BACKGROUND: The issue of cardiovascular safety of calcium channel blockers (CCBs) has been widely debated in view of reflex increase in sympathetic activity induced by immediate release (IR) / short acting formulations. It is generally agreed that such CCBs should not be used alone in the management of hypertension. AIMS: We have determined the extent to which primary care physicians prescribe CCBs as monotherapy, especially the immediate release formulations, in the management of uncomplicated hypertension and diabetic hypertension - with an emphasis upon the age of the patients. SETTING, DESIGN AND METHODS: A retrospective prescription-based study was carried out in seven out of 18 Health Centres in Bahrain. The study involved a registered population of 229,300 representing 46% of registered individuals, and 35 physicians representing 43% of all primary care physicians. The data was collected between November 1998 and January 1999 using chronic dispensing cards. RESULTS: In all categories CCBs were the third commonly prescribed antihypertensive as monotherapy, with a prescription rate of 11.1% in uncomplicated hypertension, 18% in diabetic hypertension and 20.1% in elderly patients above 65 years of age. Nifedipine formulations were the most extensively prescribed CCBs. Almost half of the CCB-treated patients were on IR-nifedipine, whereas IR-diltiazem and IR-verapamil, and amlodipine were infrequently prescribed. CONCLUSION: Prescription of IR-formulations of CCBs as monotherapy by primary care physicians does not conform with recommended guidelines. In view of concerns about the safety of such practice, measures to change the prescribing pattern are required.

BACKGROUND: Since interpretation of results of enzyme linked immuno-sorbent assay (ELISA) for diagnosis of Cytomegalovirus (CMV) infection in India is difficult, its diagnostic value required evaluation. AIMS: To evaluate the diagnostic value of ELISA against polymerase chain reaction (PCR) in CMV disease. SETTINGS AND DESIGN: Results of ELISA test for CMV antibodies in CMV-DNA PCR positive and negative patients and normal healthy blood donors were analysed. METHODS AND MATERIAL: Anti-CMV antibodies were assayed by ELISA on the sera of 26 CMV PCR positive and 21 PCR negative patients and 35 normal healthy blood donors. STATISTICAL ANALYSIS: Chi square and Fischer exact test were used for statistical analysis. RESULTS: Anti-CMV antibodies (IgG or IgG and IgM) were present in 20 (76.9%) of 26 PCR positive and 13 (61.9%) of 21 PCR negative patients. ELISA was negative in six (23.1%) of 26 PCR positive patients. Of the 28 paediatric patients, ELISA was positive in 14 (73.7%) of 19 PCR positive and three (33.3%) of nine PCR negative patients showing a statistically significant difference (Chi square test, P value 0.038). Among the 19 patients having complications after organ transplant, ELISA showed anti-CMV antibodies in six (85.7%) of seven PCR positive and 11 (91.7%) of 12 PCR negative patients showing no significant difference. CMV-DNA was not detected in the buffy coat of 35 sero-positive blood donors. CONCLUSION: ELISA has no diagnostic value in the detection of CMV activation although it may help in the differential diagnosis of CMV infection in the paediatric age group.

BACKGROUND: Cryptosporidiosis caused by the protozoa Cryptosporidium, is the common cause of diarrhoea in Acquired Immune Deficiency Syndrome (AIDS). AIM: To study the efficacy of short-term azithromycin in the management of cryptosporidiosis. SETTINGS AND DESIGN: Randomised, controlled trial. MATERIAL AND METHODS: All consecutive patients infected with Human Immunodeficiency Virus (HIV), who were positive for cryptosporidial oocysts were taken for this prospective randomised study. RESULT: Short-term azithromycin treatment for cryptosporidial diarrhoea in AIDS patients was associated with good clinical improvement but parasitological benefit was doubtful. All 13 patients, who had symptoms of cryptosporidiosis, symptomatically improved with 5 days of treatment with azithromycin and became asymptomatic after 7 days of antibiotic, but stool sample was positive for cryptosporidium even after 7 days of therapy. After 14 days of treatment with azithromycin in 13 patients, in five patients stool was free of cryptosporidial oocyst. The drug was well tolerated in all the patients. CONCLUSION: Short-term azithromycin can be used as a safe and effective treatment for symptomatic Cryptosporidiosis but not effective in eradicating Cryptosporidial infection.

BACKGROUND: Obstetric decision- making for the growth restricted foetus has to take into consideration the benefits and risks of waiting for pulmonary maturity and continued exposure to hostile intra-uterine environment. Necrotising Enterocolitis (NEC) results from continued exposure to hostile environment and is an important cause of poor neonatal outcome. AIMS: To evaluate the predictive value of abnormal Doppler flow velocimetry of the foetal umbilical artery for NEC and neonatal mortality. SETTINGS AND DESIGN: A retrospective study carried out at a tertiary care centre for obstetric and neonatal care. MATERIALS AND METHOD: Seventy-seven neonates with birth weight less than 2000 gm, born over a period of 18 months were studied. These pregnancies were identified as having growth abnormalities of the foetus. Besides other tests of foetal well-being, they were also subjected to Doppler flow velocimetry of the foeto-placental vasculature. Obstetric outcome was evaluated with reference to period of gestation and route of delivery. The neonatal outcome was reviewed with reference to birth weight, Apgar scores and evidence of NEC. STATISTICAL ANALYSIS USED: Chi square test. RESULTS: In the group of patients with Absent or Reverse End Diastolic Frequencies (A/R EDF) in the umbilical arteries, positive predictive value for NEC was 52.6%, (RR 30.2; OR 264). The mortality from NEC was 50%. When umbilical artery velocimetry did not show A/REDF, there were no cases of NEC or mortality. Abnormal umbilical or uterine artery flow increased the rate of caesarean section to 62.5% as compared to 17.6% in cases where umbilical artery flow was normal. CONCLUSION: In antenatally identified pregnancies at risk for foetal growth restriction, abnormal Doppler velocimetry in the form of A/REDF in the umbilical arteries is a useful guide to predict NEC and mortality in the early neonatal period.

BACKGROUND AND AIM: Mammalian spermatozoa are rich in polyunsaturated fatty acids and are very susceptible to attack by reactive oxygen species (ROS) and membrane lipid peroxide ion. Normally a balance is maintained between the amount of ROS produced and that scavenged. Cellular damage arises when this equilibrium is disturbed. A shift in the levels of ROS towards pro-oxidants in semen and vaginal secretions can induce an oxidative stress on spermatozoa. The aim was to study lipid peroxidation and antioxidant enzymes such as catalase, glutathione peroxidase and superoxide dismutase (SOD) and to correlate the same, with the 'water test', in male infertility. SETTINGS: Experimental study. SUBJECTS AND METHODS: Ejaculates from a total of 83 infertile and fertile healthy individuals were obtained. Lipid peroxidation and antioxidant enzyme levels were studied and correlated with water test. RESULTS: The results indicate that (i) the antioxidant enzyme catalase showed no significant changes in the various pathological samples, (ii) antioxidant enzymes SOD and glutathione peroxidase correlate positively with asthenozoospermic samples and (iii) the degree of lipid peroxidation also correlates positively with the poorly swollen sperm tails. The increase in SOD and glutathione peroxidase values, in the pathological cases represents an attempt made to overcome the reactive oxygen species. CONCLUSION: Water test could be used as a preliminary marker test for sperm tail damage by reactive oxygen species, since it correlates very well with lipid peroxidation and antioxidant enzymes.

Thrombotic microangiopathy, which broadly includes thrombotic thrombocytopaenic purpura (TTP) and haemolytic uraemic syndrome (HUS), is a multisystemic disorder that is characterised by thrombocytopaenia, microangiopathic haemolytic anemia and ischaemic manifestations, resulting from platelet agglutination in the arterial microvasculature. Acral necrosis (distal necrosis of fingers and toes) occurs usually as a sequel to severe Raynaud's phenomenon, a vasculospastic disorder frequently related to endothelial cell dysfunction. We report a case of quinine induced TTP-HUS and acral necrosis, two distinct clinical abnormalities which have not yet been reported together in association with quinine. Both of these conditions in this case resolved promptly to treatment with corticosteroids.

The colonic metastases from bronchogenic carcinoma are rare. We present a 73-year-old man presented with features suggestive of pan colitis after metastasis from undifferentiated large cell carcinoma of the lung. The plain radiograph and computed tomography scan of the chest had revealed a mass lesion in the right lower lobe of lung. He had no evidence of significant lesions elsewhere. Considering the advanced stage and poor differentiation of the tumour, no active therapy was undertaken and he survived for three months.

Spontaneous bacterial peritonitis is a common complication in patients with cirrhosis and ascites. However, spontaneous peritonitis caused by Cryptococcus neoformans is uncommon. Delayed diagnosis of cryptococcal peritonitis often results in death. We describe three cases of spontaneous cryptococcal peritonitis in patients with decompensated cirrhosis. One case had associated symptomatic human immunodeficiency virus infection. Clinical awareness of this entity may lead to the early diagnosis and proper treatment.

Spontaneous aortocaval fistula is rare, occurring only in 4% of all ruptured abdominal aortic aneurysms. The physical signs can be missed but the presence of low back pain, palpable abdominal aortic aneurysm, machinery abdominal murmur and high-output cardiac failure unresponsive to medical treatment should raise the suspicion. Pre-operative diagnosis is crucial, as adequate preparation has to be made for the massive bleeding expected at operation. Successful treatment depends on management of perioperative haemodynamics, control of bleeding from the fistula and prevention of deep vein thrombosis and pulmonary embolism. Surgical repair of an aortocaval fistula is now standardised--repair of the fistula from within the aneurysm (endoaneurysmorraphy) followed by prosthetic graft replacement of the aneurysm. A case report of a 77-year-old woman, initially suspected to have unstable angina but subsequently diagnosed to have an aortocaval fistula and surgically treated successfully, is presented along with a review of literature.

The primary aim of managing patients with acute brain injury in the intensive care unit is to minimise secondary injury by maintaining cerebral perfusion and oxygenation. The mechanisms of secondary injury are frequently triggered by secondary insults, which may be subtle and remain undetected by the usual systemic physiological monitoring. Continuous monitoring of the central nervous system in the intensive care unit can serve two functions. Firstly it will help early detection of these secondary cerebral insults so that appropriate interventions can be instituted. Secondly, it can help to monitor therapeutic interventions and provide online feedback. This review focuses on the monitoring of intracranial pressure, blood flow to the brain (Transcranial Doppler), cerebral oxygenation using the methods of jugular bulb oximetry, near infrared spectroscopy and implantable sensors, and the monitoring of function using electrophysiological techniques.

The management of musculoskeletal disorders is an increasing challenge to clinicians. Successful treatment relies on a wide range of multidisciplinary interventions. Adjunctive hyperbaric oxygen (HBO) therapy has been used as an orthopaedic treatment for several decades. Positive outcomes have been reported by many authors for orthopaedic infections, wound healing, delayed union and non-union of fractures, acute traumatic ischemia of the extremities, compromised grafts, and burn injuries. Severe side effects have also been reported with this therapy. To aid in the use of HBO therapy in orthopaedics, we reviewed 43 papers published in the past four decades and summarised the mechanisms, effectiveness, indications and contraindications, side effects, and cost impact of adjunctive hyperbaric oxygen therapy in the management of difficult musculoskeletal disorders. Adjunctive HBO therapy is an effective treatment modality for the management of some severe and refractory musculoskeletal problems. If appropriate candidates are carefully identified, hyperbaric oxygen is a limb- and sometimes life-saving therapy. HBO therapy significantly reduces the length of the patient's hospital stay, amputation rate, and wound care expenses. Thus, it is a cost-effective modality. A clinician must understand the side effects and risks of HBO treatment. Close monitoring throughout the treatment is warranted to minimise the risk to the patients.