Hepatitis A vaccination in chronic liver disease: is it really required in a tropical country like India?

Vaccination against hepatitis A virus (HAV) has been recommended in patients with chronic liver disease to prevent any decompensation due to superinfection. This may not hold good in high endemic areas for hepatitis A like India. The aim of this study was to find out the seroprevalence of anti-HAV antibodies in patients with chronic liver disease and to justify the need for vaccination against hepatitis A virus in these patients. One hundred and thirty three consecutive patients with cirrhosis of liver attending Gastroenterology department of our Institute between June 2004 and June 2005 were enrolled. Seventy-five healthy persons were taken as controls. The diagnosis of cirrhosis was based on clinical profile, biochemical, radiological (ultrasound abdomen) and endoscopic findings. The etiology of cirrhosis was based on presence of viral markers, history of significant alcohol consumption, autoimmune and metabolic workup. All patients and controls were tested for antiHAV (total) antibodies using commercially available enzyme-linked immunosorbent assay kits. Data from patients and control group were compared by unpaired 't' test and Chi square test. All subjects were in the age group 11 to 75 years. Etiology of chronic liver disease was as follows: HBV- 29.3%, HCV - 14.28%, HBV+HCV dual -1.5%, alcohol- 21.8%, Cryptogenic -23.3%, Wilson"s Disease -1.5% and Budd chiari -1.5%. The prevalence of HAV was 93.2% in patients with cirrhosis of liver and 94.6% in controls. The prevalence was almost similar irrespective of the etiology. In view of high seroprevalence of HAV antibodies among cirrhotic patients in our study and the high cost of the vaccine, the hepatitis A vaccination may not be routinely required in this part of the world.

Newborn size, infant and childhood growth, and body composition and cardiovascular disease risk factors at the age of 6 years: the Pune Maternal Nutrition Study

OBJECTIVE

To study associations of size and body proportions at birth, and growth during infancy and childhood, to body composition and cardiovascular disease (CVD) risk factors at the age of 6 years.

DESIGN

The Pune Maternal Nutrition Study, a prospective population-based study of maternal nutrition and CVD risk in rural Indian children.

METHODS

Body composition and CVD risk factors measured in 698 children at 6 years were related to body proportions and growth from birth.

MEASUREMENTS

Anthropometry was performed every 6 months from birth. At 6 years, fat and lean mass (dual X-ray absorptiometry) and CVD risk factors (insulin resistance, blood pressure, glucose tolerance, plasma lipids) were measured.

RESULTS

Compared with international references (NCHS, WHO) the children were short, light and thin (mean weight <-1.0 s.d. at all ages). Larger size and faster growth in all body measurements from birth to 6 years predicted higher lean and fat mass at 6 years. Weight and height predicted lean mass more strongly than fat mass, mid-upper arm circumference (MUAC) predicted them both approximately equally and skinfolds predicted only fat mass. Neither birthweight nor the 'thin-fat' newborn phenotype, was related to CVD risk factors. Smaller MUAC at 6 months predicted higher insulin resistance (P<0.001) but larger MUAC at 1 year predicted higher systolic blood pressure (P<0.001). After infancy, higher weight, height, MUAC and skinfolds, and faster growth of all these parameters were associated with increased CVD risk factors.

CONCLUSIONS

Slower muscle growth in infancy may increase insulin resistance but reduce blood pressure. After infancy larger size and faster growth of all body measurements are associated with a more adverse childhood CVD risk factor profile. These rural Indian children are growing below international 'norms' for body size and studies are required in other populations to determine the generalizability of the findings.

Age-related changes in the normal sagittal relationship between globe and orbit

PURPOSE

To establish the pattern of change in globe protrusion with advancing age. The findings contribute to our understanding of orbital ageing, and are useful in the longitudinal assessment of patients with orbital disease, craniofacial abnormalities and trauma.

METHODS

Ocular protrusion from the lateral orbital rim to the corneal apex was measured in 653 Caucasians aged 21-80 years. Healthy subjects only were included in the study excluding those with ocular or orbital diseases. Measurements were taken using a single instrument and observer. Data were analysed for both sexes and each eye separately.

RESULTS

The mean exophthalmometry reading in both sexes (318 female and 335 male) was 19+/-2mm. Ninety-eight percent of readings between the two eyes were within 1mm of each other and no subject had greater than 2mm of asymmetry. In all groups there was a negative linear correlation between ocular protrusion and age. This correlation was found to be highly statistically significant in all groups (r=0.56-0.65, p<0.0001). There was no statistically significant difference between change in ocular protrusion with age between the left and right eye for females or males. This study demonstrates a strong association between ocular protrusion and age in a Caucasian population. This association is an almost linear reduction in ocular protrusion with increasing age between the ages of 31 and 80. Asymmetry in ocular protrusion between the two eyes does not develop with increasing age.

HLA alleles in pre-menopausal breast cancer patients from western India

BACKGROUND & OBJECTIVES

Cytotoxic function of Natural Killer (NK) cells is regulated by the products of HLA class I genes. Associations between HLA alleles and risk for cancers have been suggested earlier. Several reports further emphasize the need to examine influence of HLA genotypes on risk for malignant disorders. Therefore, we undertook this study to assess the possibility of association of HLA-class I alleles in pre-menopausal breast cancer patients.

METHODS

Eighty one pre-menopausal breast cancer patients and 160, age and ethnicity matched healthy women from western India were studied. Genotyping for HLA class I alleles and HLA-B*40 alleles (high resolution) was performed using genotyping kits from Genovision Inc., USA.

RESULTS

Nearly two-fold higher frequency of HLA - B*40 (16%) was observed in patients compared to controls (O.R. = 2.2; 95% C.I.-1.15-4.34; P<0.02). High resolution typing for HLA-B*40 alleles revealed predominance of HLA-B*4006 allele in both the study groups. Two other important observations relate to lower frequency of HLA - B*08 in patients and homozygosity at HLA-Cw locus in significantly higher proportion of patients.

INTERPRETATION & CONCLUSION

The nature of peptides presented by HLA-B*4006 may have implications for higher frequency of HLA-B*40 in breast cancer patients. Higher frequency of homozygosity at HLA-Cw alleles in patients suggests a role for killer immunoglobulin-like receptors (KIRs) in NK cell mediated immune surveillance. Results of this study provide directions to further analyse role of immunogenetic mechanisms governing innate and adaptive immune responses contributing to modulation of risk for breast cancer.

Bone mass in Indian children--relationships to maternal nutritional status and diet during pregnancy: the Pune Maternal Nutrition Study

CONTEXT/OBJECTIVE

Bone mass is influenced by genetic and environmental factors. Recent studies have highlighted associations between maternal nutritional status during pregnancy and bone mass in the offspring. We hypothesized that maternal calcium intakes and circulating micronutrients during pregnancy are related to bone mass in Indian children. DESIGN/SETTING/PARTICIPANTS/MAIN OUTCOME MEASURES: Nutritional status was measured at 18 and 28 wk gestation in 797 pregnant rural Indian women. Measurements included anthropometry, dietary intakes (24-h recall and food frequency questionnaire), physical workload (questionnaire), and circulating micronutrients (red cell folate and plasma ferritin, vitamin B12, and vitamin C). Six years postnatally, total body and total spine bone mineral content and bone mineral density (BMD) were measured using dual-energy x-ray absorptiometry (DXA) in the children (n = 698 of 762 live births) and both parents.

RESULTS

Both parents' DXA measurements were positively correlated with the equivalent measurements in the children (P < 0.001 for all). The strength of these correlations was similar for fathers and mothers. Children of mothers who had a higher frequency of intake of calcium-rich foods during pregnancy (milk, milk products, pulses, non-vegetarian foods, green leafy vegetables, fruit) had higher total and spine bone mineral content and BMD, and children of mothers with higher folate status at 28 wk gestation had higher total and spine BMD, independent of parental size and DXA measurements.

CONCLUSIONS

Modifiable maternal nutritional factors may influence bone health in the offspring. Fathers play a role in determining their child's bone mass, possibly through genetic mechanisms or through shared environment.

Terrible triad of the elbow--role of the coronoid process: a case report

Posterior dislocation of the elbow joint with fracture of both the radial head and coronoid process, the so-called 'terrible triad', is a complex and difficult-to-treat injury. We report a case of a 34-year-old man with terrible triad of the elbow and associated injuries secondary to a fall. The patient was treated with radial head osteosynthesis, resection of the coronoid process fragments, and stabilisation of the ulnohumeral joint by Kirschner wire transfixation. The sequence of treatment steps is provided. The priority for treating multiple injuries should be established. The integrity of the coronoid process is essential for providing the elbow with maximum functionality.

Prevalence of dental caries among school children in Kulasekharam village: a correlated prevalence survey

The prevalence of the most common dental disease, dental caries has been a subject of intense debate due to its importance in statistical measurement and for the clinical control of this disease. Kulasekharam, a small village, situated in Kanyakumari District has a large number of hospitals and a dental college; yet the people seem to have a very poor knowledge about dental health. This prompted us to do a study among school children in the age group of 6-12 years to assess the prevalence of dental caries and to increase their awareness toward oral health. This paper further strives to find any correlation between patient awareness and prevalence of dental decay. The dental caries prevalence was noted to be low compared to the WHO-recommended values. The fluoride level was also tested and was found to be far below the optimal level.

Rosai-Dorfman disease recurrence with bilateral orbital masses following immunosuppressant therapy

Rosai-Dorfman disease is a rare condition characterised by massive lymphadenopathy involving the orbit in 11% of cases. Immunohistochemical analysis remains key to the diagnosis with characteristic immunohistochemical S100 staining of histiocytes and lymphocyte phagocytosis. We report the case of a 43-year-old female with recurrence of bilateral orbital Rosai-Dorfman disease following long-term immunosuppressant therapy. Long-term follow-up is advised in conservatively managed patients and surgery may offer more definitive treatment.

Immunogenicity and safety of hepatitis B vaccine (Shanvac-B) using a novel pre-filled single use injection device Uniject in Indian subjects

BACKGROUND

Hepatitis B is a major public health problem, which has now been controlled to some extent by vaccination especially with the recombinant hepatitis B vaccine, which has been proven to be safe and efficacious since its introduction in the 1990s. But problems of unsafe injection practices still persist. Now newer delivery devices like uniject are available for making vaccination very safe.

OBJECTIVE

To evaluate the immunogenicity and safety of the Hepatitis-B (Shanvac-B) vaccine in Uniject pre-filled device administered to healthy adults and infants at 0, 1, 2 months schedule.

METHODS

A total of 122 healthy subjects (62 adults and 60 infants) were administered three doses of the recombinant Hepatitis-B vaccine using Uniject pre-filled device. Blood samples for antibody titer estimation were taken before vaccination and 4-6 weeks after third dose. Subjects, parents or guardians were given diary cards to record any adverse reactions.

RESULTS

Protective immune responses to the vaccine were seen in 96.4% of adults and 100% of infants who completed the study. The Geometric Mean Titers (GMT) in adults and infants were 518.5 and 385.41 mIU/ml respectively. Mild fever, itching, and swelling at injection site were the most common side effects observed.

CONCLUSION

The safety and immunogenicity of the Hepatitis B Vaccine in the novel pre-filled device Uniject was effectively demonstrated in the present study.

ASPHALTENE CHARACTERISATION USING SPECTRAL ANALYSIS SYSTEM

Asphaltenes are the heaviest hydrocarbon component of crude oil and remain in colloidal suspension under reservoir temperature and pressure conditions. These materials may flocculate and deposit as a result of pressure, temperature and compositional changes, and consequently, disrupt production operations. This disruption can have severe implications, particularly in an offshore subsea environment. In these circumstances, it is imperative to understand the fundamental behaviour of asphaltenes prior to the development phase of any field under consideration.In this paper, we present a novel methodology to understand the thermodynamic asphaltene instability conditions using near infrared and spectral analysis system (SAS) techniques. Using the SAS technique, we were able to estimate the asphaltene particle size and growth behaviour as functions of pressure and time. Asphaltene particle size determined at the onset of asphaltene flocculation is in the order of 0.25 μm for a pressure-compensated sample. On the other hand, the asphaltene particle size is determined to be about 0.8 μm at the onset pressure using a conventional sample. Results also indicate that the particles from the pressure-compensated sample had a slower initial growth rate compared to the particles growth rate estimated from the non-pressure compensated sample. These results demonstrate the importance of representative sampling on asphaltene characterisation.

Antenatal Hydronephrosis: Negative Predictive Value of Normal Postnatal Ultrasound—a 5-year Study

AIM

To determine whether normal postnatal ultrasound, as part of a strict screening protocol for the detection and follow-up of antenatal hydronephrosis, effectively excludes the majority of babies with congenital urinary tract abnormalities that would otherwise present with a urinary tract infection.

MATERIALS AND METHODS

We retrospectively reviewed all babies who had postnatal follow-up of antenatally detected hydronephrosis over a 5-year period at our institution, a district general Trust with a specialist paediatric unit. We then studied all babies presenting with urinary tract infection before their first birthday to our institution over the same period. By cross-referencing these two study groups we were able to determine which babies developed a urinary tract infection having been previously discharged after normal postnatal ultrasound.

RESULTS

Four hundred and twenty-five babies had postnatal follow-up of antenatal hydronephrosis. Of these, 284 were investigated with ultrasound alone. In the same 5-year period, 230 babies presented with urinary tract infection before their first birthday. Only three of these babies had been previously discharged after normal postnatal ultrasound. The negative predictive value of a normal postnatal ultrasound was therefore 98.9% (281/284) for babies who subsequently presented with a urinary tract infection before their first birthday.

CONCLUSION

Careful antenatal and postnatal ultrasound with strict protocols is effective in detecting congenital renal tract abnormalities. Infants discharged after normal postnatal ultrasound are highly unlikely to still have an undetected urinary tract abnormality. We suggest that all babies with antenatal hydronephrosis are started on prophylactic antibiotics at birth, pending further investigation. All babies without features of severe obstruction antenatally should have their postnatal ultrasound delayed for a month. We recommend selective use of micturating cystourethrogram (MCUG), and delaying this investigation until the baby is 3 to 4 months old to allow for spontaneous resolution of vesicoureteric reflux. We do not believe that all babies with antenatal hydronephrosis require MCUG, providing a clear protocol is followed.

Complications of the orbital floor and maxillary sinus 30 years after Coe-Pak misplacement in the management of pan-facial fractures

We present the case of a woman who had sustained pan-facial fractures in a road traffic accident 30 years previously, and describe the ensuing unusual problems with the orbital floor and maxillary sinus as a consequence of unrecognised misplacement of a dental periodontal dressing material into the sinus. The subsequent management is discussed.

Identification of symptoms that indicate a pelvic examination is necessary to exclude PID in adolescent women

BACKGROUND

Diagnosis of chlamydia, gonorrhea, and vaginitis is now possible in adolescents using urine testing and vaginal swabs obtained by care provider or patient. However, a complete pelvic examination is necessary to diagnose pelvic inflammatory disease (PID). It is thus important to identify patients who might have pelvic inflammatory disease to assure complete gynecologic assessment of genitourinary symptoms.

PURPOSE

To determine whether adolescent patients with pelvic inflammatory disease report predictable symptoms during the medical interview and to determine what proportion of patients diagnosed with PID report at least one predictor symptom.

DESIGN

Observational study.

SETTINGS

Hospital-based adolescent clinic and Job Corps health service.

PATIENTS

A convenience sample (n = 193) of adolescent and young adult women who had a pelvic examination performed to evaluate a wide range of genitourinary symptoms.

MAIN OUTCOME MEASURE

Clinical diagnosis of pelvic inflammatory disease.

ANALYSIS

Sensitivity, specificity, and positive and negative predictive value of predictor symptoms for identifying patients given a diagnosis of pelvic inflammatory disease.

RESULTS

Twenty (10.4%) patients received a clinical diagnosis of PID. Lower abdominal pain was the most common symptom (90.0%) reported by these patients. All of the patients with PID reported either lower abdominal pain or dyspareunia in the medical history compared with 97 (56.1%) of those without PID. The presence of lower abdominal pain and/or dyspareunia in the clinical history yielded a sensitivity of 100%, specificity of 44%, and positive and negative predictive value of 17% and 100%, respectively, for identifying patients given a diagnosis of PID.

CONCLUSION

This study identified two symptoms reported in the medical history (lower abdominal pain and dyspareunia) that were associated with a clinical diagnosis of pelvic inflammatory disease. If lack of these two symptoms was used as a criterion for omitting a pelvic examination, more than one third of the patients in this study could have been evaluated for cervical and vaginal infections with urine and directly obtained vaginal swabs. Although some of these patients might have required a pelvic examination to exclude other causes of abnormal vaginal bleeding, at least 30% of the total sample could have been evaluated without a speculum and bimanual examination. If further studies support these findings, patients with symptoms suggestive of uncomplicated genitourinary infection (e.g., vaginal discharge, vaginal pruritus, or dysuria) who deny lower abdominal pain and dyspareunia can be evaluated with urine and vaginal samples in place of a speculum and bimanual examination.

Endoscopic removal of periorbital lesions

In this article, the authors describe the technique, indications and contra-indications for removing various periorbital lesions with an endoscope. The principal reason for using this technique is the excellent postoperative cosmesis. Seven patients in total had lesions removed in this manner. The only complication noted was some leakage of the contents of a dermoid cyst intraoperatively. Cosmesis postoperatively was excellent in all cases. None of the cases had to be converted to an 'open' procedure.