Isosorbide Mononitrate versus Misoprostol for Cervical Ripening and Induction of Labour at Term.

To assess the efficacy and safety of isosorbide mononitrate (IMN) compared with misoprostol for cervical ripening and labour induction at term. In this comparative study two hundred term pregnant women with indication for induction of labour were randomly divided to receive either 40 mg IMN tablet vaginally (n=100) or 50 µg misoprostol tablet vaginally (n=100) every 6 hours interval for a maximum of 4 doses. Progress & outcome of cervical ripening, labour induction and adverse effects were assessed. Change in cervical score was higher in misoprostol group than IMN group. Time from start of medication to vaginal delivery in IMN group was significantly longer, 28.66 ± 5.283 hours, than in misoprostol group, 16.12 ± 5.581 hours. Vaginal delivery occurred in 77% in IMN group and 69% in misoprostol group. There were no tachysystole or uterine hyper stimulation in the IMN group while in misoprostol group it was 17% and 11% respectively. Maternal satisfaction was higher in IMN group. Cervical ripening is satisfactory with IMN. Though misoprostol is singly more effective than IMN but IMN with oxytocin results in more vaginal delivery. Fetal and maternal side effects are less in IMN group.

Community-based evaluation of the effect of breast-feeding on the risk of microbiologically confirmed or clinically presumptive shigellosis in Bangladeshi children.

To assess the association between breast-feeding and the risk of microbiologically confirmed or clinically presumptive shigellosis, the authors performed a case-control analysis of Bangladeshi children younger than 3 years of age who were followed up for 1 month after exposure to Shigella in their residential neighborhoods. Two hundred sixty-nine cases with culture-confirmed shigellosis (n = 119) or clinically presumptive shigellosis (culture-negative dysentery, n = 150) were compared with 819 controls without Shigella diarrhea or other invasive diarrheal illnesses. The odds ratio relating breast-feeding to confirmed or presumptive shigellosis, adjusted for potentially confounding variables, was 0.48 (95% confidence interval = 0.32 to 0.72; P less than .001), suggesting a substantial protective effect. The protective association decreased with age but was still significant during the third year of life; appeared to be directly related to the degree of stunting; and was equivalent for confirmed and presumptive shigellosis. Notably, the protective association remained substantial against episodes due to Shigella which were resistant to at least one of the antibiotics customarily used for treatment of Shigella diarrhea (age-adjusted odds ratio = 0.40; 95% confidence interval = 0.22 to 0.74; P less than .01). These data suggest that breast-feeding confers a high level of protection against shigellosis throughout the first 3 years of life, especially among nutritionally compromised children, and thereby underscore the importance of promotion of breast-feeding as a central component of Shigella control programs in less developed settings.

Epidemiology of postshigellosis persistent diarrhea in young children.

BACKGROUND: Dysentery accounts for 20% of the 4.6 million diarrhea-associated deaths among children in developing countries, with the risk from death in dysenteric persistent diarrhea 10-fold higher than that in acute dysentery. Although Shigella accounts for the majority of dysenteric episodes, very little is known about the epidemiology of postshigellosis persistent diarrhea. METHODS: Rural Bangladeshi children younger than 5 years of age (n = 1,756) were followed for 1 month after exposure to sentinel cases of Shigella dysentery. The likelihood of an acute diarrheal episode becoming persistent was assessed. RESULTS: Diarrhea caused by Shigella was significantly associated with an increased risk of persistent diarrhea (age-adjusted relative risk, 1.83; 95% confidence interval, 1.19 to 2.81). Despite the use of nalidixic acid in dysenteric episodes, persistent diarrhea occurred in 23% of children with shigellosis. Infection by multiply antibiotic-resistant Shigella isolates (age-adjusted relative risk, 3.76; 95% confidence interval, 1.51 to 9.36) and occurrence of shigellosis during infancy were observed to be risk factors for initiation of Shigella diarrhea persistence. However, 88% of the persistent shigellosis episodes occurred in older children, 50% were associated with nondysenteric shigellosis and 79% were caused by Shigella species other than Shigella dysenteriae 1. CONCLUSIONS: These data demonstrate the importance of Shigella as a cause of persistent diarrhea and indicate that strategies to prevent postshigellosis persistent diarrhea must be broad-based, with a focus on older children as well as infants, management of nondysenteric as well as dysenteric disease and prevention of diarrhea caused by multiple Shigella species.

Epidemiology of shigellosis among children exposed to cases of Shigella dysentery: a multivariate assessment.

We followed 1,756 young, rural Bangladeshi children less than five years of age for one month after identification of sentinel Shigella patients in their neighborhoods. Two hundred nineteen (12%) children developed Shigella diarrhea (shigellosis) and 227 (13%) developed culture-negative dysentery. Shigella flexneri (60%) and S. dysenteriae, type 1 (15%) were the most common isolates among shigellosis cases. Within individual neighborhoods, there was poor agreement (Kappa = 0.21) between Shigella species isolated from sentinel patients and from additional cases detected during surveillance. The risk of shigellosis increased substantially after infancy and peaked in the second year of life. Severe stunting, as assessed by height-for-age, was associated with an increased risk of shigellosis (adjusted odds ratio [ORa] = 1.67, 95% confidence interval [CI] = 1.09-2.57, P < 0.05), while breast-feeding was protectively associated (ORa = 0.40, 95% CI = 0.24-0.69, P < 0.001). Only 43% of the shigellosis cases reported bloody stools; frank dysentery occurred more frequently in S. dysenteriae 1 infections than in S. flexneri infections (ORa = 5.04, 95% CI = 1.76-14.48, P < 0.01), and was also associated with severe stunting (ORa = 2.16, 95% CI = 1.01-4.58, P < 0.05). Our findings show that the high risk of shigellosis in residentially exposed Bangladeshi children results from multiple Shigella strains circulating concurrently within the same neighborhood; demonstrate that the risk is notably modified by host age, nutritional status, and dietary patterns; and illustrate that the classic picture of dysentery is relatively infrequent and is correlated with the infecting species and with host nutritional status.

Surgical management of echinococcosis of the heart.

A 23-year-old female with an echinococcal cyst in the atrioventricular groove of the heart is reported. The diagnosis and the location of the cyst were confirmed by echocardiography and cardiac catheter. Successful enucleating of the cyst with the aid of cardiopulmonary bypass and the length of follow-up is reported, along with a review of relevant literature.

Preoperative and postoperative study of left ventricular function, hemodynamics and plasma catecholamine concentrations during dynamic exercise in patients with chronic mitral regurgitation.

We studied 7 patients before and after mitral valve replacement (MVR) for chronic mitral regurgitation (MR) and 5 control subjects by echocardiography and right heart catheterization to assess left ventricular function, hemodynamics and plasma catecholamine concentrations during supine bicycle exercise. Left ventricular (LV) end-systolic dimension decreased and LV systolic function increased significantly during exercise in patients and control subjects. LV systolic function (fractional shortening and mean velocity of circumferential fiber shortening) was significantly lower in patients after MVR than before MVR (p < 0.05). Cardiac index at peak exercise was significantly higher in patients after MVR than before MVR (p < 0.05). Significantly greater augmentation in plasma norepinephrine (NE) levels were observed during exercise in patients both before and after MVR than in control subjects (p < 0.05). No significant differences in mean pulmonary artery pressure (PAP) and pulmonary capillary wedge pressure (PCWP) were observed between the patients before and after MVR. Thus, it is concluded that LV systolic and pump function (CI) during exercise were augmented by a compensatory activation of sympathetic nervous system in patients both before and after MVR for chronic MR.

Clinics in diagnostic imaging (23). Traumatic rupture of the left iliac vein.

A 3-day-old male baby with neonatal necrotising enterocolitis had a central line (Cavafex No. 18) inserted through the left femoral vein for administration of parenteral nutrition. Forty-eight hours later, he developed progressive abdominal distention with evidence of free abdominal fluid. A contrast injection done through the left femoral vein revealed retroperitoneal leakage of contrast from a traumatic rupture of the left iliac vein. The intravenous catheter was removed and he was treated conservatively with eventual recovery.

Structural perturbation of proteins in low denaturant concentrations.

The presence of very low concentrations of the widely used chemical denaturants, guanidinium chloride and urea, induce changes in the tertiary structure of proteins. We have presented results on such changes in four structurally unrelated proteins to show that such structural perturbations are common irrespective of their origin. Data representative of such structural changes are shown for the monomeric globular proteins such as horseradish peroxidase (HRP) from a plant, human serum albumin (HSA) and prothrombin from ovine blood serum, and for the membrane-associated, worm-like elongated protein, spectrin, from ovine erythrocytes. Structural alterations in these proteins were reflected in quenching studies of tryptophan fluorescence using the widely used quencher acrylamide. Stern-Volmer quenching constants measured in presence of the denaturants, even at concentrations below 100 mM, were higher than those measured in absence of the denaturants. Both steady-state and time-resolved fluorescence emission properties of tryptophan and of the extrinsic probe PRODAN were used for monitoring conformational changes in the proteins in presence of different low concentrations of the denaturants. These results are consistent with earlier studies from our laboratory indicating structural perturbations in proteins at the tertiary level, keeping their native-like secondary structure and their biological activity more or less intact.

Chronic diarrhoeal diseases in adults (a preliminary report).

The relationship of chronic diarrhoeal diseases in adults on socio-economic condition, parasitic infestation and degree of anaemia have been investigated. The disease was more prevalent in poor socio-economic group of people. Most of the patients had mixed parasitic infestations. Anaemia was present in all the cases. Difference in the degree of anaemia was not significant amongst the patients having either Ascaris or hookworm infestation.

Liver function tests in patients of pulmonary tuberculosis using four different drug regimens.

BACKGROUND: Chemotherapy is the basic approach to clinical tuberculosis control. Antituberculous therapy causes derangement of hepatic functions revealed by disturbed liver function tests. The incidence of side effects may vary depending upon a number of factors. The primary purpose of this study was to determine the relative and absolute hepatotoxicity of different antituberculous drug regimens in Pakistani population where majority of the tuberculous patients belong to poor socioeconomic status. METHODS: One hundred patients between 30 to 70 years of age with newly diagnosed pulmonary tuberculosis were selected and divided into four groups on the basis of different drug regimens. Blood and urine tests of these patients were made. Liver function tests were performed before therapy and then after one, two, three, six and nine months of treatment. RESULTS & CONCLUSIONS: Antituberculous therapy causes derangement of hepatic function to a variable extent in patients of four different antituberculous drug regimens under study. Drug combination of Streptomycin, Isoniazid and Myambutol seem to be best tolerated of all the four regimens. Monitoring of the liver function in patients on antituberculous therapy indicated that liver dysfunction most frequently occurs during first three months of therapy. There is a tendency for enzyme values to return to normal inspite of continuous treatment. The mechanism underlying this adaptation to injury to the liver is unknown. Biochemical tests in the patients presenting with jaundice yielded the pattern of acute hepatocellular necrosis with high transaminases and moderately elevated Alkaline Phosphatase. None of the patients had hepatitis associated antigen in their serum.

Changes of perinatal statistics in a semiurban setup between two time periods in Malaysia.

Hospital University Sains Malaysia (HUSM) functions as the state referral centre and the only hospital for the state of Kelantan that can offer neonatal intensive care service. The deliveries in HUSM with grand multiparity, late booking and problems of late referrals resembles a hospital serving a semiurban rather than an urban community. A comparison between the year 1989 and 1991 showed marked improvement of perinatal mortality rate from 41.32 to 24.88, which is significantly better than the improvement achieved from 1987 to 1989 (46.0 to 41.32). This was possible due to a marked fall in the early neonatal mortality rate from 10.02 in 1989 to 5.45 in 1991 and fall in the stillbirth rate from 31.61 to 19.53.

PIP: In Malaysia, obstetricians compared 1989 and 1991 perinatal deaths at the Hospital University Sains Malaysia in Kelantan State, the state referral hospital and the only hospital in the state with a neonatal intensive care unit (NICU). There were 46.98% more deliveries in 1991 than in 1989 (7114 vs. 4840). Almost all neonatal deaths took place in the NICU. The perinatal mortality rate fell considerably from 41.32 to 24.88/1000 births, largely due to the declines in the early neonatal mortality rate (10.02-5.45) and the stillbirth rate (31.61-19.53). The rate of very low birth weight (VLBW) infants born increased 11.44% (6.82 vs. 7.5/1000 live births). Their survival rate increased only slightly (54.54-59.37%). Ventilation for VLBW infants suffering from birth asphyxia and meconium aspiration contributed greatly to improvements in survival (31.7% vs. 61.5%). A greater proportion of VLBW infants survived beyond 5 days in 1991 than in 1989 (61.4% vs. 80.2%). In 1991, sepsis was the most frequent cause of death (31.15%). Prematurity also contributed considerably to neonatal mortality. The cause of fetal death was unknown in most cases (51.08%). These findings suggest that better obstetrical management and better ventilatory management of meconium aspiration and birth asphyxia contributed largely to the marked improvement in neonatal survival.

Nutritional ocular diseases and their association with diarrhoea in Matlab, Bangladesh.

The prevalence of visual defects, especially from causes associated with nutritional deficiencies, and their relation to diarrhoea in rural Bangladesh have been studied. A trained physician and a team of health workers examined visual defects in 149 villages, with a total population of 182 976. According to WHO classification, night blindness (XN) was found in only 0.03 persons/1000 population and 0.04 were found to have conjunctival xerosis (XIA) and Bitot's spot (XIB). Corneal xerosis (X2, X3A, X3B) also was found in 0.04 persons/1000. Night blindness combined with conjunctival xerosis and Bitot's spot (XN + XIA + XIB) was present in 1.69 persons/1000 and all combined stages of active xerophthalmia were seen in 0.06 persons/1000. Xerophthalmia prevailed up to age 19 years. Males had a significantly higher (2.9) incidence/1000 than did females (1.2). The total rate of keratomalacial scar for all ages was 0.31 persons/1000, while corneal opacity from other causes was seen in 2.25 persons/1000 population. More than 2.06 persons/1000 had ocular manifestations of one or more vitamin A deficiencies, while 4.47 persons/1000 had other ocular diseases, except for cataracts. Only 12.0% of all the corneal scars (XS) were due to keratomalacia. History of night blindness is a good indicator of vitamin A deficiency. In 96% of cases, night blindness was associated with conjunctival xerosis and Bitot's spot (XN + XIA + XIB). The onset of approximately 86% of cases of corneal xerosis (X2, X3A, X3B) and night blindness associated with conjunctival xerosis and Bitot's spot (XN + XIA + XIB) was related to diarrhoea.

PIP: The prevalence of visual defects, especially from causes associated with nutritional deficiencies, and their relation to diarrhea in rual Bangladesh have been studied. A trained physician and a team of health workers examined visual defects in 149 villages with a total population of 182,976. According to the World Health Organization (WHO) classification, night blindness (XN) was found in only 0.03 persons/1000 population and 0.04 were found to have connjuctival xerosis (XIA) and Bitot's spot (XIB). Corneal xerosis (X2, X3A, X3B) also was found in 0.04 persons/1000. Night blindness combined with conjunctival xerosis and Bitot's spot (XN+XIA+XIB) was present in 1.69 persons/1000 and all combined stages of active xerophthalmia were seen in 0.06 persons/1000. Xerophthalmia prevailed up to age 19. Males had a signficantly higher (2.9) incidence/1000 than did females (1.2). The total rate of keratomalacial scar for all ages was 0.31 persons/1000, while corneal opacity from other causes was seen in 2.25 persons/1000 population. More than 2.06 persons/1000 had ocular manifestations of 1 or more vitamin A deficiencies, while 4.47 persons/1000 had other ocular disease except for cataracts. Only 12.0% of all corneal scars (XS) were due to keratomalacia. A history of XN is a good indicator of vitamin A deficiency. In 96% of the cases, XN was associated with XIA and XIB. The onset of about 86% of cases of corneal xeroses (X2, X3A, X3B) and XN associated with XIA and XIB was related to diarrhea.

Structural changes of horseradish peroxidase in presence of low concentrations of urea.

The presence of very low concentrations of the widely used denaturant urea induces structural changes in the monomeric heme-containing enzyme, horseradish peroxidase (HRP). Structural alterations in the protein were reflected in quenching studies of tryptophan fluorescence using the widely used quencher acrylamide. Stern-Volmer quenching constants measured in presence of urea, even in concentrations below 100 mm, were higher than those measured in absence of the denaturant. The fluorescence emission maximum of 1, 8-ANS, used as a probe for monitoring conformational changes in the enzyme, was blue-shifted from 530 nm in aqueous buffer to 518 nm when incorporated in native HRP. This blue shift increased further by 3 nm in presence of HRP preincubated with 100 mm urea, whereupon it steadily decreased with increasing urea concentration to become zero at 8 m urea. The mean fluorescence lifetime of 1,8-ANS incorporated in HRP was much higher than that of ANS in aqueous buffer, and showed continuous variation with the concentration of urea in which the enzyme was incubated. Systematic changes in the microenvironment of the heme moiety in HRP were also reflected in the visible CD spectra of the enzyme incubated with low concentrations of urea. These results are consistent with those of our earlier studies performed with the denaturant guanidinium chloride and indicate structural relaxation of HRP, with retention of enzymatic activity and native-like secondary structure, in presence of millimolar concentrations of urea.

Initiation of food supplements and stopping of breast-feeding as determinants of weanling shigellosis.

The association between the period elapsed since weaning and the risk of shigellosis was assessed between 1 November 1987 and 30 November 1989 for a cohort of 1085 Bangladeshi children aged < 3 years. The children were followed for 1 month after exposure to Shigella spp. in their residential neighbourhoods, and the 268 who developed microbiologically confirmed (n = 118) or clinically presumptive (n = 150) shigellosis were compared with the 817 control children who did not develop either syndrome. No increase in risk was noted among breast-fed infants who received food supplements within the previous 3 months compared with those who had received supplements for longer (adjusted odds ratio (OR) = 1.2; 95% confidence interval (CI) = 0.4-3.0). However, compared with breast-fed children, non-breast-fed children had an increased risk (adjusted OR = 2.0; 95% CI = 1.3-2.9; P < 0.001), which was largely attributable to a substantially increased risk in the 3 months after stopping breast-feeding (adjusted OR = 6.6; 95% CI = 2.9-14.6; P < 0.001). The early post-cessation risk was equivalent for confirmed and presumptive shigellosis, but was particularly pronounced among the severely malnourished (adjusted OR = 10.2; 95% CI = 3.1-33.3; P < 0.001). This complex temporal pattern of risk highlights the need for precise definitions of weaning to facilitate identification of children at high risk for invasive diarrhoeal syndromes.

PIP: Between November 1987 and November 1989, International Centre for Diarrhoeal Disease Research, Bangladesh, (ICDDR,B) scientists followed for 1 month 1085 children, younger than 3 years old, who lived in the Matlab. They compared data on the 268 children who developed microbiologically confirmed on clinically presumptive shigellosis during the 30-day period with data on 817 children who did not develop symptoms of shigellosis. Children who were not breast fed were at greater risk of shigellosis than those who were breast fed (adjusted odds ratio [AOR] = 2; p .001). This risk of shigellosis was much higher during the 1st 3 months after a child stopped breast feeding (AOR = 6.6; p .001) than it was 3 months after cessation of breast feeding (AOR = 1.4). Children who suffered from severe malnutrition were at an especially high post-cessation risk of shigellosis (AOR= 10.2; p .001). These findings show a complex evolution of risk with different stages of weaning, which emphasizes the need for a precise definition of weaning in epidemiologic studies. The limited period of high risk for shigellosis (i.e., the 1st 3 months after breast feeding cessation) and the wide range in ages at which children cease breast feeding elevates the complexity of executing successful vaccination programs against shigellosis, especially live oral vaccines. The vaccines must be administered early in life, before cessation of breast feeding, in order for them to protect against shigellosis. Yet, ingestion of breast milk may reduce the immunogenicity of the vaccines.

Management of isolated radial or ulnar arteries at the forearm.

The effects of management of single forearm arterial injuries without other associated major muscular, vascular, or neurological trauma were studied. Ninety-six patients with acute injuries to either radial or ulnar arteries without obvious associated major injuries were evaluated. No patient had an ischemic hand secondary to arterial injury. The selection of operative treatment by arterial repair or ligation was by surgeon choice (50 injuries were ligated, and 46 were repaired). Six months to six years postoperative follow-up was done. The overall patency rate for all repaired vessels was 52% (24 cases). The collateral arteries appeared to be a factor causing the low patency rate. The remaining intact artery demonstrated a consistent increase in flow velocity. No subject had hand claudication; there were 51 cases (53%) of hand weakness, 27 incidents (28%) of parasthesia, and 14 incidents (15%) of cold sensitivity independent of patency of the damaged forearm vessel. In the absence of acute hand ischemia, ligation of a lacerated radial or ulnar artery is safe and cost effective.