Contact Tracing of Healthcare Workers Exposed to COVID-19 Infection in a Tertiary-Care Hospital: Containing the Contagion

Introduction

Healthcare workers (HCWs) are at higher risk of getting infected with COVID-19 infection due to their close proximity to COVID-19-positive patients. We studied the risk stratification and positivity rate in HCWs at risk of getting COVID-19 infection as well as the possible factors responsible for their being at risk of COVID-19 infection during the study period.

Material and Methods

This prospective study was conducted after approval by the institutional ethics committee. The data regarding demographic variables, risk stratification, COVID-19 (reverse-transcription polymerase chain reaction) report, and possible sources of exposure for HCWs were recorded in a proforma by personal/telephonic interviews as well as from hospital records from March 2020 to June 2021. The data generated were entered into Microsoft Excel® software and analyzed using percentages, proportions, and Chi-square tests for qualitative variables.

Results

COVID-19 infection's positivity rate was 19.5% among high-risk and 0.6% among low-risk HCW contacts. HCWs working in non-COVID-19 areas (67.9%) were more at risk than those working in COVID-19 areas (32.1%). In contrast, the COVID-19 positivity rate was significantly higher among high-risk contact HCWs from COVID-19 areas (34.2%) than in non-COVID-19 areas (12.6%). The maximum COVID-19 positivity rate was seen in high-risk contacts with body fluid exposure (21%), performing aerosol-generating procedures (20%), and close exposure in operation theaters (18%).

Conclusions

Risk stratification is an important tool to contain infection among HCWs who had unprotected close contact with a COVID-19-positive case. With appropriate contact tracing, we were able to avoid over- and under-quarantine, save many man-hours as well as contain the spread of infection. HCWs should not only wear appropriate personal protective equipment (PPE) during work hours but should also practice mask-wearing and social distancing while they are in the community.

Impact of long duration wearing of N95 masks on cardiorespiratory system and subjective sensations of health-care workers during COVID-19 era

Background and Aims

N95 mask being an essential element of personal protective equipment to be worn by health-care workers (HCWs) may lead to adverse effects and physiological stress as HCWs have to wear it for prolonged hours. Therefore, we planned to conduct a study in our intensive care unit staff to look for the effects of N95 masks on their health as well as to plan recommendations to ease them.

Material and Methods

We conducted this study on our intensive care unit nursing staff and HCWs. We noted their oxygen saturation and heart rate at baseline as well as after 1 h, 2 h, 3 h, and 6 h of duty along with their subjective sensations. Institutional ethical clearance for the same was taken. Collected data were entered in MS Excel database and analyzed using SPSS version 20.0. Fisher's Z test was applied for comparing proportion and analysis of variance for comparing two means.

Results

One hundred and nine HCWs participated in this, out of which 93 (85.3%) were females and 16 (14.7%) were males. Eighty-four (77.1%) participants were below 40 years. Twenty-three participants (21.1%) were overweight and 37 (33.9%) were obese. There was no significant drop in saturation and rise in heart rate during these hours.

Conclusions

On comparing subjective sensations of HCWs, our study found that feeling of uneasiness was found more in less than 40 years age group as compared to more than 40 years. N95 masks were found to have no impact on cardiovascular system and do not lead to hypoxia while working routinely even for prolonged hours.

Prevalence, overlap, and risk factors for Rome IV functional gastrointestinal disorders among college students in northern India

BACKGROUND/PURPOSE

There is scarcity of data on prevalence, overlap, and risk factors for functional gastrointestinal disorders (FGID) by Rome IV criteria. We evaluated these factors among medical, nursing, and humanities students.

METHODS

Rome IV Diagnostic Questionnaire (for all FGIDs), Rome III questionnaire (for irritable bowel syndrome [IBS], functional diarrhea [FDr], and functional constipation [FC]), and questionnaires assessing demography, physical activity, anxiety, and depression were used.

RESULTS

A total of 1309 college students were included (medical 425, nursing 390, humanities 494; mean age 20.5 ± 2.1 years; 36.5% males). Prevalence of Rome IV FGIDs was 26.9% (n = 352), significantly higher among females compared with males (32.3% vs. 17.6%; p < 0.001) and significantly higher among medical (34.4%) and nursing students (29.2%) compared with humanities students (18.6%) (p < 0.05). Most common FGIDs were functional dyspepsia (FD) (15.2%), IBS (6.2%), reflux hypersensitivity (3.5%), FDr (2.9%), FC (2.1%), and unspecified functional bowel disorder (2.1%). FGID overlap was present in 9.3%, most common being FD-IBS overlap (4.4%). With Rome III criteria, prevalence of IBS was higher (9.5%), while that of FDr (0.92%) and of FC (1.3%) were lower. On multivariate analysis, independent predictors for FGIDs were female gender, medical student, non-vegetarian diet, junk food, tea/coffee, poor physical activity, anxiety, and insomnia.

CONCLUSION

Rome IV FGIDs were present among one-fourth of college students with preponderance among females and medical students. FD, IBS, and reflux hypersensitivity were the most common FGIDs. Rome IV criteria led to a reduction in IBS prevalence and increase in FDr and FC prevalence. Dietary factors, physical activity, anxiety, and insomnia affected FGID prevalence.

Saroglitazar in patients with non-alcoholic fatty liver disease and diabetic dyslipidemia: a prospective, observational, real world study

Saroglitazar, a dual peroxisome proliferator activated receptor α/γ agonist, approved for diabetic dyslipidemia (DD), is potential therapeutic option for non-alcoholic fatty liver disease (NAFLD). This prospective, observational, real-world study aimed to determine efficacy and safety of Saroglitazar in patients with NAFLD and DD. We included patients with DD and NAFLD who received Saroglitazar 4 mg once daily for 24 weeks. Blood investigations, liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) (FibroScan) were compared at baseline and 24 weeks. Of 163 patients screened, 107 were included, and 101 completed 24 weeks treatment (mean age 50.4 ± 12.3 years, 78.5% males, mean body mass index 28.8 ± 4.2). After 24 weeks, alanine transaminase (ALT) reduced significantly from 94 (47-122) to 39 (31-49) (p < 0.0001) and aspartate aminotransferase (AST) (U/L) from 89 (43-114) to 37 (30-47) (p < 0.0001) and LSM (kPa) from 8.4 (7.1-9.3) to 7.5 (6.4-8.4) (p = 0.0261). CAP, glycated hemoglobin and lipid parameters also improved significantly. On linear regression, there was significant association between percent change in ALT and AST with TG reduction after treatment (p = 0.024 and 0.037 respectively).We conclude that Saroglitazar leads to significant improvement in transaminases, LSM, and CAP in NAFLD patients with DD.

Early feeding after esophageal variceal band ligation in cirrhotics is safe: Randomized controlled trial

BACKGROUND AND AIM

Oral feeding following variceal ligation in cirrhotics is usually delayed due to fear of rebleeding. Solid diet is usually further delayed (until 72 h) despite lack of evidence. We aimed to compare the impact of early versus delayed feeding on rebleeding following variceal ligation.

METHODS

This was a prospective randomized controlled trial including patients undergoing variceal ligation for active esophageal variceal bleeding. Patients were randomized into two groups. In the early-feeding group, liquid diet was given after 1 h following variceal ligation and a regular solid diet was resumed after 4 h. In the delayed-feeding group, patients fasted for the first 4 h after variceal ligation, liquid diet was given until 24 h, soft diet for the next 48 h and a regular solid diet after 72 h.

RESULTS

There were 52 and 49 patients in the early and delayed feeding groups, respectively. Very early rebleeding rates [2 (3.84%) vs 1 (2.04%); P ≥ 0.99] and delayed rebleeding rates [2 (3.84%) vs 4 (8.16%); P = 0.75] were similar in both groups. Protein and calorie intake in the early-feeding group was significantly better and early infections in active bleeders were significantly lower compared to the delayed-feeding group. One-month mortality was similar in both groups [3 (5.76%) vs 4 (8.16%); P = 0.75].

CONCLUSION

Early feeding with a regular solid diet in conscious patients after successful variceal ligation for esophageal varices is safe, provides better nutrition and results in lower incidence of infections in bleeders compared to delayed feeding.

Prevalence of Malnutrition in Parkinson's Disease and Correlation with Gastrointestinal Symptoms

Background:

Parkinson's disease (PD) patients are at a higher risk of malnutrition with the overall prevalence estimated to be 3%–60%, but there are limited data in India regarding nutritional assessment of PD.

Aim:

This study aims to assess nutritional status of PD patients and correlate the disease factors and gastrointestinal tract (GIT) symptoms with nutritional status.

Materials and Methods:

The PD cohort was assessed for demographic factors, nutritional assessment was done by Mini-Nutritional Assessment (MNA) Scale, and GI symptoms were assessed by validated scales. Age- and gender-matched cohort controls were randomly selected to correlate the GIT symptoms influencing nutritional status. The study population was divided into two groups according to the MNA score; Group I malnourished/at risk of malnutrition (score <23.5) or Group II normal nutrition (>23.5). The two subgroups were then compared.

Results:

We assessed 75 patients of PD and 35 age- and gender-matched controls. According to anthropometric criteria, 23% of the PD population was underweight, and according to biochemical assessment, 17.3% had hypoalbuminemia along with anemia. According to MNA scale, 12% were malnourished and 45.3% were at risk of malnutrition. Hence, a total of 57.3% patients in Group I (with abnormal nutrition) as compared to 14% of the controls were at risk of malnutrition while none was found to be malnourished. In our study, GIT symptoms, such as sialorrhea and dysphagia was reported by 29.3% each and constipation by 41.3% patients. While comparing GI symptoms within the two MNA groups, there was statistically significant relationship of all GI manifestations, sialorrhea (P = 0.041), dysphagia (P = 0.00081), and constipation (P = 0.0042) with malnutrition. There was no statistical significant difference between groups for age (P = 0.54), gender (P = 0.903), and duration of disease (P = 0.743).

Conclusions:

The data suggest that about 45% of PD patients are at risk of malnourishment. MNA Score is a validated nutritional assessment tool and anthropometric or biochemical measures alone cannot identify all the malnourished population. PD patients at risk of malnutrition or malnourished do have symptoms of dysphagia, sialorrhea, and constipation as compared to PD patients with normal nutrition.

Innovations in Strengthening Medical Education in India

There is a disconnect between the objectives of medical education in the country and the actual training being imparted. The present system of discipline based MBBS Curriculum has many inherent disadvantages eg. Compartmentalized teaching, poor development of problem solving skills, failure to generate interest in students and acquisition of dissociated knowledge are few of them. The SPICES model of medical education ie. (Student centered, Problem based, Integrated, Community oriented, Elective enabling and Systematic exposure) may be better suited to our country. Assessment system and examination system need a very drastic change based on the needs of the Community and the stakeholders in the healthcare section. Internship programme needs to be totally revamped. The acquisition of practical skills using newer medical education technology like DOPS (Directly Observed Practical Skills), one minute preceptor and other newer methods needs to be incorporated. In our study on “DOPS” interns we found the usefulness of this methodology (FAIMER study - Chhina RS).The use of technology has revolutionized the world eg. in Space technology, Computer Sciences, Social marketing Strategies. There is an urgent need to incorporate the “MOOC” model and the Social media eg. Facebook, Twitter, We chat, Whatsapp for better coverage and more useful teaching modules. In our study, we found “Facebook” teaching to be an important component of improving the teaching methodology and acquisition of knowledge by students (FAIMER study- Sharma Anu & Chhina RS). The “Feedback” technique for improvement in the needs of student knowledge base, their aspirations, what they thought is appropriate in teaching skills and methodology was studied and powerful conclusions have been drawn in our institution. (FAIMER study-Singh Daljit). The postgraduate training seats needs to be modified as the disease burden load in the country requires. A study done by us showed a total disconnect between the need and the available resources in the State of Punjab. The requirements of the Community, Medical students, Healthcare providers and patients need to be advanced in an objectively scientific, need oriented manner in relation to medical education in India.

Chicken pox outbreak in the Intensive Care Unit of a tertiary care hospital: Lessons learnt the hard way

Varicella-zoster virus (VZV) causes 2 clinically and epidemiologically distinct forms of diseases. Chickenpox (varicella) is the disease that results from primary infection with the VZV. Herpes zoster (HZ) results from the reactivation of VZV latently infecting the dorsal root ganglia. We are reporting an outbreak of varicella infection among the health care workers (HCWs) in the Intensive Care Unit (ICU) of a tertiary care hospital. We found transmission of varicella among eight HCWs of pulmonary ICU. They had a history of contact with a patient having HZ infection. Investigation of the outbreak was conducted as per guidelines. Better dissemination of information on disease transmission, isolation of infected patients inside the hospital, and adequate protection (including vaccination) for susceptible employees are important to prevent such outbreaks.

Corticosteroid plus pentoxifylline is not better than corticosteroid alone for improving survival in severe alcoholic hepatitis (COPE trial)

BACKGROUND

Corticosteroids and pentoxifylline reduce short-term mortality in severe alcoholic hepatitis (SAH), but not to the extent desired. Combining both drugs may lead to better survival, but has not yet been studied.

AIM

To compare the efficacy of corticosteroids plus pentoxifylline with that of corticosteroids alone in improving survival of SAH patients.

METHODS

Of the 111 patients screened, 70 patients with SAH (Maddrey discriminant function (MDF) ≥ 32) were enrolled. Patients with active infection, bleeding, renal failure, or pancreatitis were excluded. Treatment was given for four weeks to group A (n = 36; prednisolone 40 mg/day plus pentoxifylline 400 mg thrice/day) and group B (n = 34; prednisolone 40 mg/day). Patients were followed up for 6 months. Data are expressed as median (range) or percentage.

RESULTS

Baseline characteristics of the two groups were similar (MDF group A 78.5 (36.8-140.9), group B 74.9 (45.6-140.2)). Four-week and six-month survival in groups A and B were not significantly different (four-week 72.2 and 73.5%, respectively, p = 1.00; six-month 30.6 and 23.5%, respectively, p = 0.417). At seven days, 55.6% of patients in group A and 64.7% in group B had a Lille score <0.45 (p = 0.473). Six-month survival was significantly higher for patients with a Lille Score <0.45 than for those with a Lille score ≥0.45 (group A 55.5 vs. 0%, p = 0.0006; group B 36 vs. 0%, p = 0.0304). Biological improvement at 28 days was significant for both groups; however, the difference between the groups was not significant.

CONCLUSIONS

For patients with severe alcoholic hepatitis, a combination of corticosteroids and pentoxifylline has no additional survival advantage compared with corticosteroids alone.

Pentoxifylline in severe alcoholic hepatitis: a prospective, randomised trial

BACKGROUND

Role of corticosteroids in treatment of severe alcoholic hepatitis (SAH) is controversial. Pentoxifylline (PTX), an inhibitor of TNF, has also been shown to decrease short term mortality in SAH. Aim of this study was to evaluate the effect of PTX on short term mortality, renal and hepatic functions in patients with SAH.

METHODS

Fifty patients with SAH {Maddrey's Discriminant Function (DF) > or = 32} were prospectively enrolled. Twenty five patients received PTX (400 mg orally, three times a day), and 25 received placebo for 4 weeks. Serum tumor necrosis factor (TNF) was measured in both groups.

RESULTS

Baseline characteristics of the two groups were similar. At 4 weeks, mortality in PTX group was lower than that in controls {20% (5/25) versus 40% (10/25) respectively; p = 0.216; RR 0.5; 95% CI 0.19-1.25}. Renal failure was the cause of mortality in 20% (1/5) patients in PTX group, and 70% (7/10) in controls (p = 0.11). Significant reduction in urea, creatinine, DF and TNF was noted in PTX group. Reduction in TNF did not correlate with reduction in creatinine or DF.

CONCLUSIONS

In patients with SAH, PTX leads to a significant improvement in renal and hepatic functions, and a trend towards decreased short term mortality.

Rifaximin improves psychometric performance and health-related quality of life in patients with minimal hepatic encephalopathy (the RIME Trial)

OBJECTIVES

Cirrhotics with minimal hepatic encephalopathy (MHE) have a poor health-related quality of life (HRQOL). Treatment of MHE is still evolving. The aim of this double-blind randomized pilot study was to assess the efficacy of rifaximin in improving neuropsychometric (NP) test performance and HRQOL in patients with MHE.

METHODS

MHE was diagnosed if any two NP tests (number and figure connection tests, picture completion, digit symbol, and block design tests) were deranged beyond 2 s.d. of normal. HRQOL was assessed using the sickness impact profile (SIP) questionnaire.

RESULTS

A total of 486 patients with cirrhosis were screened and 284 were found eligible. Out of these 115 (40.9%) had MHE, of which 21 refused consent and 94 were randomized to receive placebo (n=45) and rifaximin (n=49; 1200 mg/day) for 8 weeks. At the end of treatment, significantly more number of patients in rifaximin group showed reversal of MHE (75.5% (37/49) vs. 20% (9/45) in placebo group; P<0.0001). Rifaximin group also showed significant reduction in mean number of abnormal NP tests (baseline, 2.35 (95% confidence interval (CI), 2.17-2.53); 2 weeks, 1.29 (95% CI, 1.02-1.56), P=0.002; 8 weeks, 0.81 (95% CI, 0.61-1.02), P=0.000), compared with placebo group (baseline, 2.31 (95% CI, 2.03-2.59); 2 weeks, 2.03 (95% CI, 1.74-2.31); 8 weeks, 1.97 (95% CI, 1.69-2.25), P>0.05). The mean total SIP score also improved significantly in rifaximin group (baseline, 11.67 (95% CI, 10.31-13.03); 8 weeks, 6.45 (95% CI, 5.59-7.30); P=0.000) compared with placebo group (baseline, 9.86 (95% CI, 8.66-11.06); 8 weeks, 8.51 (95% CI, 7.35-9.67); P=0.82). Improvement in HRQOL correlated with improvement in NP tests. Rifaximin was well tolerated.

CONCLUSIONS

Rifaximin significantly improves both cognitive functions and HRQOL in patients with MHE.

Acanthamoeba encephalitis

Central nervous system infection with free-living amoebae is rare. We present a fatal case of Acanthamoeba encephalitis in a 63-year-old female from India where acanthamoebae were demonstrated and cultured from CSF. In spite of treatment with amphotericin B, fluconazole and rifampicin the patient did not survive. Amoebic infection should be suspected in a patient of encephalitis of unexplained aetiology as timely diagnosis can lead to a favourable outcome.

Urinary tract infections-microbial virulence determinants and reactive oxygen species

The human urinary tract is able to combat with the microbial invasion under normal circumstances. To cause urinary tract infection the organism has to evade the host defense mechanisms by possessing distinct properties which contribute to the virulence of the organism hence called virulence determinants Ninety percent of uncomplicated urinary tract infections are caused by Escherichia coli, hence the knowledge of the virulence determinants of this organism can be extrapolated to other uropathogenic organism as well. Virulence determinants of uropathogenic E. coli include adhesins, siderophore production, polysaccharide coating, hemolysin production, outer membrane proteins etc. The intestinal E. coli, which are the reservoir of E. coli for causing UTI, lack these virulence determinants. On the other hand these virulence determinants enable the organism to colonize and invade the urinary tract. In addition these are important in acquiring the nutrients in other wise nutrient deficient environment. Further, they also help the organisms in triggering an inflammatory response and hence bringing about pathological changes which leads to symptomatic UTI. Severity of symptomatic infections and tissue damage during the infective process depends upon the magnitude of the inflammatory response triggered by the uropathogen which in turn is dependent upon the amount of extrcellular release of reactive oxygen species by the phagocytic cells; hence role of antioxidants as an adjunct to antibiotics in the treatment of infective process needs to be evaluated further.

Clinical and anthropometric profile of children with celiac disease in Punjab (North India)

This prospective study was carried out to evaluate the clinical and anthropometric profile of 71 children confirmed to have celiac disease on the basis of clinical features, duodenal biopsy and unequivocal improvement on gluten-free diet. Serological tests were performed in 35 cases. The patients were divided into three age groups <5 years, 5-10 years, and >10 years as per the age of presentation to the hospital. Mean age was 8.7 years with a slight female preponderance. Diarrhea was the commonest presentation in group I and failure to thrive in group III. All patients in group III, had weight for age (w/a) <3rd percentile and majority (83 per cent) had short stature, with delayed puberty in all. All children had significant improvement in symptoms and growth on gluten restriction. None of the patients had been suspected to have celiac disease before, which signifies that in spite of increasing incidence of celiac disease, this disease is grossly under-diagnosed in North India where wheat is the staple diet. It is essential to make an early diagnosis of celiac disease in children to prevent growth delay.

Impact of ranitidine on prognosis after simple closure of perforated duodenal ulcer

AIM

This randomized controlled study was carried out to evaluate the role of H2 receptor antagonists after simple closure of perforated duodenal ulcer.

METHODS

A total of 192 patients who underwent simple closure for perforated duodenal ulcer were divided into two groups (A: study group and B: control group). Group A patients were treated with H2 receptor antagonists, while the patients in group B received placebo. Only 174 patients were available for endoscopic follow up.

RESULTS

At the end of 24 weeks, only 6 patients out of 90 (6.6%) in group A as compared to 18 patients out of 84 (21.4%) in group B had persistent symptoms of ulcer disease as well as endoscopically proven ulcer (p < 0.05).

CONCLUSIONS

The results indicate that H2 receptor antagonists have a definite role and endoscopic follow up is mandatory to define those cases who actually need definitive surgery.

Microbiological quality & incidence of organisms of public health importance in food & water in Ludhiana

Bacteriological analysis of 713 samples of various types of foods and related articles and potable water samples from different places in Ludhiana, Punjab was carried out. The highest counts ranging from 2.5 x 10(6)-7.5 x 10(8) organisms/g were observed in raw vegetables and fruits, followed by 3 x 10(6)-9.8 x 10(7)/ml, 8.3 x 10(4)-8.9 x 10(7)/g and 1 x 10(3)-6.7 x 10(7)/g in fruit juice, milk and its products, and salty/non milk snacks respectively. Fresh chapati, dal, rice, cooked vegetables and karhi etc., showed no microbial contamination. However, samples of these articles from road side cafes gave counts up to 1 x 10(7) organism/g. The most probable number of coliforms and Escherichia coli/100 ml of water ranged from < 1 to > 1100. Although 1332 isolates of 16 types of organisms of public health significance were obtained those of proven enteropathogenicity were enterotoxigenic Esch. coli (55), Esch. coli O157 (3), enteropathogenic Esch. coli (1), enterotoxigenic Klebsiella (23), Streptococcus faecalis (152), Bacillus cereus (133), Staphylococcus aureus (125), Aeromonas spp (47), Salmonella spp (10), Shigella spp (4) and Yersinia enterocolitica (2). Poor quality of potable water and widespread occurrence of enteropathogens in food consumed by the common man in Ludhiana was evident.

Ascitic fluid cholesterol in malignant and tubercular ascites

Cholesterol was estimated in ascitic fluid of 44 patients (29 malignant and 15 tubercular). Mean ascitic cholesterol level was significantly higher in malignant ascites (89.52 mg/dl) as compared to tubercular ascites (35.07 mg/dl). At a cut off value of 54.5 mg/dl (mean in tubercular ascites + 2SD), the sensitivity, specificity, positive and negative predictive value and overall diagnostic accuracy for differentiating malignant from tubercular ascites was found to be 89.65%, 100%, 100%, 83.33% and 93.18% respectively. Ascitic fluid cholesterol estimation is a reliable and simple test for differentiating malignant ascites from tubercular ascites.

Role of zipper in the management of abdominal sepsis

BACKGROUND

Continuous peritoneal lavage, staged laparotomies and radical peritoneal debridement have been used to reduce mortality from severe abdominal sepsis. Recently, open abdomen technique using a 'zipper' with or without mesh for abdominal lavage has shown promising results.

AIMS

To evaluate open abdominal technique using a zipper in patients with advanced diffuse peritonitis with impending or established multiple organ failure.

METHODS

Modified open abdomen technique using zipper with or without mesh was used for abdominal closure in eight patients with severe generalized peritonitis (APACHE-II score range 27-30).

RESULTS

Zipper was inserted at first laparotomy in three patients, at second exploration in four and at the time of third laparotomy in one case. Two patients required strips of mesh in addition to zipper. Six of eight patients survived and were discharged after an average period of 27 days. Two deaths were due to multisystem organ failure. In four patients additional surgical procedures like closure of perforation, temporary ileostomy and resection anastomosis of small bowel was carried out through the zipper. Zipper-mesh were removed an average of 10.5 days after insertion. Three patients developed incisional hernia at 6 months follow-up.

CONCLUSION

This technique merits further controlled trials to ascertain its indications and benefits.

Indolent gastric carcinoma

A 55 year old woman presenting with epigastric pain and dyspeptic symptoms was diagnosed to have gastric carcinoma on endoscopic biopsy independently on two occasions. She was subsequently asymptomatic without any specific therapy till she developed gastric outlet obstruction and weight loss four years later. Histology of the resected specimen revealed an adenocarcinoma infiltrating the serosa without any evidence of metastasis.

Endoscopic assessment of chloroquine phosphate-induced damage to esophageal, gastric, and duodenal mucosa

Eighteen patients with Plasmodium vivax malaria were prospectively evaluated to assess the time of onset and extent of upper gastrointestinal mucosal injury caused by oral administration of four tablets (600-mg base) of chloroquine. Endoscopy was performed in the group of three separate patients. Each patient underwent endoscopy, both before the drug was given, and at intervals of 1, 2, 4, 12, 24, and 36 h. Before the drug was given, endoscopy was normal in all of the patients. However, mucosal erosions developed in four of 18 patients who were endoscoped 24 and 36 h after chloroquine ingestion (gastric, four; duodenal, two; esophageal, one). The same doses of chloroquine failed to produce any mucosal lesions when given to these four patients while they were afebrile and when given to 11 healthy individuals who served as controls. Poor correlation was noted between subjective symptoms and endoscopic findings. In conclusion, neither malaria alone nor chloroquine alone causes mucosal lesions. However, chloroquine administered during malarial fever causes mucosal damage in susceptible individuals.

Duodeno--jejunal vascular malformation

Vascular malformations are rare but an important cause of obscure upper gastrointestinal bleeding. A patient with a large vascular malformation involving the duodenum and proximal jejunum, presenting with a severe bout of melaena, is described. The diagnosis was suspected on endoscopy and confirmed by angiography and surgery.

Chloroquine phosphate induced haematemesis

Two cases who developed haematemesis, 30 and 36 hours after ingestion of 4 tablets (600 mg base) of chloroquine phosphate are described. Upper gastrointestinal endoscopy revealed erosions in the stomach and duodenum.