Incomplete Kawasaki disease - a diagnostic and therapeutic challenge

Background The diagnosis of classical Kawasaki Disease was based on clinical criteria. The conventional criteria is particularly useful in preventing over diagnosis, but at the same time it may result in failure to recognize the incomplete form of Kawasaki Disease. Objective To suspect incomplete Kawasaki Disease, because early diagnosis and proper treatment may reduce substantial risk of developing coronary artery abnormality which is one of the leading causes of acquired heart disease in children. Method Nine cases of incomplete Kawasaki Disease were diagnosed over a period of one year. The diagnosis of incomplete Kawasaki Disease was based on fever for five days with less than four classical clinical features and cardiac abnormality detected by 2D- echocardiography. A repeat echocardiography was done after 6 weeks of onset of illness. The patients were treated with Intravenous Immunoglobulin and/or aspirin. Result The mean age of the patients was 3.83 years and the mean duration of symptoms before diagnosis was 12.1 days. Apart from other criteria all of our patients had edema and extreme irritability. All the patients had abnormal echocardiographic finding. Five patients received only aspirin due to nonaffordability of Intravenous Immunoglobulin and four patients received both aspirin and Intravenous Immunoglobulin, but the outcome was excellent in all the cases. Conclusion Incomplete Kawasaki Disease can be diagnosed with more awareness and aspirin alone may be used as a second line therapy in case of non affordability of Intravenous Immunoglobulin. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-4, 30-35 DOI: http://dx.doi.org/10.3126/jcmsn.v9i4.10234

Hymenoptera stings: a study of clinical profile, complication and outcome from a teaching hospital of central Nepal

Background Hymenoptera sting is a common health hazard in the tropics. Wasp and Bee stings can produce symptoms ranging from local allergic reactions to serious complications including anaphylaxis and multiple organ dysfunction syndromes.Objective To evaluate the clinical profile, management and early outcome of patients with gallbladder cancer.Methods We prospectively analyzed all the consecutive patients with Hymenopterid sting (Wasp and Bee stings), who were admitted in Nephrology Unit in college of Medical Sciences Teaching hospital over a period of two year; from June 2010 to May 2012. Data including demographic profile, clinical profile, complications and outcomes associated with the Hymenopterid stings were entered in a designated profroma and were analyzed.Results A total of 15 cases with Hymenopterid stings (Wasp and Bee stings) were analyzed. Majority of the cases were females (n=8). The male to female ratio was 0.88. The mean age of the case was 37.1± 17.38years. Most of the cases (n=11) were younger subjects d"45 years and majority of them felt in the age group of 21-30 years; (n=4). Mean number of stings (Wasp or Bee stings), were 46 ± 18.4 (12-74) and the mean time to reach the hospital from the bite time was 78.23±82.24 hours (30 minutes-13 days). Black Wasps were the commonest species to inflict the stings in (n=10) cases and Bees in (n=5) cases. The Hymenoptera stings were observed more frequently in the month of July to September in (n=8). The commonest site of bite was head and face seen in (n=11) cases. Among the clinical presentations the commonest clinical presentation was local burning pain and pruritus which was present in all the cases (n=15) followed by nausea (n=10). The commonest clinical sign was bipedal edema which was seen in (n=7) cases. Low Hb (defined as Hb <10gm/dl) was seen in (n=5) cases of Hymenopterid stings. Low platelet (defined as Platelet < 100X109/L) was documented in (n=10) cases. Serum creatinine >1.5mg /dl was seen in (n=7) cases. Low serum albumin (defined as Serum Albumin (<3.5gm/dl) was seen in (n=6) cases. Among the complications, the most common complication was Hepatitis which was seen in (n=9) cases, followed by Acute Kidney Injury. There was no mortality associated with Hymenopterid stings in our study. However 1 patient left against medical advice.Conclusion Black Wasps were the commonest species to inflict the stings in (n=10) cases. The most common complication of Hymenoptera sting was Hepatitis, which was seen in (n=9) of cases, followed by Acute Kidney Injury. Majority of complications were seen in Wasp stings which caused significant morbidity. No mortality was observed in our study except one case; that left hospital against medical advice. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-3, 17-24   

Prevalence of gastro-intestinal parasitic infections in goat of Madhya Pradesh, India

Gastrointestinal (GI) parasitism in animals is one of the major problems in India causing emaciation, anaemia, oedema, weakness, diarrhoea and death. Present study was designed to generate epidemiological data on GI parasitism of goats of Madhya Pradesh, India. During 8 months study period, a total of 960 samples were collected and examined by sedimentation and floatation methods followed by egg per gram out of 960 samples, 907 (94.48 %) were positive for one or more gastrointestinal parasite, wherein coccidia was predominant (82.4 %) followed by strongyles (69.27 %), amphistomes (22.71 %), Strongyloides sp. (9.17 %), Trichuris sp. (3.85 %), Moniezia sp. (3.02 %), Schistosomes sp. (2.29 %) and Fasciola sp. (1.77 %). The seasonal incidence was found highest in monsoon (98.06 %) and lowest in winter (91.67 %). The incidence of gastrointestinal parasitism was found higher in kids (96.25 %) in comparison with adult goats (93.89 %).

Hydrogen and halogen bonding in a concerted act of anion recognition: F− induced atmospheric CO2 uptake by an iodophenyl functionalized simple urea receptor

Halogen bonding plays a key role in the fixation of atmospheric CO₂ because air-stable crystals of HCO₃⁻ dimer by a simple urea based para-iodo substituted acyclic receptor in the presence of n-TBA salt of F⁻ in MeCN solution.

Serum thyrotrophin at baseline predicts the natural course of subclinical hyperthyroidism

OBJECTIVE

Optimal therapeutic strategies for subclinical hyperthyroidism are undecided. Overt disease develops in a minority of cases, but the risk factors for progression remain unclear. We examined whether a baseline thyrotrophin (TSH) predicted progression to overt hyperthyroidism in asymptomatic individuals with subclinical hyperthyroidism.

DESIGN, PATIENTS AND MEASUREMENTS

This was a retrospective study of 323 patients with subclinical hyperthyroidism seen in our institution from 2003 to 2010 (mean age 71 years, males 26·9%, females 73·1%, mean follow-up duration 32 months, range 6-93 months). Serum TSH and free thyroxine (FT4) were documented at baseline and during follow-up. After excluding individuals with nonthyroid causes of low TSH, patients were grouped according to initial TSH as: TSH 0·10-0·39 mU/l (grade I) and TSH < 0·10 mU/l (grade II).

RESULTS

Only 38 patients (11·8%) developed overt hyperthyroidism with annual progression rates of 0·6-3·7%. Most patients reverted to normal thyroid status (31·6%) or remained subclinically hyperthyroid (56·7%). Progression to frank hyperthyroidism was higher in grade II than in grade I patients (20·3% vs 6·8%, P < 0·001, Chi square test). Kaplan-Meier curves showed faster progression rates in grade II than grade I (P < 0·001, log rank test). In stepwise multivariate Cox regression analysis, TSH < 0·1 mU/l was associated with overt hyperthyroidism (hazard ratio 3·4, confidence interval 1·6-7·0), whereas age, gender, FT4 and aetiological diagnosis were not associated with hyperthyroidism.

CONCLUSIONS

Thyrotrophin predicts overt hyperthyroidism in asymptomatic individuals with subclinical hyperthyroidism. Patients with TSH < 0·10 mU/l have a higher risk of progressing to hyperthyroidism than those with TSH 0·10-0·39 mU/l.

Clinical and radiographic evaluation of zinc oxide eugenol and metapex in root canal treatment of primary teeth

OBJECTIVES

The aim of this study was to evaluate clinically and radiographically zinc oxide eugenol (ZOE) and Metapex as root canal filling material in primary teeth.

MATERIALS AND METHODS

Forty-two necrotic primary teeth in two groups of children in the age group of 4-7 years were obturated with ZOE and Metapex and were followed up clinically and radiographically for a period of 6 months postoperatively.

RESULTS

The overall success rates of ZOE and Metapex were 85.71% and 90.48%, respectively.

CONCLUSION

Both ZOE and Metapex gave encouraging results; however, Metapex can be used more safely whenever there is a doubt about the patient's return for follow-up.

Water soluble nanoporous nanoparticle for in vivo targeted drug delivery and controlled release in B cells tumor context

Multitasking nanoparticles are gaining great attention for smart drug delivery systems. The exploration of the nano-scale opens new concrete opportunities for revealing new properties and undiscovered cell-particle interactions. Here we present a biodegradable nanoporous silicon nanoparticle that can be successfully employed for in vivo targeted drug delivery and sustained release. The bare nanoporous nanocarriers can be accurately designed and fabricated with an effective control of porosity, surface chemistry and particle size, up to a few nm. The proposed nanoparticles exhibit several remarkable features including high payload, biodegradability, no toxicity, and multiple loading in water without the need of additional chemical reagents at room temperature. The targeting strategy is based on phage display technology that was successfully used to discover cell surface binding peptide for murine B lymphoma A20 cell line. The peptide used in combination with the nanoporous nanoparticles allows an efficient in vivo targeting, a sustained release and a sensible therapeutic effect.

A randomized, controlled trial of vitamin D supplementation upon musculoskeletal health in postmenarchal females

CONTEXT

There has been a resurgence of vitamin D deficiency rickets throughout the developed world, with infants and adolescents being primarily affected. Adolescence is a crucial period for muscle and bone mineral accumulation.

OBJECTIVE

The aim was to determine the effect of vitamin D supplementation on the adolescent musculoskeletal system.

DESIGN AND SETTING

We conducted a community-based, double-blind, randomized controlled trial in a secondary school.

PARTICIPANTS

Postmenarchal 12- to 14-yr-old females participated in the trial. Ninety-nine were screened, 73 were included in randomized controlled trial, and 69 completed the trial. There were no adverse events.

INTERVENTION

Four doses of 150,000 IU vitamin D(2) (ergocalciferol) were given over 1 yr.

MAIN OUTCOME MEASURES

Dual-energy x-ray absorptiometry, peripheral quantitative computed tomography, and jumping mechanography were used.

RESULTS

At follow-up, 25-hydroxyvitamin D [25(OH)D] status was 56.0 ± 8.9 nmol/liter in the intervention group and 15.8 ± 6.6 nmol/liter in controls. There were no effects of supplementation on bone; however, for muscle function, efficiency of movement improved in the vitamin D-treated group. There was an interaction between baseline 25(OH)D concentration and response to vitamin D supplementation for muscle jump velocity.

CONCLUSIONS

Despite improvements in 25(OH)D status, treatment with vitamin D(2) was not shown to increase mineral accretion, bone geometry or strength, muscle force, or power. There were greater increases in jump velocity in girls with the lowest baseline 25(OH)D concentrations. Lack of effect of intervention after the period of peak mineral and muscle mass accretion suggests that earlier action is required.

Blockade of tachykinin NK1/NK2 receptors in the brain attenuates the activation of corticotrophin-releasing hormone neurones in the hypothalamic paraventricular nucleus and the sympathoadrenal and pituitary-adrenal responses to formalin-induced pain in the rat

Evidence from pharmacological studies has implicated substance P (SP), a natural ligand of tachykinin NK(1) receptors which can also interact with NK(2) receptors, in the generation of pressor and tachycardic responses to stress. Using selective blockade of brain NK(1) and NK(2) receptors, we tested in conscious rats the hypothesis that SP initiates, within the neuronal brain circuits, the sympathoadrenal, hypothalamic-pituitary-adrenal (HPA) and behavioural responses to noxious stimuli. Formalin injected s.c. through a chronically implanted catheter in the area of the lower leg was used as a pain stimulus. Rats were pretreated i.c.v. with vehicle or the selective, nonpeptide antagonists of tachykinin NK(1) and NK(2) receptors, RP 67580 and SR 48968, respectively. Ten minutes thereafter, formalin was injected s.c. and the cardiovascular responses were recorded, plasma concentrations of catecholamines, adrenocorticotrophic hormone (ACTH) and corticosterone were determined and the expression of the inducible transcription factor c-Fos in the paraventricular (PVN) and supraoptic nuclei was detected to identify neurones which were activated during pain stimulation. Blockade of NK(1) and NK(2) receptors attenuated the formalin-induced increases in mean arterial pressure and heart rate, adrenaline and ACTH concentrations in plasma, and completely abolished the pain-induced c-Fos expression in corticotrophin-releasing hormone neurones localised in the parvocellular division of the PVN. The results obtained provide pharmacological evidence that tachykinins, most probably SP, act as mediators within the neuronal circuits linked to the initiation and control of the cardiovascular, sympathoadrenal, HPA and behavioural responses to pain stimuli and provide an excitatory input to corticotrophin-releasing hormone neurones in the PVN to activate the HPA axis. Our data demonstrating the inhibition of the complex response pattern to noxious stimuli and stress are consistent with the proposed anxiolytic and antidepressant activity of NK(1) and NK(2) receptor antagonists.

Ellis van Creveld syndrome with unusual association of essential infantile esotropia

Ellis-van Creveld syndrome is a rare short-limbed disproportionate dwarfism characterized by postaxial polydactyly, several skeletal, oral mucosal and dental anomalies, nail dysplasia and in 50-60% cases of congenital cardiac defects. It is an autosomal recessive disorder with mutations of the EVC1 and EVC2 genes located on chromosome 4p16. Patients with this syndrome usually have a high mortality in early life due to cardiorespiratory problems. We present the case of a six- month-old female infant with Ellis-van Creveld syndrome - essential infantile esotropia, which has been infrequently documented in the literature.

Participation of the prolactin-releasing peptide-containing neurones in caudal medulla in conveying haemorrhagic stress-induced signals to the paraventricular nucleus of the hypothalamus

The prolactin-releasing peptide (PrRP) has been proposed to be a co-transmitter or modulator of noradrenaline (NA) because it colocalises with NA in the A1 (in the ventrolateral reticular formation) and A2 (in the nucleus of the solitary tract; NTS) cell groups in the caudal medulla. The baroreceptor signals, originating from the great vessels, are transmitted primarily to the NTS, and then part of the signals is conveyed to the hypothalamic neuroendocrine neurones via the ascending NA neurones. The hypotensive haemorrhagic paradigm was employed to examine whether the PrRP-containing neurones in the caudal medulla participate in conveying signals to the hypothalamic neuroendocrine neurones. Among the caudal medullary A1 or A2 neurones, the majority of the PrRP-immunoreactive (-ir) neurones became c-Fos-ir at 2 h after hypotensive haemorrhage. Hypothalamic corticotrophin-releasing hormone-ir neurones and vasopressin-ir neurones became c-Fos positive in parallel with the activation of medullary PrRP-ir neurones. After delivery of retrograde tracer fluorogold (FG) to the paraventricular nucleus of the hypothalamus (PVN), part of the PrRP/FG double-labelled neurones in the A1 and A2 became c-Fos-ir after haemorrhage, demonstrating that PrRP-ir neurones participate in conveying the haemorrhagic stress-induced signals from the medulla to the PVN. PrRP and/or NA were microinjected directly to the PVN of conscious rats, and they presented a synergistic action on arginine vasopressin release, whereas an additive action was observed for adrenocorticotrophin release. These results suggest that the PrRP-containing NA neurones in the caudal medulla may relay the haemorrhagic stress-induced medullary inputs to the hypothalamic neuroendocrine neurones.

Ozone nucleolysis for management of pain and disability in prolapsed lumber intervertebral disc. A prospective cohort study

SUMMARY

The prevalence rate of low back pain in a number of studies ranged from 22% to 65% in one year, and lifetime prevalence ranged from 11% to 84%. Over the years many percutaneous minimally invasive therapeutic modalities have evolved. Intradiscal oxygen-ozone therapy has also showed promising results. We undertook a prospective cohort study to evaluate the therapeutic outcome of oxygen-ozone therapy on patients with lumber disc herniation in the Indian population. After obtaining ethical committee and investigational review board permission, 53 consecutive patients complying with selection criteria were treated with a single session of oxygenozone therapy. All presented with clinical signs of lumber nerve root compression supported by CT and MRI findings. All patients received 3-7 ml of ozone-oxygen mixture at an ozone concentration of 29-32 mc/ml of oxygen. Therapeutic outcome was assessed after three weeks, three months, six months, one year and two years on a visual analog scale and Oswestry low back pain disability questionnaire. Pain intensity was significantly reduced following treatment (VAS baseline 7.58-/+0.86, after three weeks 2.75-/+1.42 and after two years 2.64-/+2.14). Similarly the Oswestry disability index showed a remarkable improvement in the functional status of the patients (p<0.05). No major complication was observed in this case series. Oxygen-ozone treatment is highly effective in relieving low back pain due to lumber disc herniation.