Fetal Klippel-Trenaunay-Weber Syndrome: Antenatal Diagnosis and Postnatal Management

Context

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare disease characterized by a triad of venous malformations, vascular skin nevus and asymmetric hypertrophy of bone and soft tissue. The spectrum of disease in utero varies from asymptomatic nevus flammeus to life threatening complications like Kasabach-Merritt phenomena.

Aim

The aim of this study was to review our experience of antenatal diagnosis of KTWS and it's postnatal management.

Settings and Design

This was a retrospective observational study of all pregnant women who were antenatally diagnosed with KTWS and postnatally confirmed at a tertiary care center in north India between 2012 and 2021.

Subjects and Methods

The electronic medical records were reviewed and data were collected regarding demographic information, obstetric history, clinical presentation, sonographic findings, mode of delivery, fetal outcome, and follow-up.

Results

During the study period, four fetuses were diagnosed with KTWS on sonography. Three women were multigravida whereas one was a primigravida. Two women opted for medical termination of pregnancy and one each had liveborn child and an intra-uterine fetal death. KTWS was confirmed in all cases. The liveborn child underwent treatment for the vascular malformation and is alive at 4 years of age.

Conclusions

This study attempts to add onto the available literature regarding the spectrum of prenatal presentations of KTWS. It emphasizes the importance of prenatal diagnosis and follow-up of the fetus/neonate.

Amniotic Fluid Mesenchymal Stromal Cells Derived from Fetuses with Isolated Cardiac Defects Exhibit Decreased Proliferation and Cardiomyogenic Potential

Amniotic fluid mesenchymal stromal cells (AF-MSCs) represent an autologous cell source to ameliorate congenital heart defects (CHDs) in children. The AF-MSCs, having cardiomyogenic potential and being of fetal origin, may reflect the physiological and pathological changes in the fetal heart during embryogenesis. Hence, the study of defects in the functional properties of these stem cells during fetal heart development will help obtain a better understanding of the cause of neonatal CHDs. Therefore, in the present study, we compared the proliferative and cardiomyogenic potential of AF-MSCs derived from ICHD fetuses (ICHD AF-MSCs) with AF-MSCs from structurally normal fetuses (normal AF-MSCs). Compared to normal AF-MSCs, the ICHD AF-MSCs showed comparable immunophenotypic MSC marker expression and adipogenic and chondrogenic differentiation potential, with decreased proliferation, higher senescence, increased expression of DNA-damaged genes, and osteogenic differentiation potential. Furthermore, the expression of cardiac progenitor markers (PDGFR-α, VEGFR-2, and SSEA-1), cardiac transcription factors (GATA-4, NKx 2-5, ISL-1, TBX-5, TBX-18, and MeF-2C), and cardiovascular markers (cTNT, CD31, and α-SMA) were significantly reduced in ICHD AF-MSCs. Overall, these results suggest that the AF-MSCs of ICHD fetuses have proliferation defects with significantly decreased cardiomyogenic differentiation potential. Thus, these defects in ICHD AF-MSCs highlight that the impaired heart development in ICHD fetuses may be due to defects in the stem cells associated with heart development during embryogenesis.

Folate Receptor Alpha is Decreased in Pregnancy Affected with Fetal Neural Tube Defect: A Case Control Study

BACKGROUND

Neural tube defect (NTD) is a multifactorial disorder. Decrease transfer of folate to the developing embryo is one of the etiologies. It could be due to decrease folate receptors resulting in NTD in fetus.

OBJECTIVE

To analyze serum folate receptor alpha (FOLR1) concentration in women having fetus with NTD and compare it with women having normal fetus during and after pregnancy.

MATERIAL AND METHODS

This was a prospective case control study conducted in a tertiary care hospital. Pregnant women with detected isolated NTD in fetus were enrolled as cases and equal number of matched pregnant women without any fetal congenital malformation were recruited as controls. Serum FOLR1 levels were analyzed in cases and controls during pregnancy and 6 weeks after delivery.

RESULTS

Mean serum FOLR1 concentration during pregnancy was 70.5 pg/mL (range: 23.8-98.5 pg/mL) and 103.9 pg/mL (range: 70-110 pg/mL) in cases and controls, respectively. Serum level of FOLR1 was 448.9 pg/mL (range: 133.5-475) and 414.5 pg/mL (range: 269.7-412.5) in cases and controls at 6 weeks postpartum, respectively. There was statistically significant difference (P < 0.001) between cases and control during pregnancy but not in postpartum (P = 0.092). There was significant increase in level of FOLR1 in both cases and control at 6 weeks postpartum as compared to antenatal period.

CONCLUSIONS

Maternal serum FOLR1 is significantly reduced in pregnancy with fetal NTD as compared to normal pregnancy. The level is significantly increased in postpartum period in both groups. FOLR1 level being similar in both groups in postpartum indicates that it is not influenced by the history of fetal NTD.

A Comparative Study of Rapid SARS-Cov-2 Antigen Detection Assay against RT-PCR Assay for Diagnosis of COVID-19 in a Tertiary Hospital of Kathmandu

Background The Coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus (SARS-CoV-2) has spread worldwide since its first recorded case in the city of Wuhan, China, in December 2019. SARS-CoV-2 infection causes asymptomatic to sever pneumonia. Severe cases may develop acute respiratory disease symdrome (ARDS), with an average mortality rate of 6.9%. Real Time Reverse Transcriptase Polymerase Chain Reaction (rRT-PCR) assay is the current reference standard laboratory method for the diagnosis of SARS-CoV-2 infection. However, it takes around 6-8 hours to get the result and is time consuming. Therefore, rapid and accurate tests for SARS-CoV-2 screening are essential to expedite disease prevention and control. Lateral flow immunoassay using monoclonal anti SARS-CoV-2 antibodies which target for SARS-CoV-2 antigen can be complimentary screening test if their accuracy were comparable to that of the real time reverse transcriptionpolymerase chain reaction (RT-PCR) assay. Objective To find the sensitivity and specificity of a rapid antigentest kit in comparison to reverse transcription-polymerase chain reaction (RT-PCR). Method A cross-sectional hospital based study was carried out at Shree Birendra Army Hospital, Kathmandu for a period of four months. Result Our finding shows sensitivity and specificity of rapid diagnostic tests (RDT) Ag kit as 60.6% and 96.4% respectively. Positive and negative predictive value was 83.7% and 89.0%. Likewise, positive and negative likelihood ratio was 17.0 and 0.4. The overall accuracy of the antigen kit was 88.1% in comparison to reverse transcriptionpolymerase chain reaction (RT-PCR) as the gold standard. Conclusion Our study concluded the use of rapid antigen kit is mainly useful for screening purposes.

Serum Bile Acid Levels in Women With Intrahepatic Cholestasis of Pregnancy in India

Introduction

Intrahepatic cholestasis of pregnancy (ICP) manifests as unexplained intense pruritus in the third trimester of pregnancy and is often diagnosed based on elevated serum bile acid measurement. There are no data from India on serum bile acid levels in pregnant women with ICP.

Methods

Pregnant women with significant pruritus during the third trimester of gestation and with elevated serum alanine aminotransferase and/or aspartate aminotransferase (normal: <40 IU/L) were taken as having ICP. Serum BA levels were measured in them and in nonpregnant women and healthy pregnant women without itching.

Results

Of the 3735 pregnant women screened, 105 (2.8%) had ICP (age 28 [26-32] years; gestational age 32 [30-36] weeks; primigravida 32.3%, and 95.3% normal fetal growth). Median (interquartile range) serum bile acid levels in nonpregnant women (n = 61; 28 [25-31] years) and pregnant women without ICP (n = 59; 28 [25-31] years) were similar (3.7 [1.6-5.1] μmol/L and 3.7 [2.2-5.8] μmol/L, respectively). By comparison, serum bile acid level in women with ICP (n = 105; 28 [26-32] years) was significantly higher (20.2 [12.7-39.5] μmol/L; P < 0.05 each), being above 10 μmol/L in 88 (83.8%). The optimum cut-off for the diagnosis of ICP in our population was ≥8.6 μmol/L, with sensitivity of 87.6%, specificity of 93.3% and area under the receiver-operator characteristics curve of 0.937 (95% CI: 0.904-0.970).

Conclusion

Serum BA levels in healthy Indian nonpregnant and pregnant women are similar to those in other populations and can be used to diagnose ICP with an optimal cut-off being 8.6 μmol/L.

Triage of antenatal care through telehealth during COVID-19 pandemic in a tertiary care centre of North India

Background:

Telemedicine facilitates patient care in various fields including antenatal care. Its application and usefulness need objectification and can be a guide to using this service in the care of pregnant women.

Material and Methods:

This was a prospective observational study conducted from May 2020 to December 2020. Following the telemedicine practice guideline of the country, 3,360 teleconsultations were sought by 862 antenatal patients. The duration of each call, an indication of referral and pregnancy risk stratification were noted. Further management was classified into three categories depending upon the need for an immediate hospital visit, no hospital visit or scheduled visit after at least 48 h after the first contact.

Results:

The antenatal cases were referred for either maternal, foetal or both indications in 24.7, 54.8 and 20.5% of the cases, respectively. Women were classified as low risk (61.6%), high risk (35.7%) and severe risk (2.7%). In 1.4% of the patients, history and review of the records could not be done through telemedicine. The average time spent was 16.6 min for the first contact and 3.1 min for subsequent contacts. Further management was done with immediate visits in 385 (45.3%), scheduled hospital visits in 292 (34.3%) women and no tertiary care hospital visit in 173 (20.4%).

Discussion:

Women (20.4%) not called to the maternal-foetal medicine department of the institute were managed along with the treating obstetrician and no difference in pregnancy outcome was noted.

Conclusion:

Antenatal care can be provided following triage over teleconsultation and 1.4% of the women may not be able to use telehealth.

Feto-maternal and renal outcomes of nephrotic syndrome in pregnancy

Proteinuria can range from subnephrotic to nephrotic amounts during pregnancy, though nephrotic syndrome (NS) is rare (0.012%-0.025%). Without a renal biopsy, this distinction may be difficult at times. The objective of our study was assessing about renal and feto-maternal outcomes of these patients. This study was done in a tertiary-care hospital in north India from 2010 to 2019. We included all pregnant women with nephrotic-range proteinuria, with no signs or symptoms suggestive of pre-eclampsia. We studied their treatment modalities, renal, maternal, and fetal outcomes. Eighteen eligible pregnant women diagnosed with NS with no features suggestive of pre-eclampsia or associated comorbidities were included. The gestational age of presentation was 23.2 ± 1.36 weeks. The average proteinuria was 4.38 ± 0.76 g/day. The patients were managed conservatively without kidney biopsy. About 16.7% of pregnancies had worsening of hypertension and acute kidney injury which recovered after delivery. Anasarca was troublesome for four patients requiring fresh-frozen plasma infusion. All were managed conservatively; however, five patients were started on empirical immunosuppression, all five with steroids, while two required the addition of calcineurin inhibitors as well. All had live births, but 25.7% each had preterm and intrauterine growth restriction while one required neonatal intensive care unit admission. The degree of proteinuria had an impact on maternal and fetal outcomes, especially on risk to pre-eclampsia. NS during pregnancy needs evaluation and counseling. Majority of them can be managed conservatively yet specific therapies can safely be tried among symptomatic ones. Despite good outcomes, a sizeable risk to maternal and fetal complications can occur.

Maternal and fetal outcomes in pregnant females with rheumatic heart disease

Background

Cardiac diseases are seen in 1–3% of pregnancies. In developing countries rheumatic heart disease (RHD) contributes a major cause of cardiac disorders.

Objective

To study the maternal and fetal outcome in women with valvular heart disease or prosthetic heart valve replacement secondary to RHD in a tertiary care center.

Method

The consecutive pregnant women with RHD attending our institute from May 2018 to August 2019 were included. A maternal adverse outcome was defined as cardiac death, new onset arrhythmia, heart failure, thromboembolic event, hospitalization for other cardiac reasons or cardiac intervention, aortic dissection, infective endocarditis and acute coronary syndrome. Fetal adverse outcome defined as fetal death, preterm birth, and low birth weight.

Result

Total 80 patients were included in this study, native RHD in 60(75%) and 20(25%) had mechanical prosthetic valve replacement. Maternal adverse event occurred in 34(42.5%), comprising of death in 1(1.2%), new onset AF 2(2.5%), 20(25%) underwent balloon mitral valvotomy, 3(3.7%) underwent mitral valve replacement, heart failure hospitalization in 7(8.7%). 1(1.2%) patient developed mitral valve infective endocarditis. Preterm delivery occurred in 19(23.7%), 7(8.7%) abortions and 1(1.2%) intrauterine death. Fetuses with low birth weight were 43(53.7%). Pregnancy with live birth occurred in 57(95%) women with valvular heart disease but no prosthesis and 16(80%) women with prosthetic valve disease.

Conclusion

Women with rheumatic heart disease carry a high risk both for mother and fetus. Early diagnosis, close follow-up during pregnancy, early recognition of deterioration in symptoms and timely cardiac intervention can lead to good maternal or fetal outcome.

Maternal and Fetal Outcomes of Pregnancy in Patients with Immune Thrombocytopenia

Introduction

Immune thrombocytopenia (ITP) complicates 1-2 cases/10,000 pregnancies in India. Management of these patients is a challenge as it is associated with potential risks of maternal bleeding episodes and neonatal alloimmune thrombocytopenia (NAITP).

Objective

To study the maternal and fetal/neonatal outcome of pregnancy in Indian patients with ITP and identify the risk factors for NAITP.

Materials and Methods

In this retrospective study, all ITP patients with pregnancy who were diagnosed and treated at our center over 8 years (August 2010- August 2018) were evaluated for their hematological, obstetrical, and fetal outcomes.

Results

Twenty-nine pregnancies in 27 ITP patients were studied. The mean interval between the diagnosis of ITP and each pregnancy was 29 ± 14.9 months. The mean baseline platelet count was 0.18 ± 0.05 X 10⁹/L. Twenty-seven (93.1%) cases were treated with oral prednisolone. Twenty deliveries (69.0%) were vaginal and 9 (31.0%) deliveries were by cesarean section. There were no major bleeding episodes during pregnancy or delivery.The mean neonatal platelet count was 1.23 ± 0.58 × 10⁹/L at birth. NAITP was seen in 3 (3.5%) neonates. No bleeds or intracranial hemorrhages were observed. Only maternal platelet count < 50 X 10⁹/L at delivery showed a statistical correlation with NAITP (p = 0.022). There was no positive correlation between NAITP and the duration of maternal ITP, the timing of ITP onset, or type of treatment.

Conclusion

Successful outcome of pregnancies in ITP patients is possible, and the risk of maternal bleeding and NAITP is low.

Congenital Chylothorax in a Neonate with Cornelia de Lange Syndrome: A Rare Complication Managed with a Novel Indigenously Prepared Milk Formulation

Congenital chylothorax is a relatively uncommon condition seen in newborn period. Treatment comprises of adequate pleural fluid drainage, octreotide infusion, total parenteral nutrition followed by medium chain triglyceride (MCT) based low fat milk preparations. The authors present a case of Cornelia de Lange syndrome with a rare presentation of antenatally diagnosed chlyothorax presenting at birth with respiratory distress. The baby was managed with skimmed milk formulation fortified with coconut oil providing low fat and high proteins.

Acute cortical necrosis in pregnancy still an important cause for end-stage renal disease in developing countries

Renal cortical necrosis (RCN) is a serious complication of acute kidney injury (AKI) and pregnancy is a clinical state closely associated with it with poor renal outcomes. The incidence is much higher in obstetrical AKI compared to other causes of RCN. Despite better medical care facilities available, this continues to be an important cause of morbidity and mortality in developing countries. This is a retrospective analysis among all pregnant females presenting with AKI from January 1999 to December 2014 at a tertiary care center in the northern part of India. We looked for the incidence of obstetrical-related RCN in our renal biopsies performed in the last 15 years and to evaluate precipitating factors responsible for RCN. RCN constituted 8.3% of pregnancy-related AKI cases in our institution. The overall incidence has been declining which was 9.09% from 1999 to 2008 to 7.8% from 2009 to 2014. The patient's median age was 29.3 ± 5.2 years. The average time to presentation from the day of delivery was 8.7 ±2.1 days. The mortality was observed in 11.7% of them with sepsis and multiorgan dysfunction present in all of them. The most common etiology for RCN was found to be septic abortion and puerperal sepsis accounting for - 15.3% each. Postpartum hemorrhage was a cause in 9.09% of patients. The most important cause of RCN was postpartum thrombotic microangiopathy which was observed in 48.7% of patients. Kidney biopsy was helpful in diagnosis in 31 patients while computed tomography scan abdomen alone helped in diagnosis in five patients. Patchy cortical necrosis in histology was seen in 35.4% of patients and morbidity in terms of prolonged hospitalization was seen in 22.7% while dialysis dependency in 61.5% of the study population. In conclusion, strategies need to be implemented in reducing the preventable causes for RCN which is not only catastrophic in terms of renal outcomes but also for social and psychological perspectives as well.

Altered Fibrinolysis in DVT: Influence of Site of Sampling

Alteration of the fibrinolytic system is considered to be important in the development of deep venous thrombosis (DVT). Using specific assays for tissue plasminogen activator (t-PA) activity, t-PA inhibitor (PAI) and t-PA antigen, we measured these activities in 16 women who developed DVT during their pregnancies. A group of 24 healthy females of comparable age was studied as controls. PAI was increased in 87% of these patients compared to the healthy controls. In some of these patients a defect in release of t-PA from vascular endothelium was found as well. The site at which blood was sampled for analysis appeared to be an important criterion in the ex vivo assessment of functional t-PA reserve and PAI levels, though relatively less so for the latter measurement. The unaffected lower limbs, relative to the unaffected upper limbs, showed an increase in PAI and a demonstrable decrease in t-PA release, both representing increased risk factors for rethrombosis. The affected lower limbs showed similar but more accentuated changes in these parameters.

Homicide concealed strangulation after bobbing reins in sexually sadistic homicide

This case of sexually motivated homicide combined the perpetrator's obliteration of his victim's identity along with his attempt at concealment of the corpse and sexual gratification following ligature strangulation of a young unidentified female from a minority Indian state. Sexual bondage was evident with characteristic body tying in a typical posture to fuel the killer's sexual arousal and gratification before, during and then after strangling his victim with a scarf. The victim's body was left in a sack packed with vegetables and transported from the crime site and found abandoned in a park.

Prognostic markers for colorectal cancer: estimating ploidy and stroma

Background

We report here the prognostic value of ploidy and digital tumour-stromal morphometric analyses using material from 2624 patients with early stage colorectal cancer (CRC).

Patients and methods

DNA content (ploidy) and stroma-tumour fraction were estimated using automated digital imaging systems and DNA was extracted from sections of formalin-fixed paraffin-embedded (FFPE) tissue for analysis of microsatellite instability. Samples were available from 1092 patients recruited to the QUASAR 2 trial and two large observational series (Gloucester, n = 954; Oslo University Hospital, n = 578). Resultant biomarkers were analysed for prognostic impact using 5-year cancer-specific survival (CSS) as the clinical end point.

Results

Ploidy and stroma-tumour fraction were significantly prognostic in a multivariate model adjusted for age, adjuvant treatment, and pathological T-stage in stage II patients, and the combination of ploidy and stroma-tumour fraction was found to stratify these patients into three clinically useful groups; 5-year CSS 90% versus 83% versus 73% [hazard ratio (HR) = 1.77 (95% confidence interval (95% CI): 1.13-2.77) and HR = 2.95 (95% CI: 1.73-5.03), P < 0.001].

Conclusion

A novel biomarker, combining estimates of ploidy and stroma-tumour fraction, sampled from FFPE tissue, identifies stage II CRC patients with low, intermediate or high risk of CRC disease specific death, and can reliably stratify clinically relevant patient sub-populations with differential risks of tumour recurrence and may support choice of adjuvant therapy for these individuals.

Pregnancy Check Point for Diagnosis of CKD in Developing Countries

Objective

Evidences suggest that females with CKD are associated with high risk of maternal and fetal complications. Early referral in CKD with pregnancy for specialist care may prove useful for maternal and fetal outcome.

Methods

Study looked for assessment of impact of CKD detection at the time of pregnancy and its impact on fetal and maternal outcome.

Results

A total of 465 females were retrospectively evaluated for renal status during their pregnancies, 172 females were unaware about their renal illness at the time of pregnancy, while 208 females were under regular obstetrical and nephrological follow-up during their pregnancy. 44.1% of these females in both groups had GFR < 60 ml/min. Preeclampsia was observed in 17.6% of planned pregnancies, while it was observed in 47.5% of unplanned pregnancies. Worsening of renal failure during and following pregnancy was observed among all stages of CKD, and there was greater decline in GRF with progression to ESRD earlier during or after pregnancy among unplanned pregnancies. Planned pregnancy group had better fetal outcome. Low birth babies weighing < 2500 g in unplanned group were much higher than in planned pregnancies.

Conclusions

Chronic kidney disease is often clinically silent until renal impairment is advanced. Pregnancy can be a check point for detection of renal disease and managed appropriately for better maternal and fetal outcome.

Assessment of DNA Ploidy in the ProMisE molecular subgroups of endometrial cancer

OBJECTIVE

We sought to determine whether DNA ploidy correlates with the four molecular subgroups of endometrial carcinoma (EC) as determined using ProMisE (Proactive Molecular Risk Classifier for Endometrial Cancer).

METHODS

90 cases of EC previously characterized by clinicopathological parameters, outcomes, and ProMisE molecular subgroup (POLE EDM, MMR-D, p53 wt or p53 abn) were assessed for DNA ploidy using image cytometry. Associations of ploidy with traditional clinicopathological parameters were also tested.

RESULTS

Abnormal DNA ploidy status differed amongst the ProMisE groups (p<0.001) and was found in 80.9% (17/21) of p53 abn, 37.0% (10/27) of p53 wt, 28.6% (4/14) of POLE EDM and 14.3% (4/28) of MMR-D. Abnormal DNA content was significantly associated with lower BMI (p=0.034) and grade 3 tumors (p=0.001). In the entire cohort, abnormal DNA content was significantly associated with worse progression free survival (p=0.0094) but not disease specific survival (p=0.249) or overall survival (p=0.187). When examining ploidy within each of the ProMisE groups, abnormal DNA content correlated with worse overall survival (p=0.041) and progression free survival (p=0.011) in the MMR-D group. No statistically significant relationship was seen in the remaining 3 groups.

CONCLUSION

Abnormal DNA ploidy status did correlate with the molecular subgroups of EC; abnormal DNA content was seen in the large majority of p53 abn cases. Abnormal ploidy however was also seen in smaller numbers in the p53 wt, POLE EDM and MMR-D groups; therefore abnormal DNA content was not a specific marker for any one molecular group. The addition of ploidy to the ProMisE molecular categories conferred additional prognostic value within the MMR-D group, which merits further study.

Intracranial hemorrhage from giant aneurysm in pregnancy: A rare association

We report a case of giant aneurysm causing subarachnoid hemorrhage in a pregnant female. A 25-year-old female presented with sudden onset of severe headache and vomiting with altered sensorium and right hemiplegia. On investigation, she had a giant supraclinoid segment internal carotid artery (ICA) aneurysm. She was planned for digital substraction angiography, but during the procedure she deteriorated neurologically and went into spontaneous labor. The baby was a male child with weight of 1.1 kg. She was taken up for surgery and aneurysm was clipped. We discuss the rare occurrence of intracranial hemorrhage in pregnancy due to a giant ICA aneurysm.

Dissecting intracranial aneurysm in pregnancy: A rare association

We report a case of dissecting aneurysm of the right posterior cerebral artery presenting with sudden onset headache and altered behavior during labor. A 26-year-old P1001 with uncomplicated antenatal period, except history of headache off and on since 32 weeks of pregnancy, developed sudden onset headache and altered behavior during 3^rd stage of labor. She had vaginal delivery and a live born male baby was delivered with good Apgar score. The CT was suggestive of subarachnoid hemorrhage and DSA was suggestive of dissecting aneurysm of the right P2 segment with hypoplasia of right P1 segment and A1 segment of posterior and anterior cerebral artery, respectively. The patient was managed conservatively. At 4-month follow-up, the patient was doing well. We discuss about the rare association of a dissecting aneurysm and pregnancy, especially dissection of the posterior cerebral artery.

Optically trapping tumor cells to assess differentiation and prognosis of cancers

We report an optical trapping method that may enable assessment of the differentiation status of cancerous cells by determining the minimum time required for cell-cell adhesion to occur. A single, live cell is trapped and brought into close proximity of another; the minimum contact time required for cell-cell adhesion to occur is measured using transformed cells from neural tumor cell lines: the human neuroblastoma SK-N-SH and rat C6 glioma cells. Earlier work on live adult rat hippocampal neural progenitors/stem cells had shown that a contact minimum of ~5 s was required for cells to adhere to each other. We now find the average minimum time for adhesion of cells from both tumor cell lines to substantially increase to ~20-25 s, in some cases up to 45 s. Upon in vitro differentiation of these cells with all-trans retinoic acid the average minimum time reverts to ~5-7 s. This proof-of-concept study indicates that optical trapping may be a quick, sensitive, and specific method for determining differentiation status and, thereby, the prognosis of cancer cells.

Phosphate adsorption from wastewater using zirconium (IV) hydroxide: Kinetics, thermodynamics and membrane filtration adsorption hybrid system studies

Excessive phosphate in wastewater should be removed to control eutrophication of water bodies. The potential of employing amorphous zirconium (Zr) hydroxide to remove phosphate from synthetic wastewater was studied in batch adsorption experiments and in a submerged membrane filtration adsorption hybrid (MFAH) reactor. The adsorption data satisfactorily fitted to Langmuir, pseudo-first order and pseudo-second order models. Langmuir adsorption maxima at 22 °C and pHs of 4.0, 7.1, and 10.0 were 30.40, 18.50, and 19.60 mg P/g, respectively. At pH 7.1 and temperatures of 40 °C and 60 °C, they were 43.80 and 54.60 mg P/g, respectively. The thermodynamic parameters, ΔG° and ΔS° were negative and ΔH° was positive. FTIR, zeta potential and competitive phosphate, sulphate and nitrate adsorption data showed that the mechanism of phosphate adsorption was inner-sphere complexation. In the submerged MFAH reactor experiment, when Zr hydroxide was added at doses of 1-5 g/L once only at the start of the experiment, the removal of phosphate from 3 L of wastewater containing 10 mg P/L declined after 5 h of operation. However, when Zr hydroxide was repeatedly added at 5 g/L dose every 24 h, satisfactory removal of phosphate was maintained for 3 days.

Removal of phosphorus by a high rate membrane adsorption hybrid system

Membrane adsorption hybrid system (MAHS) was evaluated for the removal of phosphate from a high rate membrane bioreactor (HR-MBR) effluent. The HR-MBR was operated at permeate flux of 30L/m(2)h. The results indicated that the HR-MBR could eliminate 93.1±1.5% of DOC while removing less than 53% phosphate (PO4-P). Due to low phosphate removal by HR-MBR, a post-treatment of strong base anion exchange resin (Dowex(∗)21K-XLT), and zirconium (IV) hydroxide were used as adsorbent in MAHS for further removal of phosphate from HR-MBR effluent. It was found that the MAHS enabled to eliminate more than 85% of PO4-P from HR-MBR effluent. Hence, HR-MBR followed by MAHS lead to simultaneous removal of organics and phosphate in a reliable manner. The experiments were conducted only for a short period to investigate the efficiency of these resins/adsorbents on the removal of phosphorus and high rate MBR for organic removal.

Clinical study of anemia in women attending the College of Medical Sciences Bharatpur

OBJECTIVE To study the clinical profile of Anemia in Women attending the College of Medical Sciences-Teaching Hospital, Bharatpur, Chitwan.MATERIALS & METHODS The Study was conducted among 100 women patients attended to the College of Medical Sciences- Teaching Hospital, Bharatpur, Chitwan. Their blood samples were tested and related socio-demographic information was collected. The associated Clinical signs and symptoms with hemoglobin level and the occurrence of anemia were assessed.RESULT The peak incidence of Anemia was in the age group of 20-24 yrs (59.7%), and severity of anemia was correlated with sings and symptoms. Majority of them had Microcytic Hypochromic anemia (43.1%) with serum iron level below normal level and increased TIBC (total iron binding capacity) were observed.CONCLUSION The high prevalence of Nutritional anemia suggests the dietary advice to be emphasized strongly.Journal of College of Medical Sciences-Nepal, 2014, Vol-10, No-3, 23-28

Status of Vitamin D and its Association with Stroke Risk Factors in Patients with Acute Ischemic Stroke in a Tertiary Care Hospital

INTRODUCTION

Vitamin D deficiency has been associated with many neurological illnesses. The status of Vitamin D in Nepalese ischemic stroke patients is still unknown. This study aims to assess the status of vitamin D and its association with stroke risk factors in patients with acute ischemic stroke from Central Nepal.

METHODS

A total of 60 patients with ischemic stroke were included in the study. Their clinical profile and Vitamin D status were assessed. Frequency distribution, Pearson χ2test and Kruskal-Wallis test were performed for statistical analysis using SPSS-IBM 20.

RESULTS

The median (IQR) age of the patient was 65 (53.25, 70.75) years, ranging from 18-87 years. Thirty-four (56.7%) were males. Fourty-eight (80%) patients had hypertension and 34 (56.7%) were smoker. Previous stroke was present in six (10%) cases. Thirty-seven (61.6%) patients had low levels of Vitamin D out of which 26 (43.3%) had vitamin D insufficiency and 11 (18.3%) had vitamin D deficiency. Vitamin D level was significantly associated with previous history of stroke (P=0.043).

CONCLUSIONS

Vitamin D deficiency occurs in patients with ischemic stroke. Previous episodes of stroke with low vitamin D levels could be a cause of recurrent strokes. Further studies are necessary to establish the role of vitamin D in acute ischemic stroke in Nepalese population.

Management of traumatically intruded young permanent tooth with 40-month follow-up

BACKGROUND

Intrusive luxation injuries often result in severe damage to the tooth, periodontal ligament and pulpal tissue. Furthermore, treatment outcome is often unpredictable because of the large number of injury related variables which influence choice of treatment and prognosis. This report presents the case of a 9-year-old boy with a 6 mm intruded permanent maxillary central incisor with an open apex.

METHODS

The treatment option chosen was to wait and watch for 'spontaneous re-eruption'. At the end of two weeks, the tooth showed signs of pulp necrosis and external root resorption. A palatal mucoperiostal flap was reflected and endodontic access was established, following which an intracanal medicament of calcium hydroxide was applied. By the end of the fifth month, there was radiographic evidence of apical barrier formation and by the tenth month, the tooth had re-erupted to the level of the adjacent central incisor. Root canal treatment was completed at the end of 24 months and the root was reinforced using a glass fibre post.

RESULTS

At the last follow-up visit (40 months after trauma), the tooth was asymptomatic and radiographic examination showed satisfactory periapical and periodontal healing.

CONCLUSIONS

Spontaneous re-eruption is possible, even in severely intruded teeth with open apices.

Higher Incision at Upper Part of Lower Segment Caesarean Section

INTRODUCTION

To determine if the upper part of the lower segment of the uterus is a better site for cesarean incision then the traditionally used lower end.

METHODS

This is a case-control study (1:1 ratio) conducted from 1(st) October 2012- 30(th) September 2013 observed between transverse incision at the upper part of the lower segment versus traditional lower segment of the uterus. Two hundred caesarean sections were performed via a transverse uterine incision at the upper part of the lower segment and equal numbers of uterine incision was performed at traditional lower segment. To obtain less intraoperative bleeding high incision made at thicker wider muscular part at of the upper part of lower segment about 2-3 cm distances from vesico-uterine serosa.

RESULTS

The estimated volume of blood loss in high incision 188±60.1 ml was significantly less compared to traditional incision 330.1± 86.5 ml (p<0.05). Duration of operation 30.5± 6.6 minute versus 45.3±7.2 minute and tearing the uterine incision was significantly less with the high incision versus traditional incision. Other procedural and patient benefits are noted.

CONCLUSIONS

An incision at the upper part of the lower segment reduces blood loss, enhances uterine retraction, predisposes to fewer complications, is easier to repair, precludes bladder adhesion to the suture line and reduces operation time.

Intrauterine Gauze Packing in Primary Post Partum Hemorrhage following Caesarean section: A Clinical study

Aims: To study the effectiveness of uterine gauze packing to manage and prevent primary postpartum haemorrhage during cesarean delivery. Methods: This was a prospective study that was conducted in the department of obstetrics and gynecology, first affiliated hospital of Chongqing Medical University from Jan to May 2011. Patients included in the study were those with intractable postpartum hemorrhage not responding to medical treatment and for prevention of hemorrhage that could develop during cesarean section. Exclusion criteria included cases of ruptured uterus and vaginal deliveries.Packing was done using 2 m long and 10 cm wide sterilized gauze from the fundus through the cesarean incision with its end passing through cervix into the vagina and left for 24-48 hours or removed earlier in cases of failure to control hemorrhage. Results: Intrauterine gauze packing during cesarean section to arrest primary postpartum hamorrhage is a successful non-invasive technique. Intractable primary postpartum hamorrhage encountered in 42 (30.9%) cases had PPH after cesarean section. Placenta previa found in 48 (35.3%) cases unresponsive to uterotonics drugs was the commonest cause of uterine gauze packing. Intrauterine gauze packing was successful in 130 (95.6%) cases. Conclusions: Uterine packing is a cost effective, quick and safe procedure to manage and prevent primary PPH during cesarean delivery. Uterine packing is of benefit in achieving hemostasis particularly in cases of post partum hemorrhage due to low-lying placenta previa/accreta associated with lower segment bleeding conserving the uterus in women with cesarean delivery. Nepal Journal of Obstetrics and Gynaecology / Vol 7 / No. 1 / Issue 13 / Jan- June, 2012 / 33-36 DOI: http://dx.doi.org/10.3126/njog.v7i1.8833

Sudden death in advanced abdominal pregnancy: a case report and discussion of the related medicolegal issues

We report sudden unexpected death in a 35-year-old woman with pregnancy of seven months duration. There was an allegation by the parents of the woman that she was subjected to an assault prior to death. Autopsy examination showed an abdominal pregnancy with a dead fetus, ruptured gestational sac, massive haemorrhage and secondary placental attachment. During her antenatal check-ups, she had persistently complained of abdominal pain and loose stools, but the diagnosis of abdominal pregnancy was missed clinically and on ultrasound scan. In this paper we discuss the diagnostic difficulties and medicolegal issues in such cases.

Thyroid peroxidase antibody in hypothyroidism: it's effect on pregnancy

OBJECTIVE

To find out the prevalence of thyroid peroxidase antibodies (TPO) in pregnant women with hypothyroidism and to analyze its effect on pregnancy outcome.

METHODS

The prospective study was conducted on well-controlled hypothyroid pregnant patients attending the antenatal clinic at Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India from July 2009 to June 2011 and has delivered. The women were grouped into two groups depending on presence or absence of TPO antibody. Maternal complications during pregnancy and perinatal outcome were noted and compared between these two groups.

RESULTS

During the study period, 2479 women attended the high-risk pregnancy clinic. Among which 196 women were found to be hypothyroidism making prevalence of hypothyroidism as 7.91%. A total of 140 were found to be well controlled (5.6%) and included for study. Amongst the women with hypothyroidism, 40% were TPO positive. Complications like threatened abortion, spontaneous abortion, preterm delivery, fetal malformations, intrauterine growth restriction, and adverse fetal outcomes like poor apgar scores and prolonged nursery admissions were more in patients with positive TPO antibodies.

CONCLUSION

TPO positivity is considered as high risk for pregnancy complications and hence those patients should be monitored more carefully.

Hepatitis E virus infection causing isolated fetal ascites: a case report

Maternal hepatitis infection, excepting hepatitis E, causing isolated fetal ascites with variable outcome has been reported previously. We present a case of maternal hepatitis E virus (HEV) infection causing isolated fetal ascites which resolved spontaneously during pregnancy and resulted in a term live-born baby with anti-HEV seropositivity. A 39-year-old primigravida woman was diagnosed with acute HEV infection at 15 weeks of gestation. Ultrasound at 19 weeks showed significant fetal ascites with abdominal calcifications. Fetal karyotype did not show any abnormality. Cord blood was positive for anti-HEV IgM and negative for other intrauterine infections. Ultrasound at 25 weeks showed partial resolution of fetal ascites with complete resolution at 30 weeks. She delivered a healthy baby at 38 completed weeks, with normal liver enzymes at birth and 1-month follow-up.

Prognostic importance of DNA ploidy and DNA index in stage I and II endometrioid adenocarcinoma of the endometrium

BACKGROUND

We evaluated the prognostic importance of DNA ploidy in stage I and II endometrioid adenocarcinoma (EAC) of the endometrium with a focus on DNA index.

PATIENTS AND METHODS

High-resolution DNA ploidy analysis was carried out in tumor material from 937 consecutive patients with International Federation of Gynecology and Obstetrics (FIGO) stage I and II EAC of the endometrium.

RESULTS

Patients with diploid (N = 728), aneuploid tumor with DNA index ≤ 1.20 (N = 118), aneuploid tumors with DNA index >1.20 (N = 39) and tetraploid tumor (N = 52) had 5-year recurrence rates 8%, 14%, 20% and 12%, respectively. Patients with aneuploid tumor with DNA index >1.20 had a poorer 5-year progression-free survival (67%) and overall survival (72%) compared with the patients with aneuploid tumor with DNA index ≤ 1.20 (81% and 89%, respectively). Aneuploid tumors with DNA index ≤ 1.20 relapsed mainly in the vagina and pelvis, whereas aneuploid tumors with DNA index >1.20 relapsed predominantly outside pelvis.

CONCLUSIONS

The recurrence risk for the patients with aneuploid tumor is higher than the patients with diploid tumor in EAC of the endometrium. Based on DNA index with cut-off 1.20, aneuploid tumors can be separated into two subgroups with different recurrence pattern and survival.

Rare association of fetal posterior urethral valve with ureteric stricture

BACKGROUND

Amongst the various causes of obstructive uropathies, pelviureteric junction obstruction, bilateral ureterovesical junction obstruction and vesicoureteral reflux are common. The association of posterior urethral valve and ureteric stricture has not been reported so far.

CASE

We report a rare case of fetal obstructive uropathy presenting as combination of ureteric stricture with posterior urethral valve and its consequences like cystic dysplastic kidneys and urinoma.

CONCLUSION

Combination of urinary malformation may be due to basic primary pathology and its secondary consequence at a distant site.

Complete Pentalogy of Cantrell with craniorachischisis: a case report

BACKGROUND

Pentalogy of Cantrell is a rare malformation syndrome consisting of a specific combination of ventral midline defects, uncommonly found to be associated with other anomalies.

CASE

We report a case of complete Pentalogy of Cantrell with craniorachischisis diagnosed in-utero at 19 weeks of gestation through antenatal ultrasonography. Fetal autopsy following termination of the pregnancy confirmed the presence of the sonographically detected malformations and also revealed associated transposition of great vessels (TGV) in the fetus.

CONCLUSION

Co-occurrence of such ventral and dorsal midline defects suggests the possibility that common genetic and environmental factors influence the early stages of development of the ventral as well as dorsal embryonic midline.

Pain during rigid cystoscopy: a prospective randomized controlled study comparing the benefit of cooled and room temperature lignocaine gel

Lignocaine gel is an established topical anesthetic agent for cystoscopy in awake patients. We performed a prospective randomized study to evaluate whether cooling the lignocaine gel to 4 degrees C decreases the pain perception during cystoscopy in male patients. Sixty consecutive male patients undergoing rigid cystoscopy were randomized into two groups. Group I received 15 ml of 2% lignocaine hydrochloride gel at 4 degrees C and group II received the same agent at room temperature (20 degrees C). Cystoscopy was performed and pain perceived during the procedure was assessed by independent evaluator using Wong-Baker FACES pain scale rating chart. The mean pain score in group I was lower (4.32 +/- 1.70) than that in group II (5.28 +/- 1.99), but this difference was statistically not significant (p=0.191). However significantly greater percentage (84% Vs 52%) of patients with cooled lignocaine wished to have same anesthetic in future for similar procedure (p=0.032). In conclusion, cooling the lignocaine gel to 4 degrees C does not decrease the pain perception during rigid cystoscopy in male patients.

Association of polymorphic pattern of the (AT) × (T)y motif of β-globin gene in North Indian thalassemia patients with variable clinical expression

Among the polymorphic genetic markers of the β-globin gene cluster, the (AT) × (T)y motif and a common C→T variation at -158 of the Gγ globin gene were investigate din 20 β-thalassemia IVSI-5 (G→C) homozygous patients with variable clinical manifestation and 10 normal subjects from north India to deduce any association with the co-inherited genetic polymorphism. We found (AT)(7)(T)(7) repeat motif in all the 20 chromosomes of normal subjects and two different sequence configuration(AT)(8)(T)(5), (AT)(9)(T)(5) in the patient group whereas the presence of -158(C→T) Gγ was quite polymorphic. We conclude that polymorphism -158(C→T) Gγ and (AT) × (T)y sequence variation other than (AT)(7)(T)(7) could influence the phenotype by increasing Hb F expression.

Histological Pattern of Gynecological Cancers

Abstract