Biomedical subjects
Publications and source records attributed to R Chawla.
A case of thoracopagus conjoined twins encountered in the second stage of labor is presented. Delivery was possible by the vaginal route after reducing the fetal bulk by destructive operations. Problems in obstetric management of these cases are discussed and the importance of proper antenatal evaluation is stressed.
The successful management of nitrobenzene poisoning in a 21-year-old patient is presented. We report our experience of ventilatory care with additional intravenous methylene blue and ascorbic acid therapy. Pulse oximeters available at present are not useful in patients treated with methylene blue and should be used cautiously in the presence of cyanosis of unknown aetiology.
The conversion of inter-alpha-trypsin inhibitor (I alpha I) into active, acid-stable derivatives by proteolytic degradation has been tested with 10 different proteinases. Of these, only plasma kallikrein, cathepsin G, neutrophil elastase, and the Staphylococcus aureus V-8 proteinase were found to be effective, each releasing more than 50% of this activity. However, a strong correlation between inhibitor degradation and significant release of acid-stable activity could only be found with the V-8 enzyme. Inhibition kinetics for the interaction of native I alpha I, the inhibitory fragment released by digestion with S. aureus V-8 proteinase, or the related urinary trypsin inhibitor, with seven different proteinases indicated that all had essentially identical Ki values with an individual enzyme and, where measurements were possible, nearly identical second order association rate constants. Significantly, none of the five human proteinases tested, including trypsin, chymotrypsin, plasmin, neutrophil elastase, and cathepsin G, would appear to have low enough Ki values to be physiologically relevant. Thus, the role of native I alpha I or its degradation products in controlling a specific proteolytic activity is still unknown.
Twenty-two patients with smear-negative miliary tuberculosis underwent fiberbronchoscopy and brush smears; bronchial aspirates and transbronchial lung biopsy specimens were obtained. A definite diagnosis of tuberculosis was made in 16 (73 percent) patients. A rapid diagnosis was established in 14 of these 16 patients either from brush smears alone (three) or bronchial aspirate smear alone (one) or exclusively by histopathologic study of biopsy specimens (seven). Both brush smears and biopsy histopathology results provided the diagnosis in three patients. Bronchial aspirate culture was the only positive specimen in two patients. No serious complication resulted from the procedure. Our experience substantiates previous reports of the value and safety of fiberbronchoscopy in the rapid diagnosis of smear-negative miliary tuberculosis.
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With a view to assess the efficacy of intrathecal pentazocine for post-operative pain relief, 60 patients randomly divided into 6 equal groups were administered graded doses (0, 1, 2, 3, 4 and 5 mg respectively) of pentazocine lactate, intrathecally along with 1 per cent bupivacaine. The duration of analgesia was found to be dose related till 3 mg. Higher doses did not increase the duration of analgesia nor were any untoward effects observed. It is concluded that intrathecal pentazocine is safe and effective for post-operative pain relief and 3 mg is the minimum effective dose without side effect.
Fifty smear-negative pulmonary tuberculosis patients underwent fibreoptic bronchoscopy. Bronchial aspirate smears of twelve patients and post-bronchoscopic sputum smears of fourteen patients were positive for acid-fast bacilli (AFB). Bronchial biopsy provided the diagnosis in 9 out of 30 patients. Brush smears were positive in 28 patients, being the only positive sample in ten cases. A high yield from brush smears was obtained due to their preparation from caseous material wherever visible in the bronchi. With these results a rapid diagnosis was established in 36 of the 50 patients. When culture results were available, a definite diagnosis of tuberculosis was made in 45 of the patients. The yield from brush smears was found to be significantly better when compared to bronchial aspirate smears (p less than 0.01) and post-bronchoscopic sputum smears (p less than 0.01).
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Because protein-calorie undernutrition is common in patients with neoplastic disease, nutritional support is often recommended. It is uncertain, however, that methods of supplemental alimentation successful in noncancerous subjects are suitable in cancer patients. We measured elemental balances, serum proteins, anthropometrics (triceps skinfold and mid-arm muscle area), and creatinine/height ratio in 15 undernourished patients with advanced cancer and in 10 noncancer undernourished controls during central venous or enteral hyperalimentation and found the following. (a) During central venous hyperalimentation, cancer patients showed significantly less improvement than the noncancerous controls in body weight (median increment, 5 kg in cancer patients and 8.5 kg in noncancerous), albumin (0.1 g/dl in cancer patients and 0.5 g/dl in noncancerous patients), creatinine/height ratio (4% of standard in cancer and 10% of standard in noncancer), and mid-arm muscle area (4% of standard in cancer and 11% of standard in noncancer). During enteral hyperalimentation, gains in body weight and albumin by cancer patients were significantly inferior to those in noncancerous subjects. Triceps skinfold increments, in contrast, were similar during both central venous and enteral hyperalimentation for cancer and noncancerous patients. (b) While nitrogen retention was similar in cancer and noncancer patients, the cancer group retained significantly less magnesium and phosphorus (delta Mg in cancer patients, 3.2 mEq/day central, -2.7 mEq/day enteral; delta Mg in noncancer patients, 11.9 mEq/day central, 10.1 mEq/day enteral; delta P in cancer patients, 0.13 g/day central, 0.07 g/day enteral; delta P in noncancer patients, 0.27 g/day central, 0.33 g/day enteral). The poorer balances of cancer patients were caused by increased urinary, not fecal, loss. These findings indicate a partial block in repletion of lean body mass or abnormal composition of newly deposited lean body mass when undernourished patients with advanced cancer receive hyperalimentation.
There are many theoretical and practical advantages to enteral rather than parenteral administration of nutrients. However, it is unlikely that enteral supplementation of nutritional intake as presently practiced will be successful as a primary therapy for most patients with the cancer cachexia syndrome. The most likely role of enteral nutritional support (ENS) is in conjunction with other therapies. This modality deserves evaluation in surgery with curative intent. Changes in diet are effective in reducing the gastrointestinal symptoms of abdominopelvic irradiation, but the effect of ENS on the hematologic toxicity of radiation therapy and on response rates and survival is unclear. Elemental diets can reduce the gastrointestinal toxicity of conventional doses of 5-FU, but they worsen the mortality and hematologic toxicity of higher doses. Factors such as protein, fat, and carbohydrate sources, degree of hydrolysis of protein, lactose content, and timing of dietary manipulations are important in evaluating the response to ENS.
A randomized study was performed in advanced cancer to test the effectiveness of total parenteral nutrition (TPN) in maintaining and improving nutrition, to examine the effects of TPN on tumor growth, and to determine if TPN altered chemotherapy response rates, treatment tolerance, and survival. Forty-five patients on identical chemotherapy were randomized to TPN versus ad libitum feeding. TPN was well tolerated. No clinical or tumor marker evidence suggesting neoplastic growth stimulation was obtained. Chemotherapy-related complications and chemotherapy responses did not differ between the two groups. TPN had little effect on performance status. TPN patients gained an average of 2.8 kg before chemotherapy, but triceps skinfold and mid-arm muscle area did not change significantly during TPN. Survival did not improve with TPN. We conclude that current techniques of TPN are of limited benefit in advanced colon cancer. A small subset of patients with short-gut malabsorption may be helped. Further study is needed to determine the mechanisms of cancer undernutrition and to refine nutritional supplementation techniques on the basis of these mechanisms.
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The incidence and course of acute renal failure following cardiopulmonary bypass (CPB) was retrospectively analyzed. The incidence of oliguric acute renal failure was 1.5% and the mortality rate was 27%, a figure substantially lower than previously reported. Both peritoneal dialysis and hemodialysis were initiated early, with a mean of 3.6 days between the onset of acute renal failure and initiation of dialysis. Survivors had a mean duration of acute renal failure of 24 days. Deaths were caused by cardiac failure (one) and sepsis (two). Mortality rate from acute renal failure complicating CPB resembles that from acute renal failure related to other causes and may be lowered by early aggressive dialysis.
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