Care-seeking practices in rural Rajasthan: barriers and facilitating factors

Poor care seeking contributes significantly to high neonatal mortality in developing countries. The study was conducted to identify care-seeking patterns for sick newborns in rural Rajasthan, India, and to understand family perceptions and circumstances that explain these patterns. Of the 290 mothers interviewed when the infant was 1 to 2 months of age, 202 (70%) reported at least one medical condition during the neonatal period that would have required medical care, and 106 (37%) reported a danger sign during the illness. However, only 63 (31%) newborns with any reported illness were taken to consult a care provider outside home, about half of these to an unqualified modern or traditional care provider. In response to hypothetical situations of neonatal illness, families preferred home treatment as the first course of action for almost all conditions, followed by modern treatment if the child did not get better. For babies born small and before time, however, the majority of families does not seem to have any preference for seeking modern treatment even as a secondary course of action. Perceptions of 'smallness', not appreciating the conditions as severe, ascribing the conditions to the goddess or to evil eye, and fatalism regarding surviving newborn period were the major reasons for the families' decision to seek care. Mothers were often not involved in taking this critical decision, especially first-time mothers. Decision to seek care outside home almost always involved the fathers or another male member. Primary care providers (qualified or unqualified) do not feel competent to deal with the newborns. The study findings provide important information on which to base newborn survival interventions in the study area: need to target the communication initiatives on mothers, fathers and grandmothers, need for tailor-made messages based on specific perceptions and barriers, and for building capacity of the primary care providers in managing sick newborns.

Do laparoscopy and intraoperative ultrasound have a role in the assessment of patients with end-stage liver disease and hepatocellular carcinoma for liver transplantation?

BACKGROUND

Liver transplantation is the treatment of choice for patients with end-stage liver disease (ESLD) and early hepatocellular carcinoma (HCC), Routine laparoscopy with intraoperative ultrasound was employed in an attempt to improve patient selection for transplantation. Our aim was to assess whether laparoscopy improved the patient selection with ESLD and HCC being considered for transplantation.

METHODS

We retrospectively reviewed the clinical notes and transplant database of all patients with ESLD complicated by HCC, being assessed for liver transplantation, from January 2000 to April 2005.

RESULTS

Twenty-five patients with ESLD and HCC underwent assessment for liver transplantation. Eight were deemed untransplantable on cross-sectional imaging alone. Sixteen patients underwent laparoscopy and intraoperative ultrasound. One patient had undergone a previous segmental hepatectomy and laparoscopy was not technically feasible. At laparoscopy, all 16 patients were found to be free from extrahepatic disease and major vascular involvement. All 16 patients were listed for transplantation. At transplantation, one patient was found to have extrahepatic disease; the procedure was abandoned. One patient was found to have lesser curvature lymphadenopathy, Two patients had major vascular involvement noted in the explanted liver. All these findings were missed on pretransplant imaging and at laparoscopy.

CONCLUSIONS

As an additional investigation, laparoscopy did not improve staging or alter the management of patients with HCC being assessed for liver transplantation. Since July 2005, we have ceased routine laparoscopic assessment of patients prior to listing. The decision use laparoscopy on patients is now being taken on a more selective basis.

A functional Fas promoter polymorphism is associated with a severe phenotype in type 1 autoimmune hepatitis characterized by early development of cirrhosis

Genome scanning studies suggest an important role for genes outside the major histocompatibility complex in autoimmunity. Key candidates are those genes involved in immune regulation and preservation of immune homeostasis, including the genes involved in apoptosis. Our aim was to determine the association between the Fas gene polymorphism at position -670 and susceptibility, clinical expression, and outcome in type 1 autoimmune hepatitis (AIH). An adenosine to guanine single nucleotide polymorphism in the Fas gene (TNFRSF6) promoter was assessed in 149 well-characterized Caucasoid patients and 172 matched controls. Patients and normal subjects had the similar TNFRSF6-670 allele and genotype frequencies. Serum aspartate aminotransferase (510 +/- 77 vs 283 +/- 53 U/l), gamma-globulin (3.3 +/- 0.2 vs 2.6 +/- 0.2 g/dl), and immunoglobulin G (2976 +/- 223 vs 2324 +/- 203 mg/dl) levels were higher in patients with the guanine/guanine genotype than in those with the adenosine/adenosine genotype. Cirrhosis at presentation was more common in patients with the adenosine/adenosine or adenosine/guanine genotypes than in those with the guanine/guanine genotype (29% vs 6%). Polymorphism of the Fas gene at position -670 does not influence susceptibility to AIH, but may affect the early development of cirrhosis.

The use of drotrecogin alfa (activated) in a patient with recent orthotopic liver transplant

Drotrecogin alfa has been shown to reduce mortality in severe sepsis. However, it remains unlicensed for use in patients with previous liver transplantation. We report its use in such a case. Prior to administration a risk benefit analysis was performed in line with General Medical Council recommendations. This included being satisfied that no appropriately licensed alternative would better serve the patient's needs and that sufficient evidence existed to demonstrate the safety and efficacy of the drug. Responsibility was taken for prescription, monitoring and follow up. The process was carefully documented and the patient recovered fully with no adverse effects. To date the only published data on the use of drotrecogin alpha in transplant recipients is a case series of three patients. Further published data may encourage review of the licence.

Impact of simple interventions on neonatal mortality in a low-resource teaching hospital in India

OBJECTIVE

To evaluate impact of simple interventions on neonatal mortality in a low-resource teaching hospital in India.

STUDY DESIGN

Before-and-after intervention trial setting: limited resource teaching hospital;

DESIGN

Before and after study.

INTERVENTIONS

A package of simple interventions was evolved. The interventions included: rational admissions and early discharge, entrusting mothers in care-giving, enforcing asepsis routines, aggressive enteral feeding, abandoning unnecessary interventions, protocol-based management, rational antibiotics and training and empowerment of nurses.

STATISTICAL METHODS

The categorical and continuous variables were compared with chi (2) and two-tailed tests, respectively.

RESULTS

Neonatal mortality rate declined significantly during the intervention period as compared to control period (20.3 versus 29.3 per 1000 live births; relative risk 0.69, 95% confidence interval (CI) 0.57 to 0.85). Most significant decline occurred in sepsis-related deaths. The survival of neonates with birth weight 1000 to 1499 improved over two folds (56.7% versus 24.5%, P<0.01). There was a significant decline in antibiotics use (635/878, 72.3% versus 299/897, 23.2%; P=0.00). The duration of stay in neonatal unit was decreased by a mean of 1.5 day (95% CI 0.9 to 2.8 days) after interventions.

CONCLUSIONS

Simple interventions can result in a significant decline in neonatal mortality in hospitals with limited resources. This package is likely to be effective in hospitals with a high proportion of the sepsis deaths.

Polymorphisms in the T cell regulatory gene cytotoxic T lymphocyte antigen 4 influence the rate of acute rejection after liver transplantation

BACKGROUND

The cytotoxic T lymphocyte antigen 4 (CTLA-4) gene encodes for a membrane bound (mCTLA-4) and a soluble (sCTLA-4) isoform, which are both involved in regulation of T cell function. The CTLA-4 +49A/G single nucleotide polymorphism (SNP) influences expression of mCTLA-4; +6230G/A SNP affects the production of sCTLA-4.

AIM

To examine whether these functional SNPs influence the rate of rejection after liver transplantation.

PATIENTS AND METHODS

Liver graft recipients (n = 483) were genotyped for both SNPs, and haplotypes were reconstructed. Association with rejection was tested by the log rank test using the Kaplan-Meier method with time to the first acute rejection episode as outcome. Multiple analysis of SNPs together with demographic factors was performed by Cox regression.

RESULTS

Three haplotypes were observed in the cohort: +49A/+6230A, +49A/+6230G, and +49G/+6230G. The +49A/+6230G haplotype was significantly and dose dependently associated with acute rejection (p = 0.01). Of the demographic factors tested, only underlying liver disease was significantly associated with rejection. Adjusted for underlying liver disease, each additional +49A/+6230G haplotype allele resulted in a significantly higher risk of acute rejection (risk ratio 1.34 (95% confidence interval 1.04-1.72); p = 0.02). Patients who lacked this haplotype had the lowest, carriers an intermediate, and homozygotes the highest risk of acute rejection.

CONCLUSION

The CTLA-4 +49A/+6230G haplotype, which encodes for normal mCTLA-4 expression but reduced sCTLA-4 production, is a co-dominant risk allele for acute rejection after clinical liver transplantation. This implies that even under immunosuppression, CTLA-4 is critically involved in the regulation of the human immune response to allogeneic grafts.

Immunohistochemical assessment of hepatitis C virus antigen in cholestatic hepatitis after liver transplantation

BACKGROUND

Patients with common variable immunodeficiency may exhibit rapidly progressive hepatitis when infected with hepatitis C virus (HCV), leading to cirrhosis and liver failure. Liver transplantation in these patients may result in a cholestatic form of HCV reinfection with exceptionally high virus loads.

AIMS

To report an immunohistochemical investigation of the pretransplant and post-transplant liver of one such patient.

METHODS/RESULTS

On immunohistochemical staining of frozen sections with anti-HCV core monoclonal antibody or fluorescein labelled human polyclonal anti-HCV IgG, no HCV antigens were demonstrated in the native cirrhotic liver removed at transplant, despite a viral load of 10(6.4) genomes/g. The transplanted liver, collected six weeks post-transplant, exhibited cholestatic recurrent hepatitis, had an HCV virus load of 10(10) genomes/g of liver, and revealed HCV antigen in the cytoplasm of most hepatocytes, with a pronounced periportal distribution. No virus antigen was demonstrable in other cell types. The core antigen was also detected in paraffin wax embedded, formaldehyde fixed tissue of this liver after high temperature antigen retrieval, but not in the native cirrhotic liver or a selection of HCV positive livers collected pretransplant from immunocompetent patients. Attempts to delineate the distribution of E1, NS3, and NS4 antigens were unsuccessful because monoclonal antibodies to these antigens produced "false positive" staining of foci of hepatocytes in the post-transplant livers of HCV seronegative patients with cholestasis.

CONCLUSION

This case provided an opportunity to study the natural development of HCV during acute infection in the absence of an immune response, and may help to elucidate the pathogenesis of HCV recurrence in liver allografts.

The histopathology of congenital pouch colon associated with anorectal agenesis

The colonic pouch excised during surgery in 17 patients with congenital pouch colon associated with anorectal agenesis (CPC) was subjected to detailed histological examination after staining with hematoxylin and eosin. The patients included 11 newborns, 3 infants, and 3 older children. The most frequently observed abnormalities were acute and chronic inflammation of the mucosa and submucosa, focal or generalized thinning of muscle layers, especially of the outer muscle coat, disorganized muscle layers, a decreased number of mature ganglion cells, and neuronal hyperplasia and hypertrophy in nerve plexuses. Ectopic heteroplastic tissues were identified in 2 patients. These findings suggest that the colonic pouch in CPC represents abnormally developed colonic tissue and points to the similarity with segmental dilatation of the colon. The neuromuscular abnormalities explain the physiological characteristics of the colonic pouch, namely weak peristalsis as well as the propensity to undergo marked dilatation even after tubularization.

Chemokine receptor 5 and primary biliary cirrhosis: a two-centre genetic association study

BACKGROUND

Chemokines and their receptors are important mediators of leucocyte trafficking and are suggested to be critical for establishment of inflammatory autoimmune processes. CC chemokine receptor 5 (CCR5) is expressed preferentially by CD4+ T cells. We hypothesised that the CCR5delta(Delta)32 genotype, which impairs surface expression of CCR5 in heterozygotes and is linked to a functional polymorphism of CD45RA expressed on suppressor-inducer-like 'naive' CD4+ T cells, may modulate the inflammatory process in primary biliary cirrhosis (PBC).

METHODS

CCR5Delta32 polymorphism was determined by PCR in 226 Caucasian PBC patients and 197 racially matched controls from two geographical areas, Newcastle, UK and Padua, Italy. (UK: 144 PBC, 105 controls, Italy: 82 PBC, 92 controls).

RESULTS

When the two series were analysed separately, there were no significant differences in the genotype distribution comparing patients and controls (UK: wt/wt 72% vs 76%; wt/Delta32 28% vs 22%; Delta32/Delta32 0% vs 2%, P=0.24; Italy: wt/wt 72% vs 82%; wt/Delta32 27% vs 17%; Delta32/Delta32 0% vs 1%, P=0.14). However, when the data for the two series were pooled and reanalysed, we found an increase in the CCR5Delta32 mutation in PBC patients vs controls (28% vs 21%, OR=1.43, P=0.03), but there was no evidence that this Delta32 polymorphism is associated with less severe disease.

CONCLUSIONS

Although this two-centre genetic association study is large compared with others performed in PBC, taken separately, each geographically based cohort of patients and controls is underpowered to detect a small effect of this functional polymorphism. This emphasises the need for far larger case-control collections to address which polymorphic markers or haplotypes might modify the pathogenesis and clinical course of PBC. We propose that multi-centre collaboration on an international scale in 'orphan' complex liver diseases such as (PBC) is supported by the International Association for the Study of the Liver and promoted via their journal with development of a brief format for web-based publication of studies.

Cytological diagnosis of cholangiocarcinoma with rib metastasis in a young female--a case report

Intrahepatic cholangiocarcinomas are second most common primary tumors of the liver. They are usually seen in 6th to 7th decades of life and at an advanced stage leading to poor prognosis. Their occurrence in the young age group is rare. Histopathological features of this tumor are well documented but literature regarding cytomorphological features on FNA is limited. We describe the cytological features of this tumor in a young woman presenting primarily with a rib metastasis. FNA smears from hard lump in the right chest wall and liver mass showed small round tumor cells arranged in the form of sheets, clusters and occasional tubules. The cells showed mild pleomorphism and bland nuclear morphology. Intimately admixed with tumor cells were spindle shaped fibroblastic cells. Serum alpha-fetoprotein level was within normal limit. Special stain for bile and immunocytochemical staining for NSE, chromogranin and CALLA were all negative. Cholangiocarcinoma was diagnosed based on cytological findings and special stains and this diagnosis was histologically confirmed on biopsy.

[Dantrolene. Pharmacological and therapeutic aspects]

Malignant hyperthermia (MH) is a genetic, potentially life-threatening disorder of the skeletal muscle presenting during or following general anaesthesia. Trigger agents are volatile anaesthetics and depolarising muscle relaxants. Dantrolene is the only available drug for effective and specific MH therapy, which reduces significantly the mortality rate. Dantrolene is a skeletal muscle relaxant that depresses the excitation-contraction coupling,however, the specificity of action remains unknown. Recent studies identified the ryanodine receptor, the calcium release channel of the sarcoplasmic reticulum, as the direct molecular target of dantrolene. In addition to its use for MH, dantrolene is used in other disorders such as neuroleptic malignant syndrome and spasticity. Since dantrolene is weakly water soluble, the clinical preparation is time and manpower consuming. New agents have been synthesized, but because of economic considerations no registration for clinical usage has been realised.

Hepatitis C virus particles of different density in the blood of chronically infected immunocompetent and immunodeficient patients: Implications for virus clearance by antibody

The purpose of this study was to analyse the influence of the humoral immune response on the generation and clearance of hepatitis C virus (HCV) RNA containing particles in the blood of chronically infected patients. Blood samples were fractionated by sequential flotation ultracentrifugation and HCV RNA was recovered in three fractions: low density of < 1.063 g/ml, intermediate density of 1.063-1.21 g/ml, and high density of > 1.21 g/ml. Serum low-density lipoproteins co-fractionated with the low-density particles, and high-density lipoproteins co-fractionated with the intermediate-density particles. Immunoglobulins were found exclusively in the high-density fractions. In patients with congenital immunodeficiencies, with no or low serum antibodies to the virus, mean HCV RNA titres were equal in each fraction, at approximately 10(5) IU/ml. In antibody-positive, immunocompetent patients, however, virus titres in the low-density fraction and those in the high-density fraction were reduced or absent in most patients, suggesting that virus particles in these fractions are subject to antibody-mediated clearance. Particles of intermediate density were approximately equal in titre in both patient groups, suggesting that these particles are neither generated by, nor cleared, as a result of the humoral immune response. Immunoprecipitation experiments indicated that particles of intermediate density were not complexed with either high-density lipoprotein or immunoglobulins. Elucidation of the mechanisms by which these particles are generated and maintained in the blood may provide valuable insight into the mechanism of virus persistence.

Glial choristoma

Glial choristoma is a developmental malformation of heterotopic central nervous tissue with limited growth potential. It is considered to be one of the very rare choristomatous lesions involving the oral cavity. This report details the morphological characteristics of glial choristoma arising from the palate in a newborn. Bulk of the tissue comprised of mature neuroglial tissue with astrocytes representing developing brain, cystic spaces lined by cuboidal epithelium indicating ependymal layer. Clinical features, associated malformations and histomorphology of this lesion is discussed.

Hepatitis associated with Chinese herbs

Traditional Chinese herbal medicines are widely available in Western society and are popular as a form of 'natural' alternative medicine. Their use is increasing, as they are perceived to be free of side effects, but they remain largely unregulated. We describe two patients who suffered severe hepatitis, one of whom died, after taking Chinese herbal remedies for minor complaints. We also review the English-language literature on hepatitis associated with Chinese herbs. Two products appear to be implicated frequently: Jin bu huan was taken by 11 patients, and Dictamnus dasycarpus was taken by six patients, including both fatal cases. It is difficult to provide conclusive evidence of what caused hepatitis, as these products are mixtures that may contain adulterants. These cases highlight not only the potential dangers of these products to consumers but also the need for greater control of their manufacture and use.

Familial primary biliary cirrhosis and autoimmune cholangitis

AIM

Autoimmune cholangitis has been proposed as a separate disease entity from primary biliary cirrhosis without serum antimitochondrial antibodies. The ultimate answer to the question of whether autoimmune cholangitis and primary biliary cirrhosis are distinct will require detailed comparison of aetiologic factors and pathogenic mechanisms.

METHODS AND RESULTS

Two families are described each of which has one member with classical antimitochondrial antibody positive biopsy-proven primary biliary cirrhosis and a first degree relative with antimitochondrial antibody negative but antinuclear antibody positive autoimmune cholangitis (biopsy proven in one case). Study of such families should allow analysis of the contribution of shared genetic risk factors versus varying environmental triggering mechanisms to disease pathogenesis.

CONCLUSIONS

We suggest a European registry of families, such as the two described, which are rare within one centre, to facilitate elucidation of pathogenetic factors.

Neuroglial cyst: a rare occurence in abdomen and pelvis

We hereby report a case of a child who presented with abdominal distension and urinary retention. Radiological investigations and exploratory laparotomy revealed a cystic mass in the sacral region pushing the urinary bladder anteriorly and upwards. Histopathological examination revealed neuroglial elements. Neuroglial cysts are uncommon outside the central nervous system and this is the first report of its occurrence in abdomen and pelvis.