Low-dose ketamine infusion for labor analgesia: a double-blind, randomized, placebo controlled clinical trial

Most primary and secondary level hospitals in developing countries provide inadequate labor analgesia due to various medical, technical and economic reasons. This clinical trial was an effort to study the efficacy, safety and feasibility of intravenous [IV] ketamine to provide labor analgesia. A total of 70 parturients were consented and randomly assigned to receive either IV ketamine or 0.9% saline. A loading dose of ketamine [0.2 mg/kg] was followed-by an infusion [0.2 mg/kg/h] until the delivery of the neonate. Similar volume of saline was infused in the placebo-group. Intramuscular meperidine was the rescue analgesic in both groups. The pain score, hemodynamic parameters of mother and fetus and the anticipated side-effects of ketamine were observed for. The newborn was assessed by the Neonatologist. The pain score showed a decreasing trend in the ketamine group and after the 1[st] h more than 60% of women in the ketamine group had pain relief, which was statistically significant. There was no significant clinical change in the maternal hemodynamics and fetal heart rate. However, 17 [48.5%] of them had transient light headedness in the ketamine group. All the neonates were breast fed and the umbilical cord blood pH was between 7.1 and 7.2. The overall satisfaction was significantly high in the intervention group [P = 0.028]. A low-dose ketamine infusion [loading dose of 0.2 mg/kg delivered over 30 min, followed-by an infusion at 0.2 mg/kg/h] could provide acceptable analgesia during labor and delivery

Response to hepatitis B vaccination in high risk population.

Hepatitis B vaccine is well established as very efficacious, but immune response to the vaccine is highly individual specific. A study involving fifty vaccinees was undertaken at the Hepatitis Laboratory, National Institute of Communicable Disease, Delhi. One ml (20 microgram) of Engerix B vaccine (recombinant yeast derived vaccine) was administered in the standard three dose schedule (0, 1 and 6 months). The sero-conversion of the vaccinees was 24%, 66%, 76% and 78% at 1 month, 6 months, 7 months, and 12 months respectively. There was no seroconversion in 22% of the vaccinees. Sero-conversion was assessed using Macro ELISA test (Ausab, Abbott Labs) for Anti HBs reactivity.

Prevalence of North India of hepatitis B carrier state amongst pregnant women.

The study was undertaken to determine the hepatitis B carrier rate in North India along with the relative infectivity of the carriers. A total of 1,112 pregnant women were investigated for hepatitis B carrier state during their routine visits to antenatal clinics. All three tiers of the health care delivery system were included from four regions of North India. The sera were screened for the presence of hepatitis B surface antigen (HBsAg), hepatitis B "e" antigen (HBeAg), and antibody to hepatitis B "e" antigen (Anti-HBe) by third generation Macro ELISA tests. The average hepatitis B surface antigen carrier rate was 9.5%. The carriers were found to be of relatively low infectivity with HBeAg and Anti-HBe present in 12.0% and 25.3% of the HBsAg carriers respectively, and both these markers absent in 62.7%. It was concluded that in the past decade the hepatitis B endemicity in North India has probably increased, but the relative infectivity of the carriers remains the same.

Non Hepatitis viruses in causation of acute sporadic non-A, non-B viral hepatitis.

Viruses other than Hepatitis viruses i.e. Cytomegalovirus, Epstein-Barr Rubella etc., can cause a clinical picture resembling that of viral hepatitis. Consequently, these viruses can falsely contribute to the diagnosis of Non-A, Non-B hepatitis amongst of sporadic jaundice. This study attempts to find out the possibility of occurrence of such an event.

Further observations on comparison of immunization coverage by lot quality assurance sampling and 30 cluster sampling.

Lot Quality Assurance Sampling (LQAS) and standard EPI methodology (30 cluster sampling) were used to evaluate immunization coverage in a Primary Health Center (PHC) where coverage levels were reported to be more than 85%. Of 27 sub-centers (lots) evaluated by LQAS, only 2 were accepted for child coverage, whereas none was accepted for tetanus toxoid (TT) coverage in mothers. LQAS data were combined to obtain an estimate of coverage in the entire population; 41% (95% CI 36-46) infants were immunized appropriately for their ages, while 42% (95% CI 37-47) of their mothers had received a second/ booster dose of TT. TT coverage in 149 contemporary mothers sampled in EPI survey was also 42% (95% CI 31-52). Although results by the two sampling methods were consistent with each other, a big gap was evident between reported coverage (in children as well as mothers) and survey results. LQAS was found to be operationally feasible, but it cost 40% more and required 2.5 times more time than the EPI survey. LQAS therefore, is not a good substitute for current EPI methodology to evaluate immunization coverage in a large administrative area. However, LQAS has potential as method to monitor health programs on a routine basis in small population sub-units, especially in areas with high and heterogeneously distributed immunization coverage.

Widespread emergence of Vibrio cholerae 0139 in India.

The National Institute of Communicable Diseases (NICD) has been monitoring the incidence of laboratory confirmed cases of cholera in Delhi in collaboration with Infectious Diseases Hospital (IDH) since 1965. Cholera and cholera-like cases from all hospitals in Delhi are admitted in IDH and the rectal swabs of all such cases are processed for isolation of Vibrio cholerae at NICD laboratory. Since April 1993, there has been isolation of Vibrio cholerae serotype 0139, in increasing numbers (831 out of 2,830, 29.2%) The isolates have been characterized and enterotoxin studies carried out. As a referral laboratory NICD has also confirmed the causative role of Vibrio cholerae 0139 in diarrhea outbreaks from various parts of the country. The implications of establishment of this newer serotype of Vibrio cholerae, as a potential epidemic strain are discussed.

Measles mortality in India: a review of community based studies.

This paper reviews the measles Case Fatality Ratios (CFRs) reported in the community based studies from India. Measles mortality varied considerably in outbreaks, prospective and retrospective studies. A median CFR of 2.5 per cent (0.2-3.7), 0.1 per cent (0-2.2) and 3.7 per cent (0-23.9) was recorded in prospective, retrospective and outbreak studies respectively. The retrospective studies seem to underestimate the measles mortality in Indian setting. Most of the outbreaks recording CFRs equal to or less than the median, 3.7 per cent, occurred in the areas where health care facilities were available for treatment of measles associated complications. Virtually in all studies, the age specific CFRs wherever recorded, were found to be the highest among infants and thereafter the ratios declined progressively. Although suggestive of, the studies did not provide sufficient data to establish an association between malnourishment and the risk of dying from measles. Measles mortality was not consistently high in any particular sex. The study makes a strong case for measles immunization at the earliest recommended age and the provision of better health services as the important public health measures for reducing the measles CFRs.

Absence of Phlebotomus argentipes Ann & Brun. (Diptera: Psychodidae) the vector of Indian kala-azar from Kamrup district, Assam.

In the past Assam was devastated by epidemics of Kala-azar. However, inspite of resurgence of this disease in Bihar and neighbouring areas Assam has remained untouched by this disease since the mid 1950s so far. The study undertaken in Kamrup district, sought to provide an entomological explanation for Assam's present freedom from Kala-azar. Sandfly collections were made in 15 villages. Three different methods were used; namely hand collections by aspirator and torch, sticky traps and examination of soft parts of cattle in the villages for mating swarms. 1049 sandflies were collected which did not include any specimens of P. argentipes. The vector of Indian Kala-azar has either been eliminated by continuous insecticide spraying in this high P. falciparum, and chloroquine resistance area or reduced to such low levels of prevalence that routine sampling methods are unable to reveal its presence. The implications of this finding are discussed in relation to Kala-azar control in India, in general.

Tobacco smoking in a defined community of Delhi.

A Community based study was conducted in urban Delhi. It was found that Smokers constituted about 32 percent of adult males in Delhi Admin. Flats, Timarpur. Proportion of smokers was highest in 41-50 years age. 31 percent of school teachers were smokers. Out of all who tried to live-up smoking, 8 percent reverted back after abstinence of two year or more. About three fourth of the smokers were worried ill effects of smoking's on them and others. Significantly higher number of non-smokers expressed opinion for total stopping of advertisement and complete ban of sale of smoking tobacco.

Case series evaluation of BCG vaccine efficacy against tubercular meningitis in children in Delhi.

Tubercular meningitis (TBM) is a very serious disease of childhood. BCG vaccination under Universal Immunisation Programme is the only available way of preventing this disease. The present series using case-control method, evaluated efficacy of BCG against TBM in children to be 57 per cent. Suggestion has been made to initiate TBM surveillance in children and conduct multicentric prospective case-control study of similar type.

Prevalence of diphtheria and tetanus antibodies in young adults in Delhi.

A total of 574 blood samples collected mainly from adult males, on a random basis, were tested for diphtheria and tetanus antibodies by Indirect Haemagglutination (IHA) test to find out the percentage of individuals with protective titres (> or = 0.015 IU/ml). A total of 502 (87.5 per cent) and 437 (76.2 per cent) of these had protective titres against diphtheria and tetanus respectively. The vaccination status of these subjects against diphtheria and tetanus was not ascertainable. The relevance of these findings is discussed.

Oral polio vaccination in infants: beneficial effect of additional dose at birth.

This study was done to assess the response of newborns to trivalent oral polio vaccine and to study any efficacy of OPV if given to infants on third day of life. The study was conducted in two groups, A (87) and B (55) of infants in Delhi, India. In group A, the children received one birth dose or 'O' dose of TOPV, followed by 3 conventional doses started at 6 weeks, and in group B the children received only 3 doses of OPV. Pre and one month post immunization serum samples were tested for the presence of neutralising antibodies. In addition, in group A serum samples were collected at 6 weeks before the administration of 1st dose to see the sero response following 'O' dose of TOPV. It was found that administration of OPV on 3rd day of life leads to sero conversion in 15.3% of infants to all three polio virus types by the age of 6 weeks, and highest sero response was seen for polio virus type 1. Sero-conversion in group A was significantly more than sero-conversion in group B after the administration of last dose. Thus the study has established that immunization of newborns with TOPV is a safe and effective means for improving protection against the disease.

Review of the Journal of Communicable Diseases from 1982 through 1991.

Review of medical journals is not common in India. A quantitative review of the articles published in the Journal of Communicable Diseases from 1982 through 1991 was undertaken in the present study to give feedback to all concerned and stimulate them for initiating constructive criticism of medical journals published in India. Articles were categorised as per the classes of four predetermined parameters and variations in the proportions of number of articles under different classes of each parameter are briefly discussed.

Monitoring the efficacy of temephos application and use of fine mesh nylon strainers by examination of drinking water containers in guineaworm endemic villages.

Application of temephos in unsafe water sources for destroying cyclops, the intermediate hosts of guineaworm, and distribution of fine mesh nylon strainers for promoting prophylaxis against guineaworm are accepted methods of guineaworm control in different endemic countries. The existing methods of monitoring the efficacy of these guineaworm control methods are not fully informative. Examination of drinking water stored at household levels for presence of cyclops with or without Dracunculus larvae can provide information on the efficacy of these control/prophylactic methods, besides serving as a means of interpersonal health education to the community. This paper presents observations carried out in two villages in peninsular India in 1991, which revealed that while in one village complete absence of cyclops from stored water containers was attributable to the use of temephos in the village and straining of drinking water, in the other village, with no temephos application, 15.6 per cent of containers contained varying numbers of cyclops in them. Implications of these observations for guineaworm eradication activities are discussed.

Status of lymphatic filariasis in some select slum clusters of Delhi.

Filaria surveys conducted in some select slum clusters namely Hari Nagar, Yamuna pusht near Vijaya Ghat along the Ring Road and Timarpur in Delhi during 1989, 1991 and 1992 respectively, covering a population of approximately 5000 slum dwellers revealed the presence of bancroftian microfilaria (mf) carriers and disease cases. The mf and disease rates (per cent) in these three slum areas were in the order of 6.3, 2.2, 3.7 and 1.4, 0.5 and 0.1 respectively. The mf density varied from 3.1 to 12.3 per 20 cumm. blood. High ten man hour densities of Culex quinquefasciatus (581) in Yamuna pusht followed by (355) in Timarpur were recorded during entomological investigations. Hari Nagar accounted for least ten man hour density of Cx. quinquefasciatus (160), because collection was made during winter months (November-December). The dissection of Cx. quinquefasciatus did not reveal any human filarial infection except in Yamuna pusht where out of 139 only one Cx. quinquefasciatus was found infective.