Biomedical subjects
Publications and source records attributed to A M Cherian.
Rickettsiosis is generally believed to have disappeared from many parts of India. However, the serological testing of 37 residents of southern India who presented with fever of unknown aetiology in 1996-1998 confirmed that spotted fever, epidemic/endemic typhus and scrub typhus continue to occur in southern India. The epidemiology and magnitude of the problem need to be evaluated.
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We present a case of a young man who presented with fever and nonspecific epigastric symptoms and fluid collection in the lesser omental sac, which was proved to be of tubercular etiology.
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Organic insecticide poisoning continues to be a major health problem not only in the developing communities but also in the Western population. The insecticides commonly used are the organophosphates, organocarbamates, organochlorides and pyrethroids. Patients with organic insecticide poisoning present with a spectrum of manifestations ranging from gastrointestinal symptoms of nausea, vomiting and diarrhoea to severe neurological manifestations of fasciculations, seizures and neuromuscular weakness and paralysis or cardiac manifestations of arrhythmias and conduction disturbances. A strong clinical suspicion is necessary to make an early diagnosis of insecticide poisoning. Treatment is primarily supportive and includes decontamination, protection of airways and cardiac and respiratory monitoring. Specific therapy for organophosphates and organocarbamates includes the use of anticholinergics. The use of oximes, especially high dose, is controversial and may be associated with a higher mortality rate. Low-dose oximes given early in the course of the illness may be beneficial. This paper reviews the literature on organic insecticide poisoning worldwide.
Kikuchi's disease is a histologically alarming self-limiting condition typically affecting the lymph nodes of young females. A 13-year-old girl was presented with fever, skin rash and cervical lymphadenopathy. On examination she was found febrile, mild pallor was present and she had lymphadenopathy. Liver was palpable. Cervical lymph node biopsy showed histiocytic necrotising lymphadenitis (Kikuchi's disease). Dengue virus serology for IgG blot showed evidence of seroconversion in serial samples. She was treated with antibiotics and fluconazole and cyclosporin A. During hospitalisation she developed retinal vasculitis. She was reviewed after one month and showed rashes of subacute cutaneous lupus erythematosus. This case can be described to be a triggering event by dengue viral infection causing abnormal immune response leading initially to Kikuchi's disease and later on to systemic lupus erythematosus.
Snake bite is the common cause of morbidity and mortality in India. Snake antivenom, although very effective, is expensive, scarce, and associated with side effects. The conventional dose may not be required in all cases and a smaller dose may be as effective. A randomized double blind controlled trial was conducted to compare the effect of lower versus the conventional (high) dose. Patients presenting within 24 hours of snake bite with hematological or neurological evidence of systemic envenomation were included in the study. Patients were randomized either to receive high dose (2 vials over 1 hour, followed by 2 vials over 4 hours and repeated 4 hourly until clotting parameters normalized and then 2 vials as infusion over 24 hours) or low dose (2 vials over 1 hour, followed by 1 vial over four hours, repeated 4 hourly until clotting parameters were normalized and then 1 vial as an infusion over 24 hours). Thirty one patients received high dose and 29 a low dose. The mean dose of antivenom used was significantly different in the two groups (8.9 and 4.7, respectively). There was no mortality. The duration of stay was 4.94 and 3.48 days, respectively. There was no difference in the transfusion, dialysis or ventilation requirement of the two groups. Low dose regimen is more effective and required 5 vials less than the conventional dose. Each vial costs Rs. 200, so the estimated savings is Rs. 1000 per patient.
OBJECTIVES: There are many studies in the literature on single drug therapy (monotherapy) for mild to moderate hypertension. These studies show comparable efficacy, side effect profile and compliance. It has not been shown yet, whether the number of patients controlled on monotherapy can be improved by systematically stopping a drug which does not adequately control blood pressure and starting another drug in a sequential manner until blood pressure is well controlled. The aim is to show that sequential drug monotherapy (SDM) is as good as step care therapy (SCT) in controlling mild to moderate hypertension. METHODS: Patients attending three medical outpatient departments of Christian Medical College and Hospital, with mild to moderate hypertension uncontrolled on single drug therapy formed the patient population. They were then randomised to the sequential drug monotherapy or step care therapy. The choice of one of the five antihypertensive drugs was left to the attending physician. RESULTS: Thirty two and 42 patients entered the study and 28 and 35 completed the study in SCT and SDM group, respectively. Follow up was for a period of three months. BP was controlled 100% each in SCT and SDM groups. Efficacy with intention to treat was 85.2% in SCT and 81.8% in SDM group. Percent controlled with second drug was 82 and 71, controlled with third drug was 18 and 14 in SCT and SDM, respectively. Mean duration of treatment for control for BP was 1.7 and 2.3 months in SCT and SDM groups respectively. Average cost in SCT was Rs 66.28 and in SDM was Rs 45.53 per month (p = 0.005). Incidence of ADR was 28.6% and 10.5% in SCT and SDM groups, respectively (p = 0.06). CONCLUSIONS: SDM is as effective as SCT, SDM offers the following advantages: less expensive, better compliance, fewer complications, drug interaction and thus improved quality of life.
Headache following lumbar puncture is a well known and well described complication. Various manoeuvres have been tried to prevent post lumbar puncture headache--the commonest being bed rest for 4 to 24 hours following lumbar puncture, though its value is questionable. Randomised controlled clinical trial was done to evaluate the effect of 24 hours bed rest on the incidence and severity of post lumbar puncture headaches. Two hundred and eight patients were randomly allocated to either the ambulant or the bed rest group. Patients were interviewed by a single investigator on days 0, 1, 2 and 7 about the presence and nature of headache. Other relevant clinical and laboratory data pertaining to the lumbar puncture was collected. The overall incidence of post lumbar puncture headache was 17%; 15% in the ambulant and 18% in the bed rest group. Of the patients who had headaches, severe headache was observed in 57% in the ambulant and 12% in the bed rest group (p = 0.02). Other variables did not alter the outcome of headaches. Bed rest does not appear to alter the incidence of post lumbar puncture headaches, but reduces the severity in those who get headaches, after a lumbar puncture.
BACKGROUND: Pleural biopsy is invaluable for the etiological diagnosis of pleural diseases in the presence of an exudative pleural effusion. Conventionally, pleural biopsy is either performed with the Cope's or the Abrams pleural biopsy needles. A few investigators have used the Tru-cut biopsy needle with or without ultrasound guidance. We report our experience in performing closed pleural biopsy using a Tru-cut needle without ultrasound guidance in moderate to large exudative pleural effusion. We used a perpendicular approach to biopsy the pleura instead of the tangential approach described earlier. METHODS: Closed Tru-cut biopsy was performed in 27 consecutive patients with exudative pleural effusion who volunteered to undergo the procedure. The biopsy specimen was sent for histopathology. Pleural fluid analysis and other relevant investigations required to obtain a specific diagnosis were carried out. RESULTS: A specific diagnosis of tuberculosis was obtained on histopathology of pleural tissue in 12 out of 16 patients (diagnostic yield 75%) and in 5 out of 7 patients with malignancy (diagnostic yield 71%). Among the other 4 patients, other causes of exudative pleural effusion were detected in 3 and in 1 patient, no specific diagnosis could be made, despite extensive investigation. CONCLUSION: Closed pleural biopsy using a Tru-cut needle is effective for the specific diagnosis of exudative pleural effusion. The use of a perpendicular approach to biopsy the pleura does not seem to increase the complication in moderate to large pleural effusion.
Rational drug use workshops were conducted in various centres in India. The effects of these workshops on some of the indicators for rational drug use are discussed. An evaluation based on responses to questionnaires does not permit the measurement of the effects on practice changes, and only perceived changes by the respondents are indicated. Within the short period of evaluation, drug use skills and awareness about various aspects of rational drug use are perceived to have improved. There is a need to re-emphasize through personal interaction and workshops the concept of rational drug use.
AIDS was diagnosed in 187 men and 24 women (M:F = 8:1) from April 1987 till December 1994 at the Christian Medical College Hospital, Vellore. The doubling time of the occurrence of AIDS cases was 14 months; during 1987-90 there were an average of 5.7 cases per year; in 1991-93 there were 28 per year; in 1994 there were 104 cases. The mean age of patients was 33 yr for men and 31 for women. Among men, the primary mode of infection was heterosexual contact with female commercial sex workers. Among women, the most common source of infection was their husbands. There were 4 bisexuals and one homosexual subject who might have acquired infection by having sex with other men. There were 135 subjects from urban and 76 from rural communities. Most subjects belonged to the lower socio-economic classes. These data show that HIV infection had been very widespread in this region, both urban and rural.
This study highlights our experience with 53 patients with mild to moderate hypertension who had monotherapy with Enalapril, one of the newer Angiotensin Converting Enzyme inhibitors. Enalapril was found to be effective in controlling blood pressure in 41 patients (77%). In 12 patients (23%) addition of one more drug was necessary for control of hypertension. Side effects were noted in 9 patients (17%). In two patients the adverse reactions were severe enough to warrant withdrawal of the drug.
Guillain-Barre Syndrome (GBS) is one of the commonest demyelinating diseases of the peripheral nervous system. This retrospective cohort study reports the outcomes of 97 patients in a large teaching hospital in South India. Fifty patients were treated with steroids and 47 had no steroids. Twenty one of the 41 evaluable patients in the steroid group had functional improvement at discharge as compared to 20 of 42 evaluable patients in the non-steroid group. Six patients in each group had worsening of their weakness. Steroids did not show any significant beneficial effect in either improving the disability scores at discharge (steroid-0.42 vs. non-steroid-0.29) or in reducing the duration of ICU stay (4 vs. 8 median days). A higher proportion of patients on steroids developed complications (p = 0.02). The median duration of hospital stay was 16 days in the steroid group as opposed to 14 days in the group not treated with steroids. The mortality was 6 in the steroid treated group and 5 in the non-steroid group. Steroids have no significant benefit on the outcome of GBS.
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Organophosphorus (OP) poisoning is most frequently encountered among our community. Treatment of poisoning is primarily aimed at reversing the effects of the compound by administration of atropine. Oximes have been shown to be efficacious in case reports. The dose of this drug in these reports varies from 1 gm which is a very low dose and physiologically no dose, to doses upto 16 gm. This is also a very expensive imported drug which causes the nation considerable loss of foreign exchange. We report our experience with the use of two treatment regimens of Pralidoxime (P2AM) in the management of patients with OP poisoning in a prospective trial. Seventy-two adult patients presenting to a large university affiliated teaching institution with a history of consumption of OP compounds and requiring intensive care were entered into the trial. Patients were randomized using a block randomisation to receive either a single bolus dose of 1 gm P2AM at admission (Low dose group) followed by placebo infusion over the next 4 days or a single placebo bolus at admission followed by P2AM 12 gm as a continuous infusion over the next 4 days. Outcome measures analyzed were mortality, duration of ICU stay, need for ventilation and duration of ventilation, time to recovery of consciousness, development of intermediate syndrome and infections. A higher prevalence of intermediate syndrome (p = 0.08) was observed in the high dose group. Ventilatory requirement was also more in the high dose group (p = 0.09). Since this was an equivalence study designed to show that the low dose was as effective as the high dose, these results attain greater significance as the low dose group fared better than the high dose group, even though the pre-test hypothesis was in the reverse direction. Subgroup analysis of patients who received at least 1 gm of P2AM within 12 hours of ingestion of the OP poison with those who received P2AM after 12 hours, showed that there was a significant reduction of intermediate syndrome (p = 0.05) but no significant difference was noted in number ventilated. High dose P2AM infusion has no role in the routine management of patients with OP poisoning. These results also suggest that the time of administration of P2AM after the ingestion of the poison mabe a crucial factor which determines response to therapy. A prospective double blind placebo controlled trial is now justified in the light of the above findings.
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