Factors associated with unexplained sudden deaths among adults aged 18-45 years in India - A multicentric matched case-control study

BACKGROUND OBJECTIVES

In view of anecdotal reports of sudden unexplained deaths in India's apparently healthy young adults, linking to coronavirus disease 2019 (COVID-19) infection or vaccination, we determined the factors associated with such deaths in individuals aged 18-45 years through a multicentric matched case-control study.

METHODS

This study was conducted through participation of 47 tertiary care hospitals across India. Cases were apparently healthy individuals aged 18-45 years without any known co-morbidity, who suddenly (<24 h of hospitalization or seen apparently healthy 24 h before death) died of unexplained causes during 1 st October 2021-31 st March 2023. Four controls were included per case matched for age, gender and neighborhood. We interviewed/perused records to collect data on COVID-19 vaccination/infection and post-COVID-19 conditions, family history of sudden death, smoking, recreational drug use, alcohol frequency and binge drinking and vigorous-intensity physical activity two days before death/interviews. We developed regression models considering COVID-19 vaccination ≤42 days before outcome, any vaccine received anytime and vaccine doses to compute an adjusted matched odds ratio (aOR) with 95 per cent confidence interval (CI).

RESULTS

Seven hundred twenty nine cases and 2916 controls were included in the analysis. Receipt of at least one dose of COVID-19 vaccine lowered the odds [aOR (95% CI)] for unexplained sudden death [0.58 (0.37, 0.92)], whereas past COVID-19 hospitalization [3.8 (1.36, 10.61)], family history of sudden death [2.53 (1.52, 4.21)], binge drinking 48 h before death/interview [5.29 (2.57, 10.89)], use of recreational drug/substance [2.92 (1.1, 7.71)] and performing vigorous-intensity physical activity 48 h before death/interview [3.7 (1.36, 10.05)] were positively associated. Two doses lowered the odds of unexplained sudden death [0.51 (0.28, 0.91)], whereas single dose did not.

INTERPRETATION CONCLUSIONS

COVID-19 vaccination did not increase the risk of unexplained sudden death among young adults in India. Past COVID-19 hospitalization, family history of sudden death and certain lifestyle behaviors increased the likelihood of unexplained sudden death.

Subthalamic Deep Brain Stimulation in Parkinson's Disease: A Boon or Bane - A Single Centre Retrospective Observational Study from India

Background  Subthalamic deep brain stimulation (STN-DBS) for refractory Parkinson's disease (PD) is more of a modality of treatment that is empirical, for which a physiological explanation is being sought. This study was done to determine the outcome and complications of patients undergoing STN-DBS for PD. Methods  This retrospective observational cohort study was conducted in an advanced neuromedicine facility in eastern India for 9 years (August 2013-August 2022), which included all patients undergoing STN-DBS. Results  A total of 53 patients were operated on during the study period. The mean age group of the study population was 60.5 (standard deviation [SD]: 8.2) years with a male (33 [62.3%]) predominance. The most common presenting complaints included rigidity and hypokinesia (27), severe dyskinesia (21), and tremors (17). During the postoperative period, rigidity and hypokinesia (21), severe dyskinesia (16), and tremors (12) improved significantly in a subset of the patients. The majority (45 [84.9%]) of these cases received bilateral monopolar simulation, whereas three patients (5.7%) had bilateral bipolar stimulation. Unilateral bipolar stimulation was used in five (9.4%) patients. In the immediate postoperative period, they were initiated on limb, speech, and swallowing therapy as indicated. Surgery-related complications were seen in five (9.4%) cases. At 6 months of follow-up, a significant improvement in the Unified PD rating scale component (mainly motor examination and complication of PD therapy) was noted in the majority (36 [67.9%]) of patients. One patient developed neuroleptic malignant syndrome and succumbed to his illness on the fourth postoperative day. Conclusion  Given these findings, STN-DBS appears to be a good, safe, and effective treatment for a subset of medically refractory PD with an overall improvement in two-thirds of the study cohort and less than 10% risk of complications.

A clinico-epidemiological profile, coinfections and outcome of patients with Influenza Like Illnesses (ILI) presenting to the emergency department during the COVID-19 pandemic

Background

During the COVID-19 pandemic, many patients presented to the emergency department (ED) with features of Influenza-like illnesses (ILI) and with other atypical presentations. This study was done to determine the etiology, co-infections, and clinical profile of patients with ILI.

Methods

This prospective observational study included all patients presenting to the ED with fever and/or cough, breathing difficulty, sore throat, myalgia, gastrointestinal complaints (abdominal pain/vomiting/diarrhea), loss of taste and altered sensorium or asymptomatic patients who resided in or travelled from containment zones, or those who had contact with COVID-19 positive patients during the first wave of the pandemic between April and August 2020. Respiratory virus screening was done on a subset of COVID-19 patients to determine co-infection.

Results

During the study period, we recruited 1462 patients with ILI and 857 patients with the non-ILI presentation of confirmed COVID-19 infection. The mean age group of our patient population was 51.4 (SD: 14.9) years with a male predominance (n-1593; 68.7%). The average duration of symptoms was 4.1 (SD: 2.9) days. A sub-analysis to determine an alternate viral etiology was done in 293 (16.4%) ILI patients, where 54 (19.4%) patients had COVID 19 and co-infection with other viruses, of which Adenovirus (n-39; 14.0%) was the most common. The most common symptoms in the ILI-COVID-19 positive group (other than fever and/or cough and/or breathing difficulty) were loss of taste (n-385; 26.3%) and diarrhea (n- 123; 8.4%). Respiratory rate (27.5 (SD: 8.1)/minute: p-value < 0.001) and oxygen saturation (92.1% (SD: 11.2) on room air; p-value < 0.001) in the ILI group were statistically significant. Age more than 60 years (adjusted odds ratio (OR): 4.826 (3.348-6.956); p-value: <0.001), sequential organ function assessment score more than or equal to four (adjusted OR: 5.619 (3.526-8.957); p-value: <0.001), and WHO critical severity score (Adjusted OR: 13.812 (9.656-19.756); p-value: <0.001) were independent predictors of mortality.

Conclusion

COVID-19 patients were more likely to present with ILI than atypical features. Co-infection with Adenovirus was most common. Age more than 60 years, SOFA score more than or equal to four and WHO critical severity score were independent predictors of mortality.

A single - center retrospective observational study on patients undergoing Encephalo-Duro-Arterio -Myo-Synangiosis in patients with moyamoya disease

BACKGROUND:

Many cases of moyamoya disease are refractory to conventional medical therapy, hence surgical revascularization techniques have emerged as one of the primary choices of treatment. In this study, we present the functional and angiographic outcomes of patients undergoing encephalo-duro-arterio-myo-synangiosis (EDAMS).

METHODS:

This is a retrospective observational cohort study, done over 8 years (2012–2020) in a neurological center in Eastern India. Data were retrieved from the hospital's electronic system, recorded in a standard data abstract sheet, and analyzed.

RESULTS:

This study included 75 patients, with a male (n = 42; 56.0%) preponderance. Majority belonged to the pediatric age group (≤18 years) (n = 70; 93.3%); remaining adult population included 5 (6.6%) patients. The most common presenting complaint was that of an ischemic cerebrovascular accident (CVA) (n = 57; 76.0%). Symptomatic hemispheres (n = 69; 92.0%) were treated and later followed if they had progressed to bilateral disease formation. Preoperative DSA showed 50 (71.4%) to have Suzuki grade 3 type of angiographic findings. Postoperative complications included worsening unilateral hemiparesis 4 (40%), slurring of speech (n = 2; 20.0%), hematoma (n = 2; 20.0%), and surgical site infection (n = 2; 20.0%). One patient succumbed to his illness on the second postoperative day. A postoperative angiogram showed regression of moyamoya vessels in the majority (n = 69; 93.3%) of patients. All (n = 74; 100%) had an intensification of transdural vessels; none had a regression. None of the study participants showed an intensification of moyamoya vessels. Many of our patients (83.8%) had a good grade of revascularization (modified Matsushima and Inaba A and B), while 16.2% had low-grade revascularization (grade C). On assessing outcomes using a modified Rankin Score, a large number of our patients had an excellent (n = 45, 60%) neurological outcomes.

CONCLUSION:

There was a bimodal age distribution with most of them presenting with ischemic CVA. This procedure (EDAMS) had good angiographic (Matsushima and Inaba) and functional (modified Rankin Score) outcomes.

The adverse effects of Ketamine on Procedural Sedation and Analgesia (PSA) in the Emergency Department

Background:

Procedural sedation and analgesia (PSA) in the emergency department (ED) is mainly used for wound irrigation, reduction of fractures, and wound closure. Ketamine is one of the most commonly used drugs for PSA in the ED. The study was conducted in the ED of a large tertiary care hospital in southern India to evaluate the adverse effects of Ketamine on PSA.

Materials and Methods:

This is a prospective observational study performed in the ED for 6 months (October 2019–March 2020) in 151 patients who required Ketamine for PSA. Titrated doses of Ketamine was administered in all patients; hemodynamic variables and adverse events were recorded at timed intervals.

Results:

During the study period, a total of 151 patients in the ED required PSA. The mean age of the study Cohort was 37 ± 15 years, and males accounted for 83%. All individuals obtained adequate sedation and pain relief. It was found that the incidence of adverse reactions to Ketamine was higher in young people (18- to 40-year-old), which was 63%. The most common adverse reaction in the study population was 39 cases of hypertension (44.8%), followed by vomiting in 25 cases (28.7%) and delusion in 6 cases (4%). There was no significant adverse effect in any patients which necessitated admission.

Conclusion:

Ketamine is a drug with good analgesic, sedative properties and has been shown to have a good safety profile with minimal adverse events for use as PSA in ED. Side effects were most common in the younger adult age group and hypertension was the most common side effect.

Role of cerebrospinal fluid C-reactive protein in tuberculous meningitis

Background

Tuberculosis (TB) is still a significant health problem worldwide. Central nervous system TB amounts to 10% of all cases of TB. Despite advances in the pharmacological management of TB, the overall outcomes remain poor with significant mortality and morbidity. There are no predictors for neurological outcomes in tuberculosis meningitis (TBM). In this study, we aimed to evaluate the role of cerebrospinal fluid (CSF) C-reactive protein (CRP) in predicting mortality and neurological outcome in TBM. Method: In this observational study, all patients with TBM were recruited prospectively over a 12-month duration. Baseline demographic data, laboratory parameters, and Imaging findings were collected. CSF CRP was obtained on the CSF sample collected at the time of diagnosis. Patients were followed up at 3 months to assess neurological status and mortality.

Results

Seventy-one patients with TBM were recruited in this study. The overall mortality in this study was 22.5% of patients. The primary composite outcome of mortality and adverse neurological outcome occurred in 40.8%. The CSF CRP levels ranged between 0.1 and 4.8 mg/dl, and the mean CSF CRP level was 1.11 mg/dl. The Relative risk for a patient with high CSF CRP to develop adverse outcome was 1.84 (P = 0.038). CSF CRP was a good predictor of mortality with a relative risk of 2.92 (P = 0.027). Stroke in TBM had a high incidence of 47.9% and a relative risk of 3.42 for an adverse neurological outcome. CSF CRP did not predict the occurrence of stroke. Hydrocephalus and elevated intracranial pressure were good predictors of stroke.

Conclusion

TBM is a disease with significant mortality and morbidity. CRP level in the CSF can be measured, but a highly sensitive scale may be needed as the mean values were much lower compared to the serum values. CSF CRP Levels showed significant associations with adverse outcomes and mortality.

Evaluation of Carotid Flow Time to Assess Fluid Responsiveness in the Emergency Department

Background:

Assessing fluid responsiveness in critically ill patients is challenging. Objective, noninvasive tests that are easy to perform are needed. Doppler measurements of dynamic carotid artery parameters such as carotid blood flow (CBF) and carotid flow time (CFT) are being studied as the potential indicators of volume responsiveness, but the data supporting its use are sparse.

Methods:

This prospective, observational study was conducted in the adult emergency department from June to September 2018. Patients who were prescribed a bolus of 500 ml of crystalloid for any indication were enrolled. Carotid Doppler was performed before and after a fluid bolus to measure the change in CBF and CFT. The aim of our study was to determine if CFT can be used as a marker of fluid responsiveness.

Results:

During the 4-month study period, 209 patients were recruited through convenient sampling after obtaining informed written consent. 29.6% of patients presented with a mean arterial pressure (MAP) <65, among whom 58.1% had septic shock. The baseline CBF was 643.0 ± 212.7 ml/min, and it was 583.9 ± 207.1 ml/min and 668 ± 210.8 ml/min in hypotensive and normotensive patients, respectively. Considering a >10% increase in CBF as fluid response, there were 59% responders and 41% nonresponders. The MAP increased by 9.5% in the responders, while there was no significant change in CFT after the fluid bolus. There was no difference in CFT among the responders as compared to the nonresponders. There was no correlation between the change of CBF and CFT (r^[207] = 0.013, P = 0.061) after the fluid bolus.

Conclusion:

Though easy to perform, CFT is probably not a good indicator of fluid responsiveness.

Blood alcohol levels in road traffic accidents: Factors associated and the relationship between history of alcohol consumption and blood alcohol level detection

Introduction:

Alcohol consumption contributes to a significant number of road traffic accidents (RTAs), and data regarding the reliability of history and blood alcohol content (BAC) in RTA victims are scant.

Methodology:

This retrospective study was conducted in the emergency departments (EDs) over 6 weeks. All adult RTAs presenting within 12 h of the incident were included for analysis.

Results:

The study cohort included 369 RTA patients, with the mean interval before presentation being 3 h (standard deviation: 2.22). Two-wheeler accidents (77.2%) were the predominant mode of injury. Usage of a helmet and seat belt was documented in a meager (6.4% [17/267] and 8.8% [3/34], respectively). A positive history of alcohol consumption was reported by 19.5% of cases (72/369). However, BAC was detectable in 30.1% of cases (111/369), with an alarming 19.78% (73/369) being above the legal limit for driving. Nearly 77.5% (86/111) of those who tested positive for alcohol consumption were driving the vehicle involved. Positive BAC levels showed a significant association with young age (18–39 years), male gender, two-wheeler usage, and between 5 PM and 12 AM.

Conclusion:

A history of alcohol consumption leading to an RTA is not reliable in the ED. Hence, measuring BAC levels in all RTA patients provides an objective and reliable form of documentation for medico-legal purposes.

Injury Patterns and Outcomes of Trauma in the Geriatric Population Presenting to the Emergency Department in a Tertiary Care Hospital of South India

Background:

The geriatric population is more prone for injuries with complications due to their associated comorbidities. This study was done to understand the mode, severity, and outcome of injuries among geriatric patients presenting to the emergency department (ED).

Materials and Methods:

This retrospective study included all patients >60 years who presented with trauma between October 2014 and March 2015. Details of the incident, injuries, and hospital outcome were noted.

Results:

Among 8563 geriatric patients, who presented to the ED during the study, 427 (4.9%) patients were trauma related. The mean age was 69 (standard deviation: 6.76) years with 87.6% being young-old (60–79 years) and 12.4% being old-old (>80 years). Majority (63.2%) were Priority 2 patients. The median time between the incident and ED arrival among Priority 1 patients was 3 h (interquartile range: 2–5). Common modes of injuries were slip and fall (37.4%), two-wheeler accidents (25.8%), fall from height (9.1%), and pedestrian (8.9%). The ED team alone managed 25.8% of patients. Specialty departments referred to included orthopedics (48%), neurosurgery (18.3%), plastic surgery (4.2%), HLRS (4%), and others. Injuries due to slip and fall were significantly more among the old-old (P = 0.001), and two-wheeler accidents were more among the young-old (P = 0.001), respectively. Superficial head injuries (28.8%), extremity (24.8%), facial (18.7%), and traumatic brain injuries (17.8%) were common presentations. Thoracic injuries were significantly more among the old-old (P < 0.001). Half (46.3%) of the young-old were discharged stable (P = 0.017). In-hospital mortality rate was 0.7% (3/427), while 12.9% (55/427) left against medical advice due to poor prognosis.

Conclusion:

Our study demonstrates the pattern of injury seen in the elderly in an urban setting in India. From this, we perceive the need for a prospective study evaluating the causes for geriatric trauma, which would help work on ways to prevent and minimize injuries in the elderly.

Pagers and stethoscopes as vehicles of potential nosocomial pathogens in a tertiary care hospital in a developing country

It has long been recognized that stethoscopes and other inanimate objects carry virulent micro-organisms that can cause nosocomial infections in susceptible patients. Among the frequently used items in hospitals are pagers and stethoscopes. The manner in which these items are used has the potential to cause colonization of bacteria and transfer of these bacteria to another person. This prospective study was performed in order to assess the colonization rates among randomly selected pagers and stethoscopes. We found that 15 (25%) pagers and 11 (27.5%) stethoscopes were contaminated. Enterococci (10%) were the most common isolates found followed by Staphylococci (8%) and Enterobacteriaceae (7%). There was no significant difference in the rates of colonization between shared and personal pagers ( P = 0.16). Stethoscopes were more likely to be contaminated with Enterococci compared to pagers ( P = 0.013, 95% confidence interval 1.3–52.9).

Our findings confirm the need for protocols to prevent transmission of infection through inanimate objects.

Genotype phenotype correlation in Wilson's disease within families--a report on four south Indian families

AIM

To study the genotype phenotype correlation in Wilson's disease (WD) patients within families.

METHODS

We report four unrelated families from South India with nine members affected with WD. Phenotype was classified as per international consensus phenotypic classification of WD. DNA was extracted from peripheral blood and 21 exons of ATP7B gene and flanking introns were amplified by polymerase chain reaction (PCR). The PCR products were screened for mutations and the aberrant products noted on screening were sequenced.

RESULTS

Four separate ATP7B mutations were found in the four families. ATP7B mutations were identical amongst affected members within each family. Three families had homozygous mutations of ATP7B gene while one family had compound heterozygous mutation, of which only one mutation was identified. We noted concordance between ATP7B gene mutation and Wilson's disease phenotype amongst members within each family. The age of onset of symptoms or of detection of asymptomatic disease, baseline serum ceruloplasmin and baseline urinary copper levels were also similar in affected members of each family. Minor differences in phenotype and baseline serum ceruloplasmin level were noted in one family.

CONCLUSION

We report concordance between ATP7B mutation and WD phenotype within each family with > 1 member affected with WD. Homozygous ATP7B mutation was present in 3 of the 4 families studied. Our report supports allelic dominance as a determinant of WD phenotype. However, in one family with compound heterozygous mutation, there was a similar WD phenotype which suggests that there may be other factors determining the phenotype.

ATP7B mutations in families in a predominantly Southern Indian cohort of Wilson's disease patients

OBJECTIVE

To analyze ATP7B mutations in Wilson's disease (WD) patients from the Indian subcontinent and to correlate these with WD phenotype.

METHODS

We studied 27 WD patients from 25 unrelated families. Twenty-two families were from three southern Indian states - Tamil Nadu andhra Pradesh and Kerala. We applied conformation- sensitive gel electrophoresis (CSGE) to screen for the mutations in patients and their families. PCR products exhibiting aberrant patterns in CSGE were subjected to direct DNA sequencing. As siblings affected by WD within a family share identical ATP7B genotype, we compared WD phenotype among affected siblings within families.

RESULTS

ATP7B mutations were detected in 22 of the 25 probands -13 were homozygotes and 9 were compound heterozygotes. Eleven novel mutations were detected. Only two common mutations were found: G3182A in 4 (16%) and C813A in 3 (12%) probands. 'Hot spots' for ATP7B mutations were exons 18 and 13. Lack of common dominant mutations prevented correlation of individual ATP7B mutations with WD phenotype. Symptomatic WD in a live sibling was not found in any family. In 8 families, a sibling died of presumed WD - in 6 of these, WD phenotype was identical to that in the proband.

CONCLUSIONS

We describe the spectrum of ATP7B mutations including 11 novel mutations in Indian WD patients and document lack of a single dominant mutation. Identical WD phenotype among siblings in only 6 of 8 families with >1 child affected by WD suggests that factors other than ATP7B mutations influence WD phenotype.

Significance of the hepatitis C virus (HCV) core antigen as an alternative plasma marker of active HCV infection

PURPOSE

To evaluate the role of core antigen (Ortho trak-C assay) as a marker of active HCV infection in comparison to HCV RNA as detected by reverse transcription polymerase chain reaction (RT-PCR).

METHODS

This evaluation was carried out during January 2000 to December 2003 in HCV infected individuals who were treatment naomicronve or were on anti-viral therapy. Additionally, sequential plasma samples from patients on clinical follow-up were included in this study. A total of 167 samples from 61 patients were tested by trak-C and RT-PCR. HCV RNA detection was achieved by a RT-PCR. Trak-C assay results were also compared in a limited proportion of these samples with known HCV viral load and genotype.

RESULTS

Of 167 samples tested, 56.9% were RNA positive and 43.1% were RNA negative while 50.3% were trak-C positive and 49.7% were trak-C negative, yielding a sensitivity of 85.3% and a specificity of 95.8% for the trak-C assay (Kappa co-efficient = 0.8). The concentration of HCVcAg and HCV RNA showed significant correlation (n=38, r=0.334, P =0.04). The trak-C assay detected the most prevalent HCV genotypes in India without significant difference (P =0.335). The difference between mean absorbance values of HCV RNA positive samples compared to HCV RNA negative samples in the trak-C assay was highly significant (P < 0.000). Qualitative results of trak-C assay and RT-PCR were comparable in 93% of follow-up samples.

CONCLUSIONS

Trak-C assay can be recommended for confirmation of HCV infection and follow-up in laboratories with resource-poor facilities.

Tuberculosis among healthcare workers in a tertiary-care hospital in South India

It is possible that tuberculosis is transmitted from patients to healthcare workers (HCWs). However, there are few data on this from developing countries. The object of this study was to document the incidence of tuberculosis among HCWs in the Christian Medical College (CMC), Vellore, India during a 10-year period (January 1992-December 2001). Data were collected from records maintained in the staff and students health services of CMC. A total of 125 cases were diagnosed during the period of study. The overall incidence of sputum positive cases was similar to that observed in the general population, during most years. However, it appears that focal outbreaks occur with transmission between HCWs. The chance of developing extra-pulmonary tuberculosis was higher in HCWs compared with the general population.

Toxic megacolon in a renal allograft recipient with cytomegalovirus colitis

We report a 35-year-old man, a renal allograft recipient, who presented with toxic megacolon. Segmental biopsies from the colon were consistent with cytomegalovirus colitis. Serum polymerase chain reaction for cytomegalovirus DNA confirmed the diagnosis. He was treated with ganciclovir but, though his abdominal condition improved initially, he worsened later and succumbed to his illness.

Should health care workers in the tropics be immunized against varicella?

In tropical regions, chickenpox affects both adults and children. Therefore, healthcare workers in the tropics are vulnerable to hospital-acquired varicella infection and they may transmit infection to susceptible hospitalized individuals. Although the varicella vaccine is safe and effective, its cost is a deterrent to its use in routine immunization programmes. In order to assess whether vaccination of susceptible healthcare workers to prevent hospital-acquired transmission may be justified, we have documented the frequency of varicella among healthcare workers in our hospital. There were 96 admissions for varicella during the 1993-1997 period; staff and student nurses accounted for 76%. The peak season of admission was from February to April. The attack rate in staff and student nurses was 0.78 and 1.54 per 100 person-years, respectively. While community outbreaks of varicella occur in this region once in 4-5 years, hospital outbreaks of varicella occurred every year. This poses the risk of transmission to hospitalized patients, with serious consequences among immunocompromized individuals. Therefore, we recommend systematic selective vaccination of susceptible healthcare workers to break this cycle of annual varicella outbreaks among hospital personnel.

Hepatopulmonary syndrome: clinical perspectives

Hepatopulmonary syndrome consists of a triad of chronic liver disease, pulmonary gas exchange abnormalities and pulmonary vascular dilatation in the absence of detectable cardiopulmonary disease. Patients usually present with symptoms of liver disease and the clinical recognition of this condition is a challenge. Newer non-invasive tests facilitate the diagnosis. Therapeutic strategies for this condition are still dismal. Liver transplantation is a possible curative option for a subgroup of patients with hepatopulmonary syndrome.

Impact of introduction of sharps containers and of education programmes on the pattern of needle stick injuries in a tertiary care centre in India

Documentation of needlestick injuries was started in the Christian Medical College Hospital, Vellore in 1993. In 1995 large sharps containers were introduced, accompanied by an intensive education programme. Details of documented injuries from 1993 to 1999 were analysed using the Epi-Info software. A total of 347 injuries occurred, mainly due to improper disposal of needles, re-capping and carelessness during use. The percentage of injuries attributed to disposal fell from 69.2% in 1995 to 38.5% in 1996 (after the education programme). A further decrease was noted after the additional introduction of small sharps containers. In 1995, 73% of injuries involved housekeeping staff, this fell to 12% in 1998. Relatively simple interventions decreased the numbers of injuries, and we recommend that all healthcare institutions should have a system of documenting needlestick injuries, and take measures to decrease their incidence.

Clinical manifestations and survival pattern of Wilson's disease

BACKGROUND

Wilson's disease usually presents in childhood. Early recognition and treatment is crucial to retard the progression of this disease, which can be debilitating, if not fatal. We analysed the clinical manifestations and survival pattern of patients admitted at our centre from 1993 to 1996.

METHODS

Hospital records of patients were reviewed to obtain the clinical manifestations. The survival status of patients was determined by a prospective follow up. The Kaplan-Meier survival curve and univariate Cox proportional hazards model were used to determine the survival pattern and risk for death in Wilson's disease.

RESULTS

A total of 60 patients were studied. The median age at onset of symptoms was 12 years (range 5-52 years). The log rank test showed a significant difference in the mean (SD) survival between patients who presented with hepatic [87.36 (15.26) months] and neurological symptoms [114.33 (9.14) months]. Cox proportional hazards analysis showed a hazard ratio of 4.9 for patients with a hepatic presentation compared to those with neurological presentation.

CONCLUSION

The presentation of Wilson's disease is not limited to the paediatric age group. Patients with a hepatic presentation had a five-fold higher risk of mortality when compared to those with a neurological presentation.

Vesical varix in cirrhosis of liver

Vesical varices in portal hypertension are rare. We report a patient with portal hypertension who developed recurrent painless hematuria. Cystoscopy was normal. Doppler ultrasound and MR angiography showed a dilated paraumbilical vein within the falciform ligament coursing down to the urinary bladder wall and draining into the right internal iliac vein. He underwent liver transplantation for decompensated chronic liver disease. He is in good health and has not had further episodes of hematuria.

Spontaneous fungal peritonitis in patients with hepatitis B virus-related liver disease

Spontaneous bacterial peritoneal infections is recognized as a very common complication of cirrhotic ascites, but isolation of fungus in pure culture from ascitic fluid is relatively rare, even more so in the human immunodeficiency virus (HIV)-negative or nonimmunocompromised hosts. We describe two patients of spontaneous fungal peritonitis where the isolate was Cryptococcus neoformans. Both cases suffered from hepatitis B virus (HBV) infection. The clinical and laboratory profiles of both patients were similar to those of conventional spontaneous bacterial peritonitis. We suggest that it would be prudent to heighten clinical suspicion for fungal peritonitis in such cases.

Familial intrahepatic cholestatic cirrhosis with positive antimitochondrial antibody: familial primary biliary cirrhosis

We present three siblings (out of four) with intrahepatic cholestatic disease and cirrhosis. Two of the siblings, a 33-year-old woman and a 34-year-old man had advanced liver disease- with the liver histology showing established cirrhosis with chronic cholestasis and excess copper accumulation. Both died two years later due to hepatic encephalopathy. The third sibling, a 37-year-old man on routine check-up was found to have abnormal liver functions. The liver biopsy showed marked bile ductular proliferation with bridging fibrosis, reduction in interlobular bile ducts, and excess copper accumulation. The presence of antimitochondrial antibody in the serum in 1 in 320 dilutions in all three patients and 1 in 80 dilutions in the oldest healthy sibling and hypergammaglobulinemia in all the siblings confirmed the diagnosis of familial primary biliary cirrhosis. Antinuclear and smooth muscle antibodies were not present. Clinical and biochemical improvement has been noted in the third sibling after therapy with ursodeoxycholic acid.

Preventing transmission of blood-borne pathogens to health care workers

Health care workers are exposed to blood-borne pathogens, mainly the human immunodeficiency virus, hepatitis B virus and hepatitis C virus. Infection by these viruses leads to chronic or fatal illnesses which are expensive and difficult to treat. Individuals who harbour these viruses may be asymptomatic and hence all patients should be assumed to harbour a blood-borne pathogen. All health care workers should take adequate precautions (a set of guidelines termed 'universal precautions'). Methods of preventing transmission of blood-borne pathogens include vaccination against hepatitis B virus, following universal precautions and taking adequate post-exposure prophylaxis.