Autoimmune hepatitis: a study of 50 patients.

INTRODUCTION: Autoimmune hepatitis (AIH) is a well-defined entity in the West but there are sparse Indian data on this disease. AIM: To study the clinical profile and response to treatment of Indian patients with AIH. METHODS: This is a part retrospective and part prospective study of 50 patients (median age 48 years, range 11-82; 43 women) seen between 1995 to 2001, diagnosed to have AIH as per the revised scoring system. Clinical and laboratory profile, response to treatment, and complications of treatment were analyzed. RESULTS: AIH accounted for 6% of all patients with liver disease seen during the period. The presenting symptoms were gastrointestinal in 43 and non-gastrointestinal in 7, with median symptom duration of 6 months (range 2 weeks to 40 years). Forty patients (80%) had chronic liver disease. Associated illnesses were present in 28 patients. Twenty-six patients were classified as definite and the rest as probable AIH. Forty-nine patients had Type 1 AIH. Five patients had overlap syndrome. Forty-five patients (90%) received immunosuppressive therapy. Twelve of 18 patients receiving only prednisolone and 21 of 27 patients receiving prednisolone and azathioprine combination responded. Thirteen (26%) patients had therapy-related complications (infectious 5, non infectious 8) with two treatment-related deaths. CONCLUSION: Type 1 AIH was the predominant type of AIH. The majority of patients with AIH presented with chronic liver disease. There was good response to immunosuppressive therapy. Therapy-related complications occurred in one-fourth of patients.     

Management of cerebral hemispherectomy in children

Surgical removal of a cerebral hemisphere may be undertaken in patients with intractable seizure disorders. Anesthetic management of such patients has not been reviewed in detail before. This study retrospectively analyzed hospital records of ten patients undergoing cerebral hemispherectomy at the Johns Hopkins Hospital between July 1983 and February 1988. Patient records were reviewed for diagnosis, physical characteristics, preoperative medications, anesthetic management, and postoperative course in the intensive care unit (ICU). Massive and sudden blood loss was a common finding in these patients, and during the intraoperative and postoperative periods, fluid resuscitation frequently was an ongoing process. In some patients, the blood loss exceeded one blood volume and was associated with coagulopathy, hypokalemia, and hypothermia. Urine output was elevated by a glucose-induced diuresis in some patients, giving misleading information as to intravascular volume status. Seizures and hemorrhage into the hemispherectomy cavity were management problems in the ICU. From this review, the authors conclude that blood loss may be marked and precipitous during surgical removal of a cerebral hemisphere. Monitoring of intra-arterial pressure and central venous pressure (CVP) is necessary for patient management during the intraoperative and postoperative periods. Intravenous (IV) access should allow rapid intravascular volume administration as it becomes necessary. Patients should remain intubated and observed closely during the immediate postoperative period due to difficulties with hemodynamic stability, seizures, and hemorrhage.     

Fear of falling and postural control in Parkinson's disease.

This study investigated the relationship between fear of falling (FOF) and qualitative and quantitative postural control in Parkinson's disease (PD). Fifty-eight nondemented PD patients were studied along with age-matched healthy controls. The degree of FOF was estimated using the Activities-specific Balance Confidence scale. Qualitative postural control was evaluated using a component of the Unified Parkinson Disease Rating Scale. Postural control was quantified, using centre of pressure measures obtained from a force plate, for eight standing balance tests of different challenges. The results showed that FOF was more evident for PD patients when compared with healthy individuals of similar age. Furthermore, FOF was significantly associated with a qualitative estimate of postural control in PD; individuals with PD who had a greater degree of posture impairment reported greater FOF. The results also showed that an estimate of FOF may help to explain quantitative postural instability in PD. FOF, when coupled with a qualitative estimate of postural control, was able to explain a greater amount of variation in quantitative balance performance for five of the eight balance tests. When considered independently, the qualitative measure of postural control, in general, could not well predict quantitative balance performance. The greater degree of FOF and its possible association with altered postural control suggests that FOF should be considered as an important, independent risk factor in the assessment and treatment of postural instability in patients with PD.     

Epiphrenic diverticulum of the esophagus.

Esophageal diverticula are rarely found at the terminal portion, where they are called supradiaphragmatic or epiphrenic diverticula and occur in association with motility disorders of the terminal esophagus. We present here two cases of epiphrenic esophageal diverticulum, one of which was treated surgically.     

Septicemias in cancer patients during parenteral nutrition: contributing factors and detection by weekly blood cultures

Infections constitute the main complication of parenteral nutrition, particularly in cancer patients, but prediction of catheter-related septicemias (CRS) has been little investigated. We have evaluated, in 200 consecutive episodes of parenteral nutrition (PN) in cancer patients, the factors contributing to infectious complications, and the predictive value of weekly blood cultures performed through the nutrition catheter. The median duration of PN was 22 days with a total of 5816 patient-days of PN, neutropenia (neutrophils < 1,000/mul) being present in 872 (15%). Catheters were placed either in a jugular vein (71% single-lumen silicone catheters, 18.5% double-lumen Hickman-Broviac catheters) or in a femoral vein (10.5%). We observed 62 episodes of septicemia of which 22 were CRS (11% incidence for the 200 cycles) and 40 were non-CRS (20% incidence); CRS were mostly due to Staphylococcus epidermidis (14 22 ). Neutropenic patients as a group did not suffer more CRS than non-neutropenic patients, but the risk of CRS was slightly increased when expressed per day of neutropenia (8 CRS/872 days vs 14 CRS/4942 days without neutropenia, P < 0.05). On the other hand, a femoral insertion site was associated with a much higher incidence of CRS (9 CRS/21 femoral catheters vs 13 CRS/179 jugular catheters, P < 0.0001). It was possible to evaluate 20 episodes of CRS for their predictability by weekly blood cultures: the sensitivity for detecting CRS due to Staphylococcus epidermidis was 67%, the specificity 92%, the negative predictive value 98% and the positive predictive value 36%. The simple and widely available procedure of routine surveillance blood cultures performed through the PN catheter should be further investigated, because it could help the clinician to determine the origin of recent fever, particularly to exclude CRS and avoid unnecessary removal of PN catheters.     

Median rhomboid glossitis: secondary to colonisation of the tongue by Actinomyces (a case report).

Median rhomboid glossitis is an inflammatory lesion of the tongue, now believed to be secondary to candidiasis. We document a case of median rhomboid glossitis with heavy colonisation by Actinomyces in a 60-year-old male. We propose that Actinomyces, like Candida, induces pseudoepitheliomatous hyperplasia of the mucosa of the tongue and florid inflammatory hyperplasia of the underlying connective tissue, resulting in the characteristic elevated lesion. Actinomyces has not earlier been implicated as a cause of median rhomboid glossitis.