A cross-sectional study on factors including HIV testing and counselling determining unsafe injecting practices among injecting drug users of Manipur

In India, a steep increase in the prevalence of HIV (0% to 50% within six months) among the IDUs has been reported in Manipur, a north eastern state in 1990. In spite of large scale intervention program like educational campaign and widespread voluntary HIV testing in this state, the infection has quickly spread to the heterosexual population at large. The determinants of risk taking behaviors like sharing of unclean needle among the IDU population has been explored in this paper. A cross sectional study has been carried out among all of the 488 IDUs who attended any detoxification centers and prison during last two years at Imphal, the capital city of this state. Self reported behaviors based on the pre-scheduled interview were recorded and participation rate was satisfactory. The data was compared to a similar survey carried out by us in 1990. Although there has been decline in risk behavior among the IDUs, a logistic regression analysis reveals that unsafe needle sharing behavior is not influenced by the knowledge on HIV transmission, educational status or history of HIV testing or serostatus of the individual. The limitation of cross sectional nature of the study, bias due to collection of data in prison, self reported behavior, possible differences with street samples of the addict are discussed.

Clinical features of HIV infection in drug users of Manipur

BACKGROUND

The human immunodeficiency virus was first detected in young intravenous drug users in Manipur in 1989 and it quickly reached a high prevalence in this group. Diagnostic facilities are scarce and it is thus important to suspect the presence of the infection by its clinical features.

METHODS

We did a cross-sectional survey for 13 months among residents of different detoxification centres of Imphal, Manipur, to study the sensitivity, specificity and positive predictive values of different signs and symptoms occurring at the early phase of the infection.

RESULTS

Most of the young injectors in this survey were found to be in the early phases (stage I 43%; stage II 32%; stage III 15% and stage IV 9.9%) of the World Health Organization clinical staging of human immunodeficiency virus infection and disease. Herpes zoster, oral candidiasis, pruritic papular eruptions, jaundice and lymphadenopathy had positive predictive values of 100%, 100%, 93%, 93% and 88% respectively. Cryptosporidial diarrhoea and tuberculosis (pulmonary and extrapulmonary) were also encountered.

CONCLUSION

Intravenous drug users in Manipur who have human immunodeficiency virus infection suffer from different opportunistic infections which give rise to clinical features that are easily recognizable. It is important to be aware of these in areas which lack diagnostic facilities for confirming the infection.

The collagen types in the attachment zone of rotator cuff tendons in the elderly: an immunohistochemical study

OBJECTIVE

The attachment zone of the rotator cuff tendons in the elderly was studied immunohistochemically in order to determine how degenerative changes affected the pattern of collagen fiber distribution.

METHODS

Twenty-seven cuffs with their bony insertion were obtained from 22 postmortem cases of both sexes ranging in age from 52 to 90 years and without a history of shoulder ailments. In addition, 3 cuff specimens from cadavers in the 3rd and 4th decades were examined for comparison. Sections of formalin fixed tissues were stained by peroxidase antiperoxidase (PAP) technique using monoclonal antibodies against types I, II and III collagen.

RESULTS

Degenerative changes affecting the fibrocartilage primarily were characterized by calcification, fibrovascular proliferation and microtears. In addition, they were found in all the cuff tendons of elderly individuals but not in those from younger subjects. Immunohistochemically, the attachment zone in areas without degenerative lesions showed collagen type I labelling strongly in bone but only moderately in the fibrocartilage. The predominant labelling in the fibrocartilage was for collagen type II, and collagen type III labelled principally in perichondrocytic areas. The tide-mark showed inconsistent labelling for any of the collagen types. In the presence of degenerative lesions, the disposition of fiber types was interrupted by calcification and microtears. Collagen type II composition of the fibrocartilage was markedly altered by the presence of fibrovascular tissue which labelled only for collagen type III.

CONCLUSION

We conclude that severe degenerative changes in the cuff tendons of elderly individuals, alter the collagen characteristic of the rotator cuff and that the changes could be associated with impairment of biomechanical properties of the attachment zone, and may give rise to the clinical syndrome of enthesopathy.

Immunohistochemical distribution of type I, II and III collagens in the rabbit supraspinatus tendon insertion

The collagen fibres in the area of attachment of the supraspinatus tendon to bone were studied immunohistochemically in 12 mature female New Zealand white rabbits. The labelling of type I collagen was uniformly prominent in the bone as well as in the fascicles of the tendon proper but inconspicuously scattered in the unmineralised and mineralised zones of the fibrocartilage. Type II collagen, not detected in the tendon proper, was widespread in both zones of the fibrocartilage. Type III collagen, on the other hand, appeared to be confined mainly to the zone of unmineralised fibrocartilage, in addition to its presence in the endotenon of the tendon proper. The region of the tidemark failed to show immunostaining for any of the collagen fibre types. In conclusion, this study demonstrates that, although all the principal fibrous collagen types are constituents of the supraspinatus tendon at its attachment site, the distribution pattern of immunolabelling varies from zone to zone.

Aortic rupture and false aneurysm formation following balloon angioplasty of coarctation in an adult: successful treatment by urgent surgery

A 25-year-old man developed a false aneurysm as a result of acute disruption of the aortic wall immediately after successful balloon dilatation of his coarctation. He underwent emergency resection of the false aneurysm and end-to-end anastomosis of the descending aorta with an excellent result. The diagnosis and management of this complication are discussed.

Effects of immobilization on the capsule of the canine glenohumeral joint. A structural functional study

The effects of immobilization on the function of the glenohumeral joint and its capsule were investigated in eight beagle dogs. One foreleg of each animal was immobilized in a spica cast, and the dogs were euthanized after 4, 8, 12, and 16 weeks of immobilization in groups of two. The contralateral limb and the forelegs of two normal beagles were used as controls. At the time of euthanasia, the range of motion, intraarticular filling volume during passive movements of the joint, and intraarticular filling volume to rupture the capsule were measured. The synovium, including the capsule and the subscapular bursa, were examined histologically. In the immobilized limb, there was progressive restriction in the range of motion with increases in intraarticular pressure, and the filling volume that was required to cause a rupture of the capsule diminished. Morphologically, the capsule and the subscapular bursa showed focal adhesions. Thus, it appeared that immobilization of these canine forelimbs produced changes in the glenohumeral joint that resembled those of frozen shoulder in humans.

Epidemic of herpes zoster following HIV epidemic in Manipur, India

Since 1989, injecting drug use (IDU) related HIV infection has affected thousands of young adults in Manipur, a north eastern state of India bordering Myanmar following a similar kind of epidemic in adjoining countries like Thailand and Myanmar. During a clinical surveillance of a group of HIV positive IDUs for a natural history study at Manipur, herpes zoster (HZ) emerged as the most specific early HIV related illness (positive predictive value of 100%) in patients belonging to the age group of 12-45 years. Data collected from the dermatology departments of the two main hospitals of the state revealed that there had been an epidemic of HZ since 1990 (rate of 1990 being 11.3/1000 compared to 6.5/1000 in 1989, P value < 0.0001) among males of 12-45 years. The epidemic of HZ has been attributed to the preceding epidemic of IDU related HIV in the same age and gender group occurring 1 year earlier. HZ should be recognised as a marker condition similar to tuberculosis indicating the necessity of screening for HIV in regions where the dual problem of IDU and HIV exist in young adults.

Macrophage-directed delivery of doxorubicin conjugated to neoglycoprotein using leishmaniasis as the model disease

The antileishmanial potency of doxorubicin conjugated to mannose-human serum albumin (man-HSA) was tested in experimental visceral leishmaniasis. Conjugation of doxorubicin did not decrease the affinity of the neoglycoprotein for the macrophage mannose receptor. Conjugated doxorubicin eliminated intracellular amastigotes of Leishmania donovani in peritoneal macrophages almost 12.5 times more efficiently than did the free drug and greatly reduced and possibly eliminated splenic intracellular parasites in four consecutive dosages at 5 micrograms/kg/day for 45 days. Free drug at a similar dose had little effect. The leishmanicidal effect of doxorubicin conjugate can be prevented by competitive inhibitors such as man-HSA or mannan and inhibitors of receptor-mediated endocytosis such as colchicine and monensin. These results not only indicate the potential of doxorubicin as an effective chemotherapeutic agent for leishmaniasis but also establish the use of mannosylated neoglycoprotein as a drug carrier in the therapy of macrophage-associated diseases.

Periarticular soft tissue conditions causing pain in the shoulder

Pain originating in periarticular soft tissues of the shoulder is a common clinical problem among the aged patients of both sexes, but it has become increasingly frequent in young individuals because of a health-oriented life style. In the past year, a considerable progress has been made in diagnosing these conditions, especially with the aid of magnetic resonance imaging. Our understanding of the pathogenesis of these conditions, however, has advanced very little, and we hope that more efforts will be devoted in the future to elucidate how the periarticular soft tissues of the shoulder react to diverse injuries they are exposed to.

Classification and definition of tendinopathies

The authors have classified tendinopathies into two categories. The majority of the tendinopathies are in the primary category in which lesions arise in the substance of the tendon. The authors emphasize that not all tendinopathies are degenerative in nature. Some primary tendinopathies are reactive, such as calcifying tendinitis.

Surgical repair of rotator cuff ruptures. The importance of the subacromial bursa

We examined biopsy specimens obtained during surgery on 115 patients with complete rotator cuff rupture. The vascularised connective tissue covering the area of rupture and the proliferating cells in the fragmented tendons reflected more of the features of repair than of degeneration and necrosis. The main source of this fibrovascular tissue was the wall of the subacromial bursa. These features clearly indicated a vigorous reparative response which might play an important role in tendon reconstitution and remodelling. We therefore suggest that extensive debridement along with subtotal bursectomy, commonly practised during surgical repair of rotator cuff rupture, should be avoided. Although strong suture margins are essential for good operative results, debridement should be judicious and preserve as much as possible of the bursa and the associated fibrovascular tissue.

Shoulder pain and reflex sympathetic dystrophy

Shoulder pain has become one of the commonest clinical problems in modern North American society. The pathogenetic mechanisms vary widely, and often times, speculations about the underlying pathology have not been substantiated by investigative studies. In the past year, progress in our knowledge about shoulder pain has not been significant. We discuss the topic by dividing shoulder pain into four categories: 1) shoulder pain of local origin; 2) pain referred to the shoulder; 3) shoulder and neck pain; and 4) shoulder pain and reflex sympathetic dystrophy. It appears that a thorough history taking, an understanding of the psychosocial background of the patient, and a complete physical are equally important in the clinical evaluation of painful shoulders.

Usefulness of a new technique for hind limb immobilization in rats for the study of tendon healing

To study wound repair in rat Achilles tendon, we utilized a novel surgical method for immobilizing only one hind limb. In this technique, the femoral vessels were preserved while the skin, muscles, nerves and the shaft for the femur were transected. The limb was then rotated and sutured to lie on the posterolateral flank of the animal. The recovery was prompt and the procedure affected the routine growth and metabolism of the animal minimally throughout the period of experimentation. In the immobilized limb, healing of the Achilles tendon was studied after subtotal severance in the midsection. The rats were killed at intervals of 1, 2, and 4 weeks postoperatively. After 1 week, the surface of the wound was covered by a thin layer of cells. A gap persisted underneath and showed fibrovascular proliferation at the margins. In 2 weeks, the gap was completely occupied by fibrovascular tissue that was beginning to align along the long axis of the tendon. By the 4th week, remodeling had occurred and the site of the wound had almost blended with the rest of the tendon. We conclude that this new technique of hind limb immobilization causes little stress on the animal, and it can be useful for the study of tendon healing.

The ultrastructure of the coracoacromial ligament in patients with chronic impingement syndrome

In an ultrastructural study of the cells and matrix of the coracoacromial ligament (CAL) in 11 patients with impingement syndrome (IS), the cells appeared variegated, in contrast to those in normal CALs. Many showed degenerative changes such as lipid inclusions in the cytoplasms or swelling of cytoplasmic organelles, especially in the vicinity of fibrin exudate where the collagenous matrix disappeared. However, some cells had increased cytoplasmic organelles, including an elaborate Golgi apparatus, indicating enhanced synthetic activity. The matrix, instead of consisting of packed collagenous fibers of fairly uniform diameter as seen in the normal CAL, contained collagen fibers of varying diameters and microfibrils. The ultrastructural features of both the cells and the matrix were suggestive of chronic effects of strain on the ligament. In patients with chronic IS, the CAL has been implicated as the likely cause of impingement when no significant bony or articular abnormality exists. This was not substantiated by the present findings. The changes in the CAL in IS are possibly secondary, and are probably induced by alterations in soft-tissue structures of the subacromial compartment.

Mast cells in the rat heart during normal growth and in cardiac hypertrophy

Mast cells in rat hearts were studied quantitatively during normal postnatal growth and in two types of cardiac hypertrophy. Normally, cardiac mast cell density in 11-12-day-old animals is very low, but increases markedly in the following 2-3 weeks to its highest values, with a subsequent decline toward adult values. At the peak of mast cell density, the percentage of mast cells in close proximity to capillaries is also highest. In adult animals, mast cell counts are significantly higher in the right ventricle than in the left. This relation is preserved even when the right ventricle is hypertrophic, as in rats born at simulated high altitude. Chronic hypertension and swimming have little effect on the mast cell density in rat hearts. Conspicuous changes in the mast cell density at the time of capillary proliferation seem to indicate a special role played by these cells in the formation of new vessels.

Global review on ORT (oral rehydration therapy) programme with special reference to Indian scene

This communication is an attempt to review the status and implementation of the Oral Rehydration Therapy in the programme for Control for Diarrhoeal Diseases. The Global and the Indian situations are separately discussed, with more emphasis on the latter. Use of Home Available Fluids (HAF), Salt Sugar Solution (SSS). Commercial packets of ORS and the Government supplied packets of ORS are also assessed.

Report of an outbreak of diarrhoeal disease caused by cholera followed by rotavirus in Manipur

An outbreak of acute diarrhoeal disease between August and October 1985 in 3 districts of Manipur state was investigated amongst 9,29,077 population at risk. The overall attack rate and case fatality rate were 0.2% and 0.9% respectively. Hospital records revealed that 58.8% of cases occurred amongst older children above 5 years of age. V.cholera was isolated from 25.3% of cases sampled. Interestingly, increased frequency in weekly admission of cases amongst children during first two years of life increased in the beginning of October when the original peak of diarrhoeal outbreak was about to decline. The October peak was caused by rotavirus which could be detected from 50.0% of diarrhoeal children in this age group. This possibly reflected beginning of the usual rotavirus diarrhoea season in the locality.

The role of the coracoacromial ligament in the impingement syndrome. A clinical, radiological and histological study

Seventeen patients with a painful arc syndrome and tenderness over the coracoacromial ligament were selected to demonstrate the changes in the coracoacromial ligament in the impingement syndrome. Plain X-ray examination was normal and a preoperative subacromial bursogram demonstrated impingement in only three out of 17 patients. However, at operation the subacromial space under the coracoacromial ligament, which normally admits the tip of the little finger, appeared unusually tight and barely accessible in 15 out of 17 patients. Histological examination of the biopsied ligament showed degenerative changes but no increase in fibrous tissue. We conclude that in the absence of bony overgrowth the initial change is an increased volume of the soft tissues in the subacromial space. Consequently, the space is compromised by the swelling of its contents, which exert abnormal pressure on the overlying coracoacromial ligament and cause degenerative changes in the ligament. The symptoms of impingement appear because of the unyielding nature of the coracoacromial ligament. Subacromial bursography may not be a reliable test when the coracoacromial ligament is the site of impingement.

Mitochondrial inclusions in renal epithelial cells of magnesium-deficient rats

In rats with prolonged magnesium deficiency, paracrystalline inclusions in mitochondria were found frequently in the epithelial cells of the thick ascending limb of Henle, especially in the region of the upper medulla. The inclusions presented a variegated appearance. Some were filamentous aggregates, many had alternating dark and light bands, and others were elongated rectangular densities. They were not found in tubules with calcific deposits where the cells showed degenerative changes. This suggested that the inclusions were probably due to altered cell metabolism and not products of cell degeneration.

Merits and pitfalls in morphological assessment of cardiac growth

The basic principles of quantitative morphological analysis of myocardial tissue are presented. Particular attention is paid to the effects of stimulated cardiac growth on the relationship between cell size and various indices of myocardial capillary supply in pressure-overloaded rat hearts. The importance of adequate sampling and of the number of measurements is stressed with respect to reliable estimation of the mean values but even more for assessment of variability of the measured data. When estimating myocardial capillary supply by average values of capillary density and/or of areas supplied by a single capillary, this crucial information is missing. Therefore the merits of more advanced techniques allowing for the estimation of variability of capillary spacing are critically examined and the significance of their application to myocardial tissue is outlined (method of concentric circles and method of triangular nets). Finally, the importance of variability of capillary spacing on oxygen supply is demonstrated. The variability of capillary spacing alone may affect oxygen supply independently of the average values of intercapillary distance.