A prospective study on adult patients of severe malaria caused by Plasmodium falciparum, Plasmodium vivax and mixed infection from Bikaner, northwest India.

BACKGROUND & OBJECTIVES: Description of severe vivax malaria and mixed species infection requires good clinical study. The present study was undertaken to evalute the characteristics of severe malaria patients in Bikaner, northwest India. METHODS: This prospective study included 539 admitted adult patients of severe malaria (Plasmodium falciparum 274, P. vivax 221, and mixed infection of Pv + Pf 44). The diagnosis was confirmed by polymerase chain reaction. The categorization of severe malaria was done strictly as per WHO criteria. RESULTS: The distribution of severe manifestation was similar in severe vivax, falciparum and mixed infections except more cases of thrombocytopenia in P. vivax (p=0.030) and in mixed infection (p=0.004). The risk of developing severe malaria was greatest in patients of mixed infection [53.01% (44/83)] in comparison to Plasmodium falciparum malaria [49.37% (274/555), RR= 1.135; p=0.616] and P. vivax malaria [45.38% (221/ 487), RR = 1.299, p=0.243]. Hepatic dysfunction was the commonest pernicious syndrome [P. falciparum 50% (137/274), P. vivax 43.89% (97/221), and mixed infections 54.55% (24/44)]. Multiorgan dysfunction was present in 40.26% (217/539) patients, the risk was greatest in mixed infection [90.90% (40/44)] in comparison to P. falciparum monoinfection [37.59% (103/274), RR = 12.238; p=0.0001] or P. vivax monoinfection [33.48% (74/ 221), RR = 13.25; p=0.0001]. The risk of mortality in severe malaria was 6.31% (34/539) in which mixed infection had greater risk [9.09% (4/44)] in comparison to P. falciparum [7.30% (20/274); OR = 1.270 (CI 0.347-4.217); p=0.757] or P. vivax [4.52% (10/221); 0R 2.110 (CI 0.527-7.826); p=0.260]. INTERPRETATION & CONCLUSION: Severe vivax or falciparum malaria had almost similar features and prognosis including mortality. Risk of developing severe malaria, multiorgan dysfunction and mortality was more in patients of mixed infection in comparison to P. falciparum or P. vivax monoinfection. A multicentric study on larger number of patients requires further confirmation.

Clinical profiles of 13 children with Plasmodium vivax cerebral malaria.

BACKGROUND: Bikaner region is endemic for both P. vivax and P. falciparum malaria. Usually, cerebral malaria is caused by P. falciparum but it has been reported recently also in P. vivax mono-infection. Epidemiologic studies and clinical descriptions of P. vivax cerebral malaria in children are rare. AIMS: To describe the clinical features of PCR-confirmed cerebral malaria owing to P. vivax mono-infection and its clinico-laboratory profile in Bikaner, Northwest India. METHODS: This observational prospective study was based on detailed clinical and laboratory investigation of children admitted with cerebral malaria owing to P. vivax between November 2008 and December 2010. Cerebral malaria was categorised according to the WHO (2000) criteria for P. falciparum and the diagnosis of P. vivax mono-infection was established by peripheral blood film and rapid diagnostic tests and confirmed by polymerase chain reaction. The possibility of other diseases/infections causing similar illness were investigated thoroughly. RESULTS: Thirteen children with P. vivax cerebral malaria were studied, eight of whom (61·5%) had multi-organ (two or more organs) dysfunction. Other associated severe manifestations included severe anaemia (7), hepatic dysfunction (2), renal dysfunction (2), bleeding manifestation (2), respiratory distress (2), metabolic acidosis (2) and shock (one). Hypoglycaemia was not observed in any patient. There was no evidence of neurological sequelae. All the children were managed according to WHO guidelines using intravenous artisunate. Thrombocytopenia was detected in five and hyponatraemia in four children. CONCLUSION: P. vivax mono-infection can cause cerebral malaria and multi-organ dysfunction.

The Ebbinghaus retention curve: training does not increase the ability to apply pressure immobilisation in simulated snake bite--implications for snake bite first aid in the developing world.

Pressure immobilisation (PIM) has been recommended for field management of bites by some venomous snakes. A narrow range of pressures under the encompassing wrap is necessary for PIM to limit venom spread. This study sought to evaluate the effect of focused training on volunteers' ability to apply PIM and to retain such skill over time. Forty volunteers were randomly divided into two groups: Group 1 (N=20; controls) received standard written instructions in PIM application; and Group 2 (N=20) received focused instruction during a 4-h training session (including hands-on practice and real-time feedback regarding pressures achieved). After voicing confidence with the technique, volunteers were tested at 1h, 1 day, 3 days and 3 months post training. One-hour post training, no volunteers in the control group were successful in applying PIM with the correct pressure. Twelve volunteers (60%) in Group 2 achieved target pressures 1h after training. However, there was rapid loss of ability to apply PIM correctly by Group 2, falling to just 25% success at 3 days, with little further deterioration at 3 months. Neither written instructions nor intense training with feedback adequately prepares individuals to apply PIM with correct pressures under the wrap.

Glyceryl trinitrate spray in the management of painful diabetic neuropathy: a randomized double blind placebo controlled cross-over study.

OBJECTIVES: Various drugs are effective in the management of painful diabetic neuropathy, but none is completely satisfactory. The objective of this study is to test the effectiveness and safety aspect of glyceryl trinitrate (GTN) in the management of painful diabetic neuropathy as a nitric oxide (NO) donor with local vasodilating properties in spray form. DESIGN: Randomized double blind placebo controlled cross-over study. METHODS: Fifty patients with painful diabetic neuropathy (type 2) were screened consecutively, out of which two were excluded (1 with HbA(1)c>11 and one withdrew his consent). The remaining 48 were given either drug (group A) or placebo (group B) in the first phase. After thorough clinical assessment in the first phase, quantitative assessment of pain was done by McGill Pain Questionnaire, Visual Analogue Score, Present Pain Intensity and 11 point Lickerts Scale, at the beginning and after 4 weeks, followed by 2 weeks wash out period and thereafter receiving 4 weeks of cross-over regimen. Adverse drug effects were assessed periodically. RESULTS: Of the 48 patients, five dropped out, two in group A and three in group B. Both groups A and B experienced significant improvement in pain score in their drug phase of trial, when compared to placebo phase of other group (p<0.001). After crossing over the treatment arm, patients of group B observed significant improvement in all pain scores compared to group A (p<0.001). The numbers needed to treat (NNT) calculated on VAS as pain parameters came out to be 4. The drug was well tolerated by all the patients except palpitation and headache for some days in five patients. CONCLUSION: GTN spray, a well tolerated drug, provides significant improvement in painful diabetic neuropathy. These data provide a basis for future trials for longer duration in a larger group of patients.

Zero prevalence of diabetes in camel milk consuming Raica community of north-west Rajasthan, India.

OBJECTIVES: Preliminary trials reflected the low prevalence of diabetes in Raica community consuming camel milk habitually. Our objective was to describe the prevalence and clinical factors associated with impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and diabetes (DM) among adults (>or=20 years) in large population group. DESIGN: Population based, cross sectional study METHODS: 2099 participants from different villages of north-west Rajasthan were selected using stratified sampling of a representative Raica and non-Raica Community, consuming or not consuming camel milk. Demographic, clinical, anthropometric parameters were obtained and oral glucose tolerance tests were performed in all individuals to diagnose IFG, IGT and DM. Associations were investigated using multivariate logistic regression using SPSS Version 10.0. RESULTS: In the present study, the prevalence of diabetes in Raica community consuming camel milk (RCCM, n=501) was 0%; Raica community not consuming camel milk (RCNCM, n=554) was 0.7%; non-Raica community consuming milk (NRCCM, n=515) was 0.4% and non-Raica community not consuming camel milk (NRCNCM, n=529) was 5.5%. Stepwise logistic regression analysis showed that consumption of camel milk was statistically highly significant as protective factor for diabetes. Multiple logistic regression analysis revealed that camel milk consumption and community factor were associated with decreased prevalence of diabetes. CONCLUSION: Camel milk consumption and lifestyle have definite influence on prevalence of diabetes. Hence, adopting such life pattern may play protective role in preventing diabetes to some extent.

Hospital-based case series of 175 cases of serologically confirmed brucellosis in Bikaner.

OBJECTIVE: To study the clinical spectrum of brucellosis in Bikaner (Northwest India). METHODS: A total of 175 cases were diagnosed as brucellosis during the period of six year (June 1997 to May 2003). They were studied for clinical profile and treated by rifampicin and doxycyclin and additionally streptomycin for initial 14 days in patients of neurobrucellosis. These patients were followed up to 3 months. RESULTS: Patients of brucellosis presented with a wide spectrum of clinical manifestations. Out of 175 cases 155 were from rural area. Age ranged between 12-60 years (124 males, 51 females). Analysis of risk factors revealed history of raw milk ingestion (86.86%), occupational contact with animals (81.14%), handling of infected material (62.28%), household contact (16%) and 2 patients were veterinarian. Joint pain (83.43%) and fever (77.71%) were the commonest presenting feature. Sacroiliac joint was most commonly involved (46.86%). 31 cases had involvement of multiple joints. Other mode of presentation were neurobrucellosis (18.86%), manifested as polyradiculoneuropathy, myeloradiculopathy, meningoencephalopathy and polyradiculomyeloencephalopathy; predominant pulmonary involvement (4.0%) presented as bronchitis, pneumonia and pleural effusion; epididymoorchitis, infective endocarditis, nephrotic syndrome and recurrent abortion. All patients responded well to the treatment. CONCLUSION: Brucellosis is an important emerging zoonotic disease but it is often under-diagnosed due to lack of suspicion and diagnostic facilities despite the fact that cattle farming (an important high risk group) is one of the main occupation in rural area. This report should infuse the awareness about this reemerging disease specifically in high-risk group.

Magnitude of dyslipedemia and its association with micro and macro vascular complications in type 2 diabetes: a hospital based study from Bikaner (Northwest India).

AIM: Type 2 diabetes is not only associated with hyperglycemia but also with disorders of lipid metabolism. The aim of this study was to investigate the association of dyslipedemia with micro and macro vascular complications of diabetes. METHODS: Population based cross sectional study included 4067 diabetic patients who visited hospital during January 2000 to December 2002. Lipid profile was estimated by semi autoanalyser, Retinopathy was assessed by fundoscopy, Nephropathy by microalbuminurea, coronary artery disease (CAD) by electro cardiogram (ECG) changes, peripheral vascular disease (PVD) by doppler study and neuropathy by clinical examinations. The association of dyslipedemia with micro and macro vascular complications was assessed by regression analysis. RESULTS: The prevalence of dyslipedemia is high in diabetic population with high serum cholesterol >240mg/dl was seen in 15%, serum triglycerides >160mg/dl was seen in 42.41%, raised LDL >130mg/dl in 45.26%, VLDL >40mg/dl in 24.09% and low levels of HDL-C <40mg/dl were seen in 52.27%. On regression analysis, CAD had strong correlation with high levels of VLDL (0.76), triglycerides (0.82), LDL (0.23) and low HDL (-0.81). Similar association was seen with PVD. Diabetic retinopathy and nephropathy were found to have significant correlation with low HDL (-0.43) and raised LDL (0.37), respectively. Neuropathy was not found to have any significant correlation with lipid profile abnormalities. CONCLUSION: Lipid profile abnormalities are very common in type 2 diabetes and it has great influence on CAD and PVD. Hence, appropriate preventive and treatment strategies should be considered timely.

The changing spectrum of severe falciparum malaria: a clinical study from Bikaner (northwest India).

BACKGROUND & OBJECTIVES: Recently there were reports from all over India about changing spectrum of clinical presentation of severe malaria. The present study was planned to study the same in the northwest India. METHODS: This prospective study was conducted on patients of severe malaria admitted in a classified malaria ward of a tertiary care hospital in Bikaner, Rajasthan (northwest India) during 1994 and 2001. It included adult patients of both sexes belonging to all age groups. The diagnosis of Plasmodium falciparum was confirmed by demonstrating asexual form of parasites in peripheral blood smear. All patients were treated with i.v./oral quinine. The specific complications were treated by standard WHO protocol. The data for individual complications for both the years were analysed by applying chi-square test. RESULTS: In a prospective study in 1994 the spectrum of complication was dominated by cerebral malaria (25.75%) followed by jaundice (11.47%), bleeding tendencies (9.59%), severe anaemia (5.83%), shock (5.26%), Acute respiratory distress syndrome-ARDS (3.01%), renal failure (2.07%) and hypoglycemia (2.07%) whereas in 2001 it was dominated by jaundice (58.85%) followed by severe anaemia (26.04%), bleeding tendencies (25.52%), shock (10.94%), cerebral malaria (10.94%), renal failure (6.25%), ARDS (2.08%) and hypoglycemia (1.56%). The sharp difference for presence of jaundice and severe anaemia in 2001 and cerebral malaria in 1994 was statistically significant. Similarly, the important cause of mortality in 2001 was multiple organ dysfunction syndrome (71.10%) with predominant presentation of jaundice and renal failure, whereas in 1994, it was cerebral malaria (77.96%). INTERPRETATION & CONCLUSION: The observation of changing spectrum of severe malaria in this study and a significant increase in presentation with jaundice as an important manifestation is highly essential for primary, secondary and tertiary level health care providers for proper diagnosis and management.

A comparative study of regression of jaundice in patients of malaria and acute viral hepatitis.

BACKGROUND & OBJECTIVES: Jaundice is one of the common manifestations of severe malaria in adults. The purpose of this study is to compare the pattern of clinical and biochemical parameters such as serum bilirubin and liver enzyme levels in patients of malaria with jaundice and acute viral hepatitis. METHODOLOGY: The present study was conducted on 34 patients of malaria with jaundice and 15 patients of acute viral hepatitis. Estimation of serum bilirubin, aspartate amino transferase (AST), alanine amino transferase (ALT) and alkaline phosphatase was done daily using standard procedures in malaria patients and weekly in acute viral hepatitis patients. RESULTS: Mean level of serum bilirubin on first day in malaria and acute viral hepatitis patients was 7.07 +/- 3.94 and 10.38 +/- 7.87 mg%, whereas on Day 8 it was 1.19 +/- 1.43 and 7.88 +/- 7.02 mg% respectively. Mean level of AST on Day 1 in malaria and acute viral hepatitis patients was 158.47 +/- 120.35 and 1418.6 +/- 834.11 IU/L, whereas on Day 8 it was 41 +/- 28.33 and 775.3 +/- 399.01 IU/L respectively. Mean level of ALT on Day 1 in malaria and acute viral hepatitis patients was 220.14 +/- 145.61 and 1666.67 +/- 1112.77 IU/L, whereas on Day 8 it was 50.85 +/- 37.31 and 823.8 +/- 475.06 IU/L respectively. Mean level of serum alkaline phosphatase on Day 1 in malaria and acute viral hepatitis patients was 394.74 +/- 267.78 and 513.4 +/- 324.7 IU/L, whereas on Day 8 it was 84.76 +/- 68.50 and 369.27 +/- 207.75 IU/L respectively. INTERPRETATION & CONCLUSION: We observed that resolution of jaundice in malaria took 1-2 weeks in contrast 6 to 8 weeks in viral hepatitis. This difference in duration was statistically significant. Thus, jaundice not resolving in 1-2 weeks time in a patient of malaria requires serious consideration for presence of other concomitant diseases including viral hepatitis.

A double blind, randomised placebo controlled trial of rifampicin with omeprazole in the treatment of human cutaneous leishmaniasis.

BACKGROUND & OBJECTIVES: This study was conducted on 50 patients of Anthroponotic cutaneous leishmaniasis (oriental sore) to assess the efficacy of rifampicin and omeprazole through a double blind, randomised placebo control study. METHODS: The diagnosis of Anthroponotic cutaneous leishmaniasis (ACL) caused by Leishmania tropica was done by demonstration of Leishmania tropica (LT) bodies from the painless, dry ulcerative lesion. Each patient was assessed clinically in the beginning of the study, at the end of 2,4 and 6 weeks and all observations were compared in both the groups. Twenty-five patients received rifampicin with omeprazole (Group A) whereas other 25 patients received placebo (Group B) for a period of six weeks. RESULTS: Altogether 23 cases in group Aand 21 cases in group B completed the study. About 16 (69.7%) cases in group A and 3 (14.29%) cases in group B had complete healing, whereas 3 patients (13.04%) of group A and 4 patients (19.05%) of group B had partial response and 4 patients (17.93%) of group A and 14 patients (66.67%) of group B had no response at the end of study. The difference of two groups was statistically highly significant (p < 0.00025). All patients tolerated the drug and placebo very well and no side effect was reported. INTERPRETATION & CONCLUSION: In our opinion rifampicin and omeprazole is a highly effective, less toxic and cheaper alternative for the management of cutaneous leishmaniasis.

Divalproex sodium in the management of post-herpetic neuralgia: a randomized double-blind placebo-controlled study.

BACKGROUND: Post-herpetic neuralgia is difficult to treat. Divalproex sodium (valproic acid and sodium valproate in molar ratio 1:1) has been used successfully in the management of various painful neuropathies. AIM: To study the effectiveness and safety of divalproex sodium in the management of post-herpetic neuralgia. DESIGN: Randomized double-blind placebo-controlled trial. METHODS: We enrolled 48 consecutively attending out-patients with post-herpetic neuralgia, out of whom three were excluded (two had insufficient pain, one withdrew consent). Quantification of pain was by Short Form-McGill pain questionnaire (SF-MPQ), visual analogue scale (VAS), present pain intensity score (PPI) and 11 point Likert scale (11 PLS) at the beginning of the study, after 2 weeks, 4 weeks and at the end of the study (8 weeks). We also assessed patients' global impression of change by questionnaire at the end of the study. RESULTS: After 8 weeks treatment with 1000 mg/day divalproex sodium, there was significant reduction in pain: SF-MPQ, 20.47 +/- 2.29 to 11.90 +/- 6.52 (p < 0.0001); PPI 4.0 +/- 0.52 to 1.95 +/- 1.29 (p < 0.0001); VAS 70.17 +/- 9.21 to 31.27 +/- 29.74 (p < 0.0001) and 11 PLS 6.97 +/- 0.73 to 3.63 +/- 2.34 (p < 0.0001) in comparison to placebo (means +/- SEM). The 'global impression of change' questionnaire showed much or moderate improvement in pain in 58.2% of patients receiving divalproex vs. 14.8% of those receiving placebo. The drug was well tolerated by all patients, except one who developed severe vertigo after 10 days of treatment. DISCUSSION: Divalproex sodium provides significant pain relief in patients of post-herpetic neuralgia, with very little incidence of adverse reactions. These data provide a basis for longer trials in a larger group of patients.

Ophthalmoscopic abnormalities in adults with falciparum malaria.

We studied 424 adults with falciparum malaria admitted over 28 months. They were divided into three groups: cerebral malaria (n = 214); severe non-cerebral malaria (n = 58); and uncomplicated malaria (n = 152). Fundus examination was done daily from admission to discharge, and weekly thereafter in those with persistent changes. All patients were treated by a protocol based on WHO guidelines. Ophthalmoscopic abnormalities were: retinal haemorrhages, 40 (9.43%) (25 cerebral malaria, 10 severe non-cerebral and five uncomplicated malaria); papilloedema, 17 (7.94%) cerebral malaria and two uncomplicated malaria; blurring of disc margins, 25 (11.68%) cerebral and seven non-cerebral; retinal oedema, six (2.80%) cerebral and five non-cerebral malaria; disc pallor, five patients all with cerebral malaria; vitreous haemorrhage and hard exudate in one patient each, both cerebral malaria. Retinal haemorrhage was associated with cerebral malaria and severe non-cerebral malaria, especially with severe anaemia (p < 0.001), as compared to uncomplicated malaria (p < 0.01). The association of papilloedema and cerebral malaria was highly significant compared to severe non-cerebral malaria (p < 0.001). None of these findings was associated with statistically significant mortality, except disc pallor in cerebral malaria (p < 0.05).

Sodium valproate for painful diabetic neuropathy: a randomized double-blind placebo-controlled study.

BACKGROUND: Various drugs are effective in the management of painful diabetic neuropathy, but none is completely satisfactory. We previously found sodium valproate to be effective and safe in a short-term study. AIM: To test the effectiveness and safety of sodium valproate in the management of painful diabetic neuropathy over 3 months. DESIGN: Randomized double-blind placebo-controlled study. METHODS: Consecutive attending patients with type 2 diabetes mellitus with painful neuropathy were asked to participate in the trial: 48 agreed. Five were excluded: three with HbA(1c) > 11, one with too low a pain level and one who withdrew consent. The remaining 43 were given either drug (group A) or placebo (group B). Each patient was assessed clinically. Quantitative assessment of pain was done by McGill Pain Questionnaire, Visual Analogue Score and Present Pain Intensity, at the beginning of the study, after 1 month and after 3 months. Motor and sensory nerve conduction velocities were measured initially and after 3 months. Liver function tests and other adverse drug-related effects were assessed periodically. RESULTS: Of the 43 patients, four dropped out: one in group A and three in group B. There was significant improvement in pain score in group A, compared to group B, at 3 months (p < 0.001). Changes in electrophysiological data were not significant. The drug was well-tolerated by all patients, except one, who had raised serum AST and ALT levels after 1 month of treatment, and whose treatment was discontinued. DISCUSSION: Sodium valproate is well-tolerated, and provides significant subjective improvement in painful diabetic neuropathy.

Hepatocyte dysfunction and hepatic encephalopathy in Plasmodium falciparum malaria.

BACKGROUND: According to the WHO, signs of hepatic dysfunction are unusual, and hepatic encephalopathy is never seen in malaria. However, in recent years, isolated cases have been reported from different parts of world. AIM: To identify the evidence for hepatocyte dysfunction and/or encephalopathy in jaundiced patients with falciparum malaria. DESIGN: Prospective observational study. METHODS: We studied 86 adult patients of both sexes who had malaria with jaundice (serum bilirubin > 3 mg%). The main outcome measures were: flapping tremor, deranged psychometric test, level of consciousness, serum bilirubin level, serum aspartate transaminase (AST) and alanine transaminase (ALT) levels, blood ammonia level, viral markers for hepatitis, ultrasonography of liver and gall bladder and electroencephalography (EEG). RESULTS: The range of serum bilirubin was 3-48.2 mg% (mean +/- SD 10.44 +/- 8.71 mg%). The ranges of AST and ALT levels were 40-1120 IU/l (294.47 +/- 250.67 IU/l) and 40-1245 IU/l (371.12 +/- 296.76 IU/l), respectively. Evidence of hepatic encephalopathy was seen in 15 patients. Asterexis was observed in 9 patients, impaired psychometric tests in 12 and altered mental state in 13. Arterial blood ammonia level was 120-427 meq/l (310 +/- 98.39 meq/l). EEG findings included presence of large bilateral synchronous slow waves, pseudo burst suppression and triphasic waves. Four patients died due to multiple organ dysfunction; the others made rapid recoveries. DISCUSSION: There is strong evidence of hepatocyte dysfunction and hepatic encephalopathy in some of these patients, with no obvious non-malarial explanation. Current guidelines may need to be revised.

The role of rifampicin in the management of cutaneous leishmaniasis.

We assessed the efficacy of rifampicin in the treatment of cutaneous leishmaniasis (oriental sore) using a double-blind placebo-controlled study. We studied 46 patients with cutaneous leishmaniasis, of whom 23 received rifampicin (group A) and another 23 received placebo (group B) for a period of 4 weeks. Each patient was assessed clinically for size of lesion, type of lesion, duration of lesion, number of lesions, and distribution of lesions, initially, and at the end of 1 week, 2 weeks and 4 weeks. Biochemical tests including enzyme studies were done to detect any toxic effects of the drug. Group A patients received rifampicin 1200 mg/day in two divided doses and group B patients received two doses of an identical placebo capsule. Seventeen (73.9%) of the 23 patients receiving rifampicin had complete healing. Two (8.6%) had partial healing and four (17.3%) showed no response, whereas out of 23 patients receiving placebo one patient (4.3%) showed complete healing, eight (34.7%) patients showed partial healing and 14 (60. 98%) patients showed no healing or exacerbation of lesion. The difference was statistically significant in favour of response to rifampicin. This dose of rifampicin was well-tolerated and no side-effects were seen in any patient. In cases of cutaneous leishmaniasis where injectable treatment is not feasible or not acceptable, as in cases of multiple lesions, rifampicin is a better alternative oral treatment. It is simple to administer, cheap, more effective and less toxic than other available oral drugs, and well-tolerated by patients.

Cardiac autonomic neuropathy and its correlation with QTc dispersion in type 2 diabetes.

This study was conducted on 50 patients of diabetes mellitus type 2 and 20 healthy controls to correlate severity of diabetic cardiac autonomic neuropathy with QTc interval and QTc dispersion. Five standard cardiovascular response tests were carried out (i.e. Valsalva ratio, expiration-inspiration ratio, immediate heart rate response to standing, fall of systolic blood pressure on standing and sustained hand grip test) to determine the severity of cardiac autonomic neuropathy by scoring system. QTc dispersion was determined by subtracting heart rate-corrected minimum QTc interval (QTc min) from maximum QT interval (QTc max) from standard electrocardiogram. Severity of cardiac autonomic neuropathy strongly correlated with QTc dispersion (r = 0.760; p = 0.0001). Correlation of severity of cardiac autonomic neuropathy with QTc max and QTc mean was also found but weaker than with QTc dispersion (r = 0.663, r = 0.542, p = 0.0001 each) and no correlation was found with QTc min (r = 0.177; p = 0.17). This shows that QTc dispersion is a better predictor of cardiac autonomic neuropathy than any of above three QTc intervals. QTc max, QTc mean and QTc dispersion were significantly higher (p < 0.001) in diabetics with autonomic neuropathy (450 +/- 23, 423 +/- 22 and 57 +/- 12 msec; n = 30) than without neuropathy (407 +/- 14, 397 +/- 15 and 20 +/- 7 msec; n = 20) and control subjects (408 +/- 20, 399 +/- 19 and 19 +/- 7 msec; n = 20) but QTc min remained same in the three groups (393 +/- 21, 387 +/- 12, 388 +/- 19 msec, respectively) (p > 0.05). Correlation of QTc dispersion was stronger with QTc max (r = 0.781; p < 0.001) than QTc mean (r = 0.625; p = 0.001) but not with QTc min (r = 0.097; p = 1.0) which suggests that regional increase in QT interval due to regional autonomic denervation leads to increased QTc dispersion. Thus, QTc dispersion is a sensitive, non-invasive, simple and cost-effective predictor of cardiac dysautonomia.

Extraintestinal manifestations of idiopathic ulcerative colitis in northwestern India.

OBJECTIVE: To determine the frequency of extraintestinal manifestations in patients with idiopathic ulcerative colitis. METHODS: 46 patients underwent detailed clinical, biochemical and radiological evaluation. RESULTS: One patient (2%) had peripheral arthritis and two patients (4%) had ocular involvement in the form of anterior uveitis. No patient had mucocutaneous, vascular, or hepatobiliary manifestations, or sacroiliitis. CONCLUSIONS: The frequency of extraintestinal manifestations in patients with IUC in northwestern India is low.

Somatosensory evoked potentials (SSEPs); sensory nerve conduction velocity (SNCV) and motor nerve conduction velocity (MNCV) in chronic renal failure.

Somatosensory evoked potentials, sensory and motor nerve conduction velocity were studied in 25 patients of chronic renal failure and the results were compared with 15 healthy persons. The values more than +/- 3 S.D. were considered abnormal. SNCV was reduced in 11/25 patients; average reduction being 18 m/s (highly significant, p < 0.001); MNCV was reduced in 11/25 patients, average reduction being 20 m/s (highly significant, p < 0.001). Both SNCV and MNCV in same person were reduced in 6/25 patients. In SSEP N9, N13 and N20 were delayed in almost all the patients (highly significant, p < 0.001). Amplitude of N20 and N13 were reduced in 1 and 4 patients respectively but amplitude of N9 was normal. Out of different IPLS, Ebw-N9 was delayed in 5/25 patients (p < 0.9, insignificant); N9-N13 was delayed in 8/25 patients (p < 0.001, highly significant); N13-N20 was delayed in 1/25 patients (p < 0.01, significant). The evidence of these neurophysiological abnormalities collectively suggest the presence of central-peripheral axonopathy in this disease.

Somatosensory evoked potentials in cerebral malaria. A preliminary study.

Somatosensory evoked potentials were recorded in patients of cerebral malaria by (R) median nerve stimulation. Important observations of this study were delayed absolute latency of N20, increased N13-N20 IPL i.e. central conduction time and distorted and dispersed waveforms of N9 and N20 peaks. The possible pathologic mechanism is discussed.