Biomedical subjects
Publications and source records attributed to A Chacko.
Sixteen cases of external hydrocephalus (EH) were seen from January 1993 to June 1995. There were 13 (81.3 per cent) male and three female children. Fourteen (87.5 per cent) were under 12 months of age. Three siblings with EH were seen in one family. All but three of the 16 recovered over time without medical or surgical intervention. These three needed cerebral decongestants in the acute phase.
Nutritional support is an important aspect of the management of burn patients. Nutrition supplementation can be achieved either by 'hospital-made' or 'commercial' diets. Commercial diets are efficacious but expensive and sometimes not easily available. This study was undertaken to compare the efficacy and tolerance of a hospital-made diet with a commercial diet. Twenty patients with burns ranging from 20-50 per cent TBSA were studied to compare the efficacy and tolerance of the 'hospital-made' diet with 'commercial' preparations. Patients were divided into two groups of 10 each and randomised within each group to receive either a hospital-made diet (five patients) or a commercial diet (five patients). Efficacy of diet was assessed by evaluation of nutritional status, graft take, number of surgical procedures and duration of hospital stay. Tolerance was assessed by recording side effects such as nausea, vomiting, abdominal distention and diarrhoea. Both diets were well tolerated by all patients. There was no significant difference in nutritional status, number of surgical procedures, percentage of graft take and duration of hospital stay on either diet, suggesting that hospital-made diets are similar in efficacy and tolerance but cheaper and more easily available. They are a good alternative to 'commercial' diets, especially in poor patients.
In a tertiary referral centre, midazolam infusion was tried as treatment for 20 children with status epilepticus over a period of two years. The mean age of the children was 4.07 years. Twelve children with refractory status epilepticus had received intravenous or per rectal diazepam and intravenous phenytoin/ phenobarbitone or both before midazolam was given (0.15 mg/kg bolus followed by 1-5 micrograms/kg/min infusion). Eight children required only midazolam to control the established status epilepticus. The seizures were controlled in 19 children. The mean time required for complete cessation of seizures was 0.9 hours. The mean infusion rate required was 2.0 micrograms/kg/min. All children had regained full consciousness by a mean of 5.1 hours after discontinuation of midazolam treatment. No metabolic derangement or compromise of vital functions was noted in any of the children. Midazolam infusion is thus an effective and safe therapeutic approach for the management of childhood status epilepticus.
Total and segmental colonic transit time (radio-opaque marker method), daily stool weight, stool water and stool frequency were estimated in 10 decompensated nonalcoholic male cirrhotics and 10 male controls. Total and left colonic transit times were significantly shorter (P < 0.05) in cirrhotics as compared to controls. Stool frequency was significantly higher in cirrhosis (P < 0.01) and showed a significantly negative correlation (r = 0.73, P < 0.02) with total colonic transit time. Stool wet weight and water content were significantly higher in cirrhosis (P < 0.01) as compared to controls. Colonic transit was accelerated in cirrhosis and may be an important hitherto unrecognised factor in the etiopathogenesis of diarrhoea observed in patients with cirrhosis.
A 14-year-old girl presented with dysphagia since the age of one year. Investigations revealed two strictures at the lower esophagus. Endoscopic mucosal biopsy from the strictures showed pseudostratified columnar epithelium suggesting that tracheobronchial remnants was the cause of the stenosis. Esophageal dilatation failed to relieve her symptoms.
Magnesium status of Indian patients with cirrhosis of liver (alcoholic and non alcoholic) and the role of low magnesium in neuromuscular and neuropsychiatric manifestations of chronic liver disease were evaluated in 76 male cirrhotics (alcoholic 37, aged 48 +/- 11 yr, non alcoholic 39, aged 47 +/- 12 yr) and 37 male controls (aged 49 +/- 11 yr). Serum magnesium levels were similar in the 3 groups studied. Muscle magnesium in both groups of cirrhotics were significantly lower than in controls (alcoholic cirrhosis 33.77 +/- 16.85; non alcoholic cirrhosis 37.93 +/- 18.86 and controls 70.52 +/- 6.49 mEq/kg fat free dry mass; P < 0.001). Multiple regression analysis comparing muscle magnesium with clinical and biochemical parameters in cirrhosis showed that hepatic encephalopathy was associated significantly and independently with low muscle magnesium (Beta = -0.313; P = 0.01). These results indicate that patients with cirrhosis have significantly lower muscle magnesium than controls and suggests that low muscle magnesium may be a factor associated with or precipitating hepatic encephalopathy.
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Fifty patients with colonic tuberculosis are reported in whom a colonoscopic diagnosis confirmed by histological examination was possible in 40. Bacteriological studies did not increase the diagnostic yield. Abdominal pain was the most common symptom (90%) and an abdominal mass the most common abnormal physical finding (58%). A nodular mucosa with areas of ulceration was the usual colonoscopic finding. Ileocaecal disease was found in 16, ileocaecal and contiguous ascending colon disease in 14, segmental colonic tuberculosis in 13, ileocaecal disease and non-confluent involvement of another part of the colon in five, and pancolitis in two patients. This report emphasises that colonoscopy is a useful procedure for diagnosing colonic tuberculosis and that segmental colonic tuberculosis is not uncommon.
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Endoscopic, histological, and ultrastructural features of 21 cases of esophageal melanosis are described. These cases were detected during 1000 consecutive routine upper gastrointestinal endoscopies. Staining characteristics and ultrastructure of the pigment contained in the endoscopically visible lesions were found to be similar to those of true melanin.
Lymphocytes from seven patients who developed Haemophilus influenzae type b (Hib) disease after being vaccinated with Hib polysaccharide vaccine and from one patient who developed disease after conjugate vaccination were investigated for the ability to secrete IgG1 and IgG2, in vitro, in response to a combination of pokeweed and Staphylococcus aureus Cowan I mitogens. The eight patients were selected because they had low anticapsular antibody responses to Hib disease. Only one of the eight children had a history of previous severe, recurrent infections. This child (in whom a polysaccharide vaccine failed) had a deficiency of the second component of complement and also had a subnormal serum concentration of IgG4. Only one of the eight children, an otherwise healthy 54-mo-old with normal serum Ig concentrations, had subnormal mitogen-induced B-cell secretion of IgG1 and/or IgG2. When this child's lymphocytes were separated into T- and B-cell fractions and cocultivated with the respective fractions of the father's lymphocytes, the child appeared to have an intrinsic B-cell defect and normal T cells. There were no significant differences (p greater than 0.3) in the respective geometric means of the in vitro secretion of IgG1 or IgG2 of the B cells from the children with polysaccharide vaccine failure and those of 14 healthy controls of similar ages as the patients (IgG1, 1524 versus 3497 ng/mL per 10(5) lymphocytes; IgG2, 79 versus 89 ng/mL per 10(5) lymphocytes). Thus, despite the presence of impaired serum anticapsular antibody responses to Hib disease, most children who develop Hib disease after Hib polysaccharide vaccination have normal in vitro B-cell secretion of IgG1 and IgG2 in response to mitogens.
A miniature osmotic pump has been developed (Osmet) with ALZA, Palo Alto, USA, which can be swallowed, will pass through the stomach and small intestine and then deliver its contents (240 microliters) over eight hours in the large bowel. In vitro studies showed the pumps started to discharge after four to five hours and emptied at a reasonably constant rate of 20.4 microliters/h from 9-16 h (9.6%/h). In vivo studies using gamma-scintigraphy in seven healthy subjects show that the pumps left the fasting stomach at 1.2 h (range 0-3) and arrived in the caecum by 6.4 h (range 5-9). Mean start-up time was 5.3 (0.2) h and the rate of discharge was 15.9 microliters/h for pumps studied from 6-12 h and 17.2 microliters/h for those studied from 10-20 h. This device is simple, safe and effective for the delivery of tracer substances to the caecum and colon without interfering with patients' normal lifestyle.
A young female presented with haemolytic anaemia due to dapsone overdosage. She developed peripheral neuropathy and marked visual impairment with a cherry red spot on the macula, possibly due to toxic retinal vascular damage; both these resolved in due course. Cherry red spot due to dapsone poisoning has not been reported previously.
To investigate the basis of the immune defect in children who acquire invasive Haemophilus disease despite previous vaccination with Haemophilus influenzae type b (Hib) polysaccharide vaccine, we determined the ability of vaccine failure patients with low levels of serum anticapsular antibody (less than 1 microgram/ml) to respond to reimmunization. Thirty-four patients, ranging in age from 27 to 61 months, were vaccinated with either Hib polysaccharide (n = 20) or Hib polysaccharide-outer membrane protein conjugate vaccine (n = 14). All but three of the children had normal serum concentrations of immunoglobulins, including IgG2. The geometric mean serum anticapsular antibody concentration of the group given polysaccharide vaccine increased from 0.27 microgram/ml before vaccination to 0.65 microgram/ml 1 month later (p less than 0.05), but the magnitude of the response was nearly 10-fold less than that of 31 age-matched control children given polysaccharide vaccine (6.3 micrograms/ml, p less than 0.001). In contrast, all 14 patients with vaccine failure who were given conjugate vaccine showed increases of fivefold or more in serum anticapsular antibody (geometric means 0.35 and 12.8 micrograms/ml, respectively; p less than 0.001). All patients with vaccine failure who did not respond to polysaccharide vaccine were subsequently given conjugate vaccine, and all had high antibody responses. Most patients tested showed increases in complement-mediated serum bactericidal activity. These data suggest that immunization with conjugate vaccine confers protection against Hib disease to children who, because of genetic or other reasons, cannot respond to the unconjugated form of the polysaccharide vaccine.
Whole gut transit was measured in a group of 21 healthy volunteers and 21 patients with tropical sprue by radio-opaque marker technique, using mean transit time single (MTTS) and single stool transit (SST) method. Mean SST in controls was 25.8 (1.4) (SE) hours, which is considerably shorter than in controls in temperate zones. Mean SST (23.7 (0.6) h) correlated significantly with average MTTS (24.9 (1.6) h) (r = 0.88; p less than 0.001) confirming that SST is a valid method to measure intestinal transit in the tropics. Patients with tropical sprue had a mean SST similar to controls (24.4 (1.1) h), in spite of significantly higher faecal weights (580 (41.2) g v 252 (17.2) g; p less than 0.001).
The amount and form of nitrogen lost from the human small intestine and the dietary factors which influence it have been studied in six ileostomists. Over a six day period the subjects were fed a series of diets including low nitrogen (LND) 0.17 g N/day, LND + soya beans (5.87 g N/day) and a high fibre diet (HFD) (10.6 g N/day). The soya beans were fed either whole or pureed to test the effect of physical form of food. Total N, protein, amino acids, urea, and ammonia were measured in ileostomy effluent which was collected throughout the study. Total N excretion was LND 0.91 (0.04) (SE) g/day; LND + whole soya beans (WSB) 2.26 (0.15) g/day; LND + pureed soya beans (PSB) 1.42 (0.12) g/day (WSB v PSB, p less than 0.001); and HFD 2.17 (0.11) g/day (HFD v PSB, p less than 0.001, HFD v WSB, NS). N losses as urea, ammonia, and free amino acids were less than 10-15% of total N, the remainder being protein (48-51%) and (by difference) peptides (20-30%). Eighty to 85% of effluent N was in the insoluble (pellet) fraction except on the low N diet where it was 66%. The physical form of food clearly influenced N digestibility in the soya beans whilst changes in dietary fibre seem not to have a significant effect.
Fecal energy excretion was measured by bomb calorimetry, in a group of 30 healthy volunteers and 15 patients with tropical sprue, to determine the absorption of nutrient energy. The mean energy absorption in the healthy volunteers (91.6%) was less than in similar subjects in temperate climates. The reduction of energy absorption in the volunteers, who all have tropical enteropathy, suggests that this condition leads to wastage of 5% of energy intake. In patients with tropical sprue the energy absorption was significantly lower. A strict metabolic balance study was not essential to detect energy malabsorbers.
A review of 13 cases of suspected child abuse in which radionuclide (RN) scans, radiographic skeletal surveys, and sufficient follow-up were available showed that the RN scans were insensitive, even though fractures were more than 48 hours old at the time of the scan. Frequently missed lesions included skull and extremity fractures. Furthermore, soft tissue and visceral abnormalities that were identified on radiographic examination went undetected on RN scan. We conclude that, although the RN scan may augment the radiographic examination, it should not be used alone to screen for the battered child.