Profile of 208 patients with inborn errors of immunity at a tertiary care center in South India

Primary immune deficiencies or inborn errors of immunity (IEI) are a heterogeneous group of disorders that predispose affected individuals to infections, allergy, autoimmunity, autoinflammation and malignancies. IEIs are increasingly being recognized in the Indian subcontinent. Two hundred and eight patients diagnosed with an IEI during February 2017 to November 2021 at a tertiary care center in South India were included in the study. The clinical features, laboratory findings including microbiologic and genetic data, and treatment and outcome details were analyzed. The diagnosis of IEI was confirmed in a total of 208 patients (198 kindreds) based on relevant immunological tests and/or genetic tests. The male-to-female ratio was 1.8:1. Of the 208 patients, 72 (34.6%) were < 1 yr, 112 (53.8%) were 1-18 years, and 24 (11.5%) were above 18 years. The most common IEI in our cohort was SCID (17.7%) followed by CGD (12.9%) and CVID (9.1%). We also had a significant proportion of patients with DOCK8 deficiency (7.2%), LAD (6.2%) and six patients (2.8%) with autoinflammatory diseases. Autoimmunity was noted in forty-six (22%) patients. Molecular testing was performed in 152 patients by exome sequencing on the NGS platform, and a genetic variant was reported in 132 cases. Twenty-nine children underwent 34 HSCT, and 135 patients remain on supportive therapy such as immunoglobulin replacement and/or antimicrobial prophylaxis. Fifty-nine (28.3%) patients died during the study period, and infections were the predominant cause of mortality. Seven families underwent prenatal testing in the subsequent pregnancy. We describe the profile of 208 patients with IEI, and to the best of our knowledge, this represents the largest data on IEI from the Indian subcontinent reported so far.

20 Incidence of Acute Kidney Injury in Neck of Femur Fracture Patients During the COVID-19 Pandemic in Princess Royal Hospital, Telford

Aim

Patients undergoing surgical repair of neck-of-femur (NOF) fractures are at higher risk of acute kidney injury (AKI). NICE and BOAST have published guidelines to help prevent the occurrence of AKI, including adequate fluid resuscitation pre- and post-operatively. An audit was conducted during the COVID-19 pandemic to explore whether the department was adhering to NICE guidelines.

Method

AKI was defined, as per NICE Clinical Knowledge Summaries, as an increase in serum creatinine levels by 26 µmol/L or greater. Data was collected prospectively starting from December 2020 to February 2021 in the Princess Royal Hospital during the COVID-19 pandemic. All patients with NOFs were included and data on sex, age, comorbidities, and type of surgery were collected.

Results

In total, 32 patients were included in the audit with an average age of 82 years; of these, eleven patients had dynamic hip screws and eighteen patients had hemiarthroplasties. Five patients had chronic kidney disease, six patients had previous myocardial infarctions and thirteen patients had hypertension. Two patients (6.3%) were found to have an AKI post-surgery with increased creatinine levels of 27 and 28 µmol/L. Both had hypertension and underwent hemiarthroplasties.

Conclusions

Complications such as AKIs are reversible and preventable. Especially during the COVID-19 pandemic such complications can increase morbidity and mortality of patients suffering from NOF leading to longer hospital stays. The low rate of AKI following NOF repair in our Department of Trauma and Orthopaedic is attributable to adherence to NICE and BOAST fluid resuscitation guidelines.

Ultrasound-guided procedures in the management of heterotopic caesarean scar pregnancy - A review of case reports and case series

Background

Heterotopic caesarean scar pregnancy (HCSP) is where one gestational sac implants in the previous caesarean section (CS) scar and another sac implants in the uterine cavity. There is limited evidence on the management of this rare condition. Here, we present a case of HCSP in which US-guided selective reduction of the CS pregnancy (CSP) was performed using potassium chloride (KCl) to salvage the intrauterine pregnancy. We also conducted a review of published case reports to understand the determinants of outcome.

Methods

After a MEDLINE search, 23 case reports were found eligible based on quality assessment and were included in the analysis. A composite-score indicating overall obstetric morbidity was computed, and mixed-effects linear regression was implemented to identify its predictors.

Results

US-guided local treatment was the most common mode of intervention for HCSP. The regression analyses revealed that the poor obstetric outcomes, especially antepartum haemorrhage (APH) and postpartum haemorrhage (PPH), were significantly predicted by advanced gestational age at treatment and a higher number of previous CS, irrespective of the mode of treatment.

Conclusion

These results indicate that a high index of suspicion for an early ultrasound diagnosis and treatment is critical. US-guided techniques are useful in salvaging the intrauterine pregnancy with decreased maternal morbidity. The results are preliminary due to the rarity and a small number of published reports. Every CSP should be recorded in a central international registry to obtain reliable data on the diagnosis and management of women with CSP. Given the rising rates of CS, future systematic studies are warranted.

Monochorionic triamniotic triplets following conventional in vitro fertilization and blastocyst transfer

Multiple pregnancy in in vitro fertilization (IVF) is on the decline with a reduction in number of embryos transferred. But the risk of monozygotic splitting persists. The risk of monozygotic twinning in women undergoing IVF is reported to be twice that of natural conception, and monochorionic triplets are even rarer at 100 times more than natural conception. We report a case of monochorionic triamniotic (MCTA) triplets following conventional IVF and blastocyst transfer without zona manipulation. This report highlights the possibility of zygotic splitting in IVF in young couples with no family history, in centers with good experience with blastocyst transfer. MCTA triplets carry a high risk of perinatal mortality and morbidity and need multidisciplinary care. Prevention and prediction of zygotic splitting ought to be realized with better reporting and identification of possible risk factors.

Should we actively screen for urinary and anal incontinence in the general gynaecology outpatients setting?--A prospective observational study

The Department of Health in the UK recommends as good practice in continence services that opportunistic screening for urinary and anal incontinence is carried out by all healthcare professionals. The aim of this study was to record the prevalence of urinary and anal incontinence in a general gynaecology clinic. In addition, to ascertain the proportion of women with incontinence who wish further help and assess the current opportunistic screening for incontinence. Overall, the prevalence of urinary incontinence is 26.8% and the prevalence of mixed (urinary and anal) incontinence is 8.4% of women attending a general gynaecology clinic. The prevalence of both types of incontinence increases with the age of the women. Although a significant proportion wished to receive help, 61.6% of women with urinary incontinence were not specifically asked about urinary incontinence and 66.6% of women with anal or mixed incontinence were not specifically asked about anal incontinence. Our current screening for incontinence is unsatisfactory.