Manipulation of distal radius fractures: a comparison of Bier's block vs haematoma block

INTRODUCTION

Displaced distal radius fractures often require manipulation under anaesthesia. Many anaesthetic techniques are described, with the two most commonly used being Bier's block (BB) and haematoma block (HB). Despite national guidance preferring a BB, an HB is often performed instead. This study aims to compare the analgesic properties of a BB with those of an HB when manipulating distal radius fractures.

METHODS

This is an observational cohort study comparing the management of displaced distal radius fractures requiring reduction across two National Health Service trusts. Patients aged over 18 with isolated, displaced distal radius fractures were recruited. Patient demographics, AO fracture classification and grade of clinician performing the procedure were recorded. A numeric rating scale (NRS) pain score was obtained for each patient after manipulation. The quality of reduction was judged against standardised anatomical parameters.

RESULTS

Some 200 patients were recruited (100 HB, 100 BB). There were no differences in age (BB: median 66.5 years, interquartile range [IQR] 55-74; HB: median 67 years, IQR 55-74; p = 0.79) or fracture characteristics (p = 0.29) between cohorts. Patients undergoing BB had significantly lower pain scores with a lower IQR than those undergoing HB (p < 0.005). Patients undergoing BB manipulation were more likely to have the fracture reduced and normal anatomy restored (p < 0.005). BBs were performed mainly by Foundation Year 2 junior doctors, whereas HB manipulations were performed by a range of clinicians from emergency nurse practitioners to consultants.

CONCLUSIONS

BB provides better analgesia than an HB. This can be performed successfully and reliably by Senior House Officer-level junior doctors.

Overview of the serologic and molecular basis of D variants with a focus on D variants in the Indian population

Complexities of D within the Rh blood group system have long been recognized, initially using basic serologic testing and, more recently, using advanced and sensitive typing reagents. Discrepancies may arise when an individual carries a D antigen showing altered D antigen expression. These D variants are clinically important, since they may lead to production of anti-D in the carrier and induce alloimmunization in D- recipients, making their correct identification imperative. For clinical purposes, D variants can be classified into three groups: weak D, partial D, and DEL. The problem surrounding proper characterization of D variants exists because routine serologic tests are sometimes inadequate to detect D variants or resolve discrepant or ambiguous D typing results. Today, molecular analysis has revealed more than 300 RH alleles and is a better method for investigating D variants. Global distribution of variants differs, as observed in European, African, and East Asian populations. Discovery of the novel RHD*01W.150 (weak D type 150) with a nucleotide change of c.327_487-4164dup is proof. This variant, the result of an insertion of a duplicated exon 3 between exons 2 and 4 in the same orientation, was detected in more than 50 percent of Indian D variant samples in a 2018 study. The outcome of studies worldwide has led to the recommendation to manage D variant individuals as D+ or D- according to RHD genotype. The policies and workup with respect to D variant testing in donors, recipients, and prenatal women differ among blood banks, depending on type of variants predominantly encountered. Thus, a general genotyping protocol cannot be followed globally, and an Indian-specific RHD genotyping assay (multiplex polymerase chain reaction) designed to detect D variants frequently found in the Indian population was developed to save time and resources. This assay is also helpful for detecting several partial and null alleles. Identification of D variants by serology and characterization by molecular testing need to go hand-in-hand for better and safer transfusion practices.

Inner Deliberations of Surgeons Treating Critically-ill Emergency General Surgery Patients: A Qualitative Analysis

BACKGROUND

30% of elderly patients who require emergency general surgery (EGS) die in the year after the operation. Preoperative discussions can determine whether patients receive preference-sensitive care. Theoretically, surgeons frame their conversations after systematically assessing the risks and benefits of management options based on the clinical characteristics of each case. However, little is known about how surgeons actually deliberate about those options.

OBJECTIVE

To identify variables that influence surgeons' assessment of management options for critically-ill EGS patients.

METHODS

We conducted semi-structured interviews with 40 general surgeons in western Pennsylvania who worked in a variety of hospital settings. Interviews explored perioperative decision-making by asking surgeons to think aloud about selected memorable cases and a standardized case vignette of a frail patient with acute mesenteric ischemia. We used constant comparative methods to analyze interview transcripts and inductively developed a framework for the decision-making process.

RESULTS

Surgeons averaged 13 years (standard deviation (SD) 10.4) of experience; 40% specialized in trauma/acute care surgery. Important themes regarding the main topic of "perioperative decision-making" included many considerations beyond the clinical characteristics of cases. Surgeons described the importance of variables ranging from the availability of institutional resources to professional norms. Surgeons often remarked on their desire to achieve individual flow, team efficiency, and concordant expectations of treatment and prognosis with patients.

CONCLUSIONS

This is the first study to explore how surgeons decide among management options for critically-ill EGS patients. Surgeons' decision-making reflected a broad array of clinical, personal, and institutional variables. Effective interventions to ensure preference-sensitive care for EGS patients must address all of these variables.

A unique approach to screen for blood donors lacking high-prevalence antigen Inb of the Indian blood group system

The In^b antigen of the Indian blood group system is a high-prevalence antigen. The presence of alloanti-In^b in a recipient may pose a problem in finding compatible blood for transfusion. The aim of this study was to screen blood donors for In^b and to include individuals found to be In(b-) in our rare donor registry. To save resources, a unique study design was constructed. Blood group O donors were tested for In^b because their red blood cell (RBC) units could serve recipients across all ABO groups. EDTA blood samples were used for serologic and genomic testing. These samples were first tested serologically for In^a, and samples typed as In(a+) were then tested both serologically and molecularly for In^a and In^b to find homozygous IN*01/01 [i.e., the predicted In(b-) phenotype]. A cost-conservative approach in using recycling of antibody was adopted to economize available resources. Of 6300 donors, 196 donor samples typed as In(a+) and were also found to be In(b+) when tested by serologic and genomic methods. Although none of the donors typed as In(b-), the statistical analysis suggests the expected prevalence for this rare phenotype to be 0.02 percent among the total number of donors tested. In conclusion, this report presents a unique cost-conservative approach using limited reagents to screen a large number of donors for the rare In(b-) phenotype.

The In^b antigen of the Indian blood group system is a high-prevalence antigen. The presence of alloanti-In^b in a recipient may pose a problem in finding compatible blood for transfusion. The aim of this study was to screen blood donors for In^b and to include individuals found to be In(b–) in our rare donor registry. To save resources, a unique study design was constructed. Blood group O donors were tested for In^b because their red blood cell (RBC) units could serve recipients across all ABO groups. EDTA blood samples were used for serologic and genomic testing. These samples were first tested serologically for In^a, and samples typed as In(a+) were then tested both serologically and molecularly for In^a and In^b to find homozygous IN*01/01 [i.e., the predicted In(b–) phenotype]. A cost-conservative approach in using recycling of antibody was adopted to economize available resources. Of 6300 donors, 196 donor samples typed as In(a+) and were also found to be In(b+) when tested by serologic and genomic methods. Although none of the donors typed as In(b–), the statistical analysis suggests the expected prevalence for this rare phenotype to be 0.02 percent among the total number of donors tested. In conclusion, this report presents a unique cost-conservative approach using limited reagents to screen a large number of donors for the rare In(b–) phenotype.

Does routine postoperative contrast radiography improve outcomes for patients with perforated peptic ulcer? A multicenter retrospective cohort study

BACKGROUND

Perforated peptic ulcer is a morbid emergency general surgery condition. Best practices for postoperative care remain undefined. Surgical dogma preaches practices such as peritoneal drain placement, prolonged nil per os, and routine postoperative enteral contrast imaging despite a lack of evidence. We aimed to evaluate the role of postoperative enteral contrast imaging in postoperative perforated peptic ulcer care. Our primary objective was to assess effects of routine postoperative enteral contrast imaging on early detection of clinically significant leaks.

METHODS

We conducted a multicenter retrospective cohort study of patients who underwent repair of perforated peptic ulcer between July 2016 and June 2018. We compared outcomes between those who underwent routine postoperative enteral contrast imaging and those who did not.

RESULTS

Our analysis included 95 patients who underwent primary/omental patch repair. The mean age was 60 years, and 54% were male. Thirteen (14%) had a leak. Eighty percent of patients had a drain placed. Nine patients had leaks diagnosed based on bilious drain output without routine postoperative enteral contrast imaging. Use of routine postoperative enteral contrast imaging varied significantly between institutions (30%-87%). Two late leaks after initial normal postoperative enteral contrast imaging were confirmed by imaging after a clinical change triggered the second study. Two patients had contained leaks identified by routine postoperative enteral contrast imaging but remained clinically well. Duration of hospital stay was longer in those who received routine postoperative enteral contrast imaging (12 vs 6 days, median; P = .000).

CONCLUSION

Routine postoperative enteral contrast imaging after perforated peptic ulcer repair likely does not improve the detection of clinically significant leaks and is associated with increased duration of hospital stay.

Defining the representativeness heuristic in trauma triage: A retrospective observational cohort study

BACKGROUND

Under-triage of severely injured patients presenting to non-trauma centers (failure to transfer to a trauma center) remains problematic despite quality improvement efforts. Insights from the behavioral science literature suggest that physician heuristics (intuitive judgments), and in particular the representativeness heuristic (pattern recognition), may contribute to under-triage. However, little is known about how the representativeness heuristic is instantiated in practice.

METHODS

A multi-disciplinary group of experts identified candidate characteristics of "representative" severe trauma cases (e.g., hypotension). We then reviewed the charts of patients with moderate-to-severe injuries who presented to nine non-trauma centers in western Pennsylvania from 2010-2014 to assess the association between the presence of those characteristics and triage decisions. We tested bivariate associations using χ2 and Fisher's Exact method and multivariate associations using random effects logistic regression.

RESULTS

We identified 235,605 injured patients with 3,199 patients (1%) having moderate-to-severe injuries. Patients had a median age of 78 years (SD 20.1) and mean Injury Severity Score of 10.9 (SD 3.3). Only 759 of these patients (24%) were transferred to a trauma center as recommended by the American College of Surgeons clinical practice guidelines. Representative characteristics occurred in 704 patients (22%). The adjusted odds of transfer were higher in the presence of representative characteristics compared to when they were absent (aOR 1.7, 95% CI: 1.4-2.0, p < 0.001).

CONCLUSIONS

Most moderate-to-severely injured patients present without the characteristics representative of severe trauma. Presence of these characteristics is associated with appropriate transfer, suggesting that modifying physicians' heuristics in trauma may improve triage patterns.

American College of Surgeons National Surgical Quality Improvement Program as a quality-measurement tool for advanced cancer patients

BACKGROUND

Multiple studies have shown the significantly increased post-operative morbidity and mortality of patients undergoing palliative operations. It has been proposed by some authors that the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database can be used reliably to develop risk-calculators or as an aid for clinical decision-making in advanced cancer patients. ACS-NSQIP is a population-based database that by design only captures outcomes data for the first 30-day following an operation. We considered the suitability of these data as a tool for decision-making in the advanced cancer patient.

METHODS

Six-year retrospective review of a single institution's ACS-NSQIP database for cases identified as "Disseminated Cancer". Procedures performed with palliative intent were identified and analyzed.

RESULTS

Of 7,763 patients within the ACS-NSQIP database, 138 (1.8%) were identified as having "Disseminated Cancer". Of the remaining 7,625 entries only 4,486 contained complete survival data for analysis. Thirty-day mortality within the "Disseminated Cancer" group was higher when compared to all other surgical patients (7.9% vs. 0.9%, P<0.001). Explicit chart review of these 138 patients revealed that 32 (23.2%) had undergone operations with palliative intent. Overall survival for palliative and non-palliative operations was significantly different (104 vs. 709 days, P<0.001). When comparing palliative to non-palliative procedures using ACS-NSQIP data, we were unable to detect a difference in 30-day mortality (9.4% vs. 7.5%, P=0.72).

CONCLUSIONS

Calculations utilizing ACS-NSQIP data fail to demonstrate the increased mortality associated with palliative operations. Patients diagnosed with advanced cancer are not adequately represented within the database due to the limited number of cases collected. Also, more suitable outcomes measures for palliative operations such as pain relief, functional status, and quality of life, are not captured. Therefore, the sole use of thirty-day morbidity and mortality data contained in the ACS-NSQIP database is insufficient to make sound decisions for surgical palliation.

Ruptured uterine artery pseudoaneurysm: an overlooked cause of late postpartum haemorrhage

We report an exceptional case of secondary postpartum hemorrhage (PPH) twenty days after cesarean delivery, resulting from a ruptured uterine artery pseudoaneurysm (UAP). The diagnosis was initially confounded by a septic shock necessitating inotropic support in the intensive care unit. Intense vaginal bleeding occurred eleven days after uterine curettage. Doppler ultrasound showed an anechoic focus in the inferior part of the uterus with turbulent flow. Bilateral internal iliac artery angiograms revealed a left uterine artery pseudoaneurysm that was successfully embolized. UAP is a rare cause of unexplained PPH that requires a high index of suspicion for diagnosis. This first report in the anesthesia literature serves to focus our awareness on its possible occurrence, and gives track to its management. Pitfalls in UAP diagnostic are highlighted (delayed presentation, possibility of spontaneous hemostasis, and lack of typical findings on colour Doppler sonography in hypotensive patients). These pitfalls may further be confounded by a concomitant sepsis. Angiography and selective uterine artery embolization is the treatment of choice.

Failures of the Dual Articular knee prosthesis due to fracture of the polyethylene post

The Dual Articular (DA) total knee replacement was designed for revision and complex primary knee arthroplasty. A number of these knees failed due to fracture of the polyethylene post. We aimed to identify the proportion of DA prostheses that failed in this manner in our hospital. The hospital database was interrogated to identify all patients undergoing revision total knee replacement under the care of one surgeon from 1995 to 2007. Case notes were then reviewed to collect information about the history surrounding the knee surgery, and determine the patient's weight at the time of surgery. Telephone follow-up was carried out to obtain complete contemporary data. Forty-eight prostheses were implanted into 39 patients (21 male, 18 female). Thirty-two of the prostheses were DA and of these, 7 underwent arthroscopy or arthrotomy to reveal a fracture of the polyethylene post (22%). T-tests showed no statistical difference in age (p=0.73) or weight (p=0.79) between the group of DA patients with fractured posts and those without. Six of the 7 fractures were in male patients (Chi-squared; p=0.01). Patients complained of pain, clicking and instability at a mean of 7 years post-surgery. Sixteen DA2000 prostheses were implanted, but none of these had failed due to a fractured polyethylene post. A high proportion of DA prostheses failed due to post fracture. We recommend that patients with DA prostheses be kept under review to detect failures early. Pain, clicking and instability should be investigated with arthroscopy and the tibial insert exchanged as appropriate.

Hemifacial mass with extensive intralesional ossification and fat

The imaging appearance of neurofibromas is well described; however, macroscopic fat in a neurofibroma has been sparsely reported and intralesional ossification has only been documented twice in the literature. We describe a diffuse neurofibroma presenting as a hemifacial mass, atypical for the presence of extensive intralesional ossification and fat; the diagnosis was suggested on identification of other associated radiological features of neurofibromatosis.

Varied distribution of RhD epitopes in the Indian population

BACKGROUND

Inhabited by more than 4000 caste and tribal groups, India has an extremely heterogenous population. For thousands of years many tribal groups have practised endogamy and are practically genetically isolated. Traditionally, polyclonal anti-D reagent has been used for RhD typing; though monoclonal antibodies are increasingly being used. As a result, blood banks find it difficult to assign the RhD status to an increasing number of people. As monoclonal anti-D typing reagents may not detect all RhD antigen epitopes, we studied the RhD antigen epitope heterogeneity in different population groups in India.

METHODS

Red cells of 5315 RhD-positive individuals belonging to different castes and tribes of India were tested with 30 different epitope-specific monoclonal anti-D antibodies.

RESULTS

No single monoclonal antibody could detect all RhD-positive red cells detected by polyclonal antisera. The highest proportion of D antigen was detected by LHM 76/55 and BRAD-8 (98%) monoclonal antibodies.

CONCLUSION

We need to determine the correct mix of monoclonal antibodies that will detect nearly all RhD antigens detected by polyclonal anti-D sera. Similarly, before accepting monoclonal anti-D for therapeutic use, it would be necessary to determine the appropriate ones for use in the Indian population.

A multi-disciplinary approach in the management of a traumatized tooth with complicated crown-root fracture: A case report

A 13-year-old boy had fractured his maxillary right central incisor. The fracture line involved 2/3rd of the crown, compromising the pulp and extended subgingivally on the palatal aspect invading the biologic width. The procedure used to manage this case included endodontic treatment of residual tooth orthodontic extrusion to move the fracture line above the alveolar bone. Finally the tooth was restored prosthodontically.

Low HIV-1 incidence among married serodiscordant couples in Pune, India

Unlike commercial sex workers and patients attending sexually transmitted infection (STI) clinics, married couples are not typically targeted for HIV risk reduction programs in India. Thus, married partners of HIV-infected persons are at particularly high risk for HIV infection. Between September 2002 and November 2004, 457 HIV-1 sero-discordant, married couples were enrolled in a one-year prospective study of HIV transmission in Pune, India. The HIV incidence among uninfected partners was 1.22 per 100 person-years (95% CI 0.45-2.66), which is much lower than what has been previously reported among discordant couples in Africa. This may be due to higher rates of condom use, lower rates of STIs and higher CD4 T lymphocyte counts, among the Indian HIV sero-discordant couples.

Dental caries prevalence among preschool children of Hubli: Dharwad city

The prevalence of dental caries and treatment needs in the age group of 3-5 years was estimated among 1500 children of Hubli-Dharwad city. The attitude of mothers towards their children's oral health and its relation with caries prevalence was noted among 200 subjects. The prevalence of dental caries was 54.1%. The attitude of mothers towards children's oral health made a statistical difference in the mean dmft levels.

Disseminated histoplamosis

A case of disseminated histoplasmosis in a 45-year-old male patient with acquired immunodeficiency syndrome (AIDS) from Pune is reported. The patient presented with high-grade fever and pain in hypochondrium. Clinical signs were pallor and hepatosplenomegaly. Bone marrow and splenic aspirate revealed numerous intracellular oval shaped yeast forms. Histoplasma capsulatum was isolated from the bone marrow and splenic aspirate. H. capsulatum infection is an opportunistic infection usually reported from patient with AIDS in areas endemic for H. capsulatum. The present case highlights the fact that histoplasmosis could be an emerging opportunistic infection in India.

Idiopathic gingival fibromatosis - a case report

A case of 4 a year old girl with the complaint of delayed eruption of teeth is presented. She had moderate to severe, diffuse gingival enlargement in the maxilla and mandible. No deciduous teeth had erupted even at the age of five years except for incisal edges of upper, and lower anterior teeth. The diagnosis was made based on clinical examination and after ruling out drug and family history. Surgical removal of the hyperplastic tissue was done under general anesthesia.

Absence of coreceptor switch with disease progression in human immunodeficiency virus infections in India

The envelope glycoprotein of the human immunodeficiency virus (HIV) utilizes CD4 as a receptor and CCR5 and/or CXCR4 as coreceptor to gain entry into the cell. The CCR5-tropic viruses, observed early in infection, could be important in transmission and the CXCR4-tropic viruses, observed late, may play an important role in disease progression. Viruses from 40 HIV-positive, asymptomatic or symptomatic individuals in India were isolated. Of 40 isolates 39 used CCR5. Thirty-three isolates were subtype C, 3 isolates were subtype A, and 4 isolates were HIV-2. Only 1 HIV-2 isolate, from a symptomatic individual, was dualtropic. Therefore, a majority of isolates from India belonged to subtype C and all the isolates utilized CCR5 exclusively irrespective of HIV disease status.

Structure based prediction of binding affinity of human immunodeficiency virus-1 protease inhibitors

A series of computations were performed to derive a strategy for the prediction of binding affinities of non-peptidic human immunodeficiency virus-1 (HIV-1) protease inhibitors. This paper describes the development of a 3D quantitative structure-activity relationship (3D-QSAR) methodology by using receptor information of HIV-1 protease. The docking and molecular dynamics simulations were performed on a model ligand/enzyme complex to optimize the variables involved in the generation of ligand/enzyme models. The protonation scheme of the active site aspartic acid residues of HIV-1 protease was derived from a computational study. The active site aspartate is monoprotonated with a proton placed on the OD1 atom of the ASP B25. This protocol of docking and molecular dynamics (MD) simulation was then used to derive the ligand-enzyme complexes of the molecules used in the present study. The molecular mechanics interaction descriptors were calculated from these ligand/enzyme models. A partial least squares (PLS) method was used to derive a linear correlation between the interaction descriptors and the biological activity. A good correlation was observed when the change in the energy of the ligand upon complex formation and the electrostatic contributions to the solvation energy of the ligand were included in the QSAR analysis. A highest cross-validated q2 value of 0.649 was observed. This model had a conventional r2 of 0.725, and when this model was used to predict the activity of the external test set, it produced a r2pred of 0.761. The total interaction energy was partitioned into interactions in different subsites and interactions with each of the amino acid residues of the enzyme. The PLS analysis using these descriptors helped to identify the important interactions which can be exploited for the design of HIV-1 protease inhibitors.

Three-dimensional quantitative structure activity relationships (3-D-QSAR) of antihyperglycemic agents

A three-dimensional quantitative structure activity relationship study (3-D-QSAR) was performed on a set of thiazolidinedione antihyperglycemic agents using the comparative molecular field analysis (CoMFA) method. The CoMFA models were derived from a training set of 53 compounds. Fifteen compounds, which were not used in model generation were used to validate the CoMFA models. All the compounds were superimposed to the template structure by atom-based and shape-based strategies. The SYBYL QSAR rigid body field fit was also used for aligning the ligands. A total of twelve different alignments were generated. The resulting models exhibited a good cross-validated r2cv values (0.624-0.764) and the conventional r2 values (0.689-0.921). A more robust cross-validation test using cross-validation by 2 groups (leave half out method) was performed 100 times to ascertain the predictiveness of the CoMFA models. The mean of r2cv values from 100 runs ranged from 0.611-0.690. Few models exhibited good external predictivity. These models were then used to define a hypothetical receptor model for antihyperglycemic agents.

Isolation & preliminary characterization of two HIV-2 strains from Pune, India

Two HIV-2 strains were isolated from peripheral blood mononuclear cells of two HIV-2 seropositive patients with pulmonary tuberculosis by co-cultivating the cells with phytohaemagglutinin-P stimulated heterologous normal lymphocytes. Biological characterization of the isolates indicated that both isolates were syncytium inducing and induced cytopathic effect in the form of giant cells and syncytia formation in four T lymphoid cell lines. The isolates differed in their replication pattern. The isolates were confirmed as HIV-2 by nested PCR using HIV-1 and HIV-2 specific oligonucleotide primers from the env region and by supplementary tests like indirect immunofluorescence assay, syncytium inhibition assay using reference and HIV-2 reactive patients' sera, western blot and electron microscopy. Neutralization of one isolate (TB1) with two Senegal reference sera also indicated that the isolate may be related to the Senegal strain. To our knowledge, this is the first report of isolation of HIV-2 in India.

Three-dimensional quantitative structure-activity relationship of interleukin 1-beta converting enzyme inhibitors: A comparative molecular field analysis study

A three-dimensional quantitative structure-activity relationship (QSAR) study using the comparative molecular field analysis (CoMFA) method was performed on a series of interleukin 1-beta converting enzyme (ICE) inhibitors. The compounds studied have been reported to be time-dependent inhibitors of ICE. This study was performed using 49 compounds, in which the CoMFA models were developed using a training set of 39 compounds. All the compounds were modeled using the X-ray crystal structure of tetrapeptide aldehyde inhibitor/ICE complex. The inhibitor compounds were considered both as neutral species and as P1 carboxylate ionized species. Superimpositions were performed using two alignment rules, namely, an alignment of the structures based on RMS fitting of the backbone heavy atoms of each structure to compound 2 and an alignment based on SYBYL QSAR rigid body field fit of the steric and electrostatic fields of the molecules to the fields of compound 2. Use of LUMO energies or ClogP as additional descriptors in the QSAR table did not improve the significance of the CoMFA models. Steric and electrostatic fields of the inhibitors were found to be the relevant descriptors for structure-activity relationships. The predictive ability of the CoMFA model was evaluated by using a test set of 10 compounds (r2pred as high as 0.859). Further comparison of the coefficient contour maps with the steric and electrostatic properties of the receptor show a high level of compatibility.

Full-length human immunodeficiency virus type 1 genomes from subtype C-infected seroconverters in India, with evidence of intersubtype recombination

The development of an effective human immunodeficiency virus type 1 (HIV-1) vaccine is likely to depend on knowledge of circulating variants of genes other than the commonly sequenced gag and env genes. In addition, full-genome data are particularly limited for HIV-1 subtype C, currently the most commonly transmitted subtype in India and worldwide. Likewise, little is known about sequence variation of HIV-1 in India, the country facing the largest burden of HIV worldwide. Therefore, the objective of this study was to clone and characterize the complete genome of HIV-1 from seroconverters infected with subtype C variants in India. Cocultured HIV-1 isolates were obtained from six seroincident individuals from Pune, India, and virtually full-length HIV-1 genomes were amplified, cloned, and sequenced from each. Sequence analysis revealed that five of the six genomes were of subtype C, while one was a mosaic of subtypes A and C, with multiple breakpoints in env, nef, and the 3' long terminal repeat as determined by both maximal chi2 analysis and phylogenetic bootstrapping. Sequences were compared for preservation of known cytotoxic T lymphocyte (CTL) epitopes. Compared with those of the HIV-1LAI sequence, 38% of well-defined CTL epitopes were identical. The proportion of nonconservative substitutions for Env, at 61%, was higher (P < 0.001) than those for Gag (24%), Pol (18%), and Nef (32%). Therefore, characterized CTL epitopes demonstrated substantial differences from subtype B laboratory strains, which were most pronounced in Env. Because these clones were obtained from Indian seroconverters, they are likely to facilitate vaccine-related efforts in India by providing potential antigens for vaccine candidates as well as for assays of vaccine responsiveness.

Full-length human immunodeficiency virus type 1 genomes from subtype C-infected seroconverters in India, with evidence of intersubtype recombination

The development of an effective human immunodeficiency virus type 1 (HIV-1) vaccine is likely to depend on knowledge of circulating variants of genes other than the commonly sequenced gag and env genes. In addition, full-genome data are particularly limited for HIV-1 subtype C, currently the most commonly transmitted subtype in India and worldwide. Likewise, little is known about sequence variation of HIV-1 in India, the country facing the largest burden of HIV worldwide. Therefore, the objective of this study was to clone and characterize the complete genome of HIV-1 from seroconverters infected with subtype C variants in India. Cocultured HIV-1 isolates were obtained from six seroincident individuals from Pune, India, and virtually full-length HIV-1 genomes were amplified, cloned, and sequenced from each. Sequence analysis revealed that five of the six genomes were of subtype C, while one was a mosaic of subtypes A and C, with multiple breakpoints in env, nef, and the 3' long terminal repeat as determined by both maximal chi2 analysis and phylogenetic bootstrapping. Sequences were compared for preservation of known cytotoxic T lymphocyte (CTL) epitopes. Compared with those of the HIV-1LAI sequence, 38% of well-defined CTL epitopes were identical. The proportion of nonconservative substitutions for Env, at 61%, was higher (P < 0.001) than those for Gag (24%), Pol (18%), and Nef (32%). Therefore, characterized CTL epitopes demonstrated substantial differences from subtype B laboratory strains, which were most pronounced in Env. Because these clones were obtained from Indian seroconverters, they are likely to facilitate vaccine-related efforts in India by providing potential antigens for vaccine candidates as well as for assays of vaccine responsiveness.

Experience with intrauterine transfusions for severe Rh alloimmunization in a developing country

This study reports our experience with 67 intrauterine transfusions (IUTs) carried out for 27 cases of severe Rh alloimmunization, which could be useful to other developing countries with similar situations. Most of the mothers were from sections of India other than Mumbai, their socioeconomic status was low, and they were referred during the second or third trimester. The mean gestation age at first IUT was 27+/-2.9 weeks and maternal anti-D titer ranged from 1:32 to 1:512. Ultrasonography (USG) was normal in eight cases, but showed minimal or gross ascites in 8 and 11 cases, respectively. The mean +/- SD hematocrit (HCT) in three groups defined by USG was 23.5+/-1.7, 15.9+/-4, and 12+/-5.9, respectively. Amniotic fluid analysis, which proved to be an important investigation, indicated IUT in eight cases having normal USG. Six cases were severely anemic (Hb deficit >7 g/dl). By fetal cell staining, the percentage of the donor's red cells in the fetal circulation was determined. Besides Hb, blood group, direct antiglobulin test, and mean cell volume, this parameter was also useful in assessing efficacy of IUT and the need for an exchange transfusion after birth. Of 11 fetuses having gross ascites, eight and one each from the remaining two groups, were stillborn. One death may be procedure related. Two neonates died due to hemorrhagic disorder and prematurity. The overall survival rate was 55.6%. Late referral, severe Rh alloimmunization, volume overload, delay in IUT because of nonavailability of blood and use of nonirradiated blood could be the reasons for the poor outcome. Strategies for improving results are discussed.

Transmission of genetically diverse strains of HIV-1 in Pune, India

Surveillance of the different HIV-1 subtypes has important implications for developing candidate vaccines and understanding the dynamics of HIV transmission in various populations. In this study, HIV-1 viral subtypes were determined for homologies in the V3-V5 region by heteroduplex mobility assay (HMA) in 46 patients with sexually transmitted diseases (STD) in Pune, India. Proviral DNA from peripheral blood mononuclear cells (PBMCs) from 20 recent sero-coverters and 26 HIV seropositive individuals were analyzed. Of the 46 samples analyzed, 44 (96%) were HIV-1 subtype C and one each of subtypes A and B. Further analyses revealed that 29 (66%) of the C subtype samples had maximum homology to the C3-Indian reference strain, while 15 (34%) were most homologous to the C2-Zambian strain. The C3 genotype prevailed in the majority (80%) of the seropositive individuals. Most of the C3 (Indian) strains were closely homologous to each other, while more nucleotide sequence divergence was seen in C2 samples. A higher quasispecies complexity was observed in the samples collected from seropositive individuals. These findings may have important implications for the design and testing of effective candidate HIV-1 vaccines for India.

Gonadal function following ABVD therapy for Hodgkin's disease

To assess the effect of combination chemotherapy with doxorubicin, bleomycin, viablastine, and decarbazine (ABVD) on gonadal function in patients treated for Hodgkin's disease, we assessed 38 male patients with Hodgkin's disease who were > 15 years of age and in complete remission for the development of secondary sexual characteristics, sexual habits, and fatherhood after treatment. Semen analysis and serum hormone level estimation of follicle-stimulating hormone (FSH), leutinising hormone (LH), and testosterone (T) were done in all cases. Twenty-six patients received ABVD therapy and 12 received a combination of ABVD with COPP or MOPP (cyclophosphamide or nitrogen mustard, vincristine, procarbazine, and prednisone). Radiation of the pelvic region was done in one case. Median time between completion of therapy and assessment of gonadal function was 34 months (range, 12-68 months). Secondary sexual characteristics developed normally in all patients. Azoospermia was seen in one patient from the ABVD group and 10 patients from the COPP/ABVD group (p < 0.001). Serum FSH levels were significantly higher in the COPP/ABVD group than in the ABVD group (23.5 versus 4.7 mlu/ml; p < 0.001) The levels were in the normal range in 23 patients from the ABVD group, as compared to four in the COPP/ABVD group (88.5% versus 33.3%; p < 0.001). Three patients treated with ABVD fathered children post-therapy. We conclude that ABVD is associated with relatively better preservation of gonadal function.

Co-existence of hypertension and abnormal lipid profile: a hospital-based retrospective survey

Indian data on co-existence of coronary risk factors is scanty. This retrospective survey was carried out to estimate the prevalence of abnormal lipid profile and glucose metabolism in hypertensive patients. Records of persons coming for a health check-up were screened to obtain 500 consecutive evaluable records of persons with hypertension or those taking antihypertensive drugs. 57 percent of these subjects had cholesterol > or = 200 mg/dl. An elevated ratio of total to HDL cholesterol (> 4.5) was also present in 47 percent of the subjects. Serum triglycerides were > or = 200 mg/dl in 34 percent of the subjects, and > or = 400 mg/dl in 5 percent. These lipid abnormalities were more prevalent in males than females (p < 0.05). 20 percent of all the subjects were either on antidiabetic drugs or had fasting blood sugar more than 120 mg/dl.

Pulmonary microsporidial infection in a patient with CML undergoing allogeneic marrow transplant

Very few cases of human microsporidial infection have been reported. The advent of AIDS has changed this. There is increasing recognition that microsporidia are important opportunistic pathogens. However, the number of cases reported in the non-HIV population is small. We report here a case of microsporidial infection in a female patient with chronic myeloid leukemia undergoing allogeneic bone marrow transplantation. There was also an associated fungal infection. The diagnosis could be reached only after postmortem and was confirmed by electron micrography. We suggest that transplant patients are another group of patients who are susceptible to this group of opportunistic pathogens.

Total hip arthroplasty for giant cell tumour

A 32 month follow up of an uncommon case of a Giant Cell Tumour affecting the proximal end of femur is presented. Following a wide excision, the hip was reconstructed using Charnley type of low friction total hip arthroplasty. At a 32 month review, there was no recurrence and the function was good.

Results of Austin Moore replacement

Forty cases of Austin Moore Replacement done for transcervical fractures of the femur in patients were reviewed after a period of 12 to 48 months postoperatively (mean 26 mth). 30 cases (75%) had mild to severe pain of non-infective origin, starting as early as 6 months postoperatively. This was irrespective of the make, size or position (varus/valgus) of the prosthesis. Though the Aufranc and Sweet clinical scoring was satisfactory in 65% cases, radiological evidence of complications like sinking, protrusion, etc. were seen in majority of the cases. Calcar resorption was seen in 34 cases (85%) as early as 4 months postoperatively. Results of THR and bipolar replacement done for transcervical fractures in recent literature show 85% pain-free cases at 5 years. We feel that Austin Moore Replacement should be reserved for patients more than 65 years of age and those who are less active or debilitated because of other factors, because of increased acetabular wear with time in the younger individual. This is corroborated by unsatisfactory results in patients less than 65 years of age (p < 0.05).

Total hip arthroplasty in healed tuberculous hip

Total hip arthroplasty was performed in a patient who had tuberculous hip, quiescent for the last 15 years, without pre or postoperative anti-tuberculous chemotherapy. At a 27 month follow up, there has been no evidence of reactivation. A brief review of relevant literature is also presented.

Solitary synovial osteochondroma of the knee

A very rare case of solitary osteochondroma of the knee is reported. The patient presented with a slowly growing retropatellar bony tumour of 4 years duration following a minor trauma. An excisional biopsy with a total patellectomy was performed as the patellar articular surface was unsalvageable. A 20 month follow up revealed no recurrence and a functional knee. A brief review of literature is also presented.

Rapid cytoreduction in childhood leukemic hyperleukocytosis by conservative therapy

Childhood leukemic hyperleukocytosis poses a serious threat to life because of its associated metabolic complications. The present prospective trial utilized conservative management of childhood acute lymphoblastic leukemia with hyperleukocytosis (total white cell count equal or > 100 x 10(9)/L) by intravenous hydration, urinary alkalinization, and allopurinol presenting without severe life-threatening complications. The median reduction in WBC count was 81.51% (range: 66-98.8%) within a median period of 36 hours (range: 12-60 hours) following hospitalization. There were no failures or treatment related complications. Thus we conclude that in childhood acute lymphoblastic leukemia, hyperleukocytosis can be managed safely and effectively with intravenous hydration, urinary alkalinization, and allopurinol before starting any specific anti-leukemic chemotherapy avoiding risk-associated cranial irradiation, leukapheresis, and exchange transfusion.

Distal fibular giant cell tumour

A patient who reported with a slowly growing swelling ovr thee lateral aspect of the left ankle, was investigated and diagnosed to have a giant cell tumour which was confirmed on FNAC. The tumour was managed with excision biopsy and reconstruction. The case is being reported for its rare site of occurrence.

Incidence of Rh immunization between 1981 and 1992

BACKGROUND

The Institute of Immunohaematology has had an Rh clinic at the Nowrosjee Wadia Maternity Hospital since 1957. Between then and 1977, 5% Rh-negative women produced Rh antibodies. Between 1978 and 1980, the rate of immunization was reduced to 3.3%. In the present study we determined the incidence of Rh immunization between 1981 and 1992.

METHODS

ABO and Rh grouping was carried out by standard methods on 139,635 samples collected from antenatal women. Six thousand nine hundred and fourteen (5%) Rh-negative women were screened for Rh antibodies using an enzyme technique. Analysis was carried out by dividing the data into four groups, each of three years duration.

RESULTS

The number of women attending the antenatal outpatients increased steadily but the frequency of Rh-negativity remained at approximately 5%. The rate of Rh immunization among Rh-negative women declined from 3.1% during 1981-83 to 1.7% during 1990-92. The rate among pregnant women dropped from 0.16% to 0.09% and this was statistically significant (p < 0.05). The incidence of Rh immunization among Rh-negative women increased from 0.4% in the first pregnancy to 17.5% after four or more pregnancies (p < 0.01). Only 15 out of 167 Rh immunized women had received anti-D immunoglobulin previously.

CONCLUSIONS

The incidence of Rh immunization has declined during the last 12 years possibly due to family planning and extensive use of anti-D immunoglobulin. However, complete eradication of Rh haemolytic disease of the newborn will be possible only if a comprehensive Rh prophylaxis programme is instituted.

Hepatic trauma: experience of 110 cases

A total of 110 patients with hepatic injuries was treated at a major urban trauma centre between June 1988 and December 1991. The mechanism of injury was blunt trauma in 86 patients (78 per cent). Non-operative treatment was given in six patients (5 per cent). Simple hepatorrhaphy, use of topical haemostatic agents or peritoneal drainage alone were performed in 79 (72 per cent) cases. Extensive hepatorrhaphy, hepatotomy with selective vascular ligation, resection and débridement or resection, perihepatic packing and major vascular ligation were undertaken, often in combination, in 25 (23 per cent) cases. Percutaneous arterial embolization was carried out in one case. The mortality rate was 18 per cent. The most frequent postoperative complications related to hepatic injury were intra-abdominal abscess (7 per cent) and coagulopathy (5 per cent); prolonged biliary leak (3 per cent), late haemorrhage (2 per cent) and hepatic necrosis (1 per cent) were also observed.

Elimination of drug-resistant myeloma tumor cell lines by monoclonal anti-P-glycoprotein antibody and rabbit complement

The effectiveness of ex vivo chemotherapy with drugs, such as vincristine, etoposide, and Adriamycin (doxorubicin, Adria Labs, Columbus, OH) for elimination of residual tumor cells from human bone marrow grafts could be undermined by the presence of multidrug-resistant tumor cells in the bone marrow. Therefore, to supplement chemoseparation, we investigated whether MRK-16, a monoclonal antibody (MoAb) to the surface moiety of multidrug resistance-associated P-glycoprotein antigen, can eliminate drug-resistant tumor cells in the presence of rabbit complement (RC). Two doxorubicin (DOX)-resistant human myeloma tumor cell line, 8226/DOX40 (resistant to 4 x 10(-7) mol/L DOX) and 8226/DOX6 (6 x 10(-8) mol/L DOX) with high and low amounts of cell surface P-glycoprotein, respectively, and the drug-sensitive parent cell line 8226/S were used as tumor models in this study. Using the limiting dilution assay, we have shown that three cycles of treatment with 25 micrograms/mL of MRK-16 MoAb and a 1:4 final dilution of RC eliminated 2.90 +/- 0.10 logs of 8226/DOX40 cells and 1.94 +/- 0.18 logs of 8226/DOX6 cells. One and two cycles of treatment were less effective, eliminating 0.47 +/- 0.40 and 1.94 +/- 0.36 logs of 8226/DOX40 and 0.12 +/- 0.20 and 1.63 +/- 0.58 logs of 8226/DOX6 cells, respectively. The 8226/S cell growth was unaffected by one to three cycles of treatment. The cell kill was not impaired when the antibody plus complement treatment was carried out on a mixture of 8226/DOX40 or 8226/DOX6 cells with a ninefold excess of irradiated bone marrow mononuclear cells (MNCs). The three cycles of treatment with antibody plus complement did not adversely affect granulocyte-macrophage colony-forming unit (GM-CFU) survival in hematologically normal marrows (92.5% to 104% survival) or in myeloma patient marrows (85% to 100%). These results show that it is possible to eliminate drug-resistant myeloma tumor cell lines from the admixed human bone marrow by treatment with MRK-16 MoAb plus RC. This method could prove to be effective for elimination of other drug-resistant tumor cell lines including those of leukemia and solid tumors, and will be further useful for supplementing chemopurging, and immunopurging of bone marrow with other antitumor cell antibodies.

Enhanced recovery of gut-associated lymphoid tissue by infusion of buffy coat cells and gut leukocytes in the murine syngeneic bone marrow transplantation model

Ways of accelerating recovery of the mucous membrane immune system in lethally irradiated mice following syngeneic bone marrow transplantation were studied over a 35-day period by quantification of jejunal intraepithelial lymphocytes (IELs) and lamina propria plasma cells. Recovery after a low bone marrow dose allowing 100% animal survival (LBM) was compared with a high (five times minimal) dose (HBM), or a minimal dose augmented with equal numbers of buffy coat cells (LBM + BC) or small gut mucosal lymphocytes (LBM + GL). The maximal decline and subsequent peak repopulation of IELs were: LBM, days 7 through 14, peaking suboptimally by day 28; HBM, day 14, peaking suboptimally but higher than LBM by day 35; LBM + BC, days 11 through 14, peaking at control levels by day 35; and LBM + GL, day 7, peaking at control levels by day 28. The IEL decline was most severe with LBM and HBM treatment and least with LBM + GL. All transplant groups experienced maximal plasma cell decline by day 7. LBM had the most severe depletion, and LBM + GL had the least. Recovery to control levels for the LBM, HBM, LBM + BC and LBM + GL groups occurred by days 28, 21, 21, and 14, respectively. In all instances, greater than 95% of the plasma cells were IgA positive.

Regeneration of T lymphocytes from human bone marrow cells after depletion with methylprednisolone

This study evaluates the propagation of T lymphocytes in bone marrow cells after in vitro methylprednisolone treatment. Previous studies from this laboratory showed that immunocompetent T lymphocytes could be eliminated from the bone marrow cells by incubation with 15 mg/ml (0.04 M) of methylprednisolone for 1 hr. The effectiveness of the chemoseparation was assessed by E-rosette forming cell assay, mitogen-induced lymphoblastogenic responses, and lymphocyte surface markers. In this study, bone marrow cells treated with different concentrations of methylprednisolone were cultured in the presence of PHA and Interleukin-2. The mitogen-induced lymphoblastogenesis was restored in the 15 mg/ml MP-treated bone marrow cells by the 8th day of culture in the presence of Interleukin-2. The cells in the culture were analyzed by E-rosette forming cell assay. It was shown that the predominant cells in the cultures were E-rosette forming cells. This study demonstrates that immunocompetent T lymphocytes can be regenerated in the presence of mitogen and Interleukin-2 from bone marrow cells treated with 15 mg/ml of methylprednisolone.

Effect of pretreatment with cyclophosphamide on high-dose toxicity of melphalan in mice

This study was undertaken to evaluate the effect of pretreatment (or priming) with cyclophosphamide (CY) on lethal toxicity of high-dose melphalan (MELPH) in mice. In C57BL/6 X DBA/2 F1 (hereafter called B6D2F1) mice given an injection of a single dose of CY, 50 mg/kg, 1-5 days before MELPH, 20 mg/kg, improved survival was noted in only one of five experiments. Reducing the challenge dose of MELPH to 17 mg/kg did not improve survival consistently. Priming with CY, 50 mg/kg, 3 days before a dose of MELPH, 20 mg/kg, did not improve survival in CBA/J or C57BL/6 mice. These results indicate that CY is an inconsistent priming agent for abrogating high-dose MELPH toxicity in mice. A slightly earlier recovery of regenerating hemopoietic and of jejunal crypt cells was noted in CY-primed B6D2F1 mice given injections of a low dose of MELPH, 15 mg/kg. The occasional improved animal survival noted in CY-primed B6D2F1 mice might be related to this earlier cell recovery.

Functional impairment of T-lymphocytes in mouse radiation chimeras by a nucleotide-free diet

We examined the effect of a nucleotide-free diet on the immune function of mouse syngeneic bone marrow radiation chimeras. The graft-versus-host disease mortality assay revealed that GVH activity of spleen cells from radiation chimeras fed NFD (RCNFD) was reduced at 6-18 weeks after transplantation as compared with the radiation chimeras fed a control diet (RCCD). When tested 11-18 weeks after transplantation, the proliferative response of RCNFD spleen cells to phytohemagglutinin was significantly reduced at 11 and 13 weeks, the response to pokeweed mitogen (PWM) was significantly reduced at 11, 13, and 15 weeks, and the response to bacterial lipopolysaccharide remained virtually unaffected. At both six and eight weeks after transplantation, RCNFD and RCCD showed comparable numbers of CFUc/femur. RCNFD and RCCD did not differ significantly from each other in body weights or in spleen and bone marrow cellularity at 6-18 weeks after transplantation. These results suggest that dietary nucleotides are important for the normal function of mouse T-lymphocytes.