Cleistanthus collinus poisoning: experience at a medical intensive care unit in a tertiary care hospital in south India.

BACKGROUND & OBJECTIVES: Ingestion of Cleistanthus collinus causes hypokalemia and cardiac arrhythmias leading to mortality in most cases. We undertook this retrospective study to evaluate the clinical presentation and predictors of outcome in critically ill patients admitted with C. collinus poisoning. METHODS: The case records of 56 patients admitted to the medical intensive care unit (MICU) of a tertiary care teaching hospital in south India (2000-2014) with C. collinus poisoning were retrospectively analysed. RESULTS: The mean age of patients was 36.7±13.3 yr; there were 30 males. Salient clinical manifestations included hypokalemia (58%), neutrophilic leucocytosis (48.2%), acute kidney injury (AKI) (42.9%), acute respiratory failure requiring mechanical ventilation (AcRFMv) (32.1%), shock (21.4%); cardiac arrhythmias and neuromuscular weakness (19.6% each); 21 patients (37.5%) had adverse outcome. Longer time-lapsed from consumption to reaching emergency room [median (interquartile range)] (hours) [49 (22-97) vs. 28 (7-56), p =0.0380 ]; higher acute physiology and chronic health evaluation II (APACHE II) score at presentation [14 (8.25-14.75) vs. 2 (0-6) P<0.001]; and presence of the following [odds ratio (95% confidence intervals)] at initial presentation: shock [37.40 (4.29-325.98), P=0.001]; AcRFMv [26.67 (5.86-121.39), P<0.001]; elevated alanine aminotransferase [5.71 (1.30-25.03), p0 =0.021]; metabolic acidosis [5.48 (1.68-17.89), P=0.005]; acute kidney injury (AKI) [5 (1.55-16.06), P=0.007]; hyponatremia [4.67 (1.25-17.44), P=0.022]; and neutrophilic leucocytosis [3.80 (1.02-14.21), P=0.047] predicted death. A significant (P<0.001) increasing trend in mortality was observed with increasing International Program on Chemical Safety Poisoning Severity Score (IPCS-CSS) grade. INTERPRETATION & CONCLUSIONS: C. collinus is a lethal poison associated with high mortality for which there is no specific antidote. Careful search and meticulous monitoring of the predictors of death and initiating appropriate corrective measures can be life saving.

Acute accidental exposure to chlorine gas: clinical presentation, pulmonary functions and outcomes.

BACKGROUND: To study the clinical presentation, pulmonary functions and outcomes in subjects who were accidentally exposed to chlorine gas. METHODS: Prospective observational study of 64 patients who sustained acute accidental exposure to chlorine gas during a leak in the chlorination system of the public bathing pool of a temple. RESULTS: The major presenting symptoms and signs included acute dyspnoea (100%), chest discomfort (100%), cough (97%), eye irritation (88%), giddiness (72%), vomiting (46%), and heaviness in the head (44%); tachycardia (100%), tachypnoea (96%) and polyphonic wheezing (28%). All patients were managed in the emergency room with humidified oxygen inhalation and beta-2 agonist nebulisation and 52 were discharged within six hours. Twelve patients were severely affected and required hospitalisation; three of them were admitted into the intensive care unit. Three patients developed pulmonary oedema six to eight hours following admission. Pulmonary function testing (n = 12) at presentation revealed obstructive defect in eight and mixed obstructive-cum-restrictive defect in four patients. The mean duration of hospital stay was 5.1 +/- 2.1 days. None of the patients died. Reactive airway dysfunction syndrome (RADS) was observed in three of the 12 hospitalised patients, who complained of manifested persistent cough that lasted for three months period following discharge. Serial pulmonary functions recovered to normal range by the end of the six months in all patients and remained so at one-year follow-up. CONCLUSION: Acute exposure to chlorine gas is an uncommon, but important public health hazard and can cause RADS, acute lung injury and pulmonary function abnormalities, which are reversible on prompt and appropriate management.

Use of Adaptive Support Ventilation (ASV) in Ventilator Associated Pneumonia (VAP) - A Case Report.

SUMMARY: Prolonged ventilation leads to a higher incidence of ventilator associated pneumonia(VAP) resulting in ventilator dependency, increased costs and subsequent weaning failures. Prevention and aggressive treatment of VAP along with patient friendly newer modes of ventilation like adaptive support ventilation go a long way in successful management of these cases.

Myasthenic crisis-like syndrome due to Cleistanthus collinus poisoning.

Poisoning with Cleistanthus collinus frequently causes cardiac manifestations such as rhythm disturbances and also results in other manifestations such as metabolic acidosis and hypokalemia. We present the case of a patient who presented with a rare myasthenic crisis-like syndrome requiring assisted ventilation due to Cleistanthus collinus poisoning, which responded to treatment with neostigmine.

Existing record keeping system in government teaching hospitals of Karachi.

OBJECTIVE: To determine the deficiencies in the existing record keeping system (ERKS) in government teaching hospitals of Karachi. STUDY DESIGN: Descriptive, qualitative study to determine the deficiencies in the ERKS in government teaching hospitals of Karachi. SETTING: The study was conducted in four government teaching hospitals of Karachi from 1.1.1998 to 1.11.1998. METHODS: A total of 9725 pre-coded proformas were filled from 136 units of all hospitals including out patient departments (OPD), wards and emergency units. RESULTS: Majority of the records (52.2%) were retrievable within one hour. The mean +/- S.D of patients seen per day at all hospitals were 122.49 +/- 92.25 (57 OPDs), 30.04 +/- 16.24 (75 wards) and 186.25 +/- 145.80 (4 emergencies). In majority of units (57.4%), the stationary for record keeping system was either not provided or was not enough. Only 39.0% units have 75% or more required information on records. The important information (except age) i.e. temperature, pulse rate, blood pressure, diagnosis, weight, history of patient, laboratory findings, previous record and discharge report and prescribed doses of medicine were lacking. CONCLUSION: The ERKS in the government hospitals of Karachi is inadequate. It is therefore essential that uniform OPD, ward and emergency slips should be developed having all-important queries. So that data could be utilized for research purposes along with better planning and management of the hospital and procurement plan for the government.

NMR study of cyclic peptides with renin inhibitor activity.

Several cyclic analogues of renin inhibitors, based on Glu-D-Phe-Lys motif have been investigated by NMR spectroscopy and molecular dynamics calculations (MD). The 15 membered macrocycle, resulting from Glu and Lys side-chain cyclization, exhibits conformational preference. The structural evidence from NMR shows the presence of hydrogen bond between Lys NH and Glu side-chain carbonyl, resulting in a 10 membered pseudo beta-turn-like structure. The structure of the cyclic moiety is similar in all the peptides, which takes at least two conformations around Calpha-Cbeta in Glu side chain. The restrained MD calculations further support such observations and show that the macrocycle is fairly rigid, with two conformations about the Glu Calpha-Cbeta bond. The linear peptide appendages, which are essential for activity in cyclic peptides, show an extended structure in the beta-region of Ramchandran plot. These calculations also demonstrate that for the most active peptide, two major conformers each exist about the Calpha-CO bond of the Lys, D-Trp and Leu residues. In this peptide, the cyclic moiety presents a negatively charged surface formed due to the carbonyl oxygens, which are thus available to form hydrogen bonds with the receptor. The linear fragment presents further binding sites with a surface which has the hydrophobic side chains of D-Trp, Leu and D-Met on one side and carbonyls on the other side.

2,5-Anhydro sugar diacid and 2,5-anhydro sugar diamine based C 2 symmetric peptidomimetics as potential HIV-1 protease inhibitors.

Conformationally constrained molecular frameworks of the 2,5-anhydro sugar diacid (9) and 2,5-anhydro sugar diamines (10, 11) were used to construct architecturally beautiful novel C 2 symmetric peptidomimetics 1-8. Although none of these compounds showed any significant HIV-1 protease inhibitory activity, further refinements in design may lead to protease inhibitors based on these rigid carbohydrate-derived scaffolds.

Studies on conformational consequences of i to i + 3 side-chain cyclization in model cyclic tetrapeptides.

In an effort to explore the effect of ring size on the biologically active conformation of cyclic analogs of the mating pheromone alpha-factor (WHWLQLKPGQPMY) from Saccharomyces cerevisiae, eight cyclic tetrapeptides corresponding to the KPGQ portion of alpha-factor were synthesized. These N-alpha-acetyl/carboxyl amide terminal cyclic tetrapeptides were prepared on a 4-methylbenzhydrylamine resin using orthogonal Boc, Fmoc, OFm and OtBut protecting groups and HOBt-DIPC accelerated active esters or urethane-protected N-carboxyanhydrides. On-resin cyclization of the side-chain amino and carboxyl groups of the first and fourth residues, respectively, was performed with the BOP reagent to generate lactams containing 14-18 atoms. HF cleavage resulted in two products, the desired cyclic tetrapeptide and a major side product. All peptides were purified to near homogeneity (> 99%) by using reversed-phase HPLC and were characterized by FBMS and 1H NMR. Certain constrained cyclic tetrapeptides appear to be a mixture of isomers at room temperature as evidenced by HPLC and NMR. The major side product has been identified as a cyclo dimer, obtained as a consequence of interchain cyclization on the resin. CD analysis in several solvents gives evidence that some of the cyclic tetrapeptides exist in beta-turn conformations.

Expanded programme of immunization in Karachi.

Immunization status of children and their mothers and reasons for their failure to be immunized were studied. The study lasted for two months, i.e., August and September, 1993 at the Paediatric Outpatient Department of Civil Hospital, Karachi. Three groups of patients were targeted. Six hundred and twenty-four children under 1 year of age, 955 children between the ages of 1 to 5 years and 1579 mothers were registered. These women were questioned regarding their immunization status and that of their children. In the group below 1 year of age, BCG, DPT and polio (3 doses) and measles were given to 75%, 35% and 23% respectively. Tetanus toxoid (2 doses) was given to 47% of their mothers. In the group of children between 1-5 years, BCG, DPT and polio 3 doses and measles were given to 84%, 63% and 58% respectively. Tetanus toxoid (2 doses) were given to 64% of their mothers. The main reasons for not vaccinating were lack of information and lack of motivation.

Antisense BCR-ABL oligomers cause non-specific inhibition of chronic myeloid leukemia cell lines.

We have examined the effects of antisense oligomers (AOs) of various lengths, sequences and chemistry on the proliferation of eight different cell lines, five derived from patients with chronic myelogenous leukemia (CML) and three from other sources. In general, phosphodiester AOs were inactive, presumably due to degradation by nucleases present in fetal calf serum. Both BA2 and B3A2 phosphorothiolate AOs (but not corresponding sense oligomers) significantly inhibited the proliferation of three CML cell lines (BV173, LAMA84, and KYO1), but the effect was independent of the type of breakpoint expressed by each cell line, suggesting that the inhibition was sequence dependent but not sequence specific. The CML cell lines tested showed different sensitivities to inhibition of proliferation by AOs--lines with defective expression of the normal ABL protooncogene (e.g. BV173) were more readily inhibited than lines with a normal ABL message (e.g. K562). We conclude that further studies are necessary to delineate the precise mechanism(s) by which CML cell proliferation is inhibited by AOs.

A change of Plasmodium species infecting children in Karachi over the last decade.

Febrile children of both sexes, aged between 0-15 years coming to the Civil Hospital over the last 12 years had their blood tested for malarial parasite. Five hundred and twenty-six slides positive for Plasmodium were analysed for species and stage identification. Of the total 59.3% children with malaria were between 5-15 years of age. Applying the test of proportion, Plasmodium vivax was the predominant species (P < 0.01) between 1981-1985 and plasmodium falciparum between 1986-1990. This trend persisted upto 1992. As malaria due to Plasmodium falciparum is more severe with multiple complications accurate and easier methods of its diagnosis are needed at primary health care level.