Open label comparative trial of mono versus dual antibiotic therapy for Typhoid Fever in adults.

BACKGROUND: Emerging resistance to antibiotics renders therapy of Typhoid Fever (TF) increasingly challenging. The current single-drug regimens exhibit prolonged fever clearance time (FCT), imposing a great burden on both patients and health systems, and potentially contributing to the development of antibiotic resistance and the chronic carriage of the pathogens. The aim of our study was to assess the efficacy of combining third-generation cephalosporin therapy with azithromycin on the outcomes of TF in patients living in an endemic region. METHODS: An open-label, comparative trial was conducted at Dhulikhel Hospital, Nepal, between October 2012 and October 2014. Only culture-confirmed TF cases were eligible. Patients were alternately allocated to one of four study arms: hospitalized patients received either intravenous ceftriaxone or a combination of ceftriaxone and oral azithromycin, while outpatients received either oral azithromycin or a combination of oral azithromycin and cefexime. The primary outcome evaluated was FCT and the secondary outcomes included duration of bacteremia. RESULTS: 105 blood culture-confirmed patients, of whom 51 were treated as outpatients, were eligible for the study. Of the 88 patients who met the inclusion criteria for FCT analysis 41 patients received a single-agent regimen, while 47 patients received a combined regimen. Results showed that FCT was significantly shorter for the latter (95 versus 88 hours, respectively, p = 0·004), and this effect was exhibited in both the hospitalized and the outpatient sub-groups. Repeat blood cultures, drawn on day 3, were positive for 8/47 (17%) patients after monotherapy, versus 2/51 (4%) after combination therapy (p = 0·045). No severe complications or fatalities occurred in any of the groups. CONCLUSIONS: Combined therapy of third-generation cephalosporins and azithromycin for TF may surpass monotherapy in terms of FCT and time to elimination of bacteremia. TRIAL REGISTRATION: Trial registration number: NCT02224040.

Endoscopic retrograde cholangiopancreatography at Dhulikhel Hospital: outcome analysis.

BACKGROUND: Endoscopic Retrograde Cholangiopancreatography (ERCP) is an important but potentially invasive therapeutic procedure in treating various pancreatobiliary conditions. In Nepal, the ERCP services is limited to a few tertiary care centers mostly in the capital, Kathmandu. Dhulikhel hospital has started ERCP since 2011 providing services to patients from all over the country. The study analyzes the outcome from data since August 2011 to 2013 August. OBJECTIVE: To analyze the results of ERCP done in Dhulikhel hospital, Kathmandu University hospital. METHOD: This is a retrospective study. The ERCP records of all the patients done since August 2011 to August 2013 were retrieved. A total of 516 attempts of ERCP were done since August 2011 to August 2013. Out of these, 423 were included for the analysis. The repeat ERCP for the same patient due to failed cannulation or patients undergone ERCP but incomplete documentation were excluded. The demographic data, indications, the findings, the outcome in terms of success or failure to cannulation, success or failure of stone extraction, stenting and complications were all derived and analyzed. SPSS 16 version was employed for data management and analysis. RESULT: The female: male ratio was found to be 1.7 : 1. The mean age of patients were 50.57±17.8 Years. The most common indication for ERCP were: choledocholithiasis 208(49.17%); followed by: obstructive jaundice 69(16.3%) of undetermined cause, acute biliary pancreatitis 26(6.4%), suspected bile duct injury during cholecystectomy 18(4.2%), periampullary growth 21( 4.96%), Cholangiocarcinoma 12(2.8%), chronic pancreatitis 10( 2.3%), CBD stent exchange 23(5.43%), dilated cbd 21(4.96%) , acute cholangitis 14(3.3%).The most common finding was CBD stone in 308(72.81%), normal in 51(12.1% ), bile duct stricture in 45(10.63%). Bile duct injury during cholecystectomy was found in 13(3.1%), biliary obstruction due to ampullary growth and pancreatic head mass was found in 21(4.96%) and 6(1.41%) respectively. Choledochal cyst was found in 5(1.2%), chronic pancreatitis in 7(1.7%). Biliary fascioliasis was found in one (0.24%); and roundworm in 1(0.24).The most common complication was acute pancreatitis in 17(4%), post-ERCP cholangitis 6(1.4%), bleeding 6(1.4%), duodenal perforation in 1(0.2%), arrhythmia in 1(0.2%) and one death (0.2%). CONCLUSION: ERCP has been a potentially emerging therapeutic tool for various pancreato-biliary disorders in Nepal.

Upper gastro-intestinal bleeding: aetiology and demographic profile based on endoscopic examination at Dhulikhel Hospital, Kathmandu University Hospital.

BACKGROUND: The upper gastrointestinal bleeding (UGIB) is defined as bleeding within the intraluminal gastrointestinal tract from any location between the upper oesophagus to the duodenum at the ligament of Treitz. It is one of the important medical emergencies worldwide. OBJECTIVE: The objective of this study is to study the aetiology of upper gastrointestinal bleeding based on endoscopic examination findings in patients of various demographic characteristics. MATERIALS AND METHODS: This is a retrospective observational study. The endoscopic record book from 2007 January to 2009 October was reviewed for all the cases who underwent oesophago-gastro-duodenoscopic examination for upper GI bleeding. The clinico-epidemiological data of all the patients was reviewed and analyzed in concert with the aetiology of bleeding. RESULTS: A total of 90 patients (58 males, 32 females; mean age 45.32+ 18.47 years) of upper gastrointestinal bleeding was studied and analyzed in terms of aetiology of bleeding and demographic profile. Among the ethnic groups, Aryan 46 (51%) was the most common ethnic group to have upper GI bleeding followed by Newars 24 (27%), Mongolians 16 (18%), Dalits 3 (3%) and others 1 (1%). Out of 90 patients, 47( 52.2%) cases was less than 45 years of age, 30(33.3%) of 46 to 65 age ; and 13(14.4 %) more than 65 years of age. Gastric ulcer 23(25.6%) was the most common endoscopic finding, followed by oesophageal varices 14 (15.6%), acute erosive/haemorrhagic gastropathy 11 (12.2%), duodenal ulcer 9(10%), growth 7(7.8%), vascular lesions 3(3.3%), Mallory-Weiss tear 1(1.1%), fundal varices 1(1.1%) and, no cause was identified in 21(23.3%) cases. The peptic ulcer bleeding was the most common finding in Aryan 22(47.9%), whereas oesophageal varices and growth were more common in Newar 7(29.2%) and 3 (12.5%) respectively. CONCLUSION: Peptic ulcer disease is the most common cause of upper GI bleeding which was most commonly found in Aryan population; followed by oesophageal varices and growth as second and third most common causes and were more prevalent in Newar and Mongolian people.

Managing recurrent genital herpes with acyclovir.

Seventy five patients of recurrent genital herpes (RGH) treated with oral or topical acyclovir and placebo were compared and followed for periods ranging 4 to 8 years in a prospective study. Oral acyclovir definitely helps RGH patients; it shortens healing time; postpones recurrences and instills confidence in the patients. There is sufficient evidence that RGH dies a natural death with time as seen after 8 years follow up in placebo group patients. Topical use of acyclovir cream is not as useful as believed.

Clinical profile of psoriasis in North India.

A prospective study of 530 patients of psoriasis drawn from northern parts of India revealed a male preponderance; 60% patients having onset before the age of 30 years; youngest age at onset being one week and the oldest 72 years. Family history was positive in 14% cases. Only 30% psoriatics showed clear cut worsening in winter months. Skin and scalp were the commonest sites; 54% had nail changes when first seen and in 8 patients involvement of nails was the only manifestation of psoriasis. Joint symptoms were present in 10% of cases but frank arthritis was seen in only 7 cases. The presence of joint affection was invariably associated with nail abnormalities. Psoriatic arthritis among the Indian patients is not only rare but shows a milder course as compared to the western countries.

Histopathologic study of clinically normal appearing skin in lepromatous leprosy.

Skin biopsies from clinically normal skin of the scalp, axillary and groin regions in 20 lepromatous leprosy patients revealed significant histopathological findings in upto 25 percent of the patients. The positive findings could, perhaps, be enhanced by studying larger skin materials from these body areas. Indeed, no skin area appears to be immune from invasion by Myco. leprae.

Nevus unius lateralis exhibiting intraepidermal basaloid cell formation simulating superficial basal cell epithelioma.

A unilateral verrucous lesion with clinical characteristics of nevus unius lateralis (NUL) in an 18-year-old boy, showed histopathological features of intraepidermal basaloid cell formation simulating superficial basal cell epitheliomas. Biological significance of this phenomenon is discussed. The lesion is considered a most peculiar variant of NUL.

Diffuse biphasic cutaneous amyloidosis.

2 patients with primary localized cutaneous amyloidosis were seen to have widespread macular and lichenoid types of lesions. Diffuse areas of pigmentation appeared to transform gradually over years into lichen amyloidosus as a result of chronic irritation of the skin from scratching. There was no evidence of systemic amyloidosis.

Hemodialysis in Psoriasis.

Hemodialysis has proved to be a welcome addition to the various already known therapeutic modalities in the treatment of psoriasis. The procedure was attempted in 12 patients with chronic plaque psoriasis recalcitrant to conventional treatment There was a dramatic improvements in IO ofthe 12 patients.,The lesions started clearing as early as 2-4 days following first hemodialysis and most patients required 3-4 hemodialysis to be free of lesions. The remission could be maintained for as long as 9 months after the last dialysis. The possible mechanism of induction of remission due to hemodialysis is discussed.

Psoriasis in Children.

A prospective study of childhood psoriasis revealed an overall prevalence of 0. I% among the general skin diseases outpatients; 8.5 % of the Indian psoriatics having onset of their disease during childhood. The peak age of onset was between 4 and 8 years and the mean age of onset in the males was lower than the females by approximately 2 years. Family history was positive in 12.5%. Plaque variety was the commonest and guttate lesions were observed in only 25% of the cases, Itching was a promin ' ent feature of guttate lesions which were observed to be preceded in 50% of the patients by throat infection. The commonest sites were the legs, arms and the trunk. The face was involved more often than the scalp, the commonest site of affection in the adults. Nails were involved in more than 60% of the cases. The therapeutic response to coal tar treatment was satisfactory and the guttatc lesions responded well to treatmentwith penicillin. The pustularand erythrodermic varieties and psoriatic arthritis were rare in the paediatric patients.

Nocardia Mycetoma At Unusual Site.

A case of nocardial mycetoma is presented occurring at upper back. Clinical and laboratory studies established the diagnosis. Excellent therapeutic response was obtained with sulphadiazine alone within five months of therapy.

Diffuse biphasic cutaneous amyloidosis

2 patients with primary localized cutaneous amyloidosis were seen to have widespread macular and lichenoid types of lesions. Diffuse areas of pigmentation appeared to transform gradually over years into lichen amyloidosus as a result of chronic irritation of the skin from scratching. There was no evidence of systemic amyloidosis.

Red grain mycetoma of the scalp (Actinomadura pelletieri). A case report from India.

A case of red grain mycetoma on the scalp is described. The disease, caused by Actinomadura pelletieri, is extremely rare in this part of the world, and from India this is perhaps the first case with scalp involvement. The lesion showed satisfactory response to partial excision followed by chemotherapy with streptomycin.

Immunological studies in psoriasis.

The mean values of serum immunoglobulins A, G, M and D levels in 42 psoriasis patients showed no significant difference from those of control subjects. Analysis of the same sera for the presence of antiglobulin antibodies also yielded negative results. Antinuclear factor could be demonstrated in only 4.8% of the cases. The possibility that serum antiglobulins get drained into the lesions making their detection in the serum difficult, is supported by our preliminary findings of focal deposition in the stratum corneum of immune complexes of IgG, IgM and complement in tissue sections of psoriatic lesions from these patients.