Changing microbiological profile of pathogenic bacteria in diabetic foot infections: time for a rethink on which empirical therapy to choose?

AIMS/HYPOTHESIS

We studied the bacterial aetiology and antibiotic sensitivity pattern of diabetic foot ulcers in India.

METHODS

Records of 447 hospitalised patients between 1991 and 2008 were retrospectively analysed between two time periods (before and after 1999) to compare bacterial aetiology and antimicrobial sensitivity patterns. The first three consecutive cultures from the same wound during treatment were evaluated.

RESULTS

Of 1,632 cultures, 66% were polymicrobial, 23% monomicrobial and 11% sterile. In the monomicrobial group, 14% (n = 228) of cultures were Gram-negative, whereas 9% (n = 147) were Gram-positive. The most common pathogens in the first culture were Pseudomonas aeruginosa (20.1%), Staphylococcus aureus (17.2%) and Escherichia coli (16.3%). Results for the third cultures showed persistence of P. aeruginosa (15.3%) and E. coli (14.2%). Gram-negative isolates dominated over Gram-positive ones (25.3% vs 15.1%, p < 0.05). Antibiotic sensitivity patterns before and after 1999 were: piperacillin-tazobactam 74% vs 66% (p < 0.005), imipenem 77% vs 85% (NS), cefoperazone-sulbactam 47% vs 44% (p < 0.005), amikacin 62% vs 78% (NS), ceftriaxone 41% vs 36% (p < 0.005), amoxicillin-clavulanate 51% vs 43% (p < 0.05) and clindamycin 43% vs 36% (p < 0.005), respectively.

CONCLUSIONS/INTERPRETATION

Unlike in the West, in India Gram-negative bacteria were found to have always been dominant in the wounds of patients with diabetic foot infections. Infection with polymicrobial multidrug-resistant Gram-negative bacilli is common. The policy of empirical antimicrobial therapy at tertiary care needs to be changed.

Asian-Indian physicians' experience with managed care organizations

PURPOSE

There is anecdotal evidence that ethnic minority physicians are underrepresented in managed care contracts. The purpose of this paper, therefore, is to determine ethnic Asian-Indian physician-managed care organization experience and job satisfaction in the USA by age, gender, region and percent of patients in managed care organizations. DESIGN/METHODOLOGY/VALUE: A random (nation-wide) mail survey was conducted of 254 physicians who were American Association of Physicians of Indian Origin (AAPI) members during the period 1998 to 2000. Managed care experience was categorized into physician satisfaction; service quality rating; service limitations; difficulties acquiring and maintaining managed care contracts; and financial impact.

FINDINGS

Physicians in solo and group practice relied heavily on managed care enrolled patients. Limitations providing care to patients was a more serious problem than for those in staff-model health maintenance organization and hospital/clinic-based practices. Physician satisfaction was not significantly related to board certification, practice type, region and managed care participation. However, practice staff participating in managed care had the highest number of board-certified physicians.

RESEARCH LIMITATIONS/IMPLICATIONS

There was a low response rate (37 percent) to data collection using questionnaires.

PRACTICAL IMPLICATIONS

The paper underlines ethnic minority physicians' capability to get managed care contracts.

ORIGINALITY/VALUE

This is the first national study of Asian-Indian physicians and their managed care organization experience. Asian-Indian physicians are over-represented in the medical profession and hence the paper will interest those working and dealing with managed care organizations and their patients.

Computing the multifractal spectrum from time series: an algorithmic approach

We show that the existing methods for computing the f(alpha) spectrum from a time series can be improved by using a new algorithmic scheme. The scheme relies on the basic idea that the smooth convex profile of a typical f(alpha) spectrum can be fitted with an analytic function involving a set of four independent parameters. While the standard existing schemes [P. Grassberger et al., J. Stat. Phys. 51, 135 (1988); A. Chhabra and R. V. Jensen, Phys. Rev. Lett. 62, 1327 (1989)] generally compute only an incomplete f(alpha) spectrum (usually the top portion), we show that this can be overcome by an algorithmic approach, which is automated to compute the D(q) and f(alpha) spectra from a time series for any embedding dimension. The scheme is first tested with the logistic attractor with known f(alpha) curve and subsequently applied to higher-dimensional cases. We also show that the scheme can be effectively adapted for analyzing practical time series involving noise, with examples from two widely different real world systems. Moreover, some preliminary results indicating that the set of four independent parameters may be used as diagnostic measures are also included.

Sustained antibacterial activity of doxycycline-loaded poly(D,L-lactide-co-glycolide) and poly(epsilon-caprolactone) nanoparticles

AIM

To increase the entrapment efficiency of doxycycline (DXY)-loaded poly(D,L-lactide-co-glycolide) (PLGA):poly(epsilon-caprolactone) (PCL) nanoparticles by up to 70% by varying the different formulation parameters such as polymer ratio, amount of drug loading (w/w), solvent selection, electrolyte addition and pH in the formulation.

METHOD

Biodegradable polymers PLGA and PCL are used in various ratios for nanoparticle preparation using the water-in-oil-in-water double emulsion technique for water-soluble DXY. The physicochemical characterization of nanoparticles included size and surface charge measurement, study of surface morphology using scanning-electron microscopy, Fourier transform infrared spectroscopy study, differential scanning calorimetry analysis and in vitro release kinetics study.

RESULTS

The mean particle size ranged from 230 to 360 nm, as measured by dynamic laser light scattering, and scanning-electron microscopy confirmed the spherical nature and smooth surface of the nanoparticles. Fourier transform infrared spectroscopy analysis of void nanoparticles, drug-loaded nanoparticles and native DXY indicated no interaction between the drug and polymer in the nanoparticle. Differential scanning calorimetry analysis of drug-loaded nanoparticles indicated a molecular level dispersion of DXY in the formulation. The antibacterial activity of native DXY and DXY-loaded nanoparticles were tested using a strain of Escherichia coli (DH5alpha) through growth inhibition and colony-counting method. The results indicated that DXY-loaded nanoparticles are more effective than native DXY due to the sustained release of DXY from nanoparticles in the E. coli strain.

Ethnic and gender differences in psychosocial factors, glycemic control, and quality of life among adult type 2 diabetic patients

OBJECTIVE

To examine ethnic and gender differences in psychosocial factors, e.g., social support and acceptance of the disease, knowledge levels, perceived difficulty in adherence behaviors, and diabetes outcome (glycemic control and quality of life) in Type 2 diabetic patients.

METHODS

Data were collected via telephone interviews from 180 diabetic subjects (34% Hispanics, 27% Non-Hispanic whites, 18% African-Americans, and 20% Asian-Indians; 52% females) from 2 clinics. Hemoglobin A1c levels were obtained from patient charts.

RESULTS

Significant ethnic and gender differences existed in acceptance of the disease, in receiving social support, disease knowledge, perceived difficulty in self-management behaviors, glycemic control, and quality of life among Type 2 diabetic patients; differences were more pronounced by gender than by ethnicity. In general, social support and acceptance of the disease were high. However, perceived difficulty in self-management behaviors varied by racial/ethnic groups with self-monitoring of blood glucose perceived as most difficult by Hispanic respondents, dietary management was most difficult for non-Hispanic whites, while physical activity was the most difficult for African-Americans. Hispanic respondents had greatest severity of the disease (poorest metabolic control).

CONCLUSIONS

Ethnic and gender variations exist in social support, acceptance of diabetes, quality of life, and adherence behaviors. The outcomes of diabetes care can be improved if practitioners factor these differences in tailoring diabetes education and supportive care for individuals with Type 2 diabetes.

Levels of malondialdehyde and antioxidants in the blood of patients with vitiligo of age group 11-20 years

The aetiopathogenesis of vitiligo has not been fully understood. To investigate the role of oxidative stress in pathogenesis of vitiligo, we examined the blood level of antioxidants and malondialdehyde in 40 patients with generalized vitiligo and 40 healthy volunteers belonging to same age group. Our results revealed that the level of malondialdehyde was significantly raised while those of vitamin E, uric acid and ceruloplasmin were significantly lowered (P < 0.05) in patients with generalized vitiligo as compared to controls. This demonstrates the presence of an imbalance in the oxidant-antioxidant system in the blood of vitiligo patients and thus provides support for a free radical mediated damage as a pathogenic event in vitiligo.

Gender and ethnic differences in hand hygiene practices among college students

BACKGROUND

Poor hand hygiene on college campuses can be improved by promoting handwashing behavior. This observational study was conducted to evaluate gender and race/ethnic differences in hand hygiene practices among college students.

METHODS

Hand hygiene practices in college students were evaluated in 4 settings (soap and water; soap and water and visual prompts; soap and water and hand sanitizers; and soap and water, hand sanitizers, and visual prompts). The degree of hand hygiene (ie, adequate handwashing time, use of hand sanitizer, and hand-drying method) also was evaluated at various locations on campus.

RESULTS

Overall, 72.9% of students washed their hands, 58.3% practiced hand hygiene (using either soap or hand sanitizer), and 26.1% washed their hands adequately. Hand sanitizer use was low when students were given the option, and paper towel was the most common hand-drying method. In general, hand hygiene practices were better in academic buildings than in the student recreation center. Visual prompts improved handwashing behavior only among students in the "other" ethnic category, but not by gender.

CONCLUSIONS

Handwashing is the most effective way of preventing the spread of infectious diseases, and our findings have implications for the design of effective hand hygiene education programs in college students.

A community-based diabetes prevention and management education program in a rural village in India

OBJECTIVE

In this study we evaluated a 7-month community-based nonpharmacological lifestyle intervention to prevent/reduce the risk of developing diabetes and its complications in a resource-poor village in Tamilnadu, India.

RESEARCH DESIGN AND METHODS

A total of 703 village inhabitants, comprising adults and youth aged 10-92 years, were provided educational intervention using "trained trainers." Culturally and linguistically appropriate health education messages addressed diet, physical activity, and knowledge improvement. The prevalence of diabetes and the effectiveness of the intervention were assessed using select parameters.

RESULTS

The crude prevalences of diabetes and pre-diabetes among adults were 5.1 and 13.5%, respectively, while the prevalence of pre-diabetes in youth aged 10-17 years was 5.1%. Intervention reduced fasting blood glucose levels of pre-diabetic adults by 11%, pre-diabetic youth by 17%, and type 2 diabetic adults by 25%. Improvements in obesity parameters and dietary intake also occurred. A stepwise worsening of parameters progressing from the normoglycemic state to the impaired levels of pre-diabetes and diabetes was observed.

CONCLUSIONS

This study has charted the increasing prevalence of diabetes and pre-diabetes in rural India. Educational intervention was successful in reducing some of the obesity parameters and improving dietary patterns of individuals with pre-diabetes and diabetes.

Predictors of quality of life among adults with type 2 diabetes mellitus

Using a path model, this study examined the relationships among psychosocial factors (social support and acceptance of diabetes), knowledge of the disease, perceived difficulty of self-care behaviors (SCBs), and disease outcome [quality of life (QoL)] among 180 adults with type 2 diabetes mellitus. In general, respondents exhibited high levels of acceptance. The hypothesis that higher levels of social support and acceptance lead to lower perceived difficulty with SCBs was supported. High levels of social support increased acceptance and reduced SCBs. Knowledge reduced SCBs but was not associated with QoL. In the path model, SCBs influenced QoL and mediated the relationship between social support, acceptance, and QoL.

A novel pathway for the biodegradation of gamma-hexachlorocyclohexane by a Xanthomonas sp. strain ICH12

AIM

To isolate gamma-hexachlorocyclohexane (HCH)-degrading bacteria from contaminated soil and characterize the metabolites formed and the genes involved in the degradation pathway.

METHODS AND RESULTS

A bacterial strain Xanthomonas sp. ICH12, capable of biodegrading gamma- HCH was isolated from HCH-contaminated soil. DNA-colony hybridization method was employed to detect bacterial populations containing specific gene sequences of the gamma-HCH degradation pathway. linA (dehydrodehalogenase), linB (hydrolytic dehalogenase) and linC (dehydrogenase) from a Sphingomonas paucimobilis UT26, reportedly possessing gamma-HCH degradation activity, were used as gene probes against isolated colonies. The isolate was found to grow and utilize gamma-HCH as the sole carbon and energy source. The 16S ribosomal RNA gene sequence of the isolate resulted in its identification as a Xanthomonas species, and we designated it as strain ICH12. During the degradation of gamma-HCH by ICH12, formation of two intermediates, gamma-2,3,4,5,6-pentachlorocyclohexene (gamma-PCCH), and 2,5-dichlorobenzoquinone (2,5-DCBQ), were identified by gas chromatography-mass spectrometric (GC-MS) analysis. While gamma-PCCH was reported previously, 2,5-dichlorohydroquinone was a novel metabolite from HCH degradation.

CONCLUSIONS

A Xanthomonas sp. for gamma-HCH degradation from a contaminated soil was isolated. gamma-HCH was utilized as sole source of carbon and energy, and the degradation proceeds by successive dechlorination. Two degradation products gamma-PCCH and 2,5-DCBQ were characterized, and the latter metabolite was not known in contrasts with the previous studies. The present work, for the first time, demonstrates the potential of a Xanthomonas species to degrade a recalcitrant and widespread pollutant like gamma-HCH.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study demonstrates the isolation and characterization of a novel HCH-degrading bacterium. Further results provide an insight into the novel degradation pathway which may exist in diverse HCH-degrading bacteria in contaminated soils leading to bioremediation of gamma-HCH.

Validation of accuracy and community acceptance of the BIRTHweigh III scale for categorizing newborn weight in rural India

OBJECTIVE

To determine the accuracy and acceptability of a handheld scale prototype designed for nonliterate users to classify newborns into three weight categories (>or=2,500 g; 2,000 to 2,499 g; and <2,000 g).

STUDY DESIGN

Weights of 1,100 newborns in Uttar Pradesh, India, were measured on the test scale and validated against a gold standard. Mothers, family members and community health stakeholders were interviewed to assess the acceptability of the test scale.

RESULT

The test scale was highly sensitive and specific at classifying newborn weight (normal weight: 95.3 and 96.3%, respectively; low birth weight: 90.4 and 99.2%, respectively; very low birth weight: 91.7 and 98.4%, respectively). It was the overall agreement of the community that the test scale was more practical and easier to interpret than the gold standard.

CONCLUSION

The BIRTHweigh III scale accurately identifies low birth weight and very low birth weight newborns to target weight-specific interventions. The scale is extremely practical and useful for resource-poor settings, especially those with low levels of literacy.

Weak-localization correction to the anomalous Hall effect in polycrystalline fe films

In situ transport measurements have been made on ultrathin (<100 A thick) polycrystalline Fe films as a function of temperature and magnetic field for a wide range of disorder strengths. For sheet resistances Rxx less than approximately 3kOmega, we find a logarithmic temperature dependence of the anomalous Hall conductivity sigmaxy, which is shown for the first time to be due to a universal scale dependent weak-localization correction within the skew-scattering model. For higher sheet resistance, granularity becomes important and the break down of universal behavior becomes manifest as the prefactors of the lnT correction term to sigmaxx and sigmaxy decrease at different rates with increasing disorder.

Genital tuberculosis in Indian infertility patients

OBJECTIVES

To analyze the clinical and laparoscopic features of 40 infertile women with genital tuberculosis.

MATERIALS AND METHODS

This prospective clinical study was carried out at a tertiary care hospital from October 1, 2004, to August 30, 2006, with 150 infertile women in whom there was clinical suspicion of genital tuberculosis. All underwent diagnostic laparoscopy and biopsy for confirmation and other causes of infertility were excluded.

RESULTS

Among the 40 infertile women affected with genital tuberculosis there were cases of primary (n=30) and secondary (n=10) infertility; pelvic pain (n=8); menorrhagia (n=9); oligomenorrhea (n=7); hypomenorrhea (n=8); and primary (n=2) and secondary (n=2) amenorrhea. There were histories of pulmonary (n=9) and abdominal tuberculosis (n=6), ectopic pregnancy (n=4), and antitubercular treatment (n=10) in 10. There were cases of positive Mantoux test results (n=2); endometrial aspiration showing tubercular endometritis (n=10); positive acid-fast bacillus culture results (n=1); and positive polymerase chain reaction results (n=9). Laparoscopic examination revealed abnormally dilated, tortuous, and blocked fallopian tubes (n=13); peritubal and periovarian adhesions (n=18); Fitz Hugh Curtis syndrome (n=15); omental adhesions (n=18); and bowel adhesions (n=15). Hysteroscopy revealed flimsy intrauterine adhesions (n=7). All patients were treated for tuberculosis and 13 were counseled for in-vitro fertilization and embryo transfer or adoption.

CONCLUSION

Genital tuberculosis is common in India and a combination of clinical and laparoscopic diagnoses, along with endometrial histopathologic studies, acid-fast bacillus culture, and polymerase chain reaction assays provides the best available method for the diagnosis of genital tuberculosis in infertile women.

Low molecular weight proteins of outer membrane of Salmonella typhimurium are immunogenic in Salmonella induced reactive arthritis revealed by proteomics

In patients with reactive arthritis (ReA)/undifferentiated spondyloarthropathy (uSpA), synovial fluid mononuclear cells (SFMC) show proliferation to bacterial antigens that trigger ReA, i.e. Chlamydia, Yersinia, Campylobactor, Shigella and Salmonella species. We have shown previously that SFMC proliferate significantly to outer membrane proteins of S typhimurium in Salmonella induced ReA. In the present study we characterized the immunoreactive fractions of outer membrane protein (Omp) of S typhimurium in Salmonella induced ReA. Omp of Salmonella was isolated and fractionated by continuous elution sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) using Prep-Cell into eight Omp fractions based on molecular weight. Twenty-three patients with ReA were screened for the bacterial trigger using the SFMC proliferative response to crude lysates of Y enterocolitica, S flexneri, C jejuni and S typhimurium using thymidine uptake assay. SFMC from patients with salmonella induced ReA were tested against eight fractions. Seven of 23 patients with ReA had S typhimurium-induced ReA. Of these seven patients, five patients SFMC had a significant stimulation index (SI) against < 22, 22-26, 25-35 and 28-40 kDa fractions of Omp. These fractions were analysed by SDS-PAGE and matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) mass spectrometry, which revealed 10 proteins. These proteins were 37 kDa OmpA, 33 kDa TsX, 28 kDa putative Omp, 28 kDa Vac J, 39 kDa OmpD, 18 kDa OmpX, 23 kDa OmpW, 43 kDa OmpS1 and 19 kDa peptidoglycan-associated lipoprotein. In conclusion, for the first time we have identified some low molecular weight proteins in the Omps of Salmonella which are T cells immunoreactive in patients with salmonella induced ReA/uSpA.

Chemokine and chemokine receptor analysis reveals elevated interferon-inducible protein-10 (IP)-10/CXCL10 levels and increased number of CCR5+ and CXCR3+ CD4 T cells in synovial fluid of patients with enthesitis-related arthritis (ERA)

Chemokines and chemokine receptors play a major role in homing of cells to the site of inflammation. Enthesitis-related arthritis (ERA) is a chronic inflammatory arthritis and no data are available on chemokines and their receptors in ERA. Blood (20) and synovial fluid (SF) (11) was collected from patients with ERA, and peripheral blood (PB) was collected from 12 patients with polyarticular juvenile idiopathic arthritis (JIA), nine patients with systemic onset and 18 healthy controls. Chemokines [interleukin (IL)-10/CXCL10, thymus and activation-regulated chemokine (TARC)/CCL17 and regulated upon activation normal T cell expressed and secreted (RANTES)/CCL5] were measured in serum and SF. Chemokine receptor expression was measured by flow cytometry. There was no difference in blood CD4(+) T cells bearing CCR5, CCR4 and CXCR3 in ERA and healthy controls. In paired samples the median frequency of CCR5(+) CD4(+) T cells was higher in SF compared to PB (15.8 versus 3.9%, P < 0.005), as was the frequency of CXCR3(+) T cells (21.61% versus 12.46%, P < 0.05). Median serum interferon-inducible protein-10 (IP-10)/CXCL10 levels were higher in patients with ERA compared to controls (139 versus 93 pg/ml; P < 0.05). Further median SF IP-10/CXCL10 levels were higher than the serum levels (2300 pg/ml versus 139 pg/ml; P < 0.01). Serum levels of RANTES/CCL5 were higher in patients (150 ng/ml) compared to control (99 ng/ml; P < 0.01). The SF levels were significantly lower compared to serum (P < 0.05). TARC/CCL17 levels in SF were lower than serum. There is increased homing of CCR5 and CXCR3(+) CD4 cells to the SF. Increased SF levels of IP-10/CXCL10 may be responsible for this migration in patients with ERA.

The metabolic syndrome in South Asians: continuing escalation & possible solutions

The metabolic syndrome is a crucial factor in causation of type 2 diabetes mellitus (T2DM) and coronary heart disease (CHD) in South Asians. Approximately 20-25 per cent of urban South Asians have evidence of the metabolic syndrome. Furthermore, insulin resistance was reported to be present in nearly 30 per cent of children and adolescents in India, more so in girls. At the same time many young individuals have clustering of other risk factors/conditions related to insulin resistance (e.g., non-alcoholic fatty liver disease, obstructive sleep apnoea, etc.). Rapid nutritional and lifestyle transition in urbanized areas in various countries in South Asia are prime reasons for increasing prevalence of obesity and the metabolic syndrome. It is particularly important to effectively implement and strengthen population-based primary prevention strategies for the prevention of 'epidemic' of obesity and the metabolic syndrome. The lifestyle factor modification to prevent the metabolic syndrome and T2DM in South Asians should start in early childhood. Finally, there is an urgent need to conduct research studies regarding the correct definitions of the metabolic syndrome and genetic and perinatal factors related to insulin resistance in South Asians.

Osteonecrosis of the medial tibial plateau: a case report

Medial tibial plateau osteonecrosis is a disease that lacks distinguishing signs and symptoms, especially in the early stage, and requires clinicians to exercise a high degree of suspicion to prevent disease progression. We present a case of spontaneous osteonecrosis of the medial tibial plateau in a 59-year-old woman. Within 5 months of the onset of symptoms, the entire medial tibial plateau collapsed down into the metaphyseal region, causing severe varus deformity, instability, and inability to walk without crutches and a hinged knee brace. Initial symptoms of medial joint line pain and generalised swelling of the knee were attributed to early degenerative changes. Subsequent radiographs were misinterpreted as simple medial compartment arthritis. Due to severe bone loss and significant lateral collateral ligament attenuation, a total joint arthroplasty was required, using a stemmed tibial component with medial metal block and bone graft augmentation. The speed of bone collapse and the extension into the metaphysis, requiring complex joint arthroplasty, makes this case unique.

Arthritis as presenting manifestation of pure neuritic leprosy--a rheumatologist's dilemma

OBJECTIVES

Leprosy classically presents with cutaneous and neurological manifestations. In diagnosed cases of leprosy, rheumatological involvement varies from 1% to 70%. A primary articular presentation without cutaneous manifestations is not yet known. Herein, we present our experience of five cases of leprosy that presented with predominant articular involvement in the absence of cutaneous manifestations.

METHODS

The study was conducted in the Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences located in the state of Uttar Pradesh, one of the nine endemic states in India. Case records of patients with a definite diagnosis of leprosy were screened for the presenting manifestations, pattern of articular involvement, tenosynovitis, neurological signs and symptoms. Reports of nerve conduction study (NCS), nerve and synovial biopsy and other diagnostic tests were retrieved from laboratory records. Available radiographs were examined for evidence of juxta-articular osteopenia and erosions.

RESULTS

Case records of 11,740 patients were screened, of which 28 had a diagnosis of leprosy. Twenty patients had presented with rheumatological complaints primarily. Five of the patients who presented with inflammatory arthritis with/without tenosynovitis (n = 4) and tenosynovitis alone (n = 1) had pure neuritic leprosy. All of these patients had thickened peripheral nerves and abnormal NCS. Sural nerve biopsy confirmed the diagnosis of leprosy in all these cases.

CONCLUSION

A combination of tenosynovitis and thickened nerves in association with symmetric polyarthritis should raise a suspicion of leprosy even in the absence of cutaneous features.

Levonorgestrel-releasing intrauterine system vs. transcervical endometrial resection for dysfunctional uterine bleeding

OBJECTIVE

To compare the acceptability, efficacy, adverse effects, and user satisfaction of a levonorgestrel intrauterine system (LNG-IUS) and transcervical resection of the endometrium (TCRE) for the treatment of dysfunctional uterine bleeding.

METHOD

Of 50 women with a pictoral blood loss assessment chart (PBAC) score of 100 or greater, 25 had a LNG-IUS inserted (Mirena; Schering, Berlin, Germany) and 25 underwent TCRE. Procedure-related complications, PBAC score, hemoglobin levels, adverse effects, and rates of acceptability and satisfaction were recorded at 3-month intervals for a period of 12 months.

RESULTS

At the end of 1 year there were a 97% and a 94% reduction in menstrual blood loss in the LNG-IUS and TCRE groups, respectively, and hemoglobin concentration had increased by 5.5% in the LNG-IUS group and 5.2% in the TCRE group. Adverse effects were similar in both groups except for systemic effects, which were seen only in the LNG-IUS group. Satisfaction rates were about 80% in the 2 groups.

CONCLUSION

Both treatments were found to be equally effective but LNG-IUS placement requires less operator skill and entails no operative hazards, and the device provides effective contraception.

Interleukin-1 receptor antagonist gene polymorphism in patients with rheumatoid arthritis in India

BACKGROUND & OBJECTIVES

Interleukin-1 receptor antagonist (IL-1Ra) is a naturally occurring anti-inflammatory molecule that blocks action of IL-1. Polymorphism in IL-1Ra gene intron 2 results in differences in production of IL-1Ra. These polymorphisms are reportedly associated with autoimmune disease susceptibility in different studies. However, such data are lacking from India. We undertook this study to examine the IL-1Ra polymorphism as a susceptibility marker in patients with rheumatoid arthritis (RA).

METHODS

DNA samples from 107 patients with RA and 111 healthy controls were used to study genotypes of the IL-1RA gene by PCR. Allelic frequencies and carriage rates were calculated and compared in both the groups.

RESULTS

Among the 107 patients with RA, 93 were females and 75 per cent were seropositive for rheumatoid factor. The frequencies of IL-1RA alleles in controls were as follows: Allele 1 (IL- 1RN*1) was 83.33 per cent, IL-1RA allele 2 (IL-1RN*2) was 16.21 per cent and allele 3 (0.46%). In RA patients the allele frequencies were 84.11 per cent for IL-1RN*1, 14.95 per cent for IL- 1RN*2, 0.47 per cent each for IL-1RN*3 and IL-1RN*4. There was no difference in frequency of different alleles between the two groups. However, homozygosity for allele 2 was more frequent in controls (9.91%) as compared to patients (4.67%).

INTERPRETATION & CONCLUSION

Our findings indicated that IL-1RA polymorphism was not a susceptibility marker in RA nor did it show any association with seropositivity, Sjögren's syndrome or subcutaneous nodules. Further studies with large sample need to be done to confirm these findings.

MCTD: is it rare in India?

Mixed connective tissue disease (MCTD) has been rarely reported from India. Thus, we did a retrospective analysis of cases of MCTD seen at our hospital during the last 13 years. We found 16 cases among 441 patients with connective tissue disease. All the 16 patients (15 females) of MCTD fulfilled classification criteria by Kasukawa and at least one of the other two (Sharp's and Alarcon-Sergovia). Raynaud's phenomenon, sclerodactyly, puffy fingers, esophageal hypomotility, and pulmonary disease were the most common manifestations. At a median follow-up of 12 months (1-172), 12 patients developed features of limited scleroderma and three patients had pulmonary hypertension.