to be under-recognized and uncorrected. There are no studies, in our knowledge, that have assessed the impact of correction of hypomagnesaemia on the outcome of the ICU patient.

AIMS AND OBJECTIVE

To determine the standard Mg levels in a healthy population sample and to correlate it with western data. To estimate the admission Mg levels in critically ill patients admitted to the ICU and to determine if routine correction of hypomagnesaemia altered their outcomes as compared with the retrospectively collected data of a similar group of patients admitted to the same ICU prior to the routine testing of Mg levels. This was an observational study carried out in the intensive care unit of a tertiary hospital in south India.

RESULTS

The mean serum magnesium in a sample of healthy Indian population was noted to be 2.112 mg/dl, which is consistent with that of the western data. Among the critically ill admitted to the medical ICU, the incidence of Hypomagnesemia (defined as serum Mg+2 of ≤1.7mg/dl on admission), was 23.96%. The study group in whom serum Magnesium was routinely corrected, showed a decrease in the mean total duration of icu stay (94.265 vs. 99.443 hours with p=0.78); the need for mechanical ventilation (52.08% vs. 65.625%) and the duration of Mechanical Ventilation (36.64 vs. 58.75 hours with p=0.04). Mortality was significantly higher in the comparison group (p=0.01) (39.6% vs. 22.9%).

CONCLUSIONS

The range of Magnesium levels in a healthy Indian population matches that of the west despite variations in diet and lifestyle. Routine screening and replacement of magnesium in critically ill patients with hypomagnesaemia resulted in reduction of morbidity and statistically significant reduction in overall ICU mortality.

Randomised controlled trial for efficacy of unfractionated heparin (UFH) versus low molecular weight heparin (LMWH) in thrombo-prophylaxis

OBJECTIVE

To study if low dose Unfractionated heparin (UFH) is as effective and safe as Low-molecular weight heparin (LMWH) and also economical as a prophylactic agent for venous thromboembolism in medically ill patients.

METHODOLOGY

A prospective double blind randomised controlled trial consisting of 92 patients fulfilling the inclusion criteria who were admitted to Bangalore Baptist Hospital, Bengaluru, between March 2008 and July 2009 were randomised to receive Unfractionated heparin (UFH) or Low-molecular weight heparin (LMWH).

RESULTS

The result based on intention to treat (ITT)analysis with best outcome scenario: in the UFH arm there were 47 (97.9%) patients who had not developed DVT/PE as compared to 42 (95.5%) in the LMWH arm. The difference in proportion of patients who had not developed DVT/PE between UFH and LMWH was 2.4% (-5.0, 9.8). The results based on per protocol analysis: In the UFH arm there were 44 (97.8%) patients who had not developed DVT/PE as compared to 39 (95.1%) in the LMWH arm. The difference in proportion of patients who had not developed DVT/PE between the UFH and LMWH arm was 2.7% (-5.2, 10.5). Patients on UFH had higher major bleeding complications 4 (8.9%) as compared to 0 in LMWH arm. But with respect to other complications like thrombocytopenia (HIT) and mild or minimal bleeding both arms were comparable.

CONCLUSION

This study has demonstrated that low dose UFH is as effective as LMWH as a prophylactic agent for venous thromboembolism in medically ill patients and economical also.

High or low- a trial of low dose anti snake venom in the treatment of poisonous snakebites

OBJECTIVE

To demonstrate that use of lower doses of anti-snake venom is as effective as high doses and is associated with less complications and lower mortality especially in the wake of rising cost of medical treatment, the people most affected by snakebites being the poor farmers.

METHODOLOGY

A prospective descriptive study consisting of 54 snakebite patients fulfilling the inclusion criteria who were admitted to Bangalore Baptist Hospital, Bengaluru, between November 2006 and November 2008 and were treated with a low dose ASV regime. The patients were initially given 2 vials of ASV followed later with 1 vial at a time according to clotting time. Any other supportive measures were undertaken as necessary.

RESULTS

In this study the average dose of ASV required was only 6.70 +/- 3.24 vials. The complications--12.9% patients had ARF, and another 12.9% patients had neuropraralysis severe enough to require ventilatory support. There were 2 deaths (mortality of 3.7%) in the study.

CONCLUSION

Low dose ASV regime in poisonous snakebites along with supportive treatment as necessary is as good as high dose regime, and has lesser adverse effects while reducing the cost of treatment too. Hence low dose regime can be used with beneficial results in poisonous snakebites.

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.

A comparative study on idiopathic pulmonary fibrosis and secondary diffuse parenchymal lung disease

BACKGROUND AND AIMS

Clinical characteristics of patients diagnosed to have Diffuse parenchymal lung disease (DPLD) were evaluated in this study.

DESIGN AND SETTING

Retrospective evaluation, a tertiary care center in South India.

MATERIAL AND METHOD

Subjects diagnosed to have DPLD over a five-year period were included in this study. Data pertained to clinical characteristics and lab parameters were obtained. STATISTICAL CONSIDERATIONS: t- test for Mean values and chi-square test for comparing proportions were used.

RESULTS

There were 73 eligible patients included for evaluation. Secondary cause for DPLD was diagnosed in 40 (55%) and idiopathic pulmonary fibrosis (IPF) was diagnosed in 33 (45%). The mean age was 45+/-11 and 53+/-10 years, of these 5 (12%) and 17 (52%) were male subjects in the secondary DPLD and IPF group respectively. The mean age, dyspnoea, cough, clubbing and crepitations were noted to be higher in patients with IPF as compared to patients with secondary DPLD. Fifty patients were followed up for a mean of 13 months (28 secondary DPLD and 18 IPF). Follow up data was available in 46 patients. Of these subjects prednisone alone was initiated in 24 subjects and combination with azathioprine in 22. Subjective improvement in symptoms was noted in 29/46 (63%), 19 with secondary DPLD and 10 with IPF.

CONCLUSION

symptoms and signs were noted more frequently with IPF, subjective improvement to treatment was noted in 63% and the best response was noted among patients diagnosed to have sarcoidosis. A prospective trial is needed to study the long term prognosis and therapeutic response among Indian patients.

Drug resistant tuberculosis in diabetes mellitus: a retrospective study from south India

This study was conducted in a tertiary care teaching hospital in south India to evaluate the association of drug resistant tuberculosis (TB) in diabetic subjects. There were: 361 subjects with positive mycobacterial culture and susceptibility tests results over a 3-year period; 267 (74%) acid-fast bacillus smear positive; and 94 (26%) smear negative cases. One hundred and seventy-seven (49%) had resistant isolates to any one first line antiTB drugs (resistant group) and 184 (51%) had isolates sensitive to all drugs (non-resistant group). In the resistant and non-resistant subjects the mean duration of TB symptoms was, respectively, 22 months and 4.5 months, past history of TB 126 (71%) and 48 (26%), past antiTB drug therapy 126 (71%) and 47 (25%), inadequate anti TB drug therapy 42 (24%) and 23 (13%), HIV positive six and 13 subjects. There were 72 diabetic subjects [35 and 37, respectively] with a duration of diabetes 5.8 +/- 7.5 years and 3.7 +/- 5.0 years in the resistant and non-resistant groups. Twenty-six per cent of the diabetic subjects (19/72) had multi-drug resistantTB. Drug resistance to first line anti-TB drugs was not found to be associated with diagnosis or duration of diabetes mellitus.

Clinical characteristics and treatment response among patients with multidrug-resistant tuberculosis: a retrospective study

BACKGROUND

This retrospective study was conducted to evaluate the characteristics and therapeutic response among patients with multidrug-resistant tuberculosis (MDR TB).

METHODS

One hundred subjects with isolates resistant to isoniazid and rifampicin were included over a three-year period (1997-1999). There were 82% males with a mean age of 36 years, mean duration of symptoms of 29 months, and a previous history of tuberculosis in 85% (pulmonary 96% and extrapulmonary 4%).

RESULTS

HIV ELISA test was positive in two out of 28 (7%) patients while diabetes was diagnosed in 16 percent. Mean time to diagnose MDR TB was 5.5 months. Subjects had received a mean of 3.2 anti-TB drugs before the diagnosis of MDR TB was made. Forty-five patients were lost to follow-up. The rest had a median follow-up of 13.5 months (range 1-37 months). Follow-up AFB smear and culture results were available in 49 out of 55 and 26 out of 55 patients, respectively. Sputum smear became negative for AFB in 26 out of 49 (53%) and culture converison occurred in 16 out of 26 (61.5%) patients. Clinical and radiological response was noted in 31 (56%) and 13 (32.5%) out of 40 patients respectively. A mean of 5.5 drugs was used in those who achieved sputum conversion. Combination therapy containing ofloxacin in the regimen was noted to have a favourable response.

CONCLUSION

Only a limited number of patients with MDR tuberculosis have a favourable response.

Prevalence of bronchial asthma among bank employees of Vellore using questionnaire-based data

Asthma and related allergic disorders are reported to be rare in poor and developing countries and their prevalence is expected to rise with urbanisation. Investigation was carried to see the prevalence of asthma and asthma-related symptoms by using a simple questionnaire-based data collection. One hundred and twenty bank employees were studied in the age group 25-55 years in 4 centres of Vellore town. A one-page questionnaire in English regarding asthma and allergic symptoms was used to assess the prevalence and the details of medical care utilisation by those who were asthmatics. The prevalence of self-reported bronchial asthma was 8.3% and that of asthma-related symptoms 15.8%. A significant number of subjects with symptoms suggestive of asthma self-reported themselves as non-asthmatic. There was a significant association between those who had symptoms of asthma and a positive family history of asthma. Most of the asthmatic subjects using allopathic medicines reported a poor quality of life, despite treatment. The prevalence of asthma in Vellore town is more than that reported in other studies carried out at different centres in India. The prevalence may actually be higher since a significant number of subjects with symptoms suggestive of asthma reported themselves as non-asthmatic subjects. As expected, positive family history was forthcoming in subjects with asthma symptoms. Most asthmatic subjects have not experienced a significant improvement in their quality of life, which could indicate sub-optimal management. These findings can form the basis for further studies to investigate factors that lead to these variations.

Abdominal tuberculosis affecting lesser omentum

We present a case of a young man who presented with fever and nonspecific epigastric symptoms and fluid collection in the lesser omental sac, which was proved to be of tubercular etiology.

Serological evidence for the continued presence of human rickettsioses in southern India

Rickettsiosis is generally believed to have disappeared from many parts of India. However, the serological testing of 37 residents of southern India who presented with fever of unknown aetiology in 1996-1998 confirmed that spotted fever, epidemic/endemic typhus and scrub typhus continue to occur in southern India. The epidemiology and magnitude of the problem need to be evaluated.

A study on clinical profile of falciparum malaria in a tertiary care hospital in south India

Malaria continues to be a major problem in tropical countries. To study the clinical features and complications of malaria in a tertiary care hospital in south India, records of 183 patients were analysed. Among 86 patients with P. falciparum and mixed infection, 24 (28 per cent) had cerebral malaria and 32 (37 per cent) had hyperbilirubinemia. Twenty-three out of 32 (72 per cent) patients with jaundice had direct hyperbilirubinemia and elevated liver enzymes suggesting hepatocellular damage. Mortality of the order of 10 per cent was seen only in P. falciparum malaria. High incidence of hepatic involvement and hepatorenal failure were the unusual features observed in the study.

Enthesopathy: clinical recognition and significance

Enthesopathy is a common clinical finding denoting pathology at the 'entheses', i.e. attachment sites of muscles, tendons, joint capsules, ligaments and fascia to the bone. Inflammatory enthesopathy or enthesitis is a sine qua non of seronegative spondyloarthropathies (SSA). It can also be occupational, metabolic, drug induced, infective or degenerative. Bursitis closely mimics enthesitis. Ultrasound with high frequency transducers is a simple, cost-effective and feasible test to detect enthesopathy which is amenable to treatment with local steroid injections, physiotherapy and non-steroidal anti-inflammatory drugs, in addition to treatment of the primary disease. Unrecognized and untreated, it can lead to considerable morbidity.

Pulmonary nocardiosis in human immunodeficiency virus infection: a tuberculosis mimic

Patients with human immunodeficiency virus (HIV) infection are prone to develop pulmonary infections like nocardiosis. It is often misdiagnosed as pulmonary tuberculosis since the manifestations are similar. A twenty-seven years old male presented with fever, cough with expectoration and weight loss for two months. Chest radiograph showed opacity in the right mid zones. Sputum smears were negative for acid fast bacilli (AFB) and revealed gram positive branching filamentous organisms resembling Nocardia species. Subsequently, Nocardia was grown on sputum culture. HIV antibody was positive by ELISA test. He was treated with co-trimoxazole. If sputum is repeatedly tested negative for AFB in the setting of radiological suspicion of tuberculosis, testing for Nocardia species should be considered in the HIV-infected patients.

Unusual association of Kikuchi's disease and dengue virus infection evolving into systemic lupus erythematosus

Kikuchi's disease is a histologically alarming self-limiting condition typically affecting the lymph nodes of young females. A 13-year-old girl was presented with fever, skin rash and cervical lymphadenopathy. On examination she was found febrile, mild pallor was present and she had lymphadenopathy. Liver was palpable. Cervical lymph node biopsy showed histiocytic necrotising lymphadenitis (Kikuchi's disease). Dengue virus serology for IgG blot showed evidence of seroconversion in serial samples. She was treated with antibiotics and fluconazole and cyclosporin A. During hospitalisation she developed retinal vasculitis. She was reviewed after one month and showed rashes of subacute cutaneous lupus erythematosus. This case can be described to be a triggering event by dengue viral infection causing abnormal immune response leading initially to Kikuchi's disease and later on to systemic lupus erythematosus.

Organic insecticides

Organic insecticide poisoning continues to be a major health problem not only in the developing communities but also in the Western population. The insecticides commonly used are the organophosphates, organocarbamates, organochlorides and pyrethroids. Patients with organic insecticide poisoning present with a spectrum of manifestations ranging from gastrointestinal symptoms of nausea, vomiting and diarrhoea to severe neurological manifestations of fasciculations, seizures and neuromuscular weakness and paralysis or cardiac manifestations of arrhythmias and conduction disturbances. A strong clinical suspicion is necessary to make an early diagnosis of insecticide poisoning. Treatment is primarily supportive and includes decontamination, protection of airways and cardiac and respiratory monitoring. Specific therapy for organophosphates and organocarbamates includes the use of anticholinergics. The use of oximes, especially high dose, is controversial and may be associated with a higher mortality rate. Low-dose oximes given early in the course of the illness may be beneficial. This paper reviews the literature on organic insecticide poisoning worldwide.

Randomized controlled trial on the effective dose of anti-snake venom in cases of snake bite with systemic envenomation

Snake bite is the common cause of morbidity and mortality in India. Snake antivenom, although very effective, is expensive, scarce, and associated with side effects. The conventional dose may not be required in all cases and a smaller dose may be as effective. A randomized double blind controlled trial was conducted to compare the effect of lower versus the conventional (high) dose. Patients presenting within 24 hours of snake bite with hematological or neurological evidence of systemic envenomation were included in the study. Patients were randomized either to receive high dose (2 vials over 1 hour, followed by 2 vials over 4 hours and repeated 4 hourly until clotting parameters normalized and then 2 vials as infusion over 24 hours) or low dose (2 vials over 1 hour, followed by 1 vial over four hours, repeated 4 hourly until clotting parameters were normalized and then 1 vial as an infusion over 24 hours). Thirty one patients received high dose and 29 a low dose. The mean dose of antivenom used was significantly different in the two groups (8.9 and 4.7, respectively). There was no mortality. The duration of stay was 4.94 and 3.48 days, respectively. There was no difference in the transfusion, dialysis or ventilation requirement of the two groups. Low dose regimen is more effective and required 5 vials less than the conventional dose. Each vial costs Rs. 200, so the estimated savings is Rs. 1000 per patient.

A randomised control trial on sequential drug monotherapy versus conventional step care therapy in the treatment of mild to moderate hypertension

OBJECTIVES

There are many studies in the literature on single drug therapy (monotherapy) for mild to moderate hypertension. These studies show comparable efficacy, side effect profile and compliance. It has not been shown yet, whether the number of patients controlled on monotherapy can be improved by systematically stopping a drug which does not adequately control blood pressure and starting another drug in a sequential manner until blood pressure is well controlled. The aim is to show that sequential drug monotherapy (SDM) is as good as step care therapy (SCT) in controlling mild to moderate hypertension.

METHODS

Patients attending three medical outpatient departments of Christian Medical College and Hospital, with mild to moderate hypertension uncontrolled on single drug therapy formed the patient population. They were then randomised to the sequential drug monotherapy or step care therapy. The choice of one of the five antihypertensive drugs was left to the attending physician.

RESULTS

Thirty two and 42 patients entered the study and 28 and 35 completed the study in SCT and SDM group, respectively. Follow up was for a period of three months. BP was controlled 100% each in SCT and SDM groups. Efficacy with intention to treat was 85.2% in SCT and 81.8% in SDM group. Percent controlled with second drug was 82 and 71, controlled with third drug was 18 and 14 in SCT and SDM, respectively. Mean duration of treatment for control for BP was 1.7 and 2.3 months in SCT and SDM groups respectively. Average cost in SCT was Rs 66.28 and in SDM was Rs 45.53 per month (p = 0.005). Incidence of ADR was 28.6% and 10.5% in SCT and SDM groups, respectively (p = 0.06).

CONCLUSIONS

SDM is as effective as SCT, SDM offers the following advantages: less expensive, better compliance, fewer complications, drug interaction and thus improved quality of life.

Post lumbar puncture headache: is bed rest essential?

Headache following lumbar puncture is a well known and well described complication. Various manoeuvres have been tried to prevent post lumbar puncture headache--the commonest being bed rest for 4 to 24 hours following lumbar puncture, though its value is questionable. Randomised controlled clinical trial was done to evaluate the effect of 24 hours bed rest on the incidence and severity of post lumbar puncture headaches. Two hundred and eight patients were randomly allocated to either the ambulant or the bed rest group. Patients were interviewed by a single investigator on days 0, 1, 2 and 7 about the presence and nature of headache. Other relevant clinical and laboratory data pertaining to the lumbar puncture was collected. The overall incidence of post lumbar puncture headache was 17%; 15% in the ambulant and 18% in the bed rest group. Of the patients who had headaches, severe headache was observed in 57% in the ambulant and 12% in the bed rest group (p = 0.02). Other variables did not alter the outcome of headaches. Bed rest does not appear to alter the incidence of post lumbar puncture headaches, but reduces the severity in those who get headaches, after a lumbar puncture.

A randomized double-blind sham-controlled study of intrathecal human anti-tetanus immunoglobulin in the management of tetanus

BACKGROUND

Tetanus is a major cause of mortality and morbidity in developing countries. Various modalities of treatment to prevent progression of the disease and alter its outcome have been tried. This study was designed to evaluate the role of intrathecal human anti-tetanus immunoglobulin (TIG) in the management of tetanus.

METHODS

Thirty-six adult patients presenting to an university-affiliated teaching hospital were stratified based on the severity of disease into mild and severe disease, and subsequently randomly allocated to receive either 250 i.u. of TIG intrathecally or a sham procedure mimicking the lumbar puncture.

RESULTS

In mild tetanus, TIG administration significantly retarded the rate of progression (p = 0.05), reduced the duration of hospital (p = 0.01) and intensive care unit stay (p = 0.05), need for tracheostomies (p = 0.03) and the dose of sedatives required for control of spasms (p = 0.01). In mild tetanus, the mortality rates were 20% and 30% in the treated and control groups, respectively.

CONCLUSION

We suggest that TIG is useful in reducing the morbidity, progression of disease and mortality in patients presenting with mild tetanus.

Blind pleural biopsy using a Tru-cut needle in moderate to large pleural effusion--an experience

BACKGROUND

Pleural biopsy is invaluable for the etiological diagnosis of pleural diseases in the presence of an exudative pleural effusion. Conventionally, pleural biopsy is either performed with the Cope's or the Abrams pleural biopsy needles. A few investigators have used the Tru-cut biopsy needle with or without ultrasound guidance. We report our experience in performing closed pleural biopsy using a Tru-cut needle without ultrasound guidance in moderate to large exudative pleural effusion. We used a perpendicular approach to biopsy the pleura instead of the tangential approach described earlier.

METHODS

Closed Tru-cut biopsy was performed in 27 consecutive patients with exudative pleural effusion who volunteered to undergo the procedure. The biopsy specimen was sent for histopathology. Pleural fluid analysis and other relevant investigations required to obtain a specific diagnosis were carried out.

RESULTS

A specific diagnosis of tuberculosis was obtained on histopathology of pleural tissue in 12 out of 16 patients (diagnostic yield 75%) and in 5 out of 7 patients with malignancy (diagnostic yield 71%). Among the other 4 patients, other causes of exudative pleural effusion were detected in 3 and in 1 patient, no specific diagnosis could be made, despite extensive investigation.

CONCLUSION

Closed pleural biopsy using a Tru-cut needle is effective for the specific diagnosis of exudative pleural effusion. The use of a perpendicular approach to biopsy the pleura does not seem to increase the complication in moderate to large pleural effusion.

Predictors of mortality in a medical intensive care unit

BACKGROUND

Scoring systems to predict mortality in intensive care units have been developed in western populations. There is a need to identify and validate prognostic variables in the Indian context. We compared two scoring systems to predict the discharge outcome in patients admitted to a medical intensive care unit.

METHODS

Five hundred patients admitted to a medical intensive care unit were studied prospectively. Modified acute physiology and chronic health evaluation II (APACHE II) score and modified organ system failure (OSF) score were applied on the day of admission to the intensive care unit. The scores obtained by the two systems were compared using the area under the curve approach. The likelihood ratios were calculated for predicting discharge outcome.

RESULTS

The modified OSF score predicted discharge outcome better than the modified APACHE II score--receiver operating characteristic curve area (standard error-area) 0.7062 (0.0244) and 0.6068 (0.0267) for the modified OSF and the modified APACHE II scores, respectively. This was statistically significant (p < 0.001). The likelihood ratio for the modified OSF score for different cut-off points varied from 0.27 to 5.49, while the likelihood ratio for the modified APACHE II score varied from 0.11 to 2.08. This means that for an intensive care unit with a 30% overall mortality, the modified OSF score could separate patients with 10% to 70% mortality, while the modified APACHE II score could predict only 5% to 47% mortality.

CONCLUSION

The modified OSF score was superior to the modified APACHE II score in predicting mortality in patients admitted to the medical intensive care unit.

Measuring the impact of focused workshops on rational drug use

Rational drug use workshops were conducted in various centres in India. The effects of these workshops on some of the indicators for rational drug use are discussed. An evaluation based on responses to questionnaires does not permit the measurement of the effects on practice changes, and only perceived changes by the respondents are indicated. Within the short period of evaluation, drug use skills and awareness about various aspects of rational drug use are perceived to have improved. There is a need to re-emphasize through personal interaction and workshops the concept of rational drug use.

Epidemiological features of acquired immunodeficiency syndrome in southern India

AIDS was diagnosed in 187 men and 24 women (M:F = 8:1) from April 1987 till December 1994 at the Christian Medical College Hospital, Vellore. The doubling time of the occurrence of AIDS cases was 14 months; during 1987-90 there were an average of 5.7 cases per year; in 1991-93 there were 28 per year; in 1994 there were 104 cases. The mean age of patients was 33 yr for men and 31 for women. Among men, the primary mode of infection was heterosexual contact with female commercial sex workers. Among women, the most common source of infection was their husbands. There were 4 bisexuals and one homosexual subject who might have acquired infection by having sex with other men. There were 135 subjects from urban and 76 from rural communities. Most subjects belonged to the lower socio-economic classes. These data show that HIV infection had been very widespread in this region, both urban and rural.

Drug interaction: rifampicin and glibenclamide

BACKGROUND

Rifampicin is a potent inducer of the hepatic microsomal enzyme system. However, the drug has been shown to cause clinically important interactions with many drugs. This study was designed to test the interaction of rifampicin with the oral hypoglycaemic agent glibenclamide.

METHODS

Twenty-nine well-controlled diabetic patients on a combination therapy of diet and glibenclamide, and willing to participate in the trial, received a daily dose of 450 mg (body weight < 50 kg) or 600 mg (body-weight > 50kg) of rifampicin for 10 days.

RESULTS

There was a significant (p < 0.001) worsening of fasting and post-prandial blood sugar after administration of rifampicin. Dose modification of glibenclamide was required in 15 of the 17 patients in whom the diabetes became uncontrolled. Blood sugar normalized by day 6 after stopping rifampicin in all patients.

CONCLUSION

Rifampicin and glibenclamide interact. Therefore, necessary dose modifications should be made in order to achieve euglycaemia if these two drugs are given together.

Evaluation of two treatment regimens of pralidoxime (1 gm single bolus dose vs 12 gm infusion) in the management of organophosphorus poisoning

Organophosphorus (OP) poisoning is most frequently encountered among our community. Treatment of poisoning is primarily aimed at reversing the effects of the compound by administration of atropine. Oximes have been shown to be efficacious in case reports. The dose of this drug in these reports varies from 1 gm which is a very low dose and physiologically no dose, to doses upto 16 gm. This is also a very expensive imported drug which causes the nation considerable loss of foreign exchange. We report our experience with the use of two treatment regimens of Pralidoxime (P2AM) in the management of patients with OP poisoning in a prospective trial. Seventy-two adult patients presenting to a large university affiliated teaching institution with a history of consumption of OP compounds and requiring intensive care were entered into the trial. Patients were randomized using a block randomisation to receive either a single bolus dose of 1 gm P2AM at admission (Low dose group) followed by placebo infusion over the next 4 days or a single placebo bolus at admission followed by P2AM 12 gm as a continuous infusion over the next 4 days. Outcome measures analyzed were mortality, duration of ICU stay, need for ventilation and duration of ventilation, time to recovery of consciousness, development of intermediate syndrome and infections. A higher prevalence of intermediate syndrome (p = 0.08) was observed in the high dose group. Ventilatory requirement was also more in the high dose group (p = 0.09). Since this was an equivalence study designed to show that the low dose was as effective as the high dose, these results attain greater significance as the low dose group fared better than the high dose group, even though the pre-test hypothesis was in the reverse direction. Subgroup analysis of patients who received at least 1 gm of P2AM within 12 hours of ingestion of the OP poison with those who received P2AM after 12 hours, showed that there was a significant reduction of intermediate syndrome (p = 0.05) but no significant difference was noted in number ventilated. High dose P2AM infusion has no role in the routine management of patients with OP poisoning. These results also suggest that the time of administration of P2AM after the ingestion of the poison mabe a crucial factor which determines response to therapy. A prospective double blind placebo controlled trial is now justified in the light of the above findings.

Cost-effectiveness of inhaled beta-agonists v. oral salbutamol in asthma: a randomized double-blind cross-over study

BACKGROUND

Oral beta-stimulants are widely used in the management of chronic asthma in India, in spite of evidence suggesting the superiority of inhaled medication in achieving maximum bronchodilatation. An economic evaluation was performed in a randomized double-blind cross-over trial to evaluate the role of adjuvant oral beta-stimulants in the treatment of asthma.

METHODS

Patients who had seasonal or perennial asthma and were using metered dose inhalers for control of symptoms were randomly selected for the study. They received either 4 mg of oral salbutamol or placebo as adjuvant treatment. During the study they controlled their symptoms by adjusting the dose of the inhaler medication. A cost minimization technique was used to assess the economic impact of this intervention in the treatment and control periods. A sensitivity analysis was performed to assess the robustness of the conclusions.

RESULTS

The mean cost was significantly greater in the treatment period and a patient lost approximately Rs 20 per month (CI: 13 to 27; p = 0.001) as a result of the adjuvant treatment. There was no significant difference in the quality of life or peak expiratory flow rate during the two periods. The patients also noted mild but significantly increased tremors (p = 0.01) and palpitations (p = 0.001) during the treatment period. There was no treatment-to-period interaction.

CONCLUSION

Adjuvant oral beta-agonists do not improve the quality of life or bronchodilatation in asthmatics using an inhaled beta-agonist for control of symptoms.

Hyponatraemia and hiccups

BACKGROUND

Hiccups are observed in many patients with hypohatraemia. We performed a case-control study to evaluate their association in a referral teaching hospital in South India.

METHODS

Fifty consecutive patients who developed hiccups during an 18-month period were studied. They were categorized according to age group and diagnosis and controls matched for age and sex were selected from patients admitted on the same day in the medical wards. Hiccups were graded on a four-point severity scale at recruitment and every day till day 7 or till hiccups subsided.

RESULTS

The step-wise logistic regression analysis done to establish independent association showed that for every 10 mEq/L reduction in serum sodium, patients were 17 times (p = 0.001; confidence interval: 4-87) at risk of developing hiccups. The only other significant determinant of the symptom was the diagnostic category of renal failure (odds ratio = 128; confidence interval: 1-1420). The number of patients who had hyponatraemia with varying severity of hiccups showed a dose-response relationship. The crude odds ratios were 7, 58 and 320 for mild, moderate and severe hiccups.

CONCLUSION

There is a strong and independent association between hyponatraemia and hiccups in hospitalized patients. A causative association is suggested by the dose-response relationship demonstrated in the study. In many hospitals in developing countries where measurement of serum sodium is difficult and unreliable, it is important to be aware of this association since it can be easily corrected.

Outcomes in the Guillain Barre syndrome: the role of steroids

Guillain-Barre Syndrome (GBS) is one of the commonest demyelinating diseases of the peripheral nervous system. This retrospective cohort study reports the outcomes of 97 patients in a large teaching hospital in South India. Fifty patients were treated with steroids and 47 had no steroids. Twenty one of the 41 evaluable patients in the steroid group had functional improvement at discharge as compared to 20 of 42 evaluable patients in the non-steroid group. Six patients in each group had worsening of their weakness. Steroids did not show any significant beneficial effect in either improving the disability scores at discharge (steroid-0.42 vs. non-steroid-0.29) or in reducing the duration of ICU stay (4 vs. 8 median days). A higher proportion of patients on steroids developed complications (p = 0.02). The median duration of hospital stay was 16 days in the steroid group as opposed to 14 days in the group not treated with steroids. The mortality was 6 in the steroid treated group and 5 in the non-steroid group. Steroids have no significant benefit on the outcome of GBS.

Study on the effectiveness of enalapril as a monotherapy in mild to moderate hypertension

This study highlights our experience with 53 patients with mild to moderate hypertension who had monotherapy with Enalapril, one of the newer Angiotensin Converting Enzyme inhibitors. Enalapril was found to be effective in controlling blood pressure in 41 patients (77%). In 12 patients (23%) addition of one more drug was necessary for control of hypertension. Side effects were noted in 9 patients (17%). In two patients the adverse reactions were severe enough to warrant withdrawal of the drug.

Comparison of disease-specific and a generic quality of life measure in patients with bronchial asthma

BACKGROUND

Quality of life is being increasingly recognized as an important outcome in chronic and terminal illnesses. There are few publications from India on the characteristics of the instrument that measures quality of life in clinical trials. We describe a method for choosing an appropriate instrument in a randomized trial.

METHODS

We selected thirty-two patients with bronchial asthma randomly and evaluated them to compare the validity and responsiveness of the disease-specific quality of life instrument in asthma (AQL) and the generic quality of life instrument, 'Sickness impact profile' (SIP), to detect changes in their health status. Validity was determined by a priori constructs (construct validation) and the responsive coefficient was calculated by determining the relationship to the 'minimal significant change in asthma score' and the 'variability' seen in this change in stable patients.

RESULTS

The constructs used in validating the scores were that the change in quality of life score would correlate (i) highly with change in self-assessment of the disease (r > 0.7), (ii) moderately with change in physician assessment of the disease (r > 0.5), and (iii) minimally with change in peak flow reading (r > 0.3). We found both instruments to have good construct validity. The responsiveness coefficients noted for AQL and SIP were 1.8 (CI 0.65-3) and 0.7 (CI 0.3-1.2), respectively.

CONCLUSIONS

Though both AQL and SIP were valid measures of quality of life, AQL is likely to be more capable of detecting smaller changes in the health status of patients with bronchial asthma and hence was chosen as the instrument in the proposed clinical trial.

Significance of Salmonella typhi bacteriuria

Bacteriuria due to Salmonella typhi usually occurs following recent typhoid fever or in chronic carrier states. Data from 18 patients with S. typhi bacteriuria, seen during 5 years, were analyzed. Fourteen patients had localized urinary tract infection due to S. typhi. Four others had bacteriuria, probably associated with typhoid fever. Localized abnormalities of the urinary tract and kidneys and also systemic diseases were found to predispose patients to S. typhi bacteriuria. Local abnormalities encountered included urolithiasis (n = 3), prostatic hypertrophy (n = 1), and tuberculosis (n = 1). One renal transplant recipient and another with lupus nephritis had S. typhi bacteriuria. One had associated strongyloidosis, and another was pregnant.

Incidence of intermediate syndrome in organophosphorous poisoning

Seventy two patients admitted to the Intensive Care Unit following ingestion of organophosphorus compounds were studied prospectively with two different doses of pralidoxime (PAM). One group received 1 gm immediately after admission and no further PAM and the other group received infusion of PAM, 1 gm 8 hourly for four days (total 12 gms). The incidence of type II paralysis or intermediate syndrome was 47%. We observed a higher incidence in the 4 days of infusion of PAM group (61%) (20 patients) as compared to the single Bolus dose group (39%) (13 patients). Relative risk 1.48 (confidence interval = 0.9-2.4).

Osteomalacia--fifty five patients seen in a teaching institution over a 4 year period

A retrospective analysis of 55 cases of osteomalacia shows that poor calcium intake and poor sunlight exposure are the most common causes for osteomalacia. However, in patients with normal nutritional history, other disorders such as renal tubular acidosis and tumour induced osteomalacia should be looked for. A careful drug history, particularly anticonvulsant use is essential. In 4 patients there was an association between anti-tuberculous drug use and osteomalacia. Further prospective studies are needed to determine the relationship between Rifamicin use and osteomalacia.

Hyperprolactinemia in women--a series of 71 cases

Seventy one cases of hyperproloactinemia (HPRL) in women were seen over five years. Of these, twenty five had pituitary tumors, thirty three had functional HPRL, five had drug induced HPRL and four had hypothyroidism. Surgery was undertaken in fifteen women, rest were treated with bromocriptine. There were thirteen pregnancies in patients with tumor after treatment. Seven of thirty three patients with functional HPRL conceived. No patient had tumor expansion or recurrence during pregnancy. Bromocriptine was required for most patients.

Primary hyperaldosteronism--diagnostic approach and management

Primary hyperaldosteronism was detected in 1% of patients evaluated for secondary hypertension in a referral hospital in Southern India. The presence of hypokalemia with inappropriate kaliuresis (24 hr. urine K > 20mEq) was an important diagnostic clue. High resolution CT scans were found to be useful for localising the tumour. Preoperatively nifedipine and spironolactone were employed to correct hypertension and hypokalemia. The same drugs were also found to be excellent for long-term control of hypertension and hypokalemia in patients who had bilateral adrenal hyperplasia and aldosteronism.