Histomorphometric and Immunohistochemical Diagnosis of Renal Cell Carcinoma: Review Article

Renal cell carcinoma (RCC) is derived from renal tubular epithelial cells and is among the 10 most common cancers worldwide. Incidence of renal cell carcinoma is 400,000 individuals worldwide per year. The age of diagnosis is approximately 60years, and twice as many men are diagnosed as women. African Americans have a slightly higher rate of RCC than do White peoples. The reasons for this are not clear. Inherited syndromes in family, long term dialysis, smoking individuals who had quit smoking >10 years prior had a lower risk when compared to those who had quit <10 years. 22.5 pack-year smokers had a more than 50.0% increased RCC risk compared to nonsmokers, high body mass index i.e. 5kg/m2 increase in body mass index (BMI) was found to be strongly associated with RCC. BMI >35kg/m2 is associated with higher incidence of Cancer raise blood pressure- Higher BMI and hypertension were independently shown to increase the long-term risk of RCC in men. A rise of blood pressure of 10mmHg is associated with 10-22 percent risk of RCC. Clear cell carcinoma is the most common variety of renal cell carcinoma as compared to other varieties of renal cell carcinomas (68.0-75.0%). It has also been found that CAIX is positive for all papillary renal cell carcinoma and negative for CK7, AMACR & TEF. We also found that CK7, EMA, CD117 and CAIX are most commonly positive for all chromophobe renal cell carcinoma. It has been found that clear cell carcinoma is the most common variety of renal cell carcinoma as compared to other varieties of renal cell carcinomas (68.0-75.0%). Again it has also been found that CAIX is positive for all papillary renal cell carcinoma and negative for CK7, AMACR and TEF. Here it has been found that chromophobe carcinoma is most commonly positive for CK7, EMA, CD117 and CAIX. In a patient coming with signs and symptoms of renal cell carcinoma can be confirmed with the help of histoimmunological markers and in that case one can plan for a proper planning of management.

Conventional vs virtual autopsy with postmortem MRI in phenotypic characterization of stillbirths and fetal malformations

OBJECTIVE

To compare virtual autopsy using postmortem magnetic resonance imaging (MRI) with conventional autopsy with respect to phenotypic characterization of stillbirths and malformed fetuses, and acceptability to parents.

METHODS

This was a prospective diagnostic evaluation study, conducted from June 2013 to June 2015, including stillbirths and pregnancies terminated owing to fetal malformation at ≥ 20 weeks' gestation, for which parental consent to both conventional autopsy and postmortem MRI was obtained. Cases of maternal and obstetric cause of fetal demise were excluded. Whole-body postmortem MRI (at 1.5 T) was performed prior to conventional autopsy. Taking conventional autopsy as the diagnostic gold standard, postmortem MRI findings alone, or in conjunction with other minimally invasive prenatal and postmortem investigations, were assessed and compared for diagnostic accuracy.

RESULTS

Parental consent for both conventional autopsy and postmortem MRI was obtained in 52 cases of which 43 were included in the analysis. In 35 (81.4%) cases, the final diagnosis based on virtual autopsy with postmortem MRI was in agreement with that of conventional autopsy. With conventional autopsy as the reference standard, sensitivity, specificity, positive and negative predictive values of postmortem MRI were, respectively: 77.7%, 99.8%, 97.4% and 98.0% for whole-body assessment; 93.1%, 99.0%, 87.1% and 99.5% for the nervous system; 61.0%, 100.0%, 100.0% and 96.7% for the cardiovascular system; 91.1%, 100.0%, 100.0% and 98.0% for the pulmonary system; 80.6%, 99.8%, 96.7% and 98.7% for the abdomen; 96.2%, 99.7%, 96.2% and 99.7% for the renal system; and 66.7%, 100.0%, 100.0% and 97.2% for the musculoskeletal system. Virtual autopsy was acceptable to 96.8% of families as compared with conventional autopsy to 82.5%.

CONCLUSIONS

Virtual autopsy using postmortem MRI and other minimally invasive investigations can be an acceptable alternative to conventional autopsy when the latter is refused by the parents. Postmortem MRI is more acceptable to parents and can provide additional diagnostic information on brain and spinal cord malformations. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Seroepidemiology and molecular characterization of hepatitis E virus infection in swine and occupationally exposed workers in Punjab, India

Hepatitis E virus (HEV) has two discrete epidemiological patterns: waterborne epidemics in developing countries only, caused by HEV genotype I, and sporadic zoonotic outbreaks in developing and developed countries caused by genotypes III and IV. This study was designed to investigate seroprevalence, molecular detection and the characterization of HEV by nested RT-PCR in swine as well as the occupational risk to exposed human population in Punjab state of north-western India. The occupational risk-exposed group comprised of swine farmers (organized - mixed feed feeders and unorganized - swill feeders), slaughterhouse workers, sewage workers and veterinary internes. During the study period, blood and faecal samples were collected from 320 swine and 360 humans with both high and low occupational exposure risks. The overall seroprevalence of swine HEV was 65.00%, with a significantly higher seropositivity in growing pigs (2-8 months of age). The prevalence of HEV RNA in swine faecal samples by nRT-PCR was 8.75% with a significantly higher detection in swill-fed pigs. With humans in the high occupational exposure risk population, significantly higher anti-HEV IgG seropositivity was observed (60.48%) as compared to control population (10.71%). Strong evidence of association between human anti-HEV IgG seropositivity and certain occupational exposure risk groups was observed (p < 0.05). This indicates that unorganized swine farmers, slaughterhouse workers and sewage workers have higher odds of HEV infection in this study region. Percentage of nucleotide similarity between swine and human HEV isolates was less than that found in countries with zoonotic HEV outbreaks. Molecular characterization revealed the circulation of G IV and G I genotypes among swine and human population in Punjab state, respectively.

Cytogenetic, Y chromosome microdeletion, sperm chromatin and oxidative stress analysis in male partners of couples experiencing recurrent spontaneous abortions

PURPOSE

Etiology in majority of couples experiencing recurrent spontaneous abortions (RSA) is still unknown. The aim of the study was to find the role of cytogenetic abnormalities, Y chromosome microdeletion, oxidative stress (OS) and sperm DNA fragmentation in male partners of couples experiencing RSA.

METHODS

Forty-eight couples with history of RSA and 20 fertile controls were included in the study. The study subjects were divided into male partners of RSA couples with abnormal sperm parameters (SA) (N = 16), male partners of RSA couples with normal sperm parameters (NS) (N = 32) and age-matched fertile controls with normal sperm parameters (FC) (N = 20).

RESULTS

One of 48 men (2%) showed 46, XY (1qh-) chromosomal complement. None of the cases including FC showed deletion in any of the 3 AZF loci on Y chromosome long arm. Sperm count was found be significantly lower in SA cases as compared to group NS cases (P < 0.0001) and FC (P < 0.005). Sperm forward motility was found to be significantly (P < 0.05) lower in SA cases as compared to NS and FC. Male partners of RSA couples with abnormal sperm parameters had higher reactive oxygen species (ROS) levels (P < 0.005) and sperm DNA damage (P < 0.0001), however, in male partners of RSA couples with normal sperm parameters had only increased (P < 0.0001) sperm DNA damage.

CONCLUSION

Other than chromosomal anomalies, sperm DNA fragmentation and seminal OS may be the underlying pathology in RSA, thus screening for seminal ROS levels and DNA fragmentation has diagnostic and prognostic capabilities.

Molecular characterization of field isolates and vaccine strains of infectious bursal disease virus

The present investigation was conducted to study the genetic heterogenicity and molecular polymorphism among the field isolates and vaccine strains of infectious bursal disease virus (IBDV). Samples of bursa of Fabricius from 15 suspected outbreaks of infectious bursal disease (IBD) were subjected to agar gel precipitation test (AGPT), virus isolation and reverse transcription-polymerase chain reaction (RT-PCR) combined with restriction fragment length polymorphism (RFLP). Nine out of 15 samples were found positive in AGPT while 14 were found positive both by virus isolation and RT-PCR. PCR amplified 474bp fragment from the variable region of VP2. Sac I, Stu I, Alu I, Ssp I and Mbo I restriction enzymes were used for characterization of all the 14 IBDV isolates and four reference vaccine strains. Sac I, Stu I, Alu I and Ssp I could differentiate classical virulent IBD (cvIBD) vaccine virus strains from very virulent IBD (vvIBD) field isolates by their varying restriction patterns. Based on above results two field isolates (VPL and VMK) were placed in cvIBD virus group and 12 field isolates were placed in vvIBD virus group. Virus neutralisation test (VNT) using rabbit raised Georgia strain anti-serum, however, could not differentiate between cvIBD virus and vvIBD virus. It was concluded that RT-PCR combined with RFLP assay using restriction enzymes Sac I, Stu I, Alu I and Ssp I can be used for rapid differentiation and classification of field isolates of IBDV.

Prenatal diagnosis of haemophilia A by chorionic villus sampling and cordocentesis: all India Institute of Medical Science experience

BACKGROUND AND OBJECTIVE

We looked at the two most commonly used methods for prenatal diagnosis, cordocentesis and chorionic villus sampling for prenatal diagnosis of haemophilia A in an Indian setting.

MATERIAL AND METHODS

The study sample included 16 families which reported to us for prenatal diagnosis of haemophilia A at All India Institute of Medical Science, New Delhi, India. Prenatal tests were done on chorionic villus samples or on cord blood (cordocentesis). Molecular work-up included the use of indirect mutation analysis in the form of linkage markers like CA-13, CA-22, Xba1 and Bcl1 as well as direct mutation analysis in the form of inversion 1 and 22 detection. Non-molecular work-up included primarily factor VIII assays.

RESULT

Chorionic villus sampling was performed in eight mothers. Of the other eight mothers, six underwent cord blood factor VIII assays because these had absence of family history and were negative for linkage and inversion 1 and 22. One patient had a female child and another had a fetus that showed congenital abnormalities.

CONCLUSION

We found that the choice of either technique, chorionic villus or cordocentesis, is not really an alternative, but rather dependent on the gestational age of presentation.

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.

Mature ovarian teratoma with gliomatosis peritonei--a case report

Gliomatosis peritonei (GP), a rare condition related to ovarian teratomas, is characterized by miliary implants of mature glial tissues on the peritoneum or omentum. We report herein a case of mature teratoma of the ovary with GP with imaging features and pathological correlation.

Advances in alfalfa mosaic virus-mediated expression of anthrax antigen in planta

Plant viruses show great potential for production of pharmaceuticals in plants. Such viruses can harbor a small antigenic peptide(s) as a part of their coat proteins (CP) and elicit an antigen-specific immune response. Here, we report the high yield and consistency in production of recombinant alfalfa mosaic virus (AlMV) particles for specific presentation of the small loop 15 amino acid epitope from domain-4 of the Bacillus anthracis protective antigen (PA-D4s). The epitope was inserted immediately after the first 25 N-terminal amino acids of AlMV CP to retain genome activation and binding of CP to viral RNAs. Recombinant AlMV particles were efficiently produced in tobacco, easily purified for immunological analysis, and exhibited extended stability and systemic proliferation in planta. Intraperitional injections of mice with recombinant plant virus particles harboring the PA-D4s epitope elicited a distinct immune response. Western blotting and ELISA analysis showed that sera from immunized mice recognized both native PA antigen and the AlMV CP.

Detection of bovine herpesvirus-1 infection in breeding bull semen by virus isolation and polymerase chain reaction

Serum samples from 51 apparently healthy breeding bulls were screened for bovine herpesvirus-1 (BHV-1) antibodies using an avidin-biotin enzyme-linked immunosorbent assay, revealing a sero-positive prevalence rate of 45.09%. Semen samples were then collected from 12 of the sero-positive and 12 of the sero-negative bulls and tested for BHV-1 antigen using both a virus isolation assay and a polymerase chain reaction (PCR) assay; PCR was applied to detect BHV-1 deoxyribonucleic acid by using primers selected from the relatively conserved sequence of the gl glycoprotein gene to amplify a 468 base pair fragment. The PCR-amplified products were confirmed as BHV-1 by restriction enzyme, Dde 1, which produced fragments of predictable sizes, namely 340 and 128 base pairs. Positive virus isolation test results, confirmed by virus neutralisation, found BHV-1 antigen in the semen of five sero-positive and six sero-negative bulls. In comparison, positive PCR results found BHV-1 genome in the semen of six sero-positive and eight sero-negative bulls. From the 24 semen samples tested, 14 were shown to be positive by PCR and 11 by virus isolation. The sensitivity and specificity of virus isolation were 57.14% and 70% respectively, and were significantly lower than PCR. In the semen samples taken from sero-negative bulls, BHV-1 was detected more often by PCR methods than by virus-isolation, suggesting that PCR is a more sensitive method for BHV-1 screening in bulls.

Cord blood analysis for prenatal diagnosis of thalassemia major and hemophilia A

Beta thalassemia and Hemophilia A are common genetic disorders for which prenatal diagnosis (PND) is an accepted option. Our aim was to evaluate cord blood analysis as a method for PND of these disorders. Cord blood samples at 18-26 weeks gestation from nine mothers with previous thalassemia major child and five families with previous hemophilia A were studied. In the former; HbF, HbA2 and HbF were determined by high performance liquid chromatography (HPLC) and in latter; Factor VIII and IX assays were done by one stage method. In HPLC studies for thalassemia, three out of nine fetuses were affected, five were carriers and one was normal. In hemophilia PND samples, 2 out of five fetuses were affected. Thus, HPLC and factor VIII assay in cord blood are feasible alternatives for PND in Beta thalassemia and hemophilia A respectively, especially when DNA analysis is uninformative or there are financial constraints.

Colony-Stimulating Activity of Fetal Liver Cells: Synergistic Role of Stem Cell Factor in Bone Marrow Recovery from Aplastic Anemia

Previously, we and others have shown that fetal liver infusion (FLI) leads to autologous hematopoietic improvement in 40-54% of patients with aplastic anemia. However, whether this recovery was spontaneous or the effect of the infused liver cells was not clear. To dissect the role of FLI in autologous hematopoietic recovery, the colony-supporting potential of fetal liver-conditioned medium (FLCM) was evaluated in bone marrow (BM) cells of normal adult and aplastic anemia patients. In both cases, each sample of FLCM supported the growth of colony-forming cells in semi solid culture medium. The FLCM was assayed for the presence of four principal colony-stimulating cytokines, namely stem cell factor (SCF), granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-3 (IL-3), and erythropoietin (Epo). While GM-CSF, IL-3, and Epo were present in insignificant amounts or were altogether absent, 50-635 pg/ml of SCF was found in 8 of the 13 FLCM samples tested. Preliminary results of bioneutralization assay indicated the possible role of SCF, secreted by the FL cells, in colony-supporting activity of aplastic anemia and normal BM cells. Overall, our in vitro study implicates the paracrine role of infused FL cells in regenerating autologous hematopoiesis in aplastic anemia patients.

Expression in plants and immunogenicity of plant virus-based experimental rabies vaccine

A new approach to the production and delivery of vaccine antigens is the use of engineered amino virus-based vectors. A chimeric peptide containing antigenic determinants from rabies virus glycoprotein (G protein) (amino acids 253-275) and nucleoprotein (N protein) (amino acids 404-418) was PCR-amplified and cloned as a translational fusion product with the alfalfa mosaic virus (AlMV) coat protein (CP). This recombinant CP was expressed in two plant virus-based expression systems. The first one utilized transgenic Nicotiana tabacum cv. Samsun NN plants providing replicative functions in trans for full-length infectious RNA3 of AlMV (NF1-g24). The second one utilized Nicotiana benthamiana and spinach (Spinacia oleracea) plants using autonomously replicating tobacco mosaic virus (TMV) lacking native CP (Av/A4-g24). Recombinant virus containing the chimeric rabies virus epitope was isolated from infected transgenic N. tabacum cv. Samsun NN plants and used for parenteral immunization of mice. Mice immunized with recombinant virus were protected against challenge infection. Based on the previously demonstrated efficacy of this plant virus-based experimental rabies vaccine when orally administered to mice in virus-infected unprocessed raw spinach leaves, we assessed its efficacy in human volunteers. Three of five volunteers who had previously been immunized against rabies virus with a conventional vaccine specifically responded against the peptide antigen after ingesting spinach leaves infected with the recombinant virus. When rabies virus non-immune individuals were fed the same material, 5/9 demonstrated significant antibody responses to either rabies virus or AlMV. Following a single dose of conventional rabies virus vaccine, three of these individuals showed detectable levels of rabies virus-neutralizing antibodies, whereas none of five controls revealed these antibodies. These findings provide clear indication of the potential of the plant virus-based expression systems as supplementary oral booster for rabies vaccinations.

Prenatal diagnosis of haemoglobinopathies

BACKGROUND

Haemoglobinopathies constitute a major health problem in the Indian subcontinent. In the absence of any method for achieving complete cure and treatment being expensive, prenatal diagnosis and selective termination of an affected foetus is a feasible option to decrease the disease load. We report our experience with prenatal diagnosis of haemoglobinopathies over a two-and-a-half year period in 257 pregnancies.

METHODS

Amplification refractory mutation system (ARMS) was used to detect beta-thalassaemia, haemoglobin E and sickle cell mutations.

RESULTS

Five mutations in the beta-globin gene which are common in the Indian population were detected in 92.3% of mutant chromosomes, whereas 3.1% of chromosomes carried rare mutations followed by 0.8% haemoglobin E and 0.4% sickle cell mutations. Mutations in 3.3% chromosomes were uncharacterized. The prenatal procedure, carried out early in pregnancy, was a chorionic villus sampling in most cases. A confirmed diagnosis based on ARMS-PCR was given in 241 (93.8%) cases. In 10 cases (3.9%) linkage analysis was required to confirm the foetal status, as mutations in both parents were not identified or the chorionic villus sample carried the single identified mutation. Four families with haemoglobin E-beta thalassaemia and one family with sickle cell disease were also included. Of the study population, 91.25% of the couples had a previous child with haemoglobinopathy, whereas 8.75% of the couples came before the birth of the first affected child.

CONCLUSION

We conclude that ARMS-PCR is a highly sensitive technique for detecting mutations in the beta-globin gene and its efficacy in the prenatal diagnosis of haemoglobinopathies is proven.

Pathogenesis of Alfalfa mosaic virus in Soybean (Glycine max) and Expression of Chimeric Rabies Peptide in Virus-Infected Soybean Plants

ABSTRACT Infection of soybean (Glycine max) plants inoculated with particles of Alfalfa mosaic virus (AlMV) isolate 425 at 12 days after germination was monitored throughout the life cycle of the plant (vegetative growth, flowering, seed formation, and seed maturation) by western blot analysis of tissue samples. At 8 to 10 days after inoculation, the upper uninoculated leaves showed symptoms of virus infection and accumulation of viral coat protein (CP). Virus CP was detectable in leaves, stem, roots, seedpods, and seed coat up to 45 days postinoculation (dpi), but only in the seedpod and seed coat at 65 dpi. No virus accumulation was detected in embryos and cotyledons at any time during infection, and no seed transmission of virus was observed. Soybean plants inoculated with recombinant AlMV passaged from upper uninoculated leaves of infected plants showed accumulation of full-length chimeric AlMV CP containing rabies antigen in systemically infected leaves and seed coat. These results suggest the potential usefulness of plants and plant viruses as vehicles for producing proteins of biomedical importance in a safe and inexpensive manner. Moreover, even the soybean seed coat, treated as waste tissue during conventional processing for oil and other products, may be utilized for the expression of value-added proteins.

Broad ligament hematoma causing fetal death in a case of fracture pelvis

Although motor ventricular accidents complicates 6-7% of all pregnancies, the experience of pelvic fractures in near term gravid patients is limited. We present a unique case of fetal death caused by bilateral broad ligament hematomas following maternal pelvic fracture which improved our understanding of management of such cases.

Ureteric calculi masquerading metastatic lymph nodes in a case of endometrial cancer

Extensive pelvic lymph node metastasis in the absence of risk factors was noticed at surgical staging for endometrial cancer in a 55-year-old postmenopausal women. On exploration there was a dilemma as to the disappearing lymph nodes which subsequently proved to be asymptomatic ureteric calculi. The need to palpate the pelvic side walls at the time of surgery for endometrial cancer even in cases when no nodal enlargement is detected preoperatively is highlighted.

Gravid uterus in an incisional hernia

A case of gravid uterus in an incisional hernia is reported. The pregnancy was further complicated by intrauterine growth restriction, oligohydramnios and pregnancy induced hypertension. The management of the case is discussed.

Port site metastasis subsequent to laparoscopy for chronic pelvic pain

We present an interesting case of port site metastasis is a menopausal women subsequent to diagnostic laparoscopy undertaken for chronic pelvic pain, which later proved early ovarian malignancy as the source of primary. While cases of port site metastasis have mostly occurred after extensive disease the possbility of such complication should be in mind at laparoscopy of early cancer.

Hydatiform mole with coexisting live fetus in dichorionic twin gestation

A case of dichorionic twin pregnancy was diagnosed in a 29-year-old, on routine ultrasound at 12 weeks. Subsequent ultrasounds for persistent vaginal bleeding at 16 weeks revealed molar placenta with viable fetus in both gestational sacs. The patient declined any invasive prenatal testing to confirm the karyotype of the fetus. The pregnancy was managed expectantly until 21 weeks, when she had a spontaneous abortion of twin fetuses and separate placentae with attached molar tissue. A final karyotype on cord blood samples confirmed 46XY and 46XX for both fetuses. Histopathology of molar tissue reported complete mole, with diploid chromosomal pattern on subsequent DNA flow cytometry. The clinical, ultrasound and chromosomal examination suggest that there has been a quadruplet pregnancy where two embryos developed into normal fetuses and other two degenerated to complete moles.

Outcome of hepatitis E virus infection in Indian pregnant women admitted to a tertiary care hospital

BACKGROUND AND OBJECTIVES

information on the incidence and prevalence of hepatitis E virus (HEV) infection in Indian pregnant women is scanty. Only a few studies have been done so far to document the vertical route of transmission of this virus. We therefore studied the prevalence of HEV infection in pregnant women with hepatitits and the outcome of their pregnancy.

METHODS

fifty pregnant women with clinical hepatitits were included in the study. After informed consent, their blood samples were tested for potential causes of hepatitis including hepatitis A, B, hepatitis C, and hepatitis E infections.

RESULTS

of the 50 cases, 20 (40%) patients were found to be positive for IgM anti -HEV (group A) and 30 (60%) were negative for IgM anti-HEV antibodies (group B). Overall 19 patients were in their second trimester while 30 were in third trimester. Of these 52.6 per cen (10/19) of those in second trimester and 50 per cent (15/30) in third trimester had fulminant hepatic failure (FHF). Only one patient presented in the first trimester who had acute viral hepatitis (AVH) and recovered completely. Of the HEV infected women, 70 per cent were in their third trimester and remaining 30 per cent in second trimester of pregnancy. A similar percentage of patients i.e., 14 of 20 (70%) manifested with FHF while 6 (30%) had acute hepatitis leading to recovery. The percentage of women with FHF and acute hepatitis was 36.6 and 63 per cent, respectively, in group B. Upon follow up all the 13 of the 14 HEV infected patients with FHF expired and only one delivered a male baby during the illness. The fatality rate in HEV infected patients was not different between the second and third trimesters (66.6% vs. 71.43%), respectively).

INTERPRETATION AND CONCLUSIONS

this study suggests that HEV causes high mortality in pregnant women as compared to non-HEV infected pregnant women. This pilot study indicates that steps should be taken to prevent HEV infection during pregnancy.

Aplastic anaemia during pregnancy: variable clinical course and outcome

Aplastic anaemia occurring during pregnancy is a rare event and is associated with high maternal and fetal morbidity and mortality. Prognosis is poorer when aplastic anaemia develops during pregnancy and many such patients have an unsuccessful pregnancy outcome. We report two cases of aplastic anaemia associated with pregnancy. Both the patients had very different antenatal course and outcome. Their etiopathogenesis and management is discussed.

Human respiratory syncytial virus vaccine antigen produced in plants

Human respiratory syncytial virus (RSV) is the primary cause of respiratory infection in infants worldwide. Currently there is no available vaccine, although studies in animal models have demonstrated protective immunity induced by an epitope of the RSV G-protein representing amino acids 174-187. Two peptides containing amino acids 174-187 of the G-protein of the human RSV A2 strain (NF1-RSV/172-187 and NF2-RSV/170-191) were separately engineered as translational fusions with the alfalfa mosaic virus coat protein and individually expressed in Nicotiana tabacum cv. Samsun NN plants through virus infection. RSV G-protein peptides were expressed in infected plant tissues at significant levels within 2 wk of inoculation and purified as part of recombinant alfalfa mosaic virions. BALB/c mice immunized intraperitoneally with three doses of the purified recombinant viruses showed high levels of serum antibody specific for RSV G-protein and were protected against infection with RSV Long strain.

Contraceptive status and sexual behavior in women over 35 years of age in India

The aim of this paper is to survey the current contraception use and analyze the sexual patterns in women above 35 years of age in India. Five hundred women, of whom 250 were at least 35 years old and 250 were less than 35 years old (control group) were interviewed with the help of a prepared questionnaire. A permanent surgical method of contraception had been accepted by 40.4% of women > or = 35 years old versus 16.8% of women < 35 years old. Of various temporary methods, an intrauterine device (IUD) was used by 5.2% and 22.8% oral contraceptive pills (OCs) by 1.2% and 9.6%, and natural methods by 6.4% and 3.2%, in women > or = 35 years and < 35 years, respectively. No contraception was used by 25.6% women > or = 35 years. A history of medical termination was given by 67.18% of non-contraceptive users vs. 27.41% of contraceptive users in women > or = 35 years. Coital frequency was noted at 4.32 times/month in women > or = 35 years but 7.2 times/month in women <35 years. Among contraceptive users > or = 35 years, coital frequency was 4.9 times/month compared with 3.9 times/month in non-contraceptive users. There is a high acceptance of irreversible sterilization and a high abortion rate in women > or = 35 years. Use of contraceptives was linked with increased sexual activity and a decreased abortion rate.

Inversion of uterus during cesarean section

Acute inversion of the uterus is a rare complication during cesarean section. We describe one such case in which diagnosis was made immediately and reversion was performed within few minutes. A high index of suspicion and prompt management can prevent further complications.

Vesicocervical fistula: an unusual presentation

A rare case is presented of vesicocervical fistula that occurred in a woman who sought help for continuous dribbling of urine for nine years. The aetiological implications of her obstetric history are discussed in the context of previous reports in the literature. The management and outcome of this case is discussed.

Prenatal diagnosis of Duchenne muscular dystrophy

BACKGROUND

Duchenne muscular dystrophy (DMD) is one of the most common X-linked genetic disorders seen in children. Mutations in the DMD gene coding for the protein dystrophin causes the severe muscle-wasting disorder leading to death in the second decade of life. In the absence of a cure, prenatal diagnosis (PND) appears to be the best approach to reduce the burden of this disease on the individual family and ultimately on society. There are few published reports worldwide on PND and very few from the developing countries. We report our experience with PND for families with DMD using multiplex polymerase chain reaction (PCR) and microsatellite polymorphic marker analysis.

METHODS

From August 1997 to October 1999, PND was offered on request to 23 families with one or two boys affected with DMD. A total of 26 foetuses were screened for DMD. Initially the deletions in the DMD gene in the affected child were identified by multiplex PCR screening for 23 exons in 6 sets. In patients where deletions were not identified, microsatellite repeat analysis was carried out to follow the inheritance of the mutant allele. DNA was extracted from chorionic villus samples obtained by chorionic villus biopsy performed at 10-15 weeks of gestation in 17 families, and at 16-20 weeks in 6 families.

RESULTS

Deletions were identified in 20 affected boys. In 2 families, microsatellite repeat analysis was done to identify the mutant allele. Of the 26 foetuses, 5 were found to be affected with DMD and the parents opted for termination of pregnancies.

CONCLUSIONS

Multiplex PCR technology and microsatellite repeat analysis can be used effectively for PND of DMD.

Prenatal diagnosis and assessment of fetal malformations by ultrasonography in India

A multicentre study to assess the status of prenatal diagnosis of fetal malformation in India was conducted. Questionnaires were sent to the teaching hospitals and to centres in the private sector involved with ultrasonography in all the four zones. Data were obtained from 13 centres. Basic level I scans were performed on all pregnant women in 64% centres, whereas level II or targeted scans were performed as routine in 42% centres. Obstetricians performed level II scans in only 35% of cases while rest were performed by radiologists. Malformations of the central nervous system were commonest, accounting for 35-69% of all malformations, followed by genitourinary and gastrointestinal malformations. Malformations of the cardiovascular system were detected in 9.3% as abnormal four chamber view and outlet tract abnormalities, subsequently confirmed on fetal echocardiography. Invasive prenatal diagnosis by fetal blood sampling, chorion villus sampling and amniocentesis for chromosomal analysis of malformed fetuses was performed at 40% centres. At the All India Institute of Medical Sciences, approximately 11,042 ultrasound scans were performed by obstetricians as routine in all pregnant women. A total of 543 malformations were detected accounting for a 4.9% incidence of structural anomalies. A total of 98 cardiovascular malformations were detected in high and low risk pregnant women on fetal echocardiography. No database or registry exists in India to give an actual insight into the problem of congenital malformation and their prenatal diagnosis. It is important to train obstetricians in level I and II ultrasonography, to recognise centres and institutions at national and regional level, and to integrate a network of diagnostic testing. Close liaison between geneticists, radiologists, pediatric surgeons, pediatricians and obstetricians is a must for prenatal diagnosis and management of fetal malformations.

Can amniotic fluid distribution predict fetal outcome?

OBJECTIVE

This study was designed to determine whether the distribution pattern of amniotic fluid (AF) within the uterine cavity is related to perinatal outcome.

STUDY DESIGN

One-hundred women in labor with intact membranes underwent a real time ultrasound examination to measure the AF index. Patients were divided into two groups based on liquor distribution. Those with > 50% liquor distributed in upper quadrants formed the 'upper greater' group whereas the rest of the patients constituted the 'lower greater' group. Pregnancy outcome was assessed with respect to incidence of fetal heart rate (FHR) abnormalities, operative delivery, meconium stained liquor, Apgar score < 7 at 1 and 5 min and neonatal intensive care unit admissions.

RESULTS

A total of 100 patients were evaluated. The 'upper greater' group had a higher incidence of cesarean for non-reassuring FHR (40.74% vs. 9.6%, P < 0.001), persistent variable deceleration (14.8% vs. 0%, P < 0.001) and bradycardia (25.9% vs. 4.1%, P < 0.001). There was no statistically significant difference in the Apgar score < 7 at 1 min and neonatal intensive care unit admissions in the two groups.

CONCLUSIONS

Distribution of less liquor in the lower quadrants of the uterus predisposed to abnormalities in FHR and hence, cesarean section. The distribution pattern did not have a predictive value for the perinatal outcome.

Two distinct types of repression domain in engrailed: one interacts with the groucho corepressor and is preferentially active on integrated target genes

Active transcriptional repression has been characterized as a function of many regulatory factors. It facilitates combinatorial regulation of gene expression by allowing repressors to be dominant over activators under certain conditions. Here, we show that the Engrailed protein uses two distinct mechanisms to repress transcription. One activity is predominant under normal transient transfection assay conditions in cultured cells. A second activity is predominant in an in vivo active repression assay. The domain mediating the in vivo activity (eh1) is highly conserved throughout several classes of homeoproteins and interacts specifically with the Groucho corepressor. While eh1 shows only weak activity in transient transfections, much stronger activity is seen in culture when an integrated target gene is used. In this assay, the relative activities of different repression domains closely parallel those seen in vivo, with eh1 showing the predominant activity. Reducing the amounts of repressor and target gene in a transient transfection assay also increases the sensitivity of the assay to the Groucho interaction domain, albeit to a lesser extent. This suggests that it utilizes rate-limiting components that are relatively low in abundance. Since Groucho itself is abundant in these cells, the results suggest that a limiting component is recruited effectively by the repressor-corepressor complex only on integrated target genes.

Pelvic examination, transvaginal ultrasound and transvaginal color Doppler sonography as predictors of ovarian cancer

OBJECTIVE

To assess and compare the efficacy of pelvic examination, transvaginal ultrasound and transvaginal color Doppler imaging in differentiating benign and malignant ovarian tumors.

METHODS

34 patients with ovarian tumors scheduled for laparotomy underwent pelvic examination and a diagnosis of benign or malignant tumor was made. Transvaginal ultrasound was carried out to study the ovarian morphology followed by color Doppler imaging. A score of > or = 9 on Sassone scoring system or a pulsatility index < 1 was taken as suspicious for malignancy.

RESULTS

Of all the three indicators (pelvic examination, transvaginal sonography and Doppler) transvaginal sonography had the highest sensitivity (100%) and Doppler had maximum specificity (96.29%) for predicting malignancy. However, statistical analysis did not show any difference in the predicting ability of these three modalities.

CONCLUSION

Pelvic examination, transvaginal sonography and Doppler all had similar ability to predict malignancy in an adnexal mass.

Intravenous immunoglobulin as primary therapy or adjuvant therapy to intrauterine fetal blood transfusion: a new approach in the management of severe Rh-immunization

Maternal high dose intravenous immunoglobulin (IVIG) has shown promise in the management of severe Rh-immunization. Intravenous immunoglobulin, blocks Fe mediated antibody transport across the placenta and blocks destruction of fetal red cells and reduces maternal antibody levels. We have tried this new therapy in 6 patients with severe Rh-immunization, with high maternal antibody titres and previous hydrops and intrauterine deaths. Intravenous immunoglobulin was given from 13-18 weeks of gestation 3-4 weekly, till intrauterine transfusion (IUT) or delivery. Intensive fetal monitoring was done. No fetal hydrops or deaths occurred in any of the 6 cases. Only 2 cases needed intrauterine transfusion. IVIG delayed the onset of fetal anemia by 8-17 weeks thus deferring the need for IUT. All pregnancies continued till 32-36 weeks and all 6 babies did well in the neonatal period.

Karyotyping of at risk fetuses by cordocentesis in advanced gestation

Fetal blood obtained by cordocentesis was cultured to obtain rapid karyotypes of fetuses at risk during the late second trimester. Ninety nine fetal blood samples were studied for chromosomal abnormalities. The commonest indications for the procedure were abnormalities detected on ultrasonography (47.7%), and previous child with Down syndrome. Analysis of the 67 successful cultures showed four (5.9%) karyotypic abnormalities. The technique proved helpful in the obstetrical management of at risk fetuses.