Routine Cyclosporine concentration - C2 level Monitoring. Is it helpful during the early post Transplant Period?

Background

Pre dose or trough blood cyclosporine (CSA) concentration is routinely monitored and the result is used to alter patient''s drug dosing. Patients with identical pre dose blood CSA may have very different systemic exposure to the drug. Recently CSA 2 hour post dose level [C2] has been reported to correlate better with drug exposure. We undertook this study to evaluate the influence of trough and C2, CSA concentration monitoring on short-term renal allograft outcomes.

Methods

25 patients of renal transplant receiving a triple drug regimen of CSA micro emulsion (Panacea Biotec) 8mg/kg, azathioprine 1mg/kg and prednisolone 0.5mg/kg were analyzed prospectively for graft outcomes. CSA levels were monitored in whole blood by radioimmunoassay using monoclonal antibodies, at 72 hours after the transplant.

Results

The mean age of patients was 37.08 + 9.1 years. There were 20 males and 5 females. The mean age of donors was 40.2 + 8.2 years. There were 11 related donors with at least a haplomatch, 4 spousal and 10 unrelated donors with a nil antigen match. The mean pre dose CSA concentration was 289.22 + 171.9ng/ml; range (98.8 + 783.41ng/ml). The CSA concentration at 2 hours after the CSA administration was 838 + 310.87ng/ml (range, 169 + 1268ng/ml). 3 (12%) patients had acute rejection. In these patients the mean pre dose CSA concentration was 328.67ng/ml and the mean C2, CSA concentration was 1006.26ng/ml. CSA induced hemolytic uraemic syndrome was diagnosed in one patient. The trough and C2, CSA concentration levels were 174 and 870.83ng/ml respectively in this patient.

Conclusion

In our study CSA levels, trough and peak showed significant inter patient variability. The trough and C2 concentration levels did not correlate with the episodes of acute rejection. We conclude that in a triple drug regimen with fixed dosing schedules routine trough CSA level monitoring is not helpful in the acute post renal transplant period.Key Words: Cyclosporine levels, Cyclosporine trough levels, C2 levels     

Efficacy and Toxicity Profile of Methotrexate Chloroquine Combination in Treatment of Active Rheumatoid Arthritis

Background

The present study was conducted to study the efficacy and toxicity profile of methotrexate chloroquine combination in treatment of active rheumatoid arthritis.

Methods

24 patients of rheumatoid arthritis confirming to revised American Rheumatism Association (ARA) criteria were studied prospectively for twenty months. Clinical evaluation was made every 3 months. Clinical disease variables measured at each visit were number of joints with swelling, number of joints with tenderness and pain, duration of morning stiffness and physician and patient assessment of disease activity. Blood counts, liver function tests and other adverse effects due to drugs were monitored every 2 months.

Results

10 patients demonstrated more than 50% improvement. 4 patients withdrew from study, 2 because of excessive nausea and vomiting and 2 because of noncompliance. Other side effects noted were hyperpigmentation, photosensitivity, skin rashes, raised transaminases and stomatitis.

Conclusion

Methotrexate chloroquine combination has good efficacy and toxicity profile. Gastrointestinal side effects are most common and usually responsible for the discontinuation of the drugs.Key Words: Rheumatoid arthritis, Methotrexate, Chloroquine, Efficacy, Toxicity     

Correlation of Intra Vascular Cannula Insertion Technique and Ward Practices with Local Site Infection

Background

Peripheral intravascular cannulas are indispensable in modern day medical care. These cannulas, if not inserted properly, predispose a patient to various morbidities. The present study was carried out to assess the incidence of intravascular cannula associated infections and correlate it with cannula insertion techniques and ward practices.

Methods

The study was carried out in the wards of a tertiary care hospital. The study was divided into two phases, each phase comprising of 50 patients. In phase 1, cannula insertion was carried out after normal ward cleaning practices. In phase 2, cleaning of the site was done by standard surgical cleaning procedure. The cannula samples after removal were cultured and local signs of thrombophlebitis looked for at the site of insertion. Thrombophlebitis was considered a surrogate marker of local infection in the vessel wall.

Result

The relative risk of acquiring thrombophlebitis increased by 2.18 times (applying univariate analysis) by existing methods as compared to the standard method.

Conclusion

Use of standard cleaning protocol had a significant effect on decreasing the incidence of cannula associated infections and cannula related morbidity.Key Words: Intravascular cannula, Peripheral vein thrombophlebitis, Cannula associated infections     

HIV AND TUBERCULOSIS CO-INFECTION IN A REFERRAL CHEST HOSPITAL

Serving personnel of Armed Forces admitted with tuberculosis between Apr 1996–1999 were evaluated for co-infection of tuberculosis and HIV. Sixty (1.06%) of tuberculosis patients were found to be HIV positive. Initial test was done by spot kits and subsequently confirmed by ELISA on two different samples. Majority of the cases were in sexually active age group 48 (80%). Alcohol and smoking was associated in 80% cases. Thirty six (60%) were sputum smear positive for AFB. Twenty eight (46.7%) gave history of exposure to sex workers. Family members were not available for study. Sero prevalence of HIV in association with tuberculosis is less in Armed Forces compared to civil population.KEY WORDS: HIV, Seroprevalence, Tuberculosis     

KOCH'S OR CROHN'S?

Abdominal tuberculosis is not uncommon in the UK, especially in Asian immigrants. It resembles Crohn's disease clinically and radiologically, and it may be difficult to differentiate between them, even at laparotomy or histology. The distinction is important, however, for proper management of the two conditions. Every effort must be made to exclude abdominal tuberculosis before the patient is diagnosed as having Crohn's disease and is treated with steroids.