Advancing pediatric perioperative care in India: A contemporary overview

BACKGROUND

In the last 30 years, significant advances have been made in pediatric medical care globally. However, there is a persistent urban-rural gap which is more pronounced in low middle-income countries than high-income countries, similar urban-rural gap exists in India. While on one hand, health care is on par or better than healthier nations thriving international medical tourism industry, some rural parts have reduced access to high-quality care.

AIM

With this background, we aim to provide an overview of the present and future of healthcare in India.

METHODOLOGY

With the cumulative health experience of the authors or more than 100 years, we have provided our experience and expertise about healthcare in India in this narrative educational review. This is supplemented by the government plans and non government plans as appropriate. References are used to justify as applicable.

RESULTS

With the high percentage of pediatric population like other low to middle-income countries, India faces challenges in pediatric surgery and anesthesia due to limited resources and paucity of specialized training, especially in rural areas. Data on the access and quality of care is scarce, and the vast rural population and uneven resource distribution add to the challenges along with the shortage of pediatric surgeons in these areas of specialized care . Addressing these challenges requires a multi faceted strategy that targets both immediate and long-term healthcare needs, focusing on improving the facilities and training healthcare professionals. Solutions could include compulsory rural service, district residency programs, increasing postgraduate or residency positions, and safety courses offered by national and international organizations like Safer Anesthesia from Education Pediatrics, Vital Anesthesia Simulation Training, and World Federation of Society of Anesthesiologists pediatric fellowships.

CONCLUSION

India has achieved great strides in perioperative health care and safety. It has become the major international medical industry due to high-quality care, access and costs. Crucially, India needs to establish local hubs for pediatric perioperative care training to enhance healthcare delivery for children.

Quality improvement and patient safety in India-Present and future

India is a vast, populous and diverse country, and this reflects in the state of health care as well. The spectrum of healthcare services ranges from world class at one end, to a dearth of resources at the other. In the rural areas especially, there is a shortage of trained medical personnel, equipment, and medications needed to carry out safe surgery. Several initiatives have and are being made by the government, medical societies, hospitals, and nongovernment organizations to bridge this gap and ensure equitable, safe, and timely access to health for all. Training medical personnel and healthcare workers, accreditation of healthcare facilities, guidelines, and checklists, along with documentation and audit of practices will all help in improving services. This narrative review discusses the measures that have been taken, systems that have been established and the challenges involved in ensuring quality and patient safety in India.

Vulvar and vestibulovaginal hemangiosarcoma in a cow: morphological and histopathological observations

Background

Hemangiosarcoma is defined as the malignant mesenchymal neoplasm of endothelial cells. It is a common tumor affecting dogs and is very rare in cattle.

Case description

A seven-year-old three months pregnant female Holstein Friesian cross-breed cow was presented with a history of a proliferating irregular dark red friable mass in the vulvar region for the past month.

Findings/treatment and outcome

The surface of the mass had diffuse ecchymotic hemorrhages. Histopathological examination of the tissue biopsy specimen revealed unencapsulated, infiltrating neoplasm composed of numerous vascular channels with irregular borders surrounded by endothelial cells of variable sizes and shapes supported by a scanty fibrovascular stroma. Based on morphological and histopathological findings, the case was diagnosed as vulvar and vestibulovaginal hemangiosarcoma. The animal was culled due to the poor prognosis.

Conclusion

To the best of our knowledge, this is the first report of vulvar and vestibulovaginal hemangiosarcoma in a cow.

Challenges and Opportunities Facing Pediatric Anesthesia Providers in Low- and Middle-Income Countries (LMICs), India

India is a vast, populous country with a huge variability in the standards of health care. While the cities have state of the art hospitals with trained doctors, rural areas where most of the population lives, have a severe shortage of resources. Children form nearly 40% of India's population, and there is a great demand for pediatric surgical and anesthesia services. Specialty training in pediatric anesthesia, however, is still in its infancy, with the majority of children being administered anesthesia by general anesthesiologists. This review discusses the reasons behind India's ailing healthcare system and the shortage of qualified pediatric anesthesiologists. Anesthesiologists face multiple challenges in their daily work including inadequate infrastructure, paucity of medications and working equipment, nonavailability of trained help, and poor remuneration. All these factors contribute to work-related stress. On the other hand, the dearth of anesthesiologists offers ample opportunities to serve the underserved, improve the safety and quality of perioperative care in the rural areas, and improve the self-image of the anesthesiologist. A paucity of data regarding anesthesia, surgery, and work-related issues makes writing an article like this very difficult. However, it highlights the need for professional bodies to take note of these facts and play an active role in encouraging documentation, data collection, and improving standards of teaching and practice.

Leaching of Clothianidin in Two Different Indian Soils: Effect of Organic Amendment

Clothianidin is a widely used insecticide under Indian subtropical condition. The objective of this study was to generate residue data which aims to understand leaching potential of clothianidin [(E)-1-(2-chloro-1,3-thiazol-5-ylmethyl)-3-methyl-2- nitroguanidine] through packed soil column. The maximum amount of clothianidin was recovered at 0-5 cm soil depth in both Manipur (67.15%) and Delhi soil (52.0%) under continuous flow condition. Manipur and Delhi soil concentrated maximum residue with or without farm yard manure (FYM) in 0-20 cm soil depth. The effect of varying the amount of water enhanced the distribution of residues in the first 0-5 cm layer. Among the tested soils, residue was detected in the leachate from Delhi soil (0.04 µg/mL). Clothianidin leaching was minimized in soil of Manipur compared to Delhi after incorporation of FYM. As the volume of water increased upto 160 mL, mobility increased and residues moved to lower depth. Clothianidin did not leach out of the 25 cm long soil columns even after percolating water equivalent to 415.42 mm rainfall. Clothianidin is mobile in soil system and mobility can be reduced by organic amendment application.

Vacuum impregnation: a promising way for mineral fortification in potato porous matrix (potato chips)

Potato chips can be considered as an ideal carrier for targeted nutrient/s delivery as mostly consumed by the vulnerable group (children and teen agers). The present study was planned to fortifiy potato chips with calcium (Calcium lactate) and zinc (Zinc sulphate) using vacuum impregnation technique. At about 70-80 mm Hg vacuum pressure, maximum level of impregnation of both the minerals was achieved. Results showed that after optimization, calcium lactate at 4.81%, zinc sulphate at 0.72%, and vacuum of 33.53 mm Hg with restoration period of 19.52 min can fortify potato chips that can fulfil 10 and 21% need of calcium and zinc, respectively of targeted group (age 4-17 years). The present research work has shown that through this technique, fortification can be done in potato chips which are generally considered as a poor source of minerals. Further to make potato chips more fit to health conscious consumers, rather frying microwaving was done to develop mineral fortified low fat potato chips.

Does the Miller blade truly provide a better laryngoscopic view and intubating conditions than the Macintosh blade in small children?

BACKGROUND

Both Miller and Macintosh blades are widely used for laryngoscopy in small children, though the Miller blade is more commonly recommended in pediatric anesthetic literature. The aim of this study was to compare laryngoscopic views and ease and success of intubation with Macintosh and Miller blades in small children under general anesthesia.

MATERIALS AND METHOD

One hundred and twenty children aged 1-24 months were randomized for laryngoscopy to be performed in a crossover manner with either the Miller or the Macintosh blade first, following induction of anesthesia and neuromuscular blockade. The tips of both the blades were placed at the vallecula. Intubation was performed following the second laryngoscopy. The glottic views with and without external laryngeal maneuver (ELM) and ease of intubation were observed.

RESULTS

Similar glottic views with both blades were observed in 52/120 (43%) children, a better view observed with the Miller blade in 35/120 (29%) children, and with the Macintosh blade in 33/120 (28%). Laryngoscopy was easy in 65/120 (54%) children with both the blades. Restricted laryngoscopy was noted in 55 children: in 27 children with both the blades, 15 with Miller, and 13 with Macintosh blade. Laryngoscopic view improved following ELM with both the blades.

CONCLUSION

In children aged 1-24 months, the Miller and the Macintosh blades provide similar laryngoscopic views and intubating conditions. When a restricted view is obtained, a change of blade may provide a better view. Placing the tip of the Miller blade in the vallecula provides satisfactory intubating conditions in this age group.

Nonfatal air embolism during shoulder arthroscopy

An air embolism is a rare but potentially fatal complication of shoulder arthroscopy. In this article, we report the case of a patient who developed a nonfatal air embolism during shoulder arthroscopy for an acute bony Bankart lesion and a greater tuberosity avulsion fracture. The venous air embolism occurred immediately after the joint was insufflated with air for diagnostic air arthroscopy. The diagnosis was based on a drop in end-tidal carbon dioxide and blood pressure and presence of mill wheel (waterwheel) murmur over the right heart. Supportive treatment was initiated immediately. The patient recovered fully and had no further complications of air embolism. This patient's case emphasizes the importance of being aware that air embolisms can occur during shoulder arthroscopy performed for acute intra-articular fractures of the shoulder. Monitoring end tidal carbon dioxide can be very useful in early detection of air embolisms.

Comparison of oral fiberoptic intubation via a modified guedel airway or a laryngeal mask airway in infants and children

BACKGROUND

Though fiberoptic intubation (FOI) is considered the gold standard for securing a difficult airway in a child, it may be technically difficult in an anesthetized child. The hypothesis for this study was that it would be easier to perform FOI via a laryngeal mask airway (LMA) than a modified oropharyngeal airway with the advantage of maintaining anesthesia and oxygenation during the process.

MATERIALS AND METHODS

30 children aged 6 months to 5 years undergoing elective surgery under general anesthesia were randomized to two groups to have fiberoptic bronchoscope (FOB) guided intubation either via a modified Guedel airway (FOB-ORAL) or a classic LMA (FOB-LMA). In the FOB-LMA group, the LMA was removed when a second smaller endotracheal tube was anchored to the proximal end of the tracheal tube in place.

RESULTS

Oral fiberoptic intubation was successful in all children. The first attempt success rate was 11/15 (73.33%) in the FOB-LMA group and 3/15 (20%) in the FOB-ORAL group (P = 0.012). Subsequent attempts at intubation were successful after 90° anticlockwise rotation of the endotracheal tube over the FOB. The time taken for fiberoptic bronchoscopy was significantly less in FOB-LMA group (59.20 ± 42.85 sec vs 108.66 ± 52.43 sec). The incidence of desaturation was higher in the FOB-ORAL group (6/15 vs 0/15).

CONCLUSION

In children, fiberoptic bronchoscopy and intubation via an LMA has the advantage of being easier, with shorter intubation time and continuous oxygenation and ventilation throughout the procedure. Removal of the LMA following intubation requires particular care.

Unilateral pulmonary edema after laparoscopic nephrectomy

Unilateral-dependent pulmonary edema though reported in laparoscopic donor nephrectomies, has not been reported after laparoscopic non-donor nephrectomies. A 75-kg, 61-year-old man, a diagnosed case of right renal cell carcinoma was scheduled for laparoscopic nephrectomy. After establishing general anesthesia, the patient was positioned in the left-sided modified kidney (flank) position. During the 5.75-hour procedure, he was hemodynamically stable except for a transient drop in blood pressure immediately after positioning. Intra-abdominal pressure was maintained less than 15 mmHg throughout the procedure. Blood loss was approximately 50 mL and urine output was 100 mL in the first hour followed by a total of 20 mL in the next 4.75 hours. Total fluid received during the procedure included 1.5 L of Ringer's lactate and 1.0 L of 6% hydroxyethyl starch. After an uneventful procedure he developed respiratory distress in the postoperative period with a radiological evidence of dependent lung edema. Clinical and radiological improvement followed noninvasive ventilation, intravenous diuretics and oxygen therapy.

Unrecognized blunt tracheal trauma with massive pneumomediastinum and tension pneumothorax

Blunt neck trauma with an associated laryngotracheal injury is rare. We report a patient with blunt neck trauma who came to the emergency room and was sent to ward without realizing the seriousness of the situation. He presented later with respiratory distress and an anesthesiologist was called in for emergency airway management. Airway management in such a situation is described in this report.

Crossover comparison of airway sealing pressures of 1.5 and 2 size LMA-ProSeal™ and LMA-Classic™ in children, measured with the manometric stability test

OBJECTIVES

To compare airway sealing pressures, air leak, optimal positioning of the LMA-ProSeal™ and LMA-Classic™ in children.

METHODS

A crossover, randomized study was conducted in children aged 6 months-7 years weighing <20 kg scheduled for minor elective surgery under GA with sevoflurane. Either a 1.5 or 2-size LMA-ProSeal™ or LMA-Classic™ was inserted first. Optimal position of the devices was evaluated by fiberoptic bronchoscopy (FOB). Airway sealing pressures were determined under standardized conditions by the manometric stability test at the proximal end of the LMA device. Gas leak observed by auscultation over the neck and epigastrium was noted at these pressures.

RESULTS

Twenty-seven children of mean ages 29.48 ± 19.81 months and mean weight 11.23 ± 3.28 kg were included for evaluation. Airway sealing pressures were noted to be similar: 23.11 ± 8.28 cm H(2)O with LMA-ProSeal™ and 23.26 ± 8.21 cm H(2)O with LMA-Classic™. At these sealing pressures, air leak in the neck was observed in 21/27 children with LMA-ProSeal™ compared with 24/27 with LMA-Classic™ (P = 0.467). Optimal device positioning as viewed by FOB was seen in 14/27(51.8%) children with LMA-ProSeal™ and 15/27(55.6%) with LMA-Classic™. Airway sealing pressures with suboptimal position of LMA-ProSeal™ was 22.23 ± 10.23 cm H(2)O and with optimal position 23.93 ± 6.25 cm H(2)O (P = 0.612).

CONCLUSION

The LMA-ProSeal™ and LMA-Classic™ size 1.5 and 2 provide similar mean airway sealing pressures as assessed by the manometric stability test under standardized conditions, with similar air leak and optimal positioning.

Does the newer preparation of propofol, an emulsion of medium/long chain triglycerides cause less injection pain in children when premixed with lignocaine?

BACKGROUND

Injection pain during propofol administration can be particularly distressing in children. The newly available emulsion of propofol in medium and long chain triglycerides (LCT) is reported to cause less injection pain because of lower concentrations of free propofol. This study compared the incidence of injection pain during administration of propofol emulsion of LCT and propofol emulsion of medium and long chain triglycerides (MCT/LCT) both premixed with lignocaine in children.

METHODS

This prospective, randomized, double blind study was conducted after obtaining institutional ethics committee approval, parental consent and included 84 children aged 5-15 years. Preoperatively, an intravenous cannula was inserted in all children. four children were excluded. Those included, depending on the randomization, received 3 mg x kg(-1) of either propofol LCT or propofol MCT/LCT both premixed with lignocaine (0.1%). The incidence and intensity of injection pain was assessed.

RESULTS

Pain on injection of propofol LCT with lignocaine was observed in 16/40 children (40%), five of these children complained of severe pain. In comparison, 14/40 (35%) children complained of pain following propofol MCT/LCT premixed with lignocaine (P = 0.644), the intensity being severe in two children (P = 0.698).

CONCLUSIONS

Propofol MCT/LCT and propofol LCT premixed with lignocaine are both associated with pain on injection in children; the incidence and intensity of the injection pain are similar.

Epinephrine test dose in children: is it interpretable on ECG monitor?

BACKGROUND

Epidural and other regional blocks are performed in children under general anesthesia; the response to a 'test dose' may be altered during administration of general anesthetics. Limited data is available describing changes in electrocardiogram, blood pressure and heart rate (HR) following unintentional intravascular injection of a lidocaine-epinephrine-containing test dose, under sevoflurane anesthesia in children.

METHODS

Sixty-eight children undergoing elective surgeries under sevoflurane anesthesia were administered 0.1 ml x kg(-1) of 1% lidocaine with epinephrine 0.5 microg x kg(-1) or normal saline intravenously, to simulate an accidental intravascular test dose. T-wave changes in lead II on the anesthesia monitor and on a printed ECG were noted over the initial 1 min as well as changes in HR and systolic blood pressure (SBP) over an initial 3 min period.

RESULTS

Following injection of lidocaine-epinephrine, a significant increase in T-wave amplitude in lead II was noted in 91% of children on the ECG monitor and in 94% of children on the ECG printout of the same lead. In 64% of children, an increase in HR of > or =10 b x min(-1) and in 76% of children an increase in SBP of > or =15 mmHg was noted.

CONCLUSION

An increase in T-wave amplitude can easily be detected by carefully observing the ECG monitor or an ECG printout within a minute following the accidental i.v. administration of 0.1 ml x kg(-1) of 1% lidocaine-epinephrine (0.5 microg x kg(-1)) regional anesthetic test dose in children under sevoflurane anesthesia.

Monocyte apoptosis in dialysis patients is Fas ligand-mediated

BACKGROUND

The mononuclear phagocyte system plays an important role in host defense. Since dialysis patients have been reported to show enhanced leukocytes apoptosis, we evaluated the mechanism of increased apoptosis of monocytes in dialysis patients.

METHODS

Apoptotic studies were carried out on monocytes isolated from dialysis patients as well as healthy subjects. The effect of dialysis sera and membranes was evaluated on monocyte apoptosis as well as monocyte expression of proapoptotic proteins such as Fas and FasL. To confirm the role of FasL, we evaluated the effect of activated secretory products on T cell apoptosis. In addition, we studied FasL content of dialysis sera and supernatants of activated monocytes.

RESULTS

Monocytes isolated from dialysis patients (MDP) showed a greater magnitude of apoptosis when compared to monocytes isolated from healthy subjects (MHS) (MHS, 3.6 +/- 1.1% vs. MDP, 24.3 +/-1.4%). Sera of hemodialysis patients (SHD) promoted (p < 0.001) apoptosis of MHS when compared to pooled control sera (HPS) (HPS, 0.8 +/- 0.5% vs. SHD, 11.5 +/- 0.5% apoptotic cells/field). Dialysis membranes, cellulose acetate membranes in particular, promoted monocyte apoptosis. Interestingly, anti-FasL antibodies partly inhibited dialysis sera-induced monocyte apoptosis. Dialysis membranes also modulated monocyte expression of both Fas and FasL. Secretory products of activated monocytes also promoted T cell apoptosis. Dialysis sera and activated monocyte secretory products showed increased FasL content.

CONCLUSIONS

These results suggest that dialysis patients have an increased rate of monocyte apoptosis, which is mediated through a uremic milieu (serum factors). One of these serum factors seems to be FasL. In addition, dialysis membranes seem to promote apoptosis independent of the uremic milieu. The present study provides a mechanistical insight into the enhanced apoptosis of monocytes in dialysis patients.

Transforming growth factor beta induces mesangial cell apoptosis through NO- and p53-dependent and -independent pathways

BACKGROUND

Because transforming growth factor beta (TGF-beta) has been shown to have a bimodal effect on mesangial cell (MC) proliferation, we studied its effect on MC apoptosis.

METHODS

Cultured mouse MCs were used to evaluate the effect of TGF-beta. Morphologic evaluation of MC apoptosis was performed by staining cells with H-33342 and propidium iodide. To confirm the effect of TGF-beta on MC apoptosis, DNA was extracted from control and TGF-beta-treated MCs and run on gel electrophoresis. We evaluated the effect of NG-nitro-L-arginine methyl ester (L-NAME), a nitric oxide (NO) synthase inhibitor, on TGF-beta-induced MC apoptosis to determine the role of NO and studied the effect of sodium nitroprusside (SNP) and SNAP (S-nitroso-N-acetyl-penicillamine) on MC apoptosis to confirm the effect of NO. We examined the role of p53 by studying the effect of TGF-beta on MCs derived from p53 knockout mice (p53KO-MC) as well as a normogenic strain (N-MC). We also examined the effect of TGF-beta, SNP, and SNAP on apoptosis of p53 mutant (MDAMB-231) and wild-type p53 (MCF-7) breast cancer cell lines. In addition, Western blots were generated from control, TGF-beta-treated, and SNAP-treated MCs and probed for the expression of p53.

RESULTS

TGF-beta promoted MC apoptosis. Moreover, TGF-beta-treated MCs displayed integer multiples of 180 base pairs (ladder pattern). L-NAME inhibited TGF-beta-induced MC apoptosis. Furthermore, SNP and SNAP, NO donors, promoted MC apoptosis. TGF-beta also enhanced the MC expression of p53. TGF-beta induced only a moderate degree of apoptosis in MCs derived from p53KO-MC when compared with N-MCs. Similarly, the TGF-beta-induced apoptosis of MDAMB-231 was of a moderate degree when compared with MCF-7 cells.

CONCLUSIONS

We hypothesize that TGF-beta promotes MC apoptosis through NO generation and p53-dependent and -independent pathways.

Thermoregulatory spectrum in vertebrates

Thermoregulatory mechanisms and control of homeothermy are quite recent from evolutionary stand point. Animals have either simply recruited or modified other regulatory systems for the purpose of thermoregulation. The degree of such recruitments or modifications vary among different class of vertebrates thus giving rise to a relative diversity in the spectrum of thermoregulatory control and mechanisms. The review briefly summarizes the evidence showing that body temperature control is not an isolated regulated system in vertebrates, rather, a hierarchically integrated multiple system. The available information shows that pineal transduces environmental cues for photoperiodic and seasonal adjustments to the preoptic area of anterior hypothalamus via its primary secretory product, melatonin. The hypothalamus integrates the information and then sets the effector recruitment for each control system consistent with the metabolic rate of the animal taking into considerations the cost and benefit of the action taken. The overwhelming similarity in response to different constituents of the thermoregulatory spectrum contradicts the aphorism that cold-blooded animals are dependent on ambient temperature. It is our collective view that there is no fundamental difference between ectotherms and endotherms since the two vary only in the degree of their ability to maintain thermal homeostasis.

Murine lupus glomerulotropic monoclonal antibodies exhibit differing specificities but bind via a common mechanism

We recently identified that the glomerular binding activity in MRL/lpr serum consists of Abs reactive with DNA/histone adherent to glomerular basement membrane (GBM) via type IV collagen. These studies suggest the presence of multiple nephritogenic autoantibodies that bind to glomeruli via a common mechanism, an hypothesis we tested by producing glomerular binding mAbs from a nephritic MRL/lpr mouse. All 7 mAbs produced bound to glomeruli/GBM in a DNase-inhibitable fashion. The 4 mAbs that bound most avidly to glomeruli/GBM (group I) did not bind to DNA per se, and GBM binding after DNase treatment was reconstituted by histones or histone/DNA co-addition. The remaining 3 mAbs (group II) bound well to DNA, and GBM binding after DNase treatment was reconstituted by DNA but not histones. Collagenase (but not heparitinase) inhibited GBM binding of all mAbs and impaired the ability of nuclear Ags to reconstitute binding. None of the mAbs bound to type IV collagen per se. Using defined nuclear Ags, two group I mAbs bound specifically to histone H2A-H2B-DNA complexes, one bound specifically to intact chromatin, and one was polyreactive to histones. Group II mAbs bound to any nuclear Ag-containing DNA. Binding to nuclear Ags by all mAbs was altered if type IV collagen was used as the assay substrate, and in this context the common Ag for all mAbs was intact chromatin. In sum, glomerular binding mAbs exhibit differing antigenic specificities, but can be identified as either predominantly anti-histone/nucleosome (group I) or anti-DNA (group II). Regardless, binding to chromatin adherent to type IV collagen is a common property of all such mAbs.

Murine lupus glomerulotropic monoclonal antibodies exhibit differing specificities but bind via a common mechanism

We recently identified that the glomerular binding activity in MRL/lpr serum consists of Abs reactive with DNA/histone adherent to glomerular basement membrane (GBM) via type IV collagen. These studies suggest the presence of multiple nephritogenic autoantibodies that bind to glomeruli via a common mechanism, an hypothesis we tested by producing glomerular binding mAbs from a nephritic MRL/lpr mouse. All 7 mAbs produced bound to glomeruli/GBM in a DNase-inhibitable fashion. The 4 mAbs that bound most avidly to glomeruli/GBM (group I) did not bind to DNA per se, and GBM binding after DNase treatment was reconstituted by histones or histone/DNA co-addition. The remaining 3 mAbs (group II) bound well to DNA, and GBM binding after DNase treatment was reconstituted by DNA but not histones. Collagenase (but not heparitinase) inhibited GBM binding of all mAbs and impaired the ability of nuclear Ags to reconstitute binding. None of the mAbs bound to type IV collagen per se. Using defined nuclear Ags, two group I mAbs bound specifically to histone H2A-H2B-DNA complexes, one bound specifically to intact chromatin, and one was polyreactive to histones. Group II mAbs bound to any nuclear Ag-containing DNA. Binding to nuclear Ags by all mAbs was altered if type IV collagen was used as the assay substrate, and in this context the common Ag for all mAbs was intact chromatin. In sum, glomerular binding mAbs exhibit differing antigenic specificities, but can be identified as either predominantly anti-histone/nucleosome (group I) or anti-DNA (group II). Regardless, binding to chromatin adherent to type IV collagen is a common property of all such mAbs.