Fracture Management in Pyknodysostosis - A Rare Case Report

Introduction:

Pyknodysostosis is congenital osteosclerotic skeletal dysplasia of a rare entity. It is an autosomal recessive disease which presents with short stature and generalized osteosclerosis of skeleton as result of decreased bone turnover. Here, the authors report a case of pyknodysostosis who presented to our emergency room with a pathological fracture in the shaft of the femur for which operative intervention was carried out.

Case Report:

A 30-year-old female presented to our emergency room with a history of trivial injury to right thigh region and was diagnosed as fracture in her right femur shaft region. After a detailed clinical, radiological, and blood investigations, the patient was taken up for operative modality of intervention in the form of plate osteosynthesis. As the medullary canal was narrow and bone was osteosclerotic, the option of closed intramedullary interlocking nailing was ruled out. Hence, we proceeded with open reduction and internal fixation with plate osteosynthesis using a board dynamic compression plate. Post-operative period was uneventful. Patient underwent non-weight bearing mobilization for 2 months. At 10-week post-operative follow-up, the patient presented with pain over surgical site and radiological examination showed no signs of union. The patient underwent additional plating augmented with bone grafting using grafts harvested from iliac crest and synthetic bone graft. The patient developed deep-seated infection immediate post-operative period for which she was treated with wound debridement, and appropriate intravenous antibiotics were given 2 weeks and orally for 4 weeks. At 6-month follow-up, the patient is able to carry her day-to-day activity with complete recovery and radiological signs of union. The patient had classical clinical features suggestive of pyknodysostosis. Patient has 2 siblings of same family (one brother and sister) with similar clinical and radiological features.

Conclusion:

Recognition of these clinical and radiological signs is important to make the diagnosis of pyknodysostosis and prevent possible complications. Additional care must be taken in treating these patients.

Synthesis, characterization and adsorption behavior of cotton fiber based Schiff base

Structural modification of Cotton (Cot) fiber was carried out using ε-caprolactone (CL) as a monomer and oxydianiline (ODA) as a Schiff base forming agent in the presence of V₂O₅ catalyst in dimethylsulfoxide medium for 24h under air atmosphere (0.10MPa) at 80°C. The obtained products were analyzed for the characteristics and also for its adsorption of hexavalent chromium (Cr(VI)) and rhodamine 6G (R6G) dye molecules. The ¹H NMR spectrum confirms the Schiff base formation at 8.7ppm. The adsorption study confirms the Pseudo second order kinetics with Langmuir adsorption model. The structurally modified Cot fiber based Schiff base exhibited the highest adsorption behavior through chemical interaction forces. The thermodynamic parameters were determined and confirmed the endothermic adsorption process.

Multifocal tuberculous osteomyelitis: A rare presentation

A 29 year old lady presented with vague right lower quadrant abdomen and thigh pain for the past 4 years. X-ray pelvis with both hips was remarkably normal, and MRI was suggestive of osteomyelitis in right ilium and proximal femur. Biopsy confirmed the lesion as tubercular. Isolated bone involvement by tuberculosis without a joint or pulmonary involvement is extremely rare in immunocompetent patients and has not been reported in literature so for. Tuberculosis should be suspected in patients presenting with multiple bone lesions, especially in endemic areas. Prompt surgical drainage and ATT forms the mainstay of treatment.

Awareness of brain death and organ transplantation among select Indian population

BACKGROUND

With the improvement in transplant technology major organ transplantation is gradually becoming the treatment of choice in many conditions. The present study assesses the awareness of the concepts of brain death and organ transplantation among public.

METHODS

Six hundred thirty six select populations, which included office-goers of Delhi, class 12th school children of a reputed public school and villagers, were interviewed to assess their knowledge in various aspects of brain death and organ transplantation.

RESULTS

There was widespread acceptance of organ transplantation among this population. The most alarming feature was that the awareness of the concept of brain death and its importance for organ donation was extremely low. Only small number of individuals were aware that brain death is legal in India. Awareness about brain death was especially low among villagers.

CONCLUSIONS

Education about various aspects of brain deaths, its immense importance for organ donation and legality of brain death in India needs to be highlighted.

Awareness of brain death and organ transplantation among high school children

The objective of this study was to assess the awareness of the concepts of brain death and organ transplantation among high school children. One hundred and eighty eight students of class 12th of a reputed public school were studied. Structured questionnaires were used to assess their knowledge in various aspects of brain death and organ transplantation. Following the questionnaire, they were provided with educational information on brain death and organ transplantation. This was followed by similar questionnaires to assess any change in awareness of brain death and organ transplantation. Results spoke of widespread awareness and acceptance of organ transplantation in the high school children. However, the awareness of various aspects of brain death was quite low. There was significant increase in awareness and acceptance of brain death after educating the students. Education about various aspects of brain death, its immense importance for organ donation and legality of brain death needs to be highlighted.

Comparison between serum and urinary sulphadimidine acetylation as predictors of isoniazid acetylator status in patients with pulmonary tuberculosis

The acetylator status of 200 pulmonary tuberculosis patients was determined by sulphadimidine (SDM) acetylation in (1) urine and (2) serum. In both estimations, distribution of the patients with regard to the acetylation rates was found to be bimodal. Based on the percent frequency distribution of acetylated SDM, the antimode for urine and serum was 65% for the former and 45% for the latter. Patients acetylating above 65% or 45% of administered SDM were taken as rapid acetylators, while those acetylating less, were slow acetylators. The ratio of slow to rapid acetylators in urine and serum was 58 : 42 and 66 : 34 respectively. The renal clearance of acetylated fraction of SDM was considerably greater as compared to that of the unacetylated fraction. Agreement between the two methods as evaluated by the kappa statistic was 0.71. The determination of the acetylator status by the SDM acetylation test in the urine is simple to perform and has acceptable accuracy. It may be used as an acceptable substitute to serum for estimating the isoniazid inactivation status which is of considerable importance when patients are treated with daily/ intermittent/once-weekly drug regimens for tuberculosis.

Behçet's disease in India: a clinical, immunological, immunogenetic and outcome study

The clinical and laboratory profile of 58 consecutive patients satisfying the ISG 1990 criteria for the diagnosis of Behçet's disease was analysed. It appears that Behçet's disease in India is predominantly 'mucocutaneous' and 'arthritic'; 'ocular' and 'neuro' Behçet's being uncommon. In comparison to published literature, the onset of disease in this part of the world is significantly delayed. The pathergy test is rarely positive. There is no significant difference in clinical presentation and laboratory investigations between children and adults with this disease; also, no sex difference was observed. A combination of oral steroids and colchicine gives good relief in most cases. Preliminary observations seem to reflect no definite association of any known class I antigen to disease in this part of the world. A detailed study on immunogenetics is underway.

Spectrum of clinical and laboratory characteristics of HIV infection in northern India

To define the impact of HIV infection in India, the clinical and laboratory profile and the correlation of CD4 count to the likely opportunistic infection in a cohort of 134 HIV positive patients in Northern India was analysed. Majority of the patients, 72% and 67.8% (children and adults respectively) were asymptomatic, having been detected during routine screening and maintained that status for a median follow-up period of 3 years. Among the symptomatic patients, oropharyngeal candidiasis was the most common opportunistic infection followed closely by tuberculosis (both pulmonary and extra pulmonary) around 3.6-4.0 years from probable HIV infection with a median CD4 of 420-578 per cmm. Infection with Cryptococcosis, Cryptosporidiosis and cytomegalovirus occurred only after a significant fall in CD4 to < 100/cmm usually around 8-10 years from probable HIV infection. Pneumocystis carinii pneumonia was the terminal event among the 12 deaths at a mean CD4 count of 6/cmm. Non specific constitutional symptoms like fever, prolonged diarrhoea and significant weight loss were frequent. In general, the clinical profile of Indian patients with HIV bears much resemblance to African countries owing perhaps to the similar background of poverty, malnutrition and endemic infection.

Adult onset Still's disease in northern India: comparison with juvenile onset Still's disease

The present study compared the clinical and laboratory picture, the disease course and outcome in 31 patients having adult onset Still's disease (AOSD) with 23 patients having juvenile onset Still's disease (JOSD). The median age at disease onset was 20 and 7 yr for AOSD and JOSD patients, respectively. On analysing and comparing our data on these two groups, no significant differences emerged except that adults had a significantly lower time interval from disease onset to remission as compared to juveniles. Upon comparison of data on our AOSD patients with that published from abroad, rash, adenopathy and sore throat were less frequent. No clinical or laboratory variables were found to predict the subsequent disease course and outcome in either group. The functional outcome was good in about 70% of both groups and mortality was low. It is concluded that the clinical picture and outcome in AOSD is similar to that of JOSD.

Sociodemographic characteristics of HIV infection in northern India

134 patients testing positive for HIV antibody during the period 1986-1993 were included in the present study. An in-depth analysis of the subjects revealed that the adult males seemed to have the highest propensity for HIV infection in this part of the country. Marital status had no bearing on incidence and route of seropositivity. This was not so in females. Extramarital heterosexual contact was the mode of HIV acquisition in adults in contrast to blood transfusion in children. Clinically, most of these patients were still asymptomatic. At presentation, oral Candidiasis was common. Pneumocystis carinii pneumonia (PCP) was the leading cause of death.

Utility of an observation unit in the emergency department of a tertiary care hospital in India

This retrospective study was conducted to evaluate whether an observation unit (OU) attached to the emergency department (ED) of a tertiary care hospital in India is safe, is effective in minimizing hospitalization of acutely ill patients and is acceptable to the patients. Of 115,916 patients who attended the ED, 11,130 (9.6%) were observed in the OU. The average period of observation was 7.74 h. Of the patients observed, 21.3% required hospitalization, while 78.5% were discharged after treatment. Twenty-four patients left the hospital against medical advice, and three patients died in the OU. It is concluded that an OU in the ED is safe in treating acutely ill patients, is effective in reducing substantially the number of patients requiring admission to the hospital, and is acceptable to the patients.

Profile of HLA-B27-related 'unclassifiable' seronegative spondyloarthropathy in females and its comparison with the profile in males

Unclassifiable seronegative spondyloarthropathy (SSA) syndrome is primarily considered to be an affliction of males. In this report from northern India, 25 HLA-B27 antigen positive females with this condition are described and compared with 39 HLA-B27-positive males with the same disease. All these patients presented with typical features of spondyloarthropathy such as predominantly lower limb synovitis, enthesopathy and inflammatory spinal pain. The onset was insidious in 56% of the females and in 64% of the males. The mean age of onset as also the mean duration of symptoms prior to diagnosis were significantly higher in females (26.2 vs 19.4 yr and 8 vs 2 yr, respectively). A mono- or oligo-arthritis was seen in 52% of the females and in 53% of the males, but the average number of joints involved was less in females (4.8 vs 7.7). Lower limb joints alone were involved in 56% of the females and 49% of the males, with the knees, ankles and hips being most commonly involved, often asymmetrically. The mean degree of symmetry was significantly lower in females (62 vs 76). Ninety-two per cent of females and 74% of males had inflammatory spinal pain. Radiographic sacroiliitis was demonstrable in 56% females and 74% males. It is concluded that 'unclassifiable' SSA syndrome is not infrequent in females but is diagnosed late. Fewer joints tend to be involved and there is greater tendency towards asymmetry in females.

SLE in Indian men: analysis of the clinical and laboratory features with a review of the literature

Data on the clinical and laboratory profile of 39 male lupus patients has been analysed. An attempt has been made to (1) delineate the pattern of SLE in Indian males, (2) compare it with that reported in the world literature, (3) find out differences, if any, between male children and adults with the disease, and (4) compare it with our previously published data on Indian females with SLE. Several important points were brought out in this study. First, SLE in Indian males has an earlier age of disease onset, a higher incidence of mucocutaneous and renal involvement and a lower incidence of neuropsychiatric, gastrointestinal and hematological disease in comparison to those published from the developed countries. Second, leucopenia and lymphopenia, a reflection of disease severity, occur significantly more in male children compared with adults. Thrombocytopenia is exclusively noted in adult males and virtually non-existent in children. Third, male patients overall have a less severe form of the disease in comparison with their female counterpart, as was evident by significantly less patients with hypocomplementemia, diffuse proliferative lupus nephritis and psychosis. Finally, a higher frequency of infection, particularly tuberculosis, was seen in male patients, which was the cause of death in some.

Analysis of clinical and laboratory profile in Indian childhood systemic lupus erythematosus and its comparison with SLE in adults

Data on the clinical and laboratory profiles of 83 children with SLE have been analysed and compared with data on 187 adults with the disease. The clinical features of childhood SLE are similar to those seen in adults, although clinical and laboratory parameters reflect propensity to a more severe form of the disease in the juvenile age group. However, in comparison to descriptions of childhood lupus from developed countries, in India the female-to-male ratio in this age group parallels that in adults. Renal involvement is noted to be more common, whereas gastro-intestinal and haematological abnormalities are less common. Interestingly, leucopenia, lymphopenia and nephritic type of renal involvement are commonly seen in boys with SLE, but these features are non-existent in men.

Protective & risk DR phenotypes in Asian Indian patients with rheumatoid arthritis

This study of 168 north Indian patients with rheumatoid arthritis (RA) confirms the significant association of susceptibility to RA with DR4 specificity (P less than 0.0001). This association was observed equally in familial as well as sporadic patients. The HLA-DR2 and DR5 alleles were identified to be conferring protection in RA, DR5 being reduced significantly in the non-familial patients only. None of the other DR antigens revealed any association with RA in this population, including the DR4 negative group of patients. An analysis of the DR phenotypes in patients and controls revealed that DR4 in combination with DR1 provided the highest relative risk (71.9) followed by DR4, DR4 (RR = 4.1). These results demonstrate that susceptibility to RA is not due to a single HLA specificity but the effect of a group of related epitopes occurring in common among subtypes of DR4 as well as in some DR1 alleles.

Clinical significance of anti-Sm antibody in systemic lupus erythematosus & related disorders

A retrospective analysis was undertaken of the clinical and immunological profile of 33 anti-Sm antibody positive (group I) and 243 anti-Sm antibody negative (group II) patients with systemic connective tissue diseases including systemic lupus erythematosus and related disorders (overlap, mixed and undifferentiated connective tissue diseases). The disease patterns were comparable, except for cutaneous vasculitis and hypocomplementaemia (low serum C3 levels). Vasculitis was observed in 55 per cent of group I and 35 per cent of group II subjects (P less than 0.05). Hypocomplementemia was also detected more frequently (86%) in group I as compared to group II (66%) patients (P less than 0.05). No association was found between anti-Sm antibody and renal, neuropsychiatric and cardiopulmonary features. The study thus demonstrated the association of anti-Sm antibody with immune complex mediated vasculitis.

HLA antigens in Indian population with non-specific aortoarteritis

HLA typing of Class I antigens (HLA - A & -B loci) was done for 65 patients suffering from nonspecific aortoarteritis, in Indian population. The diagnosis of these patients was based on clinical findings and confirmed by angiographic studies. Decreased phenotype frequency of HLA-A19 (p less than 0.005, relative risk 0.28), increased frequency of HLA-B5 (p less than 0.005, relative risk 2.46) and B21 (p less than 0.005, relative risk 3.25) was observed when compared with the control group. A decreased frequency of two other alleles of B locus i.e. B35 (p less than 0.005, relative risk 0.27) and B40 (p less than 0.05, relative risk 0.04) was seen in patient group as compared to control. The data indicate the possible association of HLA-B5 and B21 antigens with the nonspecific aortoarteritis.

Antibodies to extractable nuclear antigens in connective tissue disorders in India: prevalence and clinical correlations

Antibodies to Extractable Nuclear Antigens (ENAs) namely Sm, nRNP, SS-A and SS-B were studied in 397 patients with various connective tissue diseases (CTD), 146 patients with inflammatory polyarthropathies, 16 cases of systemic vasculitides, and 39 normal subjects using counterimmunoelectrophoresis and double immunodiffusion methods. Anti-ENA antibodies were positive in 40.8 percent cases of Systematic lupus erythematosus (SLE) (n = 191), 36.4 percent of overlap CTD (OCTD, n = 44), 27.8 percent of Sjogren's syndrome (n = 18), 10.6 percent of progressive systemic sclerosis (PSS, n = 66) and 2.7 percent of rheumatoid arthritis (n = 111) patients. The correlation of these antibodies with disease features was done. The significant finding was negative association of anti-nRNP antibodies (when present alone) with renal involvement. Anti-Sm antibodies did not correlate with any disease feature. The other associations included correlation of anti-nRNP with pulmonary parenchymal lesions, anti-SS-A with serositis and pulmonary hypertension, and anti-SS-B with myocarditis and recurrent diarrhoea. We conclude that Anti-ENAs may correlate with certain subsets of these diseases but the subject is controversial.

Sister chromatid exchange in human chromosomes from normal individuals and epileptic patients on combinations of anticonvulsants

Sister chromatid exchange (SCE) frequency, a sensitive indicator in mutagenicity testing, and mitotic index (MI) have been studied to observe genotoxic effects in epileptic patients on routine combinations of anticonvulsant therapy. All patients, both male and female and from various age groups, revealed an increased frequency of SCE per metaphase and a low MI (P less than 0.001) with respect to controls. A nonsignificant decrease in SCE frequency has been observed with an increase in the age of onset of epilepsy. Although the SCE frequency increased and the MI decreased in some groups with respect to the duration of epilepsy, there was no difference observed in SCE frequency with the duration of therapy.

Mutagenic risk in epileptic patients before and after anticonvulsant therapy

Therapy with anticonvulsant drugs has often been found to result in somatic chromosome aberrations in adult patients. There is also the possibility of epileptic fathers or mothers playing a role in the production of congenital malformations in their offspring. We have used the technique of sister chromatid exchange (SCE), a sensitive indicator of mutagenicity, to observe the mutagenic susceptibility in both male and female epileptic patients in different age groups prior to and after anticonvulsant therapy, and with respect to control. The frequency of SCE was significantly higher in all the age groups for treated and untreated cases compared with control. Between treated and untreated subjects in age group 26-50 years, a significantly higher SCE frequency was observed in the untreated patients (p less than 0.01). Similarly, untreated male patients showed a significantly higher SCE frequency (p less than 0.025) compared with treated male patients. Although the results of this study provide a general assessment of mutagenicity in epileptic patients that agrees with other studies and emphasizes the role of the disease in the higher occurrence of congenital malformation in their offspring, the importance of higher SCE frequency in untreated patients remains to be explained in further studies.

Distribution of HLA antigens in a sample of the North Indian Hindu population

The Indian population can be divided broadly into Dravidians and the Aryans. In this report, we have attempted to analyze the HLA genetic profile of 400 native North Indian Hindus of Aryan descent. The gene frequencies of a majority of class I and II antigens show similarity to the Caucasoid population. An interesting finding was a complete lack of antigen B14 while B16 and B41 occurred with the least frequency. Haplotype A10, B8 with significant positive linkage disequilibrium as well as showing the highest incidence is characteristic of North Indians.

Vitamin B12, folate, and iron studies in homozygous beta thalassemia

The efficacy of serum folate (SF), red blood cell folate (RCF), and serum B12 in diagnosing folate and B12 deficiency, and the effect of iron overload on hemoglobin, were studied in 157 cases of homozygous beta thalassemia (HBT). The patients had lower SF compared with normal subjects (NS) (P less than 0.001) and higher RCF than their parents (P less than 0.001) and NS (P less than 0.001). Forty percent of patients had both low SF (less than 3 ng/mL) and high RCF (greater than 600 ng/mL). Homozygous beta thalassemia patients are known to have folate deficiency. Yet, both folate and B12 deficiency status were similar in the authors' patients and NS. These deficiencies apparently were less in patients compared with their parents, who shared the same nutritional milieu (P less than 0.001). Mean hemoglobin in patients with iron overload (transferrin saturation, TS greater than 50%) was lower than in those without (P less than 0.005). The following is concluded: (1) diagnosis of folate and B12 deficiency based on SF, RCF and serum B12 is vitiated in HBT and needs a therapeutic trial; (2) iron overload of a magnitude indicated by TS greater than 50% can aggravate anemia in HBT.

A study of serum ferritin in beta thalassemia. Iron deficiency and overload

Serum ferritin, serum iron, and unsaturated iron binding capacity were studied in 64 patients with beta homozygous thalassemia (BHT), 120 patients with beta heterozygous thalassemia, and 46 normal subjects. Incidence of iron overload seen in 32 BHT cases was similar in untransfused and transfused cases. Among heterozygotes, iron stores were depleted in 24 (20%), mostly females (70.8%). Only male heterozygotes but not normals were iron deficient. In 18 (75%) heterozygotes with depleted iron stores, transferrin saturation (TS) was normal. It was also normal in 8 (25%) BHT patients and 5 (100%) heterozygotes with iron overload. In 13 (35.1%) BHT patients, it was raised in the absence of iron overload. It was concluded that iron deficiency in heterozygotes is of greater magnitude, especially in females, than hitherto known in India. Transferrin saturation is not a good indicator of either iron depletion or overload. Iron supplementation is recommended in heterozygous beta thalassemia in infants, children, and expectant mothers in geographic areas with high incidence of iron deficiency.

Biophysical studies on molecular mechanisms of abortifacient action of prostaglandins. V. CNDO/2 estimation of the relative affinities of the cations Na+, Mg2+ and Ca2+ to the carboxylic group

The paper describes the study of relative affinities of the cations Na+, Mg2+ and Ca2+ to the carboxylic group, their electronic structure and optimum binding positions on the basis of the CNDO/2 technique, using the well known supramolecular approach. The cation for this purpose was made to approach the carboxylic group in various possible directions in and out of the plane C1O1AO1B and the final parameters were evaluated for the optimum planar as well as nonplanar geometries. With the exception of Ca2+ the nonplanar geometries were always favoured over the planar ones for binding at O1A and O1B, whereas for symmetric binding between O1A and O1B planar geometries were favoured for Mg2+ and Ca2+. The distance between the cation and oxygen was slightly larger for this geometry and Etot which followed the order Mg2+ less than Ca2+ less than Na+ had the lowest value.