Clinical Profile of Multiorgan Involvement in Malaria.

Background and aims: In view of high incidence, increasing morbidity and mortality due to malaria in an endemic area like Bikaner, it was planned to study the clinical profile of multiorgan involvement in Plasmodium vivax, Plasmodium falciparum and mixed type of malaria. Material and methods: Prospective data were collected from 201 adult patients with multiorgan involvement, admitted in classified malaria ward and confirmed by asexual parasitemia in peripheral blood film. Results: Prevalence of renal failure was 57.7%, cerebral malaria 47.8%, jaundice 41.8%, severe anemia (hemoglobin [Hb] ≤5 g/dl) in 31.8%, severe thrombocytopenia, shock, septicemia in 19.9%, 12.4%, 8.96%, respectively. Out of this P. vivax was associated with renal failure in 10.4%, with cerebral malaria in 7.46%, with jaundice in 9.5% and with severe anemia in 3.5%. Multiorgan dysfunction was a major cause of death in 25.87% patients (18.4%, P. falciparum 6%, P. vivax 1.5%, mixed). Acute respiratory distress syndrome (ARDS) was found in 14 (7%) of patients out of which 13 expired. Conclusion: P. vivax which was previously considered to be benign, has now turned to be malignant. ARDS came out with the worst outcome. Early institution of dialysis and use of antimalarial drugs aggressively can result in better prognosis.

Mucoadhesive Polymeric Hydrogels for Nasal Delivery of Penciclovir.

The study evaluated different mucoadhesive polymeric hydrogels for nasal delivery of penciclovir . Gels containing poly-N-vinyl-2-pyrrolidone (PVP) were prepared with crosslinking achieved by irradiation with a radiation dose of 15 kGy being as efficient as 20 kGy. Gels containing chitosan and carbopol were also evaluated. The mucoadhesive properties of gels were measured by a modification of a classical tensile experiment, employing a tensile tester and using freshly excised sheep nasal mucosa. Considering the mucoadhesive force, chitosan gel and gel prepared with 3% PVP in presence of polyethylene glycol (PEG) 600 were the most efficient. The in vitro drug release depended on the gel composition. Higher release rates were obtained from PVP gels compared to chitosan or carbopol gels. The release rate of drug from PVP gels was increased further in presence of PEG or glycerol. Histopathological investigations proved that the PVP was a safe hydrogel to be used for mucosal delivery. The PEG in gel formulations caused less damages to the nasal mucosal compared to formulation containing glycerol.

Evaluation of antibiotic sensitivity pattern in cases of enteric fever in north west Rajasthan.

A total of 50 cases of blood culture proved enteric fever were studied for clinical response to the treatment and compared with in vivo antibiotic sensitivity pattern. Out of 50 Salmonella strains isolated, 37 were S typhi and 13 S paratyphi A. All S typhi isolates were sensitive in vitro to gentamicin and ceftriaxone while sensitivity to ciprofloxacin was 73%, ampicillin 29.7%, chloromphenicol 27%, tetracycline 27% and co-trimoxazole 13.5%. Multidrug resistance (Ampicillin, Chloramphenicol, Cotrimoxazale and Tetracycline) was observed in 62% isolates. All Sparatyphi A isolates were sensitive to all the antibiotics. Clinical response to the antibiotic therapy was as follows: Group I--Ampicillin + Gentamicin: 15 cases, clinical response (CR), 9.1% (S typhi) and 75% (S paratyphi A), mean day of defervescence 5.33 days. Group II--Ciprofloxacin: 29 cases, clinical response 47.6% (S typhi) and 75% (S paratyphi A), mean day of defervescence--5.22 days. Group--III Ceftriaxone: 30 cases, clinical response 100% in all, mean day of defervescence--4.93 days. Thus we observed highly significant discrepancy in antibiotic sensitivity pattern of the isolates and clinical response. Most importantly we observed significantly delayed clinical response to the ceftriaxone. This may be indicative of evolving resistance to ceftriaxone.

Atherosclerotic risk factors in adolescents.

METHODS: We studied 200 school going children age ranging 12-18 yr with regard to their nutritional intake, family history, anthropometric measurements, blood pressure and lipid profile. RESULTS: It was observed that adolescents received less energy from carbohydrates and more from fats in comparison to the recommended standard. Sodium intake was found to be very high whereas fibre intake was low. The prevalence of hypertension was 1.5% and hypercholesterolemia 50%. The high prevalence of hypercholesterolemia was related mainly to dietary habits of these children. Thus our study shows that for the prevention of adult atherosclerotic cardiovascular disease in Indian population measures are urgently needed towards behavioral and life style modification including change in dietary habits.

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.

Cardiovascular risk factors in tobacco-chewers: a controlled study.

BACKGROUND : Influence of habitual tobacco chewing on cardiovascular risk has not been well studied. To determine prevalence of major cardiovascular risk factors in subjects who habitually chew tobacco we performed a controlled study. METHODS : A population based case-control study was performed in Bikaner in North-western India where the prevalence of tobacco-chewing is high. Successive 200 subjects who agreed to participate in the evaluation and had a history of isolated tobacco-chewing (range 10-60 years) were enrolled (Group III). The prevalence of major coronary risk factors- obesity, truncal obesity, hypertension, fasting hyperglycemia, and lipid levels were estimated using current guidelines. Electrocardiogram was also performed in all subjects. Chest radiography and treadmill stress test was done in subjects when indicated by symptoms. 200 age- and gender-matched controls who did not use tobacco in any form (Group I) and 200 subjects who had history of smoking bidis or cigarettes for more than 10 years (range 10-55 years) (Group II) were also evaluated. RESULTS: The body-mass index and obesity were lowest in smoker group. Tobacco chewers had a significantly higher (p<0.001) systolic blood pressure (BP), diastolic BP, resting heart rate, total cholesterol, LDL cholesterol and triglycerides as compared to controls and was similar to smoker group. There was a significantly greater (p<0.01) prevalence of hypertension, hypercholesterolemia, hypertriglyceridemia, radiographic cardiomegaly and positive stress test in Group III as compared to controls. Prevalence of these risk factors was similar among Group II and Group III subjects. HDL cholesterol levels were the lowest in tobacco-chewing group (44.3+/-8.1 mg/dl) as compared to the Group I (48.4+/-7.8) and Group II (47.4+/-7.5) (p<0.001). CONCLUSIONS : There is a significantly greater prevalence of multiple cardiovascular risk factors obesity, resting tachycardia, hypertension, high total and LDL cholesterol, and low HDL cholesterol, and electrocardiographic changes in tobacco users, chewing or smoking, as compared-to tobacco non-users. Chewing tobacco is associated with similar cardiovascular risk as smoking.

Prevalence of rheumatic heart disease in school children in Bikaner: an echocardiographic study.

OBJECTIVE: To determine prevalence of rheumatic heart disease (RHD) using clinical and echocardiographic criteria and to study influence of socioeconomic status (SES) we studied school children in a north-western Indian town. METHODS: 3292 school children, age range 5-14 years, in two private schools, ten middle SES government schools and six low SES government schools were invited to participate in the study. 3002 (1837 boys, 1165 girls) were clinically examined (response 91%) of which 1042 were in private schools, 1002 in middle SES schools and 958 in low SES schools. Prevalence of cardiac murmurs and RHD based on clinical diagnosis was determined in school by a trained team of physicians. Those with a murmur were further evaluated by Doppler-echocardiography in the hospital. Group-specific and age-specific rates (prevalence/thousand) of murmurs and cardiac lesions were determined. RESULTS: A significant cardiac murmur was observed in 55 subjects (18.3/1000) with similar prevalence in boys (20.7) and girls (14.6). The prevalence of murmur was significantly greater in children belonging to low SES schools (29.2/1000) as compared to middle SES (18.9) and higher SES schools (7.6). RHD prevalence based on clinical diagnosis was observed in 50 children (16.7/1000) and was similar in boys (19.1) and girls (12.9). Clinical RHD was more in the low SES school children (28.2/1000) as compared to middle (17.0) and high SES schools (5.8). RHD was demonstrated on echocardiography in 2 children (0.67/1000). Other prevalent cardiac lesions were congenital heart disease in 5 (1.66/1000) and mitral valve prolapse in 37 (12.3/1000). CONCLUSIONS: There is a low prevalence of RHD in school children in this region compared to previous Indian studies. Cardiac murmurs are more prevalent among low SES children.

Dexamethasone therapy for bacterial meningitis in adults: a double blind placebo control study.

Routine use of steroids in the treatment of bacterial meningitis remains controversial. A prospective placebo controlled double blind study of dexamethasone was carried out in 40 patients (age>10 years) of acute bacterial meningitis. The patients were randomly assigned to receive either placebo (n=20) or dexamethasone (n=20) in addition to injection ceftriaxone 100 mg/kg/day (maximum 4 gm/day) for 14 days. Dexamethasone sodium phosphate was given in dose of 0.6 mg/kg/day in 4 divided doses, for first 4 days of therapy. First dose of dexamethasone was given 15 minutes prior to first dose of ceftriaxone. Baseline demographics, clinical and laboratory features of the two groups were similar. Clinical improvement of signs of meningeal irritation was rapid in dexamethasone group than in the placebo group, but no significant difference was observed regarding resolution of fever, headache and vomiting. Secondary fever (mean+/-SD 15.00), gastrointestinal tract bleeding (mean+/-SD 15.00) and psychiatric manifestations (mean+/-SD 10.00) were more common in dexamethasone group. Neurological complications and hearing loss were more common and severe in placebo group as compared to the dexamethasone group (p<0.05). It is concluded that dexamethasone may be beneficial in some aspects of bacterial meningitis, in adults. A study with a larger number of cases in each group is recommended.

Outbreak of polyarthritis with pyrexia in Western Rajasthan.

AIM: To establish the etiology of recent out break of polyarthritis which occurred in Kanvari village of Churu district of Rajasthan in August, 1999. METHODOLOGY: Forty eight patients of polyarthritis were studied by Hb, TDLC, ESR, CRP, throat swab Gram's stain and culture, blood culture, ASO titer, rheumatoid factor, Rose Bengal plate agglutination test, standard tube agglutination test for brucellosis, widal test, urine examination, X-ray chest, ECG and X-ray of the affected joint. RESULTS: Forty eight patients presented with acute polyarthritis with low grade fever of 1-2 week duration. Most common joint involved was sacroiliac joint (52.08%). Most of patients had multiple joint involvement (93.75%). The Rose Bengal plate agglutination test and standard tube agglutination test for brucella were positive in high titres in 44 (91.60%) patients. All the patients were treated with therapy for brucellosis and followed up for 12 weeks and responded well without complications. CONCLUSION: In case of polyarthritis possibility of brucellosis should always be kept in mind.

The role of Gardnerella vaginalis in nonspecific vaginitis in intra uterine contraceptive device users.

Two Hundred Forty patients who had Intra Uterine Contraceptive Device (IUCD) and manifested of nonspecific vaginitis were investigated for the presence of G. vaginalis. Pure growth of this organism was obtained in 14(5.8%) cases while 116(48.3%) cases showed this organism in association with other organisms e.g. Esch. coli (11.7%), Klebsiella (9.2%), Candida (9.2%), Strept. faecalis (7.3%), Proteus species (5.8%) and Staph. albus (5%).

Thrombolytic therapy for prosthetic valve thrombosis in Third World countries.

In order to clarify the role of thrombolytic therapy for treatment of prosthetic valve thrombosis, all cases admitted in the intensive care unit (ICU), between March 1987 and March 1997 with the diagnosis of prosthetic valve thrombosis and treated with streptokinase, were analysed. In total, 42 patients with clinical and echocardiographic evidence of left side tilting disc prosthetic valve thrombosis were treated. All the patients had only mitral valve prosthesis involvement. Streptokinase was administered as a bolus of 2.5 lac units over 30 minutes followed by 1 lac units/hour for 48-72 hours. Thirty-seven (88%) patients had successful thrombolysis. Overall mortality occurred in 9.5 percent patients due to systemic embolism and bleeding complications. Serial clinical, radiological and echocardiographic studies showed successful thrombolysis in 88 percent patients. This study demonstrates that streptokinase therapy is safe and effective first line treatment for left-sided prosthetic valve thrombosis and surgery should be reserved for those patients who fail to respond to thrombolytic therapy.

Study of fungi associated with bronchopulmonary disorders.

Two hundred samples from sputum (160), bronchial secretions (35) and pleural aspirate (5) were analysed from patients of bronchopulmonary disorders. One hundred nine samples (54.5%) were positive for the fungi. Candida species (50%) were the predominant fungus isolated, followed by Aspergillus species (3.5%). Among various species of Candida, C. albicans accounted for 29.5% cases of bronchopulmonary disorders.

Blood conservation in valve surgery.

Blood utilization in 40 patients undergoing elective valve surgery was prospectively studied. The patients had valvular lesions of rheumatic origin with a mean age of 29.1 years and a mean preoperative hematocrit of 35.23 +/- 4.16. Blood was removed from all patients after induction of anesthesia and reinfused after bypass (mean 365.12 +/- 66.96 ml). Membrane oxygenator was used in all the patients. All discard suction was routed through a regionally heparinised collecting and processing system, and the resulting red cell concentrate was transfused. At the conclusion of bypass, all blood remaining in the pump oxygenator was also processed by cell saver and used for subsequent reinfusion. Normovolemic anemia was accepted in hemodynamically stable patients. Thirty two patients (80%) received no bank blood or blood products during their entire hospital course. A total of twelve units of whole blood was transfused into eight patients.

Dual exposure and repair technique for ruptured aneurysms of aortic sinus of Valsalva.

Thirteen patients with ruptured sinus of Valsalva aneurysm have been operated over a 3-1/2 year period. Right coronary sinus was predominantly involved and right ventricle was the most common site of rupture. Early surgery was performed in all cases. Both aorta and chamber of entry were explored for effective repair. Main repair was always done in the chamber of rupture either with a patch or interrupted pledgeted sutures followed by assessment at either end. Subannular ventricular septal defects in three cases were closed with a common patch with additional fixation in the middle at the aortic annulus to prevent aortic leak into the left ventricle. Three patients needed aortic valve replacement for gross aortic incompetence. Postoperative echocardiographic study revealed uniformly excellent results with good aortic valve or prosthetic function. One patient developed fatal pulmonary embolism two weeks following surgery. All other surviving patients are doing well and are in NYHA class I. We recommend dual exposure and repair technique for the repair of ruptured sinus of Valsalva aneurysms for optimal results.

Mycological aspects of dermatomycosis in Ludhiana.

159 clinically diagnosed cases of dermatomycosis were examined and subjected to mycological study. In the direct microscopic examination, 78 (49.05%) cases were positive and cultures were positive in 66 (41.5%) cases. The common clinical presentation was T. corporis in 60 (37.7%) cases. The commonest species encountered was T. rubrum (42.42%) followed by Epidermophyton floccusum (15.15%), Candida (13.63%), T. violaceum (12.12%), T. mentagrophyte (6.06%) & T. tonsurans (1.5%) in this study. The prevalence of infection was more in males.