Evaluation of epidemiological and serological predictors of human immunodeficiency virus type-1 (HIV-1) infection among high risk professional blood donors with western blot indeterminate results

BACKGROUND

Indeterminate pattern of results in Western blot (WBI) for human immunodeficiency virus type-1 (HIV-1) infection may represent early HIV-1 infection or may be non-specific in origin. This issue can be resolved by follow up testing upto at least 6 months resulting in psychological distress as well as in high drop out rates among those undergoing investigation pointing out the need for additional parameters that could help in determining the status of HIV-1 infection at the time of initial testing itself in individuals with WBI pattern.

OBJECTIVE

The objectives of the present study were: (i) to determine the frequency of HIV-1 infected individuals in a group of professional donors showing WBI patterns in initial testing on the basis of follow up serological studies; (ii) to find out if any HIV related epidemiological or serological characteristics recorded at the time of initial testing could be considered as predictor for HIV-1 infection in WBI specimens; and (iii) to evaluate two alternative serodiagnostic strategies for HIV-1 infection viz. multiple EIAs based on different antigen preparations/principles and a line immunoassay (LIA) employing recombinant antigens in resolving status of HIV-1 infection in specimens showing WBI results at initial testing.

STUDY DESIGN

Professional donors with WBI patterns belonging to EIA reactive and EIA nonreactive groups were subjected to study of epidemiological profile, prevalence of sexually transmitted diseases (STD) markers and follow up serological testing for HIV-1 at 6, 12, 24 and 48 weeks intervals to record any seroconversion. The initial and follow up specimens from the donors with initial WBI results were subjected to two EIAs (one based on dot immunoassay using synthetic HIV-1 antigens and other based on microwell EIA using recombinant HIV-1 proteins) as well as to LIA.

RESULTS

Professional donors with initial WBI results, from the EIA reactive group had higher proportion of unmarried individuals (90.3%), with history of heterosexual promiscuity (75%) and visit to STD clinics (36.1%) compared with the WBI donors from the EIA nonreactive group (72.7, 42.4 and 12.1%, respectively, P values < 0.001). Prevalence of antitreponemal antibodies was higher in the former group (16.7%) compared with the later group (1.5%, P value < 0.002). Seroconversion was recorded in 4 (7.3%) out of 55 EIA reactive WBI donors from the EIA reactive group that were characterised by high optical density (OD) values in EIA, 'p24 only' pattern of band in WB and positivity by LIA at the time of initial testing. LIA was found to be more reliable test compared with combination of EIAs to determine status of HIV-1 infection in WBI specimens at the time of initial testing.

CONCLUSION

The present study points out that parameters like history of heterosexual promiscuity, prevalence of STD markers, high OD values in screening EIA, 'p24' only pattern of bands in WB and positivity by LIA could have individual predictive values for HIV-1 infection in specimens showing WBI pattern of results at initial testing.

Cognitive abilities of asphyxiated survivors beyond 5 years of age

OBJECTIVE

To evaluate the intellectual, psychoeducational and social maturity of a cohort of unimpaired asphyxiated survivors beyond 5 years of age.

DESIGN

Case control study on hospital based cohorts on a longitudinal follow up at High Risk and Well Baby Clinics of a teaching hospital.

METHODS

The demographic data of these children was recorded. A detailed physical examination was performed. The tests of cognition included the Stanford Binet and the Raven's Progressive matrices. Academic achievement was evaluated by the Wide range achievement test-Revised (WRAT-R). Assessment of visuo-motor integration was done by the Bender Gestalt Test. The proportion of children having soft neurological signs was determined. Vineland Social Maturity Scale was performed on all children.

RESULTS

Fifty-four asphyxiated and 57 matched control children participated in the study. Of the 54 asphyxiated children, 27 were tested at a mean age of 7.2 +/- 1.6 years (Group 1) and 27 were tested at a mean age of 10.9 +/- 1.52 years (Group 2). The asphyxiated children as a group performed in the normal range on tests of cognition and academic achievement but were significantly disadvantaged (p < 0.005) as compared to controls. A higher percentage of asphyxiated children had low scores on the Bender Gestalt Test as compared to controls but the difference was not significant. A significantly higher proportion of asphyxiated children of both the groups showed the presence of soft neurological signs as compared to controls. Approximately 11% of the asphyxiated children performed in the abnormal range in the Vineland Social Maturity Scale.

CONCLUSION

Cognitive abilities of asphyxiated children beyond the age of 5 years are impaired in comparison to controls, emphasizing the need for early detection and referral for special education.

Changes in anti-oxidant enzymes and lipid peroxidation in hyaline membrane disease

This study was conducted to elucidate the changes in key antioxidant enzymes e.g. Superoxide dismutase (SOD), Catalase and Glutathione peroxidase (GPx) along with lipid peroxidation (LPO) in preterm newborns having hyaline membrane disease (HMD) and thus to find out role of free radicals mediated injury in this disease. Twenty one preterm appropriate for gestational age newborns were included in the study. Eleven of them had hyaline membrane disease and ten were controls without any disease. Status of superoxide dismutase, glutathione peroxidase and catalase, the three main antioxidant enzymes and lipid peroxidation was monitored at 12-24 hours of age. SOD and catalase were found significantly elevated in cases having hyaline membrane disease along with significantly more lipid peroxidation. It is evident that free radicals result in the induction of the antioxidant enzymes; however, the elevated enzymes are unable to counteract the high concentration of the free radicals which are being produced in the diseased cases and leads to increase in lipid peroxidation in hyaline membrane disease. It is concluded that free radicals play a significant role in hyaline membrane disease and the preterm newborns have ability to induce antioxidant enzymes in response to oxidative stress.

Hypertension and insulin resistance in a native unindustrialised rural population of India

A cross-sectional survey of 2964 individuals aged 16-70 years from a rural area of North India was carried out to test the hypothesis that a rural unindustrialised hypertensive population of North India has central obesity and hyperinsulinemia. Oral glucose tolerance test was carried out on 68 newly detected hypertensives, 82 age- and sex-matched community controls and 58 genetically related members of hypertensives (family controls). Fasting blood samples were examined for plasma glucose, serum insulin and lipids. Postglucose-load blood samples were examined for plasma glucose and serum insulin. Three blood pressure readings were recorded using Random Zero Sphygmomanometer. Anthropometric measurements (waist-hip ratio, subscapular and triceps skinfold thickness) of all three groups of individuals (hypertensives, community controls and family controls) were also recorded. The hypertensives had significantly higher fasting and postglucose-load serum insulin levels (P<0.05), body mass index (21.3 vs. 19 kg/m2: P<0.05), waist-hip ratio (0.89 vs. 0.85: P<0.001), subscapular (18.5 mm vs. 12.7 mm: P<0.001) and triceps fold thickness (17.6 mm vs. 12.9 mm: P<0.05) than community controls. The family controls had significantly higher systolic blood pressure than community controls (P<0.05). The lipids were not significantly different in all the three groups. Multiple logistic regression showed that both fasting and postglucose-load serum insulin were significantly associated with hypertension independent of waist-hip ratio and body mass index. The results of the present study suggest that hyperinsulinemia is related to hypertension in a rural unindustrialised population of North India.

Correlation of coagulation abnormalities with clinical outcome in neonates of mothers with pregnancy induced hypertension

Abnormalities in coagulation profile were correlated with clinical outcome in neonates (n = 30) of mothers with pregnancy induced hypertension (PIH). Same number of neonates born to normotensive mothers was taken as control. Significant correlation was observed between decreasing gestational age and alterations in all coagulation parameters. Higher incidence of prematurity, hyperbilirubinaemia and significant prolongation in partial thromboplastin time with kaolin (PTTK) and thrombin time (TT) values were observed with increasing severity of PIH. Incidence of disseminated intravascular coagulation (DIC) was higher in preterm neonates than in term neonates.

Double blind randomized comparative evaluation of nimesulide and paracetamol as antipyretics

OBJECTIVE

To compare the efficacy and safety of nimesulide and paracetamol as antipyretic agents.

DESIGN

Double blind, randomized clinical trial.

METHODS

Hospitalized patients having fever due to a variety of infections were given either drug in a randomized manner. (Nimesulide group = 49, Paracetamol group = 50). Serial axillary temperature was recorded after drug administration and side effects monitored.

RESULTS

The mean temperature after one hour of drug administration was significantly lower in nimesulide group (p < 0.05). Significantly fewer doses of nimesulide were required to bring down the temperature on the first day (p < 0.001). The mean maximum temperature recorded on second and third day was significantly lower in the nimesulide group (p < 0.05). Adverse reactions were seen in the form of epigastric pain and vomiting in one patient in Nimesulide group and three in paracetamol group.

CONCLUSION

Nimesulide is more effective than paracetamol as an antipyretic agent and is safe for use in infants and children.

Clinical assessment of nutritional status at birth

OBJECTIVE

Clinical assessment of nutritional status of neonate using CAN score and comparison with other methods of determining intrauterine growth.

DESIGN

Cross sectional study.

SETTING

Tertiary care hospital.

SUBJECTS

637 consecutive, liveborn singleton neonates with known gestational age and no major congenital malformation.

METHODS

Birth weight, length, midarm circumference and head circumference recorded in newborns. Ponderal index and mid arm to head circumference ratio was calculated. Clinical assessment of nutritional status was done on the basis of CAN score and compared with other methods.

RESULTS

CAN score < 25 separated 60% of the babies as well nourished and 40% as malnourished. Weight for age and Ponderal Index classified 70-75% of babies as well nourished (AGA) and 25-30% as malnourished. Also MAC/HC classified nearly half the babies as well nourished and half as malnourished.

CONCLUSION

CAN score may be a simple clinical index for identifying fetal malnutrition and for prediction of neonatal morbidity associated with it, without the aid of any sophisticated equipments.

Hypercalcaemia with radiographic abnormalities in chronic myeloid leukaemia

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Neonatal mechanical ventilation--experience at a level II care centre

One hundred and fifty nine neonates were ventilated over a period of one year of whom 74 (46.54%) survived. This study aims to analyse the indications, complications and outcome of babies requiring mechanical ventilation. The early outcome measures were (i) survival rate with respect to birth weight, gestation and indication of ventilation, and (ii) Complications of assisted ventilation. One hundred and forty seven babies received IPPV and 34 received CPAP. Twenty two out of these 34 required IPPV later. Survival was cent percent on exclusive CPAP mode. HMD was the commonest indication for ventilation followed by Birth asphyxia, Apnea of prematurity, Meconium Aspiration Syndrome and Persistent Pulmonary Hypertension of the New born. Survival rates increased with increasing birth weight and gestational age, changing from 25% for < 1000 gm and 20% for < 28 wks to 53% for > 2500 gms and 50.2% for > 37 wks. Prolonged ventilatory support was needed for HMD (mean 114 hrs) and PPHN (mean 156 hrs). Commonest complication was Sepsis (26%) followed by Pulmonary hemorrhage, Pneumothorax and IVH. Lower success rates in ventilation is due to the poor survival of babies weighing < 1000 gms and those with a gestation of < 28 wks with nosocomial infections as a major complication of assisted ventilation being an additional factor.

Hepatitis B and hepatitis C in multitransfused children

The study was conducted on 75 multitransfused children aged between 2 and 13 years who attended the Department of Paediatrics, LNJPN Hospital, New Delhi from July 1990 to July 1991. These included 64 cases of thalassaemia major, 4 cases of haemophilia, 3 patients of acute lymphatic leukaemia and one each of acute myeloid leukaemia, aplastic anemia, chronic idiopathic thrombocytopenic purpura and acute haemorrhagic pancreatitis. HBsAg was tested in all, Anti-HBc was tested in 44 patients and Anti-HCV in 43 patients. Anti HDV was tested in HBsAg positive patients and IgM anti-HAV was tested in patients suffering from hepatitis. Liver function tests were evaluated in all patients. HBsAg was positive in 31% of patients; 40% of males and 15% of females were HBsAg positive, the difference being statistically significant. 84% of patients were Anti-HBc positive, 21% were anti HCV positive, 4% were Anti HDV positive. 15% of the patients had post transfusion hepatitis. Anti HCV was present in 57% of the hepatitis patients; none had anti-HAV IgM.

Extracellular matrix modulates mesangial cell apoptosis and mRNA expression of cathepsin-B and tissue transglutaminase

Mesangial matrix is a dynamic structure which modulates mesangial cell function. Since accumulation of matrix precedes the development of focal glomerulosclerosis, we studied the effect of different matrices on mesangial cell (MC) apoptosis. Suspended mesangial cells became apoptotic in a time dependent manner. Collagen type III did not modulate MC apoptosis when compared to cells grown on plastic. MCs grown on Matrigel, collagen type I and IV showed an increased number of apoptotic cells when compared to MCs grown on plastic. DNA end-labeling further confirmed these observations. MCs grown on Matrigel showed enhanced (P < 0.05) mRNA expression for tissue transglutaminase (TTG) and cathepsin-B. Mesangial cells grown on Matrigel also showed enhanced expression of superoxide dismutase (SOD). We conclude that mesangial cells require attachment to the matrix for their survival and alteration of the quality of matrix modulates mesangial cell apoptosis.

Early neonatal morbidity and mortality in 'at-risk' and 'normal' term pregnancies

It is a universally known fact that maternal well-being is related to neonatal health. This case-control study aims to assess the pattern and strength of association of neonatal morbidity and mortality (in first 7 days of life) in relation to the presence of obstetric & medical risk factors in the mother (indicating maternal ill-health). In 250 cases (at-risk pregnancies), 75 (30%) developed neonatal illnesses while 17 (6.8%) perinatal deaths occurred in first seven days. In the same number of controls (uncomplicated pregnancies) there were only two perinatal deaths and lesser number of newborns (45/250, 16.4%) developed neonatal diseases in the first 7 days. Perinatal deaths, (still births and early neonatal deaths), (OR = 9.05; AR = 88.2%) and neonatal illnesses (OR = 2.2 and AR = 45) were strongly associated with presence of maternal risk factors. This study supports the fact that 'at risk' pregnancies have highly significant chances of developing early (first 7 days) neonatal morbidity (p < 0.001) and mortality (p < 0.001). Still births also occurred significantly more (p < 0.005) in number among 'at risk' (cases) than normal term pregnancies (controls).

Sexually-transmitted disease (STD) markers in multitransfused children in relation to human immunodeficiency virus type-1 (HIV-1) infection: impact of STD markers in blood donors

Association of serological markers for various sexually transmitted diseases (STDs) with Human Immunodeficiency Virus type 1 (HIV-1) infection among heterosexually promiscuous blood donors is well recognized. However, possibility of similar association among children receiving transfusion from these donors has not been adequately explored. Study on the association of some STD markers with HIV-1 infection in multitransfused (MT) children showed that both HIV-1 positive and HIV-1 negative groups of children had significantly higher prevalence of hepatitis B virus (HBV) markers, i.e. HBsAg (23 and 30 per cent), anti-HBs (46 and 57 per cent), anti-HBc (18 and 23 per cent), antibodies to cytomegalovirus of IgM class (36 and 37 per cent) and IgG class (72.7 and 70 per cent), IgG antibodies to Herpes Simplex Virus type-2 (23 and 23 per cent) compared to control group. However, seropositivity for HIV-1 infection could not be attributed as a risk factor for any of these markers in the group of MT children. On the contrary, significant association of anti HBc, anti HCV, CMV IgG and antitreponemal antibody with HIV-1 infection could be recorded in the group of blood donors. It appeared that due to low prevalence of HIV-1 infection among blood donors in India, both HIV-1 positive and HIV-1 negative groups of MT children received transfusion from HIV negative donors predominantly resulting in a comparable prevalence of STD markers in both the groups of MT children due to cumulative effect of transfusion from HIV-1 negative donors.

Identification of a contiguous 6-residue determinant in the MHV receptor that controls the level of virion binding to cells

Murine carcinoembryonic antigens serve as receptors for the binding and entry of the enveloped coronavirus mouse hepatitis virus (MHV) into cells. Numerous receptor isoforms are now known, and each has extensive differences in its amino terminal immunoglobulin-like domain (NTD) to which MHV binds via its protruding spike proteins. Some of these receptor alterations may affect the ability to bind viral spikes. To identify individual residues controlling virus binding differences, we have used plasmid and vaccinia virus vectors to express two forms of MHV receptor differing only in their NTD. The two receptors, designated biliary glycoproteins (Bgp) 1a and 1bNTD, varied by 29 residues in the 107 amino acid NTD. When expressed from cDNAs in receptor-negative HeLa cells, these two Bgp molecules were displayed on cell surfaces to equivalent levels, as both were equally modified by a membrane-impermeant biotinylation reagent. Infectious center assays revealed that the 1a isoform was 10 to 100 times more effective than 1bNTD in its ability to confer sensitivity to MHV (strain A59) infection. Bgp1a was also more effective than Bgp1bNTD in comparative virus absorption assays, binding 6 times-more MHV (strain A59) and 2.5 times more MHV (strain JHMX). Bgp1a was similarly more effective in promoting the capacity of viral spikes to mediate intercellular membrane fusion as judged by quantitation of syncytia following cocultivation of spike and receptor-bearing cells. To identify residues influencing these differences, we inserted varying numbers of 1b residues into the Bgp1a background via restriction fragment exchange and site-directed mutagenesis. Analysis of the resulting chimeric receptors showed that residues 38 to 43 of the NTD were key determinants of the binding and fusion differences between the two receptors. These residues map to an exposed loop (C-C' loop) in a structural model of the closely related human carcinoembryonic antigen.

Multi-resistant Staphylococcus haemolyticus in a neonatal unit in New Delhi

We describe a cluster of infections in a neonatal nursery due to an infrequently reported staphylococcal species, Staphylococcus haemolyticus. S. haemolyticus resistant to penicillin, methicillin, gentamicin, erythromycin, chloramphenicol and tetracycline (PMGECT) was isolated from a series of infections in neonates (conjunctivitis 6, blood 2, pustules 2) over a period of 3 weeks in a neonatal nursery. Surveillance cultures from 22 neonates, their mothers in an adjacent maternity ward and staff revealed that S. haemolyticus with three resistance patterns (PMGECT, PMG and PME) was circulating in the unit. It was isolated from two caesarian wounds, the nose/ear/umbilicus of six asymptomatic infants and from the noses of three mothers and one nurse. S. haemolyticus showed a higher frequency of resistance to antibiotics than Staphylococcus aureus and Staphylococcus epidermidis isolated from the unit at the same time. Local and asymptomatic infections were treated with local neosporin application whereas netilmicin was used to treat systemic infection. Infections were controlled by emphasising the importance of handwashing, asepsis and eye care.

Wegener's presenting as submandibular swelling

We describe a patient in whom bilateral swelling of submandibular glands was the initial manifestation of limited Wegener's disease. The diagnosis was based on positive anti-neutrophil cytoplasmic antibody [C-ANCA], dense inflammatory infiltrate predominantly of lymphocytes in submandibular glands, presence of non-caseating ill-formed granulomas in transbronchial biopsy and resolution of symptoms following immuno-suppressive treatment.

Profile of antigen-specific antibody response detectable by western blot in relation to diagnostic criteria for human immunodeficiency virus type-1 (HIV-1) infection

BACKGROUND

Variability in the profile of antigen-reactive bands in Western blot for serodiagnosis of human immunodeficiency virus (HIV) infection may result in disagreement regarding interpretation of positive result, due to lack of consensus in the interpretive criteria laid down by various organisations.

OBJECTIVES

The objectives of this study were (i) to find out the extent of disagreement over various criteria regarding interpretation of positivity in Western blot and (ii) to review the discordance by retesting the discordant specimens using recombinant antigens as well as by performing repeat Western blot in follow-up specimens.

STUDY DESIGN

A total of 467 specimens from high-risk groups, diagnosed positive for HIV type-1 (HIV-1) infection by the criteria of at least one of the five organisations, viz. Association of State and Public Health Laboratories Directors (ASTPHLD), Consortium for Retrovirus Serology (CRSS), American Red Cross (ARC) and World Health Organisation (WHO), were analysed to find out the extent of discordance between various criteria for interpretation of Western blot positivity. The discordant specimens were subjected to line immunoassay (LIA) using recombinant antigens. Also, follow-up Western blots were performed in case of discordant specimens at 6, 12 and 24 weeks intervals.

RESULTS

We observed that criteria laid down by ASTPHLD, CDC and CRSS scored all the specimens as positive while ARC and WHO criteria scored 13 (2.8%) and 18 (3.8%) of specimens, respectively, as negatives which were detected as positives by other criteria (discordant specimens). The gp41 reactive band was the most frequently missing band, being undetectable in 11.6% of specimens while bands reactive to p24, p31, gp120 and gp160 could not be recorded in 1.9%, 9.4% and 3.2% and 1.5.% of specimens, respectively. Testing of the discordant specimens with recombinant antigen preparation and with repeat Western blot in follow-up specimens collected at 6, 12 and 24 weeks demonstrated all bands undetectable in initial Western blot, except 25% of gp41 reactive bands.

CONCLUSIONS

It is felt that before selecting any criterion for Western blot positivity, it should be evaluated in the local population at risk for HIV-1 infection with additional or follow-up tests.

Non Hepatitis viruses in causation of acute sporadic non-A, non-B viral hepatitis

Viruses other than Hepatitis viruses i.e. Cytomegalovirus, Epstein-Barr Rubella etc., can cause a clinical picture resembling that of viral hepatitis. Consequently, these viruses can falsely contribute to the diagnosis of Non-A, Non-B hepatitis amongst of sporadic jaundice. This study attempts to find out the possibility of occurrence of such an event.

Further evaluation of alternative strategy for HIV testing in India

A total 320 sera from groups at risk for HIV were evaluated by two (198 specimens) or three (122 specimens) screening tests for confirmatory anti-HIV testing in comparison to Western Blot as gold standard. Sera positive by both screening tests showed 100% correlation with Western Blot although with a false positivity rate of 3.2%. In specimens positive by 1st screening test but negative by the second, (considered negative for anti-HIV antibody as per WHO algorithm), 8.7% were found to be Western Blot positive showing the serious problem of false negativity of the proposed WHO algorithm. Employing the system of three screening test systems did not provide additional benefit for the specimens positive by initial two screening tests since all of them were positive by third test also. However, the study involving three screening tests substantiated the need for Western Blot in discordant specimens (i.e. positive by first test but negative by second), since in this group one out of 22 (4.6%) such specimens were Western Blot positive. Considering the serious consequences of both false positive and false negative results, it is felt that alternative strategy of confirmatory anti-HIV serology, although economical may not be suitable substitute for Western Blot in India at this juncture when the prevalence of HIV infection is relatively low.