Posoleucel in Kidney Transplant Recipients with BK Viremia: Multicenter, Randomized, Double-Blind, Placebo-Controlled Phase 2 Trial

Key Points

Background

Kidney transplant recipients with BK virus infection are at risk of developing BK virus–associated nephropathy, allograft rejection, and subsequent graft loss. There are no approved treatments for BK virus infection. Posoleucel is an off-the-shelf, allogeneic, multivirus-specific T-cell investigational therapy targeting BK virus, as well as five other opportunistic viruses: adenovirus, cytomegalovirus, Epstein–Barr virus, human herpesvirus 6, and John Cunningham virus.

Methods

In this phase 2, double-blind study, kidney transplant recipients with BK viremia were randomized 1:1:1 to receive posoleucel weekly for 3 weeks and then every 14 days (bi-weekly dosing) or every 28 days (monthly dosing) or placebo for 12 weeks. Participants were followed for 12 weeks after completing treatment. The primary objective was safety; the secondary objective was plasma BK viral load reduction.

Results

Sixty-one participants were randomized and dosed. Baseline characteristics were similar across groups. No deaths, graft-versus-host disease, or cytokine release syndrome occurred. The proportion of patients who had adverse events (AEs) judged by the investigators to be treatment-related was slightly lower in recipients of posoleucel: 20% (4 of 20 patients) and 18% (4 of 22) in those infused on a bi-weekly and monthly schedule, respectively, and 26% (5 of 19) in placebo recipients. None of the grade 3–4 AEs or serious AEs in any group were deemed treatment-related. No deaths, graft-versus-host disease, or cytokine release syndrome occurred. Three participants had allograft rejection, but none were deemed treatment-related by investigators. In posoleucel recipients, BK viremia reduction was associated with an increase in the circulating frequency of BK virus–specific T cells, and the presence and persistence of posoleucel was confirmed by T-cell receptor sequencing.

Conclusions

Posoleucel was generally safe, well tolerated, and associated with a larger reduction of BK viremia compared with placebo. Limitations of this study include the relatively short duration of follow-up and lack of power to detect significant differences in clinical outcomes.

Clinical Trial registry name and registration number:

Study of Posoleucel (Formerly Known as ALVR105; Viralym-M) in Kidney Transplant Patients With BK Viremia, NCT04605484.

Effect on functional outcome of robotic assisted rehabilitation versus conventional rehabilitation in patients with complete spinal cord injury: a prospective comparative study

STUDY DESIGN

Prospective Comparative Study.

OBJECTIVE

This study aims to compare the functional outcomes of Robotic-assisted rehabilitation by Lokomat system Vs. Conventional rehabilitation in participants with Dorsolumbar complete spinal cord injury (SCI).

SETTING

University level teaching hospital in a hilly state of northern India.

METHODS

15 participants with Dorsolumbar SCI with ASIA A neurology were allocated to robotic rehabilitation and 15 participants to conventional rehabilitation after an operative procedure. Pre-and Post-rehabilitation parameters were noted in terms of ASIA Neurology, Motor and sensory function scores, WISCI II score (Walking Index in SCI score), LEMS (Lower Extremity Motor Score), SCI M III score (Spinal Cord Independence Measure III score), AO Spine PROST (AO Patient Reported Outcome Spine Trauma), McGill QOL score (Mc Gill Quality of Life score), VAS score (Visual Analogue Scale) for pain and Modified Ashworth scale for spasticity in lower limbs.

RESULTS

On comparing robotic group with conventional group there was a statistically significant improvement in Robotic-assisted rehabilitation group in terms of Motor score (p = 0.034), WISCI II score (p = 0.0001), SCIM III score (p = 0.0001), AO PROST score (p = 0.0001), Mc GILL QOL score (p = 0.0001), Max velocity (p = 0.0001) and Step length (p = 0.0001). Whereas LEMS score (p = 0.052), ASIA neurology (p = 0.264 (ASIA A); 1.000 (ASIA B); 0.053 (ASIA C)), VAS score (p = 0.099), Sensory score (p = 0.422) and Modified Ashworth scale for spasticity (p = 0.136) were not statically significant when comparing between two groups.

CONCLUSION

Robot-assisted rehabilitation is superior than conventional rehabilitation in people living with SCI with AIS A neurology. Differences in the patient group, type of a lesion its and severity, duration from onset to initiation of rehabilitation, devices employed, administration of the therapies and regulation of interventions are likely the cause of variations in the findings seen in the literature for robotic assisted training.

LEVEL OF EVIDENCE

III.

Outcome of early versus delayed presentation of proximal femur fractures in children: A prospective cohort study

OBJECTIVE

We hypothesized that the exact time of fixation of paediatric proximal femur fractures will have an effect on the ultimate clinical and radiological outcome. This article aimed to compare the clinical-radiological outcomes in paediatric proximal femur fractures having early and delayed presentation.

METHODOLOGY

A prospective cohort study was conducted from January 2019 to November 2022 in patients of age of 5 to 16 years presented with proximal femur fracture and divided into two groups: group A: early presentation, presented <48hours of injury; group B: delayed presentation, presented >48hours of injury. Patients underwent internal fixation treatment modality and followed up to assess clinical outcomes and radiological outcomes, and final outcome was assessed as per Ratliff's criteria.

RESULTS

In the study of 44 patients, 72.72% were male, and 27.27% were female, with male-to-female ratio to be 2.6:1. The commonest mode of injury was fall from height accounting for 52.27% followed by road traffic accidents (RTA) in 38.63%. The most common fracture type observed was Delbet type II, which was observed in 43.18%. There was significant shorter duration of surgery in group A (p-value=0.013), VAS score (p=0.045), and limb length discrepancy (p=0.022). Also, there was a statistical difference in AVN (p-value=0.0295) and growth disturbance (p-value=0.0394) between two groups. Also, there was statistically significant difference between Ratliff's criteria two groups (p-value=0.030).

CONCLUSION

Early presentation has shorter duration of surgery, less VAS score at final follow-up, and less limb length discrepancy, less development of complications like avascular necrosis of the femoral head, and growth disturbance.

LEVEL OF EVIDENCE

III.

Role of Magnetic Resonance Imaging in Concomitant Periarticular Infections in Septic Arthritis of Large Joints in Children: A Systematic Review

Background

Septic arthritis associated with adjacent infections, presents a diagnostic challenge as the clinical presentation is similar to that of isolated septic arthritis, additional diagnostic tools are needed to detect these infections. The purpose of this study was to examine the effectiveness of magnetic resonance imaging (MRI) for diagnosis of concomitant infection in children with septic arthritis of large joints and its effect on patient outcome and treatment.

Materials and Methods

Electronic literature research of PubMed, Cochrane and Scopus, was conducted in January 2022 using a combination of MeSH, search terms and keywords. The data extracted included the study details, demographic data, the proportion of patients having a concomitant periarticular infection, clinical presentation, blood parameters and culture findings and outcomes.

Results

This review included seven studies with 499 patients. The mean age was 7.08 ± 2.38 years in the study. There was a male predominance, with 174 being males (62.36%). The most common joint involved was the hip joint (44.47%). 42.48% had concomitant periarticular infections detected by MRI. Osteomyelitis was the most common infection seen in 209 patients (41.84%). The mean duration of antibiotics given and hospital stay was significantly more in periarticular infections (P > 0.05). 32.5% of the patients with septic arthritis underwent a second surgical procedure whereas 61.11% of patients with periarticular infections underwent second procedure in this review (P > 0.05).

Conclusions

The use of MRI to diagnose these complicated infections appears to be beneficial. Multi-centric randomised control trials are needed to investigate the efficacy of MRI and its impact on patient care and outcome.

Management of Length Unstable Femur Fractures in Children by Flexible Intramedullary Nails: A Systematic Review

PURPOSE OF THE STUDY

Surgical options for paediatric femoral fractures include fl exible intramedullary nailing (FIN), plating, and external fi xators. Length unstable fractures are usually spiral, long oblique, or comminuted and are often associated with > 2 cm of shortening. The purpose of this study was to see whether FIN is effective for managing unstable femur fractures in children.

MATERIAL AND METHODS

An electronic literature search was performed up to 25 February 2022 in Cochrane Library, PubMed, and Embase databases using a combination of MeSH search terms and keywords related to the population (e.g., "child" AND "diaphyses" AND "femur"), and intervention (e.g., "nail" OR "ESIN"). The data extracted included the study details, Demographic data, surgical details, postoperative immobilization, complications, and outcome.

RESULTS

Eight studies with a total sample size of 369 patients were reviewed. The mean operative time, blood loss, and length of stay in the hospital were 67.62±12.32 minutes, 33.82±16.82 ml, and 4.9±1.27 days, respectively. The results were excellent in 61.92% of the patients, satisfactory in 32.61%, and poor in 5.43%. 4.54% of patients had major complications requiring reoperation and 32.46% of patients had minor complications. the most common complication was nail prominence seen in 26.30% of patients. Locked Ender's nail was associated with the least reoperation, malunion, and LLD rate compared to other types of FIN.

CONCLUSIONS

FIN along with a single walking spica cast is a good choice in all forms of paediatric femoral fracture patterns allowing proper alignment and rotation. Locked Ender's nail is safe and effective for managing unstable paediatric femur fracture.

KEY WORDS

pediatric femur fracture, length unstable, fl exible intramedullary nailing, submuscular plating, Flynn criterion.

Hashimoto's Thyroiditis among Patients with Thyroid Disorders Visiting a Tertiary Care Centre

Introduction

Hashimoto's thyroiditis is a chronic autoimmune lymphocytic thyroiditis characterised by thyroid autoantibodies. Early detection and treatment of this condition help in reducing the morbidity and mortality associated with it. The aim of the study was to find out the prevalence of Hashimoto's thyroiditis among patients with thyroid disorders visiting a tertiary care centre.

Methods

A descriptive cross-sectional study was conducted among patients visiting the outpatient department of a tertiary care centre. Data from 14 April 2017 to 13 April 2019 was collected between 30 June 2022 to 15 September 2022 from medical records. Ethical approval was obtained from the Nepal Health Research Council. Hashimoto's thyroiditis was diagnosed based on clinical presentation and positive antibodies to thyroid antigens. Convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval.

Results

Among 813 patients with thyroid disorders, 393 (48.33%) (44.89-51.77, 95% Confidence Interval) had Hashimoto's thyroiditis. The manifestation of the spectrum of Hashimoto's thyroiditis were euthyroid in 215 (54.70%), subclinical hypothyroidism in 102 (25.95%), subclinical hyperthyroidism in 23 (5.85%), overt hyperthyroidism in 9 (2.30%) and overt hypothyroidism in 4 (1.02%).

Conclusions

The prevalence of Hashimoto's thyroiditis among patients with thyroid disorders was higher than in other studies done in similar settings.

Keywords

anti-thyroid peroxidase antibodies; Hashimoto's thyroiditis; thyroid disorders.

Outcome analysis of ilizarov and monorail fixators in the treatment of nonunion of long bones: A systematic review and proportion meta-analysis

Introduction

Nonunion of long bones is a major complication following fractures that requires a substantial amount of investment both monetary and time from patients and surgeons. The need to comprehensively understand the complications, outcomes and distraction capability is profound, which necessitates a review of current evidence on special fixators used for distraction. The current systematic review aims to study the available literature on distraction osteogenesis using special fixators (Ilizarov and Limb Reconstruction System) in the management of nonunion (infected and non-infected).

Methods

Cochrane Library, PubMed, Scopus were searched until January 2022. The review included all original studies which used Ilizarov or Monorail Fixators/LRS in the treatment of nonunion of long bones. The quality of studies was assessed using the Modified Coleman Methodology Score.

Results

A total of 35 original studies with Ilizarov (n = 29) and LRS (n = 8) were selected including two comparative studies. The pooled data meta-analysis and the subgroup analysis of these studies found both Ilizarov and LRS fixator yield similar functional outcomes for the treatment of long bones nonunion.

Conclusion

The review was conducted to understand the scenario of nonunion in long bones. Pin tract infection is found to be the most common complication followed by adjacent joint stiffness and deformity. In our review we observed that both external fixator time and index were lower in LRS compared to Ilizarov group. Further RCT are required comparing Ilizarov and LRS fixators to effectively comment upon the superiority of the implants.

Augmentation with Fibertape Leads to Biomechanically Superior but Similar Clinical Outcomes in ACL Surgeries: Systematic Review and Meta-analysis

Purpose

The current generation has witnessed significant progress in the field of knee arthroscopy. Suture tapes have gained immense popularity due to perceived improved biomechanical support to the graft while it heals. The purpose of the present systematic review is to analyze the biomechanical construct of suture tapes in ACL repairs and reconstructions along with clinical outcomes.

Methods

Cochrane Library, PubMed, and Embase were searched until December 2021. All Biomechanical Studies on animal or cadaver knees that compared construct characteristics of suture tape in ACL repair or reconstruction and clinical studies in English focusing on outcomes following suture tape augmentation in ACL repair or reconstruction were included. The quality of clinical studies using the Modified Coleman Methodology Score (MCMS).

Results

A total of 16 studies biomechanical and 23 clinical studies were included in qualitative synthesis, leaving nine biomechanical studies for final quantitative analyses. Suture tape revealed biomechanical superiority in terms of ultimate strength, stiffness, cyclic displacement, and elongation of graft, while comparing ACLR with internal brace to standard ACLR. No significant difference in retear rates was seen in clinical studies. Clinical score(IKDC score) was found similar in both augmented and non-augmented construct. Similar results were obtained in biomechanical studies.

Conclusion

The use of suture tape as a ligament augmentation in both ACL reconstruction and ACL repair offers more strength, less elongation or displacement, and is biomechanically stable and sound. There is a lack of data to comprehensively comment upon the clinical superiority of the use of internal augmentation. However, a meta-analysis of the retear rates and clinical outcome score revealed similar outcomes between suture tape augmented and nonaugmented groups.

Hydatid Disease of Tibia Reconstructed with Allograft: A Rare Case Report and Literature Review

Background

Hydatid disease of bone shows a well-defined, multiloculated lytic lesion with the appearance of a bunch of grapes. The presenting symptoms are pain and swelling with or without pathological fracture. The treatment options include surgery followed by a long duration of albendazole. Removal of the involved bone is required to decrease the chances of recurrences.

Case Report

In our study, we have included a case of 28-year-old woman presented with complaints of pain and difficulty in weight bearing over her right lower limb for 2.5 months. Radiograph suggested an eccentric lytic lesion in midshaft of tibia and biopsy revealed granulosus cyst wall, nucleate germinal layer, the brood capsule, and protoscolices with visible hooklets. Patient was subjected to surgery with the excision of cyst along with extended curettage of bone creating a bone defect around the lesion and with anterolateral platting with coverage of bone defect by allogenic bone grafting. Patient was kept on above knee slab with non-weight-bearing mobilization for 6 weeks. Postoperative chemotherapy with Albendazole was given for 3 months. Patient was followed up every 6 weeks for 3 months and every month thereafter on outpatient basis. Return to work and patient satisfaction were excellent.

Conclusion

Definitive Surgical management with Preoperative and postoperative chemotherapy seems to be effective to avoid recurrence. The bone defect caused by the disease or surgery can be managed with a bone graft either of autograft or allograft.

Total Hip Replacement in Active and Inactive Tuberculosis Hip: A Systematic Review

Introduction

Tuberculosis of the hip joint is a debilitating disease that can result in severe joint destruction, eventually leading to painful arthritis of the hip. Total hip arthroplasty (THA) in patients with advanced arthritis offers a painless and mobile joint with good functional outcome but some aspects of THA in TB hip have been controversial in the past due to the concerns of disease reactivation, especially when disease activity is factored in. Various factors like timing of surgery, Antitubercular therapy (ATT) initiation timing, reactivation, complications etc needs to be evaluated very carefully before planning for such cases.

Methods

Electronic databases like MEDLINE, EMBASE, Cochrane library, Clinicaltrials gov and OpenGrey were searched. The key words used were "Tuberculosis", "Tuberculosis of hip", Hip tuberculosis, "TB", "THR", "total hip replacement", "total hip arthroplasty","THA", "ankylosed hip", "fused hip", "arthrodesis" along with boolean operators "AND" and "OR". Out of a total of 1634 articles, 38 were selected for full text review and 22 articles were finally included in the study.

Results

For the timing of surgery most authors relied on the inflammatory markers to settle down with ATT before performing THA. 15 authors advocated use of pre-operative ATT with 6 studies recommending at least 2 weeks and 3 studies advocating atleast 3 months of ATT pre surgery.Single stage THA was performed in most studies(214 hips vs 18 hips) as opposed to 2 or 3 stage surgery. In the active disease 72.8% of the hips had uncemented prosthesis, 25.6% hips underwent cemented and 1.5% hips had hybrid THA fixation. Overall reactivation of the infection was seen in 2.47% cases. All authors reported excellent clinical improvement (mean HHS improvement 37.17 to 88.62).

A rare case of cutaneous leishmaniasis in Kathmandu presenting with features of bacterial skin infection: A case report

Leishmaniasis is an infectious disease caused by different species of genus Leishmania and transmitted by sandflies. Lesions of CL are most commonly present in the exposed areas, and the most familiar morphological type is papulo-nodular. The diagnosis of CL should be considered while dealing with common skin lesions, as well as encountering uncommon pathologies. We present a case of a 26-year-old man living in Kathmandu originally from Humla whose clinical course was complicated by unsuccessful treatment with suspicion of bacterial skin infection. The patient first presented with an erythematous papule with some scale and crust with central ulceration over the left side of his upper lip and mild fever. With the suspicion of bacterial infection, he was initially treated with antibiotics, which showed no improvement prompting the referral to a tertiary center with further diagnostic workup. Punch biopsy confirmed the presence of amastigote form of leishmaniasis Donovan bodies. Also, the rk39 antibody test was positive. Clinicians need to pay more effort to the diagnosis of CL and include it in the differential diagnoses of patients presenting with typical lesions even if the region is not known to be endemic for CL or in the patient with no known history of insect bite.

Difference in Muscle Strength and Functional Outcome in Direct Lateral Approach versus Posterior Approach in Total Hip Arthroplasty: A Prospective Cohort Study

Background and Purpose

The choice between posterior approach (PA) and direct lateral approach (DLA) for total hip arthroplasty (THA) remains a contentious issue regarding clinical outcome optimization and restoring patient function. Previous studies have evaluated the postsurgical outcomes mostly in the form of Harris hip score (HHS), and the data to objectively measure the postoperative muscle power is scarce. We intend to objectively compare the hip abduction and extension strengths and other functional outcomes with a very simple tool in PA and DLA in the Indian population as most patients do not undergo as intensive rehabilitation in the postoperative period as in the western world.

Materials and Methods

A total of 158 patients underwent THA during the study period, of which 48 met inclusion criteria and only 42 completed 6 months follow-up. Patients were evaluated preoperatively, postoperatively at 2 weeks, 6 weeks, 3 months, and 6 months follow-up. At each visit, muscle strength was tested using a customized sling device mounted on a pulling apparatus fitted on the wall, as well as a pain score (VAS), Harris hip score (HHS), and Short Form Survey (SF-36).

Results

The study showed statistically significant better hip muscle strength at 2 weeks postoperative for leg press test and 2 weeks as well as 6 weeks postoperative for hip abduction strength in the PA. However, no differences were noted during the 3 or 6 months follow-up period among the DLA and PA. The surgical approach used has no effect on VAS, HHS, or SF-36 scorings.

Conclusion

The weak abductor mechanism at 2 and 6 weeks and extension mechanism at 2 weeks in a cohort of DLA in contrast to the PA are seen in the early postoperative period and hence are short-lived muscle weakness. However, there is no effect on VAS, HSS, and SF-36 scores. Therefore, the surgical approach is to be chosen according to the surgeon's expertise.

Distal Nerve Transfer to Restore Wrist and Finger Extension - A Systematic Review

Background: There are numerous options available for restoration of wrist and finger extension following radial nerve palsy. The aim of this study is to conduct a systematic review of the effectiveness of nerve transfer for radial nerve palsy. Methods: Electronic literature research of PubMed, Cochrane, Scopus and Lilacs database was conducted in June 2021 using the terms 'Distal nerve transfer' AND 'Radial nerve injury' 'Radial nerve palsy' OR 'Radial nerve paresis' OR 'Median nerve transfer' OR 'wrist extensor' OR 'finger extension' OR 'thumb extension' OR 'wrist motion'. The data extracted included the study details, demographic data, procedure performed and final functional outcome according to the muscle research council scale. Results: A total of 92.59% and 56.52% had satisfactory outcome following distal nerve transfer of median nerve to restore wrist and finger extension respectively. No significant correlation was found between time to injury duration and satisfactory outcomes. Conclusions: Outcomes of nerve transfers are comparable to tendon transfers. Multi-centric studies are needed to compare the results amongst various surgical procedures described. Level of Evidence: Level III (Therapeutic).

Atypical hemolytic uremic syndrome (aHUS) responsive to mycophenolate mofetil: A case report from Nepal

Introduction

An atypical hemolytic uremic syndrome is an extremely rare and life-threatening thrombotic microangiopathy. This disorder is caused by dysregulation of the alternative pathway of the complement system in association with genetic abnormalities or the development of autoantibodies. However, 30-50% of patients do not have genetic or acquired mutations in the complement system.

Case report

Patient presented with fever and periorbital swelling. She had anemia, thrombocytopenia, and deranged liver function tests. Urinalysis revealed hematuria and proteinuria. Antibody tests and genetic analysis were negative. Renal biopsy revealed findings suggestive of thrombotic microangiopathy with predominantly glomerular involvement. Thus, the diagnosis of Atypical Hemolytic Uremic Syndrome, immunofluorescence negative, genetic negative, and anti-complement negative was made.

Discussion

This article reports a case of atypical hemolytic uremic syndrome in a child with negative genetic analysis and anti-complement factor H antibody, which was treated successfully on steroid and mycophenolate mofetil. Early diagnosis along with prompt treatment and close monitoring will lead to recovery from atypical Hemolytic Uremic Syndrome.

Conclusion

Although HUS is generally associated with genetic abnormalities or a positive antibody test, some patients with HUS may present atypically with negative genetic analysis and antibody tests.

Glomus Tumour of Hand--A Commonly Misdiagnosed Pathology: A Case Series

Introduction

Glomus tumours are benign neoplasms arising from the glomus body, a network of specialized neuromyoarterial structures containing arteriovenous anastomosis and regulating temperature. It is often misdiagnosed as paronychia, arthritis, traumatic sequelae, and many other conditions including psychiatric misdiagnosis. A typical triad of paroxysmal pain, point tenderness, and cold intolerance characterize it. Surgical excision is the treatment of choice, either by transungual or lateral approaches.

Materials and Methods

We carried out a retrospective study of cases operated in our department in the last 4 years. Patients are evaluated based on either clinical parameters (Love test, Hildreth test, and cold insensitivity) or radiological parameters (X-ray and magnetic resonance imaging). Parameters such as age, gender, tumour side, presenting complaints, duration of symptoms, diagnostic modality, follow-up duration, recurrence, and postoperative nail deformity were analysed. Visual analogue scale (VAS) score was the primary statistical parameter, and the change in VAS score following surgery was analysed with paired t test.

Result

Mean preoperative VAS was 7.75 ± 0.5; in a total of four patients, and following surgery, VAS was reduced to a mean of 1 ± 1.5. Paired t test on the change of VAS score following surgery showed a significant difference in the VAS score (P = 0.002838). The average age was 39.25. The male-to-female ratio was 1:3, and the mean follow-up was 16 months (range 2-48 months). The mean duration of symptoms was 5.75 years (range 2-10 years). Two cases were in the right-hand side, and two cases were on the left-hand side; the thumb was most commonly involved with 50% (n = 2) incidence.

Conclusion

Glomus tumours are often misdiagnosed and are intervened with different treatment options before being surgically intervened. With complete surgical excision, recurrence is nil but postoperative nail growth requires nearly 10 months.

Level of Evidence

Level IV.

Intrauterine pregnancy with copper intrauterine contraceptive device in situ: A case report from Nepal

Introduction

and importance: Intrauterine pregnancy on the background of intrauterine devices heralds its rare but possible failure. Despite having an excellent contraceptive pearl index, clients with copper-T may present with typical pregnancy symptoms.

Case presentation

We present a case of a 22 year primigravida who after 42 months of successful use of copper-T, conceived an intrauterine pregnancy diagnosed at 7 weeks period of gestation.

Clinical Findings and Investigations: A positive urine pregnancy test following cessation of menstruation for 2 months was reported by the patient on presentation. Urgent transabdominal ultrasound of the abdomen and pelvis revealed a gravid uterus containing a single gestational sac corresponding to 7 weeks of gestation. After a thorough explanation about possibility of viable pregnancy and also its pros and cons, she decided to terminate the pregnancy. Manual vacuum aspiration was done with removal of copper-T.

Conclusion

Although ectopic pregnancy is a relatively common complication of intrauterine contraceptive device, it is necessary to consider the possibility of intrauterine pregnancy as a potential complication as well. Although, term pregnancies with excellent prognosis have been demonstrated in many studies after removal of intrauterine devices, close follow up is needed to identify misplaced copper-T and keep unwanted pregnancy at bay.

•

Intrauterine pregnancy in patients with intrauterine devices is rare but possible.

•

Intrauterine pregnancy with a CU-T 380 A is rather uncommon.

•

It is necessary to consider the possibility of intrauterine pregnancy as a potential complication of intrauterine device.

•

MVA or office hysteroscopy technique avid possible management.

Sputum Smear Non-conversion at the End of Intensive Phase of Tuberculosis Treatment at a Tertiary Center: A Descriptive Cross-sectional study

Introduction:

Sputum non-conversion is smear positive tuberculosis despite anti-tubercular therapy. Various factors may lead to sputum non-conversion including resistance to anti-tubercular drugs, age, gender, disease severity, non-compliance, drugs unavailability etc. Little is known and studied about the contribution of these individual factors. Our study sought to determine the prevalence of sputum smear non-conversion in patients at the end of intensive phase of tuberculosis treatment visiting a tertiary-level institution in Nepal.

Methods:

A descriptive cross-sectional study was conducted among recorded data of patients undergoing sputum Acid Fast Bacilli staining at the end of intensive phase at National Tuberculosis Control Center from April 2018 to April 2020. The study was approved by Nepal Health Research Council (Registration no: 76012020 P). The convenient sampling method was adopted. The data were analyzed using Microsoft Excel. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data.

Results:

Our study found that out of 830 samples that were tested by Acid Fast Bacilli stain at the end of intensive phase, 40 (4.82%) (3.37-6.28 at 95% Confidence Interval) were sputum smear nonconverters. The mean age of sputum non-converters was 41.25+15.543 years.

Conclusions:

The study shows that a significant proportion of patients remain acid-fast stain positive despite the treatment. However, the proportion is low compared to other similar studies around the globe. This study provides program managers with evidence to support the development of more tailored tuberculosis care and need to conduct more intensive studies about various factors that may lead to non-conversion.

Safe Conversion From Tacrolimus to Belatacept in High Immunologic Risk Kidney Transplant Recipients With Allograft Dysfunction

There is no literature on the use of belatacept for sensitized patients or regrafts in kidney transplantation. We present our initial experience in high immunologic risk kidney transplant recipients who were converted from tacrolimus to belatacept for presumed acute calcineurin inhibitor (CNI) toxicity and/or interstitial fibrosis/tubular atrophy. Six (mean age = 40 years) patients were switched from tacrolimus to belatacept at a median of 4 months posttransplant. Renal function improved significantly from a peak mean estimated glomerular filtration rate (eGFR) of 23.8 ± 12.9 mL/min/1.73 m(2) prior to the switch to an eGFR of 42 ± 12.5 mL/min/1.73 m(2) (p = 0.03) at a mean follow-up of 16.5 months postconversion. No new rejection episodes were diagnosed despite a prior history of rejection in 2/6 (33%) patients. Surveillance biopsies performed in 5/6 patients did not show subclinical rejection. No development of donor-specific antibodies (DSA) was noted. In this preliminary investigation, we report improved kidney function without a concurrent increase in risk of rejection and DSA in six sensitized patients converted from tacrolimus to belatacept. Improvement in renal function was noted even in patients with chronic allograft fibrosis without evidence of acute CNI toxicity. Further studies with protocol biopsies are needed to ensure safety and wider applicability of this approach.

Favorable outcome of Fournier gangrene in two patients with diabetes mellitus on continuous peritoneal dialysis

Fournier gangrene (FG), a form of necrotizing fasciitis of the perineum and genitals, with high morbidity and mortality in the general population, carries the additional risk of involvement of the peritoneal catheter tunnel and peritoneal cavity in patients on chronic peritoneal dialysis (PD). We describe two men with diabetes who developed FG in the course of PD. Computed tomography showed no extension of FG to the abdominal wall, and spent peritoneal dialysate was clear in both patients. Broad-spectrum antibiotic therapy with anaerobic coverage and early aggressive debridement followed by negative-pressure wound therapy and repeated debridement led to improvements in clinical status in both cases. Surgical closure and healing of the wound was achieved in one patient; the wound of the second patient is healing, but remains open. Both patients experienced prolonged hospitalization, with a serious decline in nutrition status. In patients on PD, FG can be treated successfully. However, additional measures are required to evaluate for potential involvement of the PD apparatus and the peritoneal cavity in the infectious process; and prolonged hospitalization, worsening nutrition, and multiple surgical interventions can result.

Serum lipid profile in patients with thyroid disorders in central Nepal

Thyroid dysfunction is a major public health problem among Nepalese population. Hence the study is aimed to find out the prevalence of thyroid dysfunction and to investigate the effect of it in serum lipids. Serum fT3, fT4, TSH, total cholesterol (TC), low density lipoprotein (LDL), high density lipoprotein (HDL) and triglycerides (TG) were measured using standardized assays. Overall thyroid dysfunction was detected in 25.7% of the study population with the higher prevalence among females. The distribution of overt hypothyroidism, subclinical hypothyroidism, overt hyperthyroidism and subclinical hyperthyroidism were 3.7%, 14.1%, 3.3% and 4.6% respectively. There was a positive association between hypothyroidism and TC>200, LDL>130 and TG>200mg/dl; 48.4% of hypothyroid patient had hypercholesterolemia and 32.3% had hypertriglyceridemia. The mean TC, LDL and TG levels were increased progressively with the increase in the serum TSH. It was noteworthy in this study that even a slight increase in serum TSH (between 6.2-10 mIU/L) showed significant increase in serum lipid level. However there was no association among patients with hyperthyroidism and control group.

Assessment of kidney stone and prevalence of its chemical compositions

Kidney stone analysis is the test done on the stone which cause problems when they block the flow of urine through or out of the kidneys. The stones cause severe pain and are also associated with morbidity and renal damage. There is also no clear understanding on the relative metabolic composition of renal calculi. Hence, the study is aimed to find out the chemical composition of it which can guide treatment and give information that may prevent more stones from forming. The study was carried out on the stones that had been sent to the department of Biochemistry (n = 99; M = 61; F = 38; Mean age: 33.6 +/- 14.4 years) Approximately 98.9% of stones were composed of oxalate, 95.9% of Calcium, 85.8% of phosphate, 62.6% of Urate, 46.4% of Ammonium and very few percentages of Carbonate.

Dyadic design interface between energy and agriculture: the case of Pinthali micro hydro system in Nepal

Technology, like society, is heterogeneous. It mirrors the context in which it operates. Micro hydro development in Nepal is a rural energy strategy, which relies on technology and innovation and takes place in a specific social context. In designing this energy strategy, both technology and its social context, therefore, need to be considered seriously. In technical design processes, the interplay between the content (technology) and the context (society) needs to be considered, as the outcome will affect the people. For example, the content--micro hydro system--in the domain of the context--agriculture--provides an arena for an integrated water control system. Thus, it is possible to control water for two purposes: to produce power and to provide irrigation. The end product will be "energy" as a "consumptive" output and improved food security as a "productive" output of water. Therefore, within a sociotechnical framework, energy and irrigation become constitutive outputs of the sacrosanct "water". Thus, the metaphor of power--the "sociotechnical code" of "content" and "context"--can be used with the term "agro-anergy" in the design process of micro hydro systems. Evidence suggests that this interaction can lead to a transformed water use system for both productive and consumptive output for the benefit of rural communities.

Regulation of corticotropin-releasing factor messenger RNA by nicotine in an immortalized amygdalar cell line

Preliminary data suggest that amygdalar corticotropin-releasing factor (CRF) is regulated by nicotinic agonists. We sought to confirm and extend these observations by determining the effects of various concentrations of nicotine on CRF messenger RNA expression in the AR-5 immortalized amygdalar cell line. Nicotine produced concentration- and time-dependent increases in CRF mRNA. This cell line thus confirms that nicotinic agonists stimulate amygdalar CRF and appears to be a useful model for studying molecular factors important in this interaction.

Regulation of corticotropin-releasing factor-binding protein expression in amygdalar neuronal cultures

Corticotropin-releasing factor-binding protein (CRF-BP) is known to regulate the bioavailability of CRF and may also play a role in stress behaviours. CRF-BP has been localized in the pituitary as well as central nervous system (CNS) limbic and cortical areas, including the amygdala. The signal transduction pathways which regulate amygdalar CRF-BP are not well understood. In this report, we have examined the effect of protein kinase A and C activators, CRF, dexamethasone and interleukin-6 (IL6) on CRF-BP mRNA and protein expression in dissociated fetal amygdalar cultures. CRF-BP mRNA levels were determined by Northern analysis following 12 h treatment with the following agents: forskolin (1-30 microM), CRF (1-1000 nM), phorbol-12-myristate-13-acetate (TPA; 1-50 nM), dexamethasone (1-100 nM) and IL6 (10-500 pM). Significant increases in CRF-BP mRNA were observed in response to forskolin (30 mM), CRF (100, 1000 nM), IL6 (100, 500 pM), TPA (50 nM) and dexamethasone (100 nM; P<0.05 for all; n=3-6 for all). We extended our observations of CRF-BP expression to the protein level by performing semiquantitative Western analysis of total cellular protein after treatment with the same agents. Twenty-four hour treatment with 30 microM forskolin, 1000 nM CRF, 50 nM TPA, 100 pM IL6 or 100 nM dexamethasone significantly increased CRF-BP expression (P<0.05, n=3 for each treatment). The primary cultures were then transfected with a rat CRF-BP-reporter construct containing 3500 base pairs of CRF-BP 5' flanking DNA. Treatment with all five agents produced statistically significant increases above control (P<0.05; n=3 for each). The results suggest that CRF-BP in the amygdala is stimulated by numerous pathways which may play a significant role in promoting behavioural changes.

Changes in brain corticotropin-releasing factor messenger RNA expression in aged Fischer 344 rats

Adaptation in aging may become impaired from abnormal expression of corticotropin-releasing factor (CRF) and altered CRF receptor function. In this study, we measured CRF mRNA levels in Fischer 344 rats at various ages. The brains of these rats were processed for in situ hybridization. Relative to 3-month-old rats, levels of CRF mRNA were significantly decreased in the following brain areas at the following ages: at 24 months in the paraventricular hypothalamus, at 11, 17, and 24 months in the amygdala and at 17 and 24 months in the bed nucleus of the stria terminalis. These changes may contribute to impaired adaptations to stress, cognitive decline and other pathophysiological processes during aging.

Coordinate and divergent regulation of corticotropin-releasing factor (CRF) and CRF-binding protein expression in an immortalized amygdalar neuronal cell line

CRF is a 41-amino acid neuropeptide best known for its hypophysiotropic actions. CRF is widely distributed in the central nervous system in areas beyond the hypothalamus. CRF-binding protein (CRF-BP) regulates the bioavailability of CRF, and knowledge of the regulation of CRF-BP synthesis is an integral component of understanding the actions of CRF. To better study the regulation of CRF and CRF-BP, primary amygdalar cultures were immortalized by transfection with the SV 40 large T antigen. A clonal line that expresses CRF immunoreactivity and messenger RNA was selected. The production of CRF peptide and message by this line is regulated in a manner indistinguishable from primary cultures. We also observed that the immortalized cells express CRF-BP immunoreactivity and messenger RNA. The expression of both CRF and CRF-BP is positively regulated by forskolin and interleukin-6. Unlike CRF, the expression of CRF-BP message and peptide was increased by phorbol 12-myristate 13-acetate or dexamethasone. These results demonstrate that the synthesis of CRF and CRF-BP in this clonal cell line may be regulated in parallel by some agents but not by others. These data also suggest that dexamethasone may decrease the biological availability of CRF in the amygdala by increasing the expression of CRF-BP, rather than by decreasing CRF expression.

Identification of an upstream enhancer containing an AML1 site in the human myeloperoxidase (MPO) gene

Myeloperoxidase (MPO) is an important antibacterial enzyme found only in granulocytes and monocytes. The human MPO gene is transcribed early during myelogenesis but MPO RNA synthesis ceases at the end of the promyelocyte stage of myeloid maturation. We recently identified a basal MPO promoter and several adjacent cis-elements in the proximal 5'-flanking region of this gene. Transfection studies using constructs containing several kb of 5'-flanking MPO DNA revealed the presence of a DNA segment located between bp (base pair) -4200 and bp -3800 with enhancer activity for the endogenous basal MPO promoter. Deletion studies revealed the core enhancer activity to lie between bp -4100 and bp -3844. The percentage enhancement of promoter activity is greater in MPO-expressing myeloid cells than in MPO-non-expressing myeloid cells or non-myeloid cells. Furthermore. the enhancer confers TPA- or DMSO-responsiveness upon either endogenous or exogenous promoters. DNase I footprinting and transfection experiments identified an AML1 site as a functionally important element within the enhancer. Gelshift competition and supershift experiments demonstrated the binding of the alpha subunit of the transcription factor AML1 to this site in HL-60 cells. This distal enhancer appears likely to play an important role in the control of MPO transcription during myeloid differentiation.

NPY messenger RNA is increased in medial hypothalamus of anorectic tumor-bearing rats

Previous investigations suggest that neuropeptide Y (NPY) feeding mechanisms and corticotropin releasing factor (CRF) are altered in anorectic tumor-bearing (TB) rats. To better determine the relationship of NPY and CRF synthesis to cancer anorexia we measured mRNA for these peptides in medial and lateral hypothalamus of TB and control rats. NPY and CRF mRNA were reliably detected by Northern blot analysis only in medial hypothalamus, where NPY message was elevated significantly in TB rats. CRF mRNA tended to be reduced in both pair-fed (PF) and TB rats, but did not reach statistical significance. Concentrations of NPY or CRF were not altered significantly in either the lateral or medial hypothalamus of TB or PF rats. These results suggest that the transcription of NPY is elevated in PF rats and is increased further in anorectic TB rats. The lack of significant increases in levels of peptides may be related to dilution, due to measuring a relatively large block of hypothalamic tissue. Alternatively, translation of the signal for NPY production may be inhibited, or degradation of peptide levels may be increased.

NPY upregulates genes containing cyclic AMP response element in human neuroblastoma cell lines bearing Y1 and Y2 receptors: involvement of CREB

Four NPY receptor subtypes have been cloned, and shown to be coupled to both Ca2+ and cAMP. However, very little is known about the downstream elements mediating NPY actions. It has recently been demonstrated in our laboratory that intrahypothalamic (i.h.t.) administration of NPY induces hypothalamic CaM kinase activity, cyclic AMP response element binding protein (CREB) phosphorylation and cyclic AMP response element (CRE) binding activity in rat hypothalamic nuclear proteins. In the present study, we have investigated whether these changes in CRE binding transcriptional factors activated by NPY results in gene regulation using a human neuroblastoma cell line (SK-N-BE2). This cell line which expresses the Y2 subtype of NPY receptors was transfected with a fusion gene containing 1.305 kb of human CRF 5' flanking region with a perfect palindromic CRE site linked to firefly luciferase gene. NPY treatment increased CaM kinase II activity, CREB phosphorylation and CRE binding in these cells. In transfected cells, luciferase activity was also increased by NPY (1.8-4-fold) within 4 h of treatment. Moreover, forskolin (7-30-fold), which stimulates cAMP production, and thapsigargin (6-8-fold), which mobilizes intracellular calcium, also increased luciferase activity within 4 h of treatment. PMA (phorbol-12-myristate-13-acetate), an activator of protein kinase-C, induced luciferase activity by 1.8-fold. NPY augmented forskolin-stimulated luciferase activity from 11- to 15-fold, but had no significant effect on thapsigargin-induced luciferase activity. These findings suggest that activation of protein kinase A (PKA) or CaM kinase leads to the induction of fusion gene. NPY treatment upregulated fusion gene expression through Ca2+ pathway in SK-N-BE2 cell line. Pretreatment with CREB antisense, but not the sense oligodeoxynucleotides, inhibited forskolin-, thapsigargin- and NPY-stimulated luciferase activity. However, CREB sense or antisense oligodeoxynucleotide treatment had no effect on PMA-stimulated luciferase activity. Furthermore, NPY induced CRE binding activity and the expression of CRE containing Y1 receptor gene in SK-N-MC cell line. These findings suggest that NPY can upregulate CRE containing reporter gene including Y1 receptor gene and NPY-induced reporter gene regulation in SK-N-BE2 cells is mediated by intracellular Ca2+ and CREB protein.

Interleukin-1 regulation of corticotropin-releasing factor (CRF), glucocorticoid receptor, c-fos and c-jun messenger RNA in the NPLC-KC cell line

The NPLC-KC human hepatoma cell line expresses corticotropin-releasing factor (CRF) and it has been demonstrated that CRF secretion and synthesis in this cell line increases in response to activators of the protein kinase A (PKA) and C (PKC) pathways as well as interleukin-1 (IL1). CRF expression with all three agents can be inhibited with the synthetic steroid-dexamethasone (DEX). In this report, we have examined the effect of IL1 (beta form) in the presence and absence of DEX on CRF mRNA (mRNA) expression as well as the expression of human glucocorticoid receptor (GR) mRNA and the mRNA of the proto-oncogenes (c-jun and c-fos) that have been implicated in CRF regulation. NPLC-KC cells were incubated with picomolar concentrations of IL1. Following this total RNA was extracted from the cells and Northern Blots were probed with 32P-labelled human DNA probes for the CRF, GR, c-jun and c-fos genes. Levels of mRNA expression were measured using a PhosphoImager and were normalized to mRNA levels of control probe glyceraldehyde-3-phosphate dehydrogenase (GAPD). CRF mRNA was significantly increased with IL1 treatment in a time and concentration dependent manner. CRF mRNA expression increased with increasing concentrations of IL1 over the range of 1-100 pM; expression of CRF mRNA also peaked after 24 h of 100 pM IL1 treatment and reached a level of expression approximately seven times higher than control. This pattern of expression was significantly inhibited in the presence of 100 nM DEX. Levels of the GR, c-fos and c-jun mRNAs were also significantly increased in the presence of IL1 and inhibited when DEX was co-incubated with IL1. The results reveal that IL1 stimulation of CRF mRNA expression by IL1 in the NPLC-KC cell line is accompanied by activation of GR mRNA as well as the mRNA of the immediate early genes--c-fos and c-jun. The results also demonstrate that this cell line may serve as a model system for the molecular mechanisms by which IL1 regulates CRF in central nervous system (CNS) neurons.

Regulation of corticotropin-releasing factor (CRF) messenger ribonucleic acid and CRF peptide in the amygdala: studies in primary amygdalar cultures

Amygdalar CRF has been implicated in the mediation of stress behaviors. The signal transduction pathways that regulate amygdalar CRF are not well understood. In this report, we have examined the effect of protein kinase A and C activators, dexamethasone, and interleukin 6 on CRF messenger RNA (mRNA) and CRF peptide expression in dissociated amygdalar cultures. The amygdala from E19 rat pups was dissected out bilaterally and dissociated in 0.25% trypsin for 10-15 min and plated. On day 17 in culture, CRF mRNA and peptide were measured following treatment with the following agents: forskolin, the phorbol ester-phorbol 12 myristate 13-acetate (TPA), dexamethasone, and interleukin-6 (IL6). Both forskolin and IL6, but not TPA, increased CRF mRNA in a time- and dose-dependent manner. Secretion and intracellular content of the CRF peptide also increased with both forskolin and IL6 treatment but not with TPA. Dexamethasone treatment did not alter the expression of CRF message or peptide. Transfection of the primary cultures with a rat CRF promoter-luciferase reporter construct followed by treatment with all four agents produced alterations in luciferase expression that were consistent with changes observed at the level of CRF mRNA and peptide. The results suggest that CRF regulation in the amygdala differs from that known to occur in the hypothalamus, and that elevation of IL6 levels within the central nervous system may directly act to stimulate CRF production and secretion from limbic structures such as the amygdala, to promote subsequent behavioral changes.

Identification and functional analysis of multiple murine myeloperoxidase (MPO) promoters and comparison with the human MPO promoter region

Myeloperoxidase (MPO) is an important component of the oxidative antibacterial defense system of granulocytes. Mammalian MPO gene expression has been most extensively studied in human and murine cells. Transcription of the human MPO gene appears to begin at a single initiation site and we have recently described the isolation and characterization of the corresponding human MPO promoter. On the other hand, MPO transcripts in murine myeloid cells show several distinct 5'-termini, suggesting the existence of multiple murine MPO promoters. However, significant levels of endogenous murine MPO promoter activity have not been demonstrated heretofore, although several murine MPO enhancers have been described. We now report the identification and preliminary functional characterization of four distinct murine MPO promoters. Sequence comparison of the human and murine MPO promoter regions reveals homologues of three out of four of these murine promoters within the human MPO gene. However, only one of these sites appears to be functionally active in human myeloid cells, possibly because of the interposition of Alu sequences between the putative promoter sites in the human gene.

Cis-elements in the promoter region of the human myeloperoxidase (MPO) gene

We recently reported the identification and initial characterization of the human myeloperoxidase (MPO) promoter. The minimal or basic MPO promoter lies within the proximal 128 bp of the 5'-flanking region of the MPO gene. Plasmids containing progressively larger segments of the 5'-flanking region show correspondingly greater MPO promoter activity and increased tissue specificity compared with smaller promoter fragments. These findings suggested the presence of a multiple important regulatory cis-elements in the 5'-flanking region of the MPO gene. We now report results of studies which reveal the presence of seven discrete nuclear protein binding sites (DP1-DP7) within the proximal 600 bp of 5'-flanking MPO DNA. DNase I footprinting and gel shift analyses indicate tissue-specific and/or maturation-specific differences in nuclear protein binding to most of these sites, suggesting that they play a role in transcriptional regulation. Mutation of site DP7 stimulates the activity of a 594-bp MPO promoter construct in transfection studies, whereas mutation of any of the six other sites (DP1-DP6) reduces promoter activity. These results indicate that oligonucleotides DP1-DP7 constitute cis-elements which contribute to the activity of the human MPO promoter.