An indian clinician outlook on hypertension care during Covid-19 pandemic

Funding Acknowledgements

Type of funding sources: None.

Background

Hypertension (HTN) has been found to increase the risk of Covid-19 mortality when compared with normotensives, and those discontinuing the antihypertensive treatment have an additional fatality risk.

Objective

The survey was carried out to seek the opinion of Indian healthcare practitioners (HCPs) on the risk factors, challenges and management of HTN during the ongoing Covid-19 pandemic.

Method

This was a structured web-based objective questionnaire survey involving 2545 HCPs PAN-India. The survey comprised questions related to the risk factors for HTN, home blood pressure monitoring (HBPM), BP control, treatment, complications and challenges of uncontrolled HTN during Covid-19.

Results

This study showed that tobacco use, obesity and comorbidities are top three modifiable risk factors for HTN followed by emotional stress, during Covid-19 pandemic. A majority of HCPs (44%) reported that <30% of their hypertensive patients check BP at home while 36% and 20% reported that 30-50% and >50% of their patients respectively, practice HBPM. 20%, 63%, and 17% of HCPs respectively, reported that <20%, 20-40% and >40% of their patients presented with BP > 150/100 mmHg during lockdown. Of all the HCPs, 53% and 33% respectively, reported BP increase in <20% and 20-40% of their patients on monotherapy while 14% of HCPs reported BP increase in >40% of their patients on monotherapy during the lockdown. As compared to high dose monotherapy, dual and triple combination therapies (TDC) were selected as most preferred for the management of uncontrolled BP opted by 56% and 34% of the HCPs, respectively. The dual combination antihypertensives were ranked as angiotensin receptor blockers (ARB) + diuretic (DU) > ARB + calcium channel blockers (CCB) > ARB + beta-blocker. The TDC with ARB + CCB + DU was the most favored TDC antihypertensive therapy during Covid-19 era. Acute coronary syndrome was anticipated as the most common complication of HTN in the Covid-19 pandemic, followed by renal dysfunction, cerebral ischemia and cerebral hemorrhage reported by 47%, 17%, 14% and 14% of HCPs, respectively. Multiple challenges in HTN care during Covid-19 as opined by HCPs included BP measurement while avoiding the risk of infection (57%), advising treatment via teleconsultation (48%), dose modification (41%), patient compliance (32%) and transport-related issues (30%). Most of the HCPs believed that self-monitoring of BP (32%) and economical medicines (24%) can improve medication adherence in patients with HTN.

Conclusion

The study underlined that the provision of economic medicines, single pill combinations, doctor-patient digital connect, and patient education can help in improving medication adherence leading to better outcomes in patients with HTN during Covid-19.  The study also suggested the need to enhance HBPM and the use of ARB-based dual and triple combination therapies to improve BP control in patients uncontrolled on monotherapy during Covid-19 pandemic.

Surgical innovation revisited: A historical narrative of the minimally invasive “Agarwal sliding‐clip renorrhaphy” technique for partial nephrectomy and its application to an Australian cohort

Objective

To evaluate local clinical outcomes of sliding clip renorrhaphy, from inception to current utilization for open, laparoscopic, and robotically assisted partial nephrectomy.

Methods

We reviewed prospectively maintained databases of three surgeons performing partial nephrectomies with the sliding‐clip technique at teaching hospitals between 2005 and 2019. Baseline characteristics, operative parameters, including surgical approach, RENAL Nephrometry Score, and post‐operative outcomes, including Clavien‐Dindo classification of complications, were recorded for 76 consecutive cases. We compared perioperative and 90‐day events with patient and tumor characteristics, stratified by operative approach and case complexity, using Wilcoxon rank‐sum test for continuous variables and the Chi‐squared or Fisher's exact test, for binary and categorical variables, respectively.

Results

Open surgery (n = 15) reduced ischemia time and operative time, but increased hospital admission time. Pre‐ and post‐operative estimated glomerular filtration rates did not change significantly by operative approach. Older patients (P = .007) and open surgery (P = .003) were associated with a higher rate of complications (any‐grade). Six grade ≥3 complications occurred: these were associated with higher RENAL Nephrometry Score (P = .016) and higher pathological tumor stage (P = .045). Limits include smaller case volumes which incorporate the learning curve cases; therefore, these data are most applicable to lower volume teaching hospitals.

Conclusion

The sliding‐clip technique for partial nephrectomy was first described by Agarwal et al and has low complication rates, acceptable operative time, and preserves renal function across open and minimally invasive surgeries. This series encompasses the initial learning curve with developing the technique through to present‐day emergence as a routine standard of practice.

Assessment of Corticotomy Facilitated Tooth Movement and Changes in Alveolar Bone Thickness - A CT Scan Study

INTRODUCTION

Corticotomy is an effective method of accelerating the orthodontic treatment. The aim of this study was to compare the treatment time for the extraction space closure, between corticotomy assisted and conventional orthodontic tooth movement and to check the alveolar bone thickness before and after corticotomy procedure in the corticotomy group.

SETTINGS AND DESIGN

Cross-sectional clinical study.

MATERIALS AND METHODS

Twenty patients (age>15 y) requiring orthodontic treatment with upper anterior retraction in the extraction space of 1(st) premolar were selected and were randomised into control and corticotomy group each group consisted of 10 subjects. Pre retraction, corticotomy was performed in the maxillary anterior segment. The pre and post retraction CT scans were recorded and the thickness of the alveolar plates were measured at crestal level (S1), mid root level (S2) and apical level (S3) PreTreatment (T1). The same measurements were repeated after incisor retraction was completed PostTreatment (T2).

STATISTICAL ANALYSIS

Student's t-test, Pearson correlation coefficient.

RESULTS

There was a significant difference in retraction time (days) between control and corticotomy groups (p<0.001). Also, there were significant difference in total alveolar bone thickness at the crest region for all the four incisor teeth (p<0.05). A significant difference was observed in total alveolar bone thickness at the S2 and S3 level for 11, 21 and 11, 12 and 22 (p<0.05) respectively.

CONCLUSION

Alveolar corticotomies not only accelerates the orthodontic treatment but, also provides the advantage of increased alveolar width to support the teeth and overlying structures.

Renal transplantation in HIV patients: A series of four cases

Human immunodeficiency virus (HIV) infection in a patient with end-stage renal disease was considered a contraindication for renal transplantation till now despite the advent of highly active antiretroviral therapy with the apprehension that immunosuppression would further jeopardize the already compromised immune status of the patients. Renal transplantation in HIV patients is rare in developing countries including ours. Here we report a series of four cases of renal transplantation in HIV patients.

Acute mixed cellular and humoral rejection of renal allograft with leucopenia

Diagnosis and management of acute renal allograft dysfunction often pose challenge to nephrologists during practice. Acute rejection is a major cause of acute graft dysfunction but is rare in patients with leucopenia. Acute rejection can have either humoral or cellular components or sometimes mixed components. Mixed acute cellular and humoral rejection often present as steroid resistant rejection. Here we report a patient with live related renal transplant recipient with acute graft dysfunction with leucopenia who was found to have mixed acute cellular and humoral rejection.

Histology of the terminal end of the distal rectal pouch and fistula region in anorectal malformations

OBJECTIVE

Until recently, surgeons have been posed with a dilemma---whether or not they should preserve the terminal end of the distal rectal pouch and the fistula region in anorectal malformations (ARMs). A detailed histological study of this region was conducted to establish a consensus for preserving or excising this region for reconstruction of ARMs.

METHODS

Histopathological examination using haematoxylin and eosin-stained sections of the terminal portion of the distal rectal pouch and proximal portion of the rectourogenital or rectoperineal connection was performed in 60 cases of high, intermediate and low ARMs.

RESULTS

Distorted internal sphincter was present in 93.3% of high, 90% of intermediate and 100% of low ARMs. The proximal fistula region was lined by transitional epithelium in 50% of cases, and anal glands were present in 83.3% and anal crypts in 68.3% of cases. The rectal pouch in the region of the internal sphincter and fistula was aganglionic in all cases.

CONCLUSION

This study shows that the terminal end of the distal rectal pouch and proximal fistula region possess distorted anal features with aganglionosis, and contradicts the recommendation that this region should be reconstructed in patients with malformations.

Prevalence of anaemia in pregnant & lactating women in India

BACKGROUND & OBJECTIVES

The prevalence of anaemia during pregnancy and lactation was significantly lower in the National Family Health Survey 1998-1999 (NFHS-2), using the hemocue method for haemoglobin estimation compared to earlier surveys. The present study selected seven States and used the same districts and villages studied in the NFHS-2, to see if the reported reduction in prevalence of anaemia was due to health and nutrition inputs and/or due to a different method for haemoglobin estimation.

METHODS

A total of 1,751 women (1,148 pregnant and 603 lactating- exclusively breastfeeding up to 3 months of age), from seven States- Himachal Pradesh and Haryana in north; Assam and Orissa in east; Kerala and Tamil Nadu in south and Madhya Pradesh in central India, were selected. Haemoglobin was estimated by the cyanmethaemoglobin method, so that comparison was possible with earlier studies. Data on socio-demographic characteristics, pregnancy, nutritional status and dietary intakes were collected.

RESULTS

Prevalence as well as severity of anaemia was significantly higher in the present study as compared to the NFHS-2 study data. The difference could be due to haemocue method, which gives higher haemoglobin values. The contributing factors found on multiple regression analysis for anaemia in pregnancy and lactation were: literacy, occupation and standard living index of the study women; their awareness about anaemia, its prevention by regular consumption of ironfolate tablets and increase in food intake. Maternal height, age of marriage, parity and foetal loss also contributed to haemoglobin level. There were interstate differences; lower fertility, higher literacy and better diet was observed in Himachal Pradesh as compared to Haryana. The literacy and nutritional status of women in Tamil Nadu was lower than Kerala. The remaining 3 states had poor fertility, lower social living index and nutritional status with >90 per cent women being anaemic in pregnancy and lactation. Low prevalence of severe anaemia in Orissa as compared to Assam was due to availability and consumption of iron folate tablets. The antenatal services in the first trimester and checkup by a doctor, along with availability and consumption of iron folate tablets over 3 months in all the States influenced haemoglobin levels.

INTERPRETATION & CONCLUSION

Despite the measures taken to control anaemia in pregnancy and lactation in the last two decades, the severity of nutritional anaemia continues to remain a public health issue of great magnitude, suggesting that these measures have been largely ineffective. The present findings also showed interstate differences particularly in fertility, women education, nutrition status and occupation; availability of antenatal services and iron folate tablets as possible factors responsible for differences in prevalence of anaemia.

Peak expiratory flow rate of children working in lock factories

Peak expiratory flow rate (PEFR) of 106 children working in different units of lock factory was measured and compared with age and sex matched control group of same socio-economic status children. All the children worked for about ten hours per day. It was observed that there was a significant decrease in PEFR of children working in the different units of lock factories i.e. Hand press, Polishing, Lock fitting, Lock packing units as compared to control group (P>0.001). The reduction percentage of PEFR was maximum in children working in polishing unit (25.48%).

Characterization of gibberellin producing strains of Fusarium moniliforme based on DNA polymorphism

The gibberellins are one of the major groups of growth promoting hormones and are secondary metabolites of the fungus Fusarium moniliforme (Perfect stage: Gibberella fujikuroi). Sixteen strains of Fusarium from different geographical regions and different hosts were analysed for their ability to produce gibberellins (GA) and for genetic relatedness by random amplified polymorphic DNA (RAPD). Range of gibberellin production varied between 28.9 to 600.0 mg g(-1) dry weight of mycelium in different strains of Fusarium. RAPD analysis showed completely different pattern between high, moderate and low producing strains. High producers formed nearly identical RAPD patterns, whereas the low and moderate producers gave heterologous amplification patterns. Since Fusarium pallidoroseum was in another group, it was possible to distinguish between different species of the genus Fusarium by RAPD. These investigations may find an application in the diagnosis of unknown Fusarium species and in distinguishing isolates of Gibberella fujikuroi within the section of Liseola.

Diabetic nephropathy--prevention and treatment

Diabetic nephropathy is a major cause of end stage renal failure. Non-insulin dependent diabetes mellitus (NIDDM) is more prevalent in our country than insulin dependent diabetes mellitus (IDDM). Nephropathy can be classified in IDDM patients in 5 stages which have been elaborated here. The major intervention to prevent or reduce the rate of progress in diabetic nephropathy is control of blood sugar, control of blood pressure, use of angiotensin converting enzyme inhibitors, restricting dietary protein intake, treatment with inhibitors of the formation of advanced glycosylation end products, treatment with aldose reductase inhibitors and treatment of dyslipidaemia. Once the patient of diabetic nephropathy reaches the end stage renal disease, renal replacement therapy is needed. The different modalities of renal replacement therapy are: Haemodialysis, continuous ambulatory peritoneal dialysis, kidney transplantation and kidney and pancreas transplantation. Renal replacement therapy in diabetics has to be individualised from patient to patient. Kidney transplantation is at present the option of choice.

Birth weight patterns in rural undernourished pregnant women

OBJECTIVE

To study the birth weight pattern in chronic as well as currently undernourished pregnant women.

DESIGN

Prospective study of rural pregnant women by following eligible women.

SETTING

Two adjoining blocks of rural Varanasi.

METHOD

3700 pregnant women from rural areas of Varanasi for whom data for anthropometry, hemoglobin, dietary intake, birth weight, fundal height and abdominal girth at 16 +/- 2, 28 +/- 2 and 36 +/- 2 weeks of gestation were recorded. Outcome measure was birth weight pattern of newborns.

RESULTS

Of the births, 7.2% were < 2250 g and 27.4% < 2500 g. The weekly birth weight increments in gestation 36-42 weeks were 5-53 g, only. The fundal height did not increase during 35-39 weeks of gestation (lower by 5 cm as compared to normal). Nutrition supplement in the third trimester significantly increased fundal height and abdominal girth. Fundal height below 24.5 cm at 28 weeks of gestation (1368 women) was associated with higher low birth weight deliveries.

CONCLUSION

Birth weight and fundal height increments during later pregnancy are low in undernourished pregnant women. Fundal height < 24.5 cm at 28 weeks of gestation identified women with higher risk for lowbirth weight infants. The prevalence of low birth weight was 27.4% and of prematurity was 6.6%.

Covariate-adjusted response-adaptive designs for binary response

An adaptive allocation design for phase III clinical trials that incorporates covariates is described. The allocation scheme maps the covariate-adjusted odds ratio from a logistic regression model onto [0, 1]. Simulations assume that both staggered entry and time to response are random and follow a known probability distribution that can depend on the treatment assigned, the patient's response, a covariate, or a time trend. Confidence intervals on the covariate-adjusted odds ratio is slightly anticonservative for the adaptive design under the null hypothesis, but power is similar to equal allocation under various alternatives for n = 200. For similar power, the net savings in terms of expected number of treatment failures is modest, but enough to make this design attractive for certain studies where known covariates are expected to be important and stratification is not desired, and treatment failures have a high ethical cost.

Physical growth assessment in adolescence

OBJECTIVE

To describe ponderosity indices body mass index--"BMI" and ponderal index "PI" and skin fold thicknesses (triceps, biceps, subscapular and suprailiac) for affluent Indian school going adolescents.

DESIGN

Cross sectional.

METHODS

Measurements were recorded in healthy affluent school going adolescents in public schools of 12 cities in India (boys=11,863 and girls 7,694). Means and percentiles of ponderosity indices and skinfold thicknesses at yearly intervals were derived for each sex and related to sexual maturity.

RESULTS

BMI, PI and skin fold thickness (SFT) were higher in girls. There was lower variability of these parameters with sexual maturity rating (breast/genital development stages) as compared to age, suggesting use of these indices in relation to sexual maturity for assessment of adolescent growth.

CONCLUSION

Pediatricians and endocrinologists can use these indices for assessment of thinness and obesity, in adolescent Indian children, in relation to sexual maturity for the age.

Does serum albumin at start of continuous ambulatory peritoneal dialysis (CAPD) or its drop during CAPD determine patient outcome?

The impact of serum albumin at start of continuous ambulatory peritoneal dialysis (SA1), serum albumin before death (SA2), and change in serum albumin during continuous ambulatory peritoneal dialysis (delta SA) were prospectively studied in 41 continuous ambulatory peritoneal dialysis (CAPD) patients with a follow-up of 19 +/- 11.6 months. For analysis, patients were divided into two groups at each measurement point: SA1 or SA2 > 3.0 g/dL or delta SA < 1.0 g/dL (group I), and SA1 or SA2 < 3.0 g/dL or delta SA > 1.0 g/dL (group II). On log rank test, the mortality rate was significantly higher in group II patients in relation to SA1 (p < or = 0.0001), SA2 (p = 0.0002), and delta SA (p = 0.001). On univariate Cox proportional hazard regression analysis, SA1 (p = 0.0001), SA2 (p = 0.0001), delta SA (p = 0.002), and episodes of peritonitis (p = 0.0001) were significant. On multivariate analysis, SA2 (p = 0.003) was significantly related to patient mortality. SA2 (r = 0.8; p = 0.0001), but not delta SA, was related to SA1. We conclude that SA2 is the best predictor of patient mortality on CAPD. SA2 is strongly related to SA1. Thus protein restriction in the pre-dialysis stage should be advised cautiously to avoid consequent hypoalbuminemia.

Peritoneal equilibration test in Indian patients on continuous ambulatory peritoneal dialysis: does it affect patient outcome?

The variations in peritoneal equilibration test (PET) characteristics in various ethnic groups have been reported. Data are scarce regarding the pattern of membrane characteristics in Indian patients. The factors affecting PET and the PET, in turn, affecting patient outcome are controversial issues. We prospectively analyzed 41 patients to evaluate: (1) the pattern of PET characteristics in Indian patients; (2) the factors affecting the PET; (3) the effect of membrane characteristics on patient outcome. The mean period of follow up was 17.1 +/- 9.3 months. The PET results revealed 21 high transporters (51%), 13 high-average transporters (32%), 6 low-average transporters (15%), and 1 low transporter (2%). The distribution of the various PET categories in patients below the age of 60 years and those 60 years or above was not significant (p = 0.70). The sex distribution (p = 0.94) and prevalence of diabetes (p = 0.62) were not significantly different in various PET categories. On regression analysis, PET values were not affected by the age of patients (beta = 0.80, p = 0.61). Patient survival among high and high-average transporters was significantly less compared with low and low-average transporters (p = 0.01). We conclude that Indian patients on continuous ambulatory peritoneal dialysis (CAPD) have a higher proportion of high and high-average transporters. The pattern of membrane kinetics cannot be explained by differences in patient characteristics and diabetic status. Patients with high PET values have poorer patient survival on CAPD.

Impact of the integrated child development services (ICDS) on maternal nutrition and birth weight in rural Varanasi

OBJECTIVE

To evaluate the impact of ICDS on maternal nutrition and birth weight.

SETTING

28 ICDS and 21 non-ICDS villages in two adjoining blocks of Varanasi.

METHODS

5289 pregnancies were registered during 1987-1993 in these two blocks. In the ICDS block 916 and 1453 nutrition supplemented and unsupplemented, respectively and 1748 of the non-ICDS live births with weight recorded within 48 h formed the study subjects.

RESULTS

The ICDS supplemented mothers gained 100g more in pregnancy and birth weight was higher by 58 g (p < 0.05) as compared to unsupplemented ICDS mothers. Birth weight in unsupplemented ICDS areas was 25g higher as compared to non ICDS area. ICDS supplemented women had a significantly smaller proportion of low birth weight babies (14.4%) compared to ICDS unsupplemented (20.4%) and non-ICDS women (26.3%). The corresponding prevalence of preterm births was 2.0, 2.4 and 4.3%, respectively (P < 0.001). Multiple regression analysis showed that increased wight gain in pregnancy, length of gestation, caloric intake and term hemoglobin were significantly associated with birth weight. However, the length of gestation was not influenced by factors improving the birth weight.

CONCLUSION

Undernourished pregnant women are benefitted by late pregnancy nutrition supplement

Differential response of prostate specific antigen to testosterone surge after luteinizing hormone-releasing hormone analogue in prostate cancer and benign prostatic hyperplasia

OBJECTIVE

To investigate any differences in changes in serum prostate specific antigen (PSA) levels in patients with benign and malignant prostatic disease in response to the testosterone surge after administering a luteinizing hormone-releasing hormone (LHRH) analogue.

PATIENTS AND METHODS

The study included 54 patients referred to the urology clinic with intermediate PSA levels (4-10 ng/mL) or an abnormal digital rectal examination. Forty-five patients received a single injection of LHRH analogue depot each at one week before prostate biopsy and nine served as a control group. Changes in PSA levels in response to the testosterone surge from the LHRH analogue were recorded after 5 and 7 days, and were correlated with the biopsy results. The PSA changes were compared with basal PSA levels and the free/total PSA ratio(f/tPSA).

RESULTS

Of the 45 patients who underwent prostate biopsy, histopathology showed prostate cancer in 11, benign prostatic hyperplasia in 33 and prostatic intraepithelial neoplasia in one. Patients with cancer had a significantly greater increase in serum PSA levels during the first week after LHRH injection than those in the benign and control groups. Receiver operating characteristic curves showed that the percentage change in PSA level on day 5 was more diagnostic than total PSA and f/tPSA.

CONCLUSIONS

There was a marked difference in the PSA response of patients with benign or malignant disease to the testosterone surge produced by the LHRH analogue. Although a larger study would be needed before LHRH-induced provocation could be proposed as a clinical test, in this small series the response was better than that for total PSA or f/tPSA in differentiating benign and malignant disease.

Evaluation of interstitial diode laser therapy for treatment of benign prostatic hyperplasia

In the last decade, a number of new device technologies were developed for benign prostatic hyperplasia (BPH) therapy. These technologies were introduced in an effort to reduce the morbidity of BPH therapy associated with conventional electrocautery transurethral resection of the prostate (TURP). While morbidity is reduced, the aim of new therapy is to achieve near equivalence in efficacy of outcome measures, namely, improved voided flow rate and reduced symptom score. To gain acceptance by urologists, these technologies should be easy to apply and should reduce the economic cost of BPH treatment. The Indigo 830e diode laser system offers simplified laser therapy from a miniaturized solid-state system. This pilot study demonstrates outcome equivalence to TURP in preliminary evaluation and shows an acceptable side effect profile.

Pregnancy wastage in rural Varanasi: relationship with maternal nutrition and sociodemographic characteristics

OBJECTIVE

To study the relationship between pregnancy wastage and matrnal undernutrition and other sociodemographic factors in rural Indian women.

SETTING

Rural community of Varanasi.

DESIGN

Longitudinal observation.

METHOD

In 49 villages during 1988-92, 8111 pregnancies were registered to observe for wastage. The pregnancy outcome was correlated with various factors.

RESULTS

There were 1321 abortions and 141 still births. Women's income < Rs. 250 per month, education < 10th class and protein intake < 50 g/day had significantly higher relative risks (RR) (4.1, 2.9 and 2.8, respectively) for abortions. Poor maternal nutrition was in additional important risk factor, for still births (RR 5.1 and 4.2 for maternal weight and height, respectively). A pregnancy interval over 2 years reduced both.

CONCLUSION

Low socioeconomic status, chronic undernutrition and illiteracy in rural India are associated with high pregnancy wastage.

Biliary ascariasis complicating endoscopic sphincterotomy for choledocholithiasis in India

Endoscopic sphincterotomy is the treatment of choice for patients with choledocholithiasis. Biliary ascariasis has been reported from many parts of the world but is common in Kashmir, India. We report five cases of biliary ascariasis of which four were the result of post-endoscopic sphincterotomy for choledocholithiasis. Therefore, biliary ascariasis is not an uncommon complication of endoscopic sphincterotomy.

Nutritional status of rural non-pregnant non-lactating women in reproductive age

OBJECTIVE

To find out the degree of current undernutrition in rural reproductive age women.

SETTING

49 villages of two adjoining rural blocks of Varanasi.

METHODS

6130 non-pregnant and non-lactating rural women in the age group 18-45 year were studied for sociodemographic characteristics and anthropometry, i.e., weight, height and midarm circumferance. Their percentiles for age and for weight for height were calculated by using cubic spline method.

RESULTS

The women in 10th centile weighed < 38 kg and those in > 90th centile weighed 47-48 kg; 74.2% had weight < 45 kg. The 50th centile height ranged between 148-150 cm; 13.5% were < 145 cm. For mid arm circumference 50th and 90th centile values were around 22 and 24 cm, respectively. Mid arm circumference and height had significant linear correlation with weight.

CONCLUSION

Around 50% rural UP women in pre-pregnancy state are undernourished. With age these rural women did not change in weight or mid-arm circumference.

Spontaneous passage of gallbladder calculi--facilitation by endoscopic sphincterotomy

After endoscopic sphincterotopy (ES) gallbladder motility increases leading to expulsion of crystals and stones. But this is not a universal phenomenon. We evaluated cholangiographic findings in patients emptying their gallbladder after ES for common bile duct (CBD) stones. Cholangiographic features of twenty patients expelling gallbladder calculi after ES were studied. Controls included 20 age and sex matched patients with gallstones and CBD stones, who did not expel gallstones after ES. Of 20 cases in study group, 9 recovered more than 20 stones each in the stool within 7 days of ES. Repeat ERCP showed empty gallbladder in all, whereas CBD was full of stones in 11 of the 20 cases. In the study group, low insertion of the cystic duct was more common (10 vs 0, p < 0.04), the cystic duct made a narrow angle (20 +/- 5 degrees vs 50 +/- 10 degrees, p < 0.04) with CBD before insertion and cystic duct diameter was higher (5 mm vs 2.5 mm, p < 0.04) as compared to controls. We conclude that in patients undergoing ES with intact gallbladder and small gallbladder calculi, spontaneous emptying of gallbladder calculi occurs, if cystic duct is wider, has low insertion and makes narrow angle with CBD before insertion.

Weight gain during pregnancy--a key factor in perinatal and infant mortality

OBJECTIVE

To identify risk factors for high perinatal (PMR) and infant (IMR) mortality in a rural area.

DESIGN

In 49 randomly selected villages from two adjoining blocks of rural Varanasi, all pregnant women and live births were followed for perinatal and infant mortality, during the years 1988-1992.

SUBJECTS

6790 births and their 6649 live births.

RESULTS

The PMR was 90.7 per thousand births and IMR was 98.6/1000 live births. These mortalities were significantly higher if weight gain during pregnancy was less than 7.0 kg. Low weight gain during pregnancy was also associated with significantly higher low birth weight deliveries and to some extent increased still birth rate. PMR and IMR decreased with higher levels of hemoglobin in third trimester and socioeconomic index; however, the calculated RR were not significant.

CONCLUSION

Low weight gain during pregnancy is an important risk factor for PMR and IMR.

Efficacy of amphipathic dithiocarbamates in intracellular cadmium mobilization and in modulation of hepatic and renal metallothionein in cadmium pre-exposed rat

Forty-eight hours after an intraperitoneal injection of cadmium chloride (1.5 mg Cd/kg) to female albino rats, Cd was mainly localized in the hepatic and renal supernatant cytosolic fraction (SCF). Seventy-two hours later, the total hepatic burden remained unchanged but the total renal burden was enhanced, showing its tendency to accumulate in the kidney. A single dose (0.4 mmol/kg, i.p.) of sodium N-benzyl-D-glucamine dithiocarbamate (BG.DTC) or sodium N-(4-methoxybenzyl)-D-glucamine dithiocarbamate (MeO.BG.DTC), 24 h after Cd injection, efficiently mobilized Cd from hepatic SCF, apparently from cadmium-metallothionein (Cd-MT); MeO.BG.DTC also removed Cd from hepatic nuclear mitochondrial fraction. This treatment, however, increased the renal burden of Cd, indicating that the chelating agents, at least partly, transport Cd from the liver and possibly from other sites into the kidney. Three doses of the chelators further enhanced mobilization of Cd from hepatic as well as renal SCF, as corroborated by its enhanced urinary and, to a greater extent, fecal excretion. Hepatic and renal MT were induced several-fold above normal after a single dose of Cd as well as single or repeated doses of BG.DTC or MeO.BG.DTC. Seventy-two hours after a Cd injection, the hepatic MT declined to half of the induced level while the renal MT remained elevated. Administration of BG.DTC or MeO.BG.DTC in Cd pre-treated rats produced an additive response in hepatic MT, but the response in renal MT was less than additive at one dose and slightly declined after three doses. Hepatic Zn and Cu and renal Zn increased on treatment with Cd but were depleted after a single or repeated injection of BG.DTC or MeO.BG.DTC in normal as well as in Cd pre-exposed animals. The results indicate that intracellular access of amphipathic dithiocarbamates effectively mobilizes MT-bound Cd, which is preferentially excreted in the feces, and helps avoid further burden on the kidney and consequent nephrotoxicity. Additionally, MeO.BG.DTC was a better inducer of hepatic MT to help increased capture of toxic metal from the initial circulation and consequent toxicity.

Bile lithogenicity and gallbladder emptying in patients with microlithiasis: effect of bile acid therapy

BACKGROUND & AIMS

Biliary cholesterol supersaturation, rapid nucleation of cholesterol, and altered gallbladder motility are prerequisite for gallstone formation. However, the pathogenesis of microlithiasis is not clear. The aim of this study was to determine the abnormalities of gallbladder emptying and bile composition in patients with microlithiasis.

METHODS

Nucleation time, cholesterol saturation index (CSI), and gallbladder emptying were studied in patients with microlithiasis (n = 10), patients with gallstones (n = 10), and healthy volunteers (n = 10). Bile analysis was repeated in 6 patients with microlithiasis treated with ursodeoxycholic acid (UDCA) for 8 weeks.

RESULTS

Nucleation time was shorter in patients with microlithiasis and those with gallstones than in healthy volunteers (P < 0.0001). Patients with microlithiasis had longer nucleation time than those with gallstones (P < 0.001). There was no difference in cholesterol levels and CSI in gallstone and microlithiasis patients. However, healthy volunteers had lower cholesterol levels (P < 0.01) and CSI (P < 0.01). Patients with microlithiasis had prolongation of nucleation time (P < 0.001) and lowering of CSI (P < 0.001) after UDCA therapy. Gallbladder ejection fraction was higher in microlithiasis patients than in gallstone patients (P < 0.01) but lower than in healthy volunteers (P < 0.01).

CONCLUSIONS

Patients with microlithiasis have longer nucleation time and better gallbladder emptying than patients with gallstones. Bile abnormalities can be successfully corrected with UDCA therapy in patients with microlithiasis.

Biliary stenting for management of common bile duct stones

Large and multiple common bile duct stones may defy extraction despite an adequate endoscopic papillotomy. We treated 65 patients with symptomatic bile duct stones with endoscopic stents after failed attempts at stone extraction. Of the 65 patients, bile duct stones were extracted in eight at a second attempt, 29 underwent elective surgery and 28 patients were followed with the stent in situ for 21-52 months (median 42 months). During follow up, two patients had recurrent pain and two required surgery. The remaining 24 patients remained asymptomatic. Biliary stenting is a safe and effective mode of treatment for common bile duct stones in patients who have failed stone extraction after endoscopic papillotomy.

Sequelae of early undernutrition on reaction time of rural children at 11-14 years

85 undernourished rural school children at 11-14 yr of age were randomly selected on the basis of their nutritional status during first five years of life for assessment of reaction time (RT). Audio-visual RT apparatus and electromyograph were used for the study. Early life undernourished children had prolonged RT as compared to their matched control maintaining normal nutrition status in first five years of life. The total, premotor and motor RT for audio as well as visual stimuli were affected in these undernourished children. The RT increased with severity of current undernutrition; those achieving normal nutritional status at this age continued to have prolonged RT. The study suggests that the early life undernutrition affects perceptual abilities, information processing and analytical capabilities.

Effect of endoscopic sphincterotomy on gall bladder bile lithogenicity and motility

BACKGROUND

Endoscopic sphincterotomy has been shown to inhibit stone formation in the gall bladder of experimental animals.

AIMS

To investigate the alterations in bile composition and gall bladder motility after endoscopic sphincterotomy.

PATIENTS

A study was performed of gall bladder bile composition and gall bladder motility in patients with gallstone disease ((n = 20; age 40-60 years, median age 55 years: seven men), with gall bladder calculi (n = 12) and with diseased gall bladder (chronic inflammation) without gall bladder calculi (n = 8)), who had received endoscopic sphincterotomy for common bile duct stones. Age and sex matched disease controls comprised 20 patients with gallstone disease but without stones and an intact sphincter of Oddi (with gall bladder calculi (n = 10) and diseased gall bladder without gall bladder calculi (n = 10)).

METHODS

Gall bladder motility was assessed by ultrasound. Duodenal bile collected by nasoduodenal tube after stimulation of gall bladder by intravenous ceruletid infusion was analysed for cholesterol, phospholipid, and bile acid concentrations, cholesterol saturation index, and nucleation time.

RESULTS

There was a significant reduction in mean (SEM) fasting volume (12.5 (1.7) ml v 26.4 (2.5) ml; p < 0.001) and mean (SEM) residual volume (4.34 (0.9) ml v 14.7 (0.98) ml; p < 0.001), and increase in mean (SEM) ejection fraction (65.7 (4.2)% v 43.6 (5.52)%; p < 0.001) and mean (SEM) rate constant of gall bladder emptying (-0.031/min v -0.020/min; p < 0.01) in patients who had been subjected to endoscopic sphincterotomy. Median nucleation time was significantly longer (17 days v 6 days; p < 0.006) in treated patients. There was a reduction in total mean (SEM) lipid concentrations (6.73 (0.32) g/dl v 7.72 (0.84) g/dl; p < 0.05), cholesterol (5.6 (1.5) mmol/l v 10.3 (2.23) mmol/l; p < 0.001) and CSI (0.72 (0.15) v 1.32 (0.31); p < 0.001). There was no significant change in mean (SEM) phospholipid (25.6 (3.5) mmol/l v 23.4 (6.28) mmol/l) and bile acid (93.7 (7.31) mmol/l v 105.07 (16.6) mmol/l) concentrations.

CONCLUSIONS

After endoscopic sphincterotomy there was enhanced contractility of the gall bladder, accompanied by a prolongation of nucleation time and reduction in cholesterol saturation index.

Relationship of manometric findings to symptomatic response after pneumatic dilation in achalasia cardia

BACKGROUND

Achalasia cardia is usually treated by pneumatic dilation or surgical esophagomyotomy. The role of esophageal manometry for objective assessment of symptom response is controversial.

AIM

To study the relationship between symptoms and manometric parameters before and after pneumatic dilation in patients with achalasia cardia.

METHODS

Sixteen patients with achalasia cardia underwent esophageal manometry before and after undergoing pneumatic dilation. At each time, lower esophageal sphincter (LES) pressure and mean basal esophageal-gastric pressure gradient (MIEP-MIGP) were measured.

RESULTS

Good symptom response was obtained in 12 of 16 patients. Median (range) LES pressure fell from 42 (17-51) mmHg to 18 (8-39) mmHg in those patients with a good response, and from 51 (25-68) mmHg to 29.5 (23-42) mmHg in those who responded poorly. Mean intraesophageal pressure fell below mean intragastric pressure in both the groups.

CONCLUSIONS

Esophageal manometry does not correlate with symptom improvement after pneumatic dilation in achalasia cardia. Dysphagia may persist in spite of reversal of the MIEP-MIGP gradient.

Endoscopic management of acute calculous cholangitis

Acute cholangitis is associated with significant morbidity and mortality. Endoscopic drainage procedures have been shown to be a safe and effective mode of treatment in acute cholangitis. As there is paucity of large series on endoscopic management of acute cholangitis, a study was performed to evaluate safety and efficiency of endoscopic biliary decompression in acute cholangitis. The study included 89 consecutive patients (mean age 55+/-15 years; range 35-70 years; 50 males) with acute cholangitis requiring biliary drainage. Main presenting features were upper abdominal pain (84%), fever with chills (90%) and jaundice (74%). Altered sensorium, hypotension, features of peritonitis and acute renal failure were present in 15, 11, 18 and 5%, respectively. Endoscopic procedures performed were endoscopic sphincterotomy (ES) with stone extraction (n=40); ES with endoscopic nasobiliary drainage (ENBD; n=30); ENBD without ES (n=8); and ES with stent placement (n=11). Of the 89 patients, 85 (95%) responded within 48-72 h. Endoscopic common duct clearance could be achieved in 58 of 78 (74%) patients, whereas in 11 patients undergoing stent placement, stone extraction was not attempted. Complications included post-sphincterotomy bleed (n=2), retroduodenal perforation (n=1) and acute pancreatitis (n=1) with an overall complication rate of 4.4%. All the complications were seen in patients undergoing ES with stone extraction. Mortality was 3.3%. In conclusion, endoscopic biliary drainage is a safe and effective mode of treatment for acute cholangitis. Endoscopic nasobiliary drainage or stent placement is safer than ES in acute cholangitis as an initial step.

In vivo induction of sister chromatid exchange in mouse bone marrow following oral exposure to commercial formulations of alpha-cyano pyrethroids

In vivo genetic toxicity potential of cypermethrin and deltamethrin, two alpha-cyano pyrethroid insecticides was evaluated through induction of sister chromatid exchange in mouse bone marrow cells. Groups of four healthy, adult, male albino mice were each administered with a single oral dose of 10.6, 21.1 and 32 mg cypermethrin a.i./kg b.w. or 6.6, 13.2 and 20 mg deltamethrin a.i./kg b.w. in peanut oil. For reference, a peanut-oil vehicle control and cyclophosphamide (20 mg/kg, i.p.) positive control group of animals were run in parallel. Sister chromatid exchange (SCE) analysis in bone marrow metaphase chromosomes, 24 h post-treatment, revealed modest induction with statistical significance at the highest test dose of both insecticides as compared to the vehicle control group. Further, the SCE induction by cypermethrin was more prominent than by deltamethrin. Marked induction of SCE frequency by exposure to cyclophosphamide, an alkylating mutagen, lent authenticity to these observations which, together with earlier evidence of mitotic and chromosomal abnormalities by these pyrethroids, substantiated their genetic toxicity potential and susceptibility of mammals to consequent risks.

Percutaneous transhepatic biliary drainage in the management of obstructive jaundice

BACKGROUND

Percutaneous transhepatic biliary drainage (PTBD) has been employed for decompression of the obstructed biliary tract to palliate jaundice and pruritus and for the management of cholangitis. We present our data to review the indications, therapeutic results and associated mortality and complications of this procedure. We have also studied the effect of size of drainage catheters on the improvement in liver functions and procedure related complications.

METHODS

PTBD was attempted in 41 patients (18 men, age 56 +/- 12 years; 23 women, age 55 +/- 11 years) with obstructive jaundice (37 malignant, 4 benign).

RESULTS

PTBD was successful in 39 (95%) patients. Mean serum bilirubin and alkaline phosphatase concentration declined significantly (p < 0.000001 for both) after 1 week, however thereafter decline was slow. Complete relief of pruritus and cholangitis was noted in most patients. Major complications such as cholangitis, bile leak into the peritoneum, malfunction of drainage catheter, intraperitoneal haemorrhage and renal failure, occurred in 11 (28%) patients, 2 (5%) of whom died. Large catheters (> 10 Fr) were superior to small size catheters (< 10 Fr) in relief of jaundice and had lower catheter related cholangitis.

CONCLUSIONS

We conclude that PTBD is useful for palliation of malignant obstructive jaundice with intractable symptoms and cholangitis. Catheters larger than 10 Fr should be used.

Pravastatin has no effect on bile lipid composition, nucleation time, and gallbladder motility in persons with normal levels of cholesterol

Pravastatin dissolves gallstones in patients with hypercholesterolemia by reducing the cholesterol saturation index (CSI) of bile. There are few reports on effect of pravastatin on bile lipids, CSI and nucleation time (NT) in patients with gallstones and normal plasma lipid levels, or on the effect of pravastatin on gallbladder motility. Therefore we studied the effect of pravastatin on bile lipids, CSI, NT, and gallbladder motility in persons with normal cholesterol levels. We included 10 patients (ages 32 +/- 8 years; 6 men) with symptomatic gallstones and normal plasma lipid profiles. Estimation of bile lipids, CSI, and NT in duodenal bile and gallbladder motility were done using standard methods. Subsequently each patient was given 40 mg pravastatin daily for 1 month. At completion of pravastatin therapy, bile lipids and gallbladder motility studies were repeated. After pravastatin therapy, we found no significant reduction in bile cholesterol (11.2 +/- 3.2 vs. 10.4 +/- 2.8 mmol/l), bile acids (114.6 +/- 7.4 vs. 133 +/- 16 mmol/l), phospholipids (23 +/- 3.5 vs. 24 +/- 6.2 mmol/l), CSI (1.28 +/- 0.4 vs. 1.22 +/- 0.3), and nucleation time (7 +/- 3 vs. 7 +/- 3 days). In addition, there was no significant change in gallbladder fasting volume (26 +/- 3 vs. 26.6 +/- 3 ml), residual volume (14.6 +/- 1.1 vs. 15.08 +/- 1.4 ml), ejection fraction (44% vs. 43%), and rate constant of gallbladder emptying (0.018/min vs. 0.022/min). One-month therapy with pravastatin does not alter bile lipids, CSI, NT, and gallbladder contractility in persons with normal levels of cholesterol.