Genetic variation of the blood coagulation regulator tissue factor pathway inhibitor and venous thromboembolism among middle‐aged and older adults: A population‐based cohort study

Background

Tissue factor is the main initiator of blood coagulation, and tissue factor pathway inhibitor (TFPI) is the primary inhibitor of the initiation of blood coagulation.

The genetic variation of TFPI and the relation to venous thromboembolism (VTE), that is, venous thrombosis and pulmonary embolism, remains to be clarified. This exome sequencing study aimed to determine the molecular epidemiology of the TFPI gene and the relation to VTE in a large population‐based cohort of middle‐aged and older adults.

Methods

The exomes of TFPI were analyzed for variants in 28,794 subjects without previous VTE (born 1923–1950, 60% women), who participated in the Malmö Diet and Cancer Study (1991–1996). Patients were followed until the first event of VTE, death, or 2018. Qualifying variants were defined as loss‐of‐function or nonbenign (PolyPhen‐2) missense variants with minor allele frequency less than 0.1%.

Results

No common variant was associated with VTE. Nine rare variants (two loss‐of‐function and seven nonbenign missense) were classified as qualifying and included in collapsing analysis. Prevalence of qualifying variants was 0.09%. Five individuals with VTE compared to 17 individuals without VTE carried one qualifying variant. Cox multivariate regression analysis adjusted for age, sex, body mass index, systolic blood pressure, smoking and alcohol consumption, rs6025, rs1799963, and ancestry showed a hazard ratio of 2.9 (95% CI, 1.2–7.1) for rare qualifying variants.

Conclusion

Rare qualifying TFPI variants were associated with VTE, suggesting that rare variants in TFPI contribute to the development of VTE. The qualifying TFPI gene variants were very rare, suggesting a constrained gene.

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

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

Altered Fibrinolysis in DVT: Influence of Site of Sampling

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

Homicide concealed strangulation after bobbing reins in sexually sadistic homicide

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

Prognostic markers for colorectal cancer: estimating ploidy and stroma

Background

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

Patients and methods

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

Results

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

Conclusion

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

Pregnancy Check Point for Diagnosis of CKD in Developing Countries

Objective

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

Methods

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

Results

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

Conclusions

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Optically trapping tumor cells to assess differentiation and prognosis of cancers

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

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

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

Removal of phosphorus by a high rate membrane adsorption hybrid system

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

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

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Higher Incision at Upper Part of Lower Segment Caesarean Section

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Histological Pattern of Gynecological Cancers

Abstract

Histological pattern of gynecological cancers

INTRODUCTION

The information on cancer incidence is an important basis to prioritize the preventive policy of a country. Since there are only limited reports on the gynecological cancers in Nepal, the present study was undertaken to further elucidate the incidences of different gynecological cancers by age, site and histological subtype in a large series.

METHODS

A retrospective analysis was performed in histopathologically proven gynecological malignancies by retrieving data from the archives of the Department of Pathology, BP Koirala Memorial Cancer Hospital between July 1999 and April 2004.

RESULTS

Out of total 1517 cases of gynecological cancers diagnosed, 1293 cases (85.23%) were cervical, 97 (6.39%) ovarian, 48 (3.16%) vulval, 41 (2.7%) vaginal, 32 (2.11%) endometrial cancers as well as 5 (0.33%) choriocarcinoma and 1 (0.07%) fallopian tube cancer. Squamous cell carcinoma was the commonest histologic type in cervical, vaginal and vulval cancers whereas serous adenocarcinoma and endometrioid adenocarcinoma were commonest histological types in the ovary and endometrium respectively. Gynecological cancers were most common in age between 40 and 60 years with mean age 45 years.

CONCLUSIONS

Cervical cancer is the most frequent gynecological malignancy in Nepal. Since it is a preventable disease, national screening and awareness programs are necessary to reduce the burden of the cancer and to improve the health of women in Nepal.

Twin Pregnancy with Fetus Papyraceous

A successful pregnancy outcome with vaginal delivery of a term single live fetus in case of twinpregnancy with other twin papyraceous, (vanished in second trimester) is an uncommon fi nding.Ten percent of all perinatal deaths are related with dizygotic twins. The rate of intrauterine fetaldemise in multiple pregnancies is as high as three times of monozygotic. Most frequently used andsuggested method is follow-up of the maternal coagulation system by a series of lab test. Sonographyis a visual tool to confi rm the diagnosis. In case of monofetal death of twin pregnancies, the type ofplacenta should be analysed and then follow up and treatment modalities of these cases should bechoosen.Key Words: death, fetal, pregnancy, single, twin

Twin pregnancy with fetus papyraceous

A successful pregnancy outcome with vaginal delivery of a term single live fetus in case of twin pregnancy with other twin papyraceous, (vanished in second trimester) is an uncommon finding. Ten percent of all perinatal deaths are related with dizygotic twins. The rate of intrauterine fetal demise in multiple pregnancies is as high as three times of monozygotic. Most frequently used and suggested method is follow-up of the maternal coagulation system by a series of lab test. Sonography is a visual tool to confirm the diagnosis. In case of monofetal death of twin pregnancies, the type of placenta should be analysed and then follow up and treatment modalities of these cases should be choosen.

Study of breast lump of 2246 cases by fine needle aspiration

The purpose of this study was to analyze breast lesions causing breast lump with special reference to patients younger and older than 30 years of age diagnosed by fine-needle aspiration (FNA) and to evaluate the histology of the cases diagnosed as suspicious of malignancy in FNA. All patients who underwent FNA during four years period (2000-2004) were included in this study. The FNA procedure was performed and interpreted by the experienced pathologists. Histological evaluation of the suspicious cases in FNA was done and was based on excisional biopsy or mastectomy specimen. Out of 2246 FNA performed, 1840 were diagnosed as non-malignant, 6 atypical ductal hyperplasia, 52 suspicious of malignancy and 348 as malignant. The most common non-malignant lesions included 975 (43%) fibroadenosis, 180 (8%) fibroadenoma, 126 (6%) abscess and 96 (4%) fibrocystic changes. The patients were further divided into two groups: group I consisted of 918 patients aged 30 years and younger and group II consisted of 1328 patients above 30 years. In group I, 444 (48.4%) were diagnosed as fibroadenosis and only 15 (1.6%) cases were malignancies. In group II 531 (40%) were fibroadenosis and 333 (25%) were malignant. Patients more than 30 years old had significantly higher malignancy diagnoses (P<0.001). The odds of being diagnosed as malignant tumor among the higher age group patients (>30 years) is 21 times larger (confidence interval 12.4, 35.6) than the younger patients (<30 years). In 63% (27/43) of the suspicious cases, malignancy was diagnosed in histological examination. Cancer and Fibroadenosis are two most common causes of breast lumps in Nepal. Incidence of malignancy is significantly lower in patients aged 30 years and younger than in patients aged older than 30 years. Suspicious FNA cases should be evaluated histologically to rule out malignancy.

One gene, many phenotypes

"Phenotype" is the visible or quantifiable effect of the expression of a gene, whereas the specific genetic constitution responsible for a phenotype is called "genotype". It was hoped that phenotype could be accurately predicted if the genotype could be characterized. But, the relationship between the genotype and phenotype is not straightforward. Similar genetic lesions can have entirely different phenotypes. In recent years, there has been tremendous progress in the understanding of the genetic basis of diseases. The extent to which it will be possible to relate findings at the DNA level to the clinical phenotype is difficult to delineate on many occasions. The elucidation of mechanisms underlying genotype-phenotype discrepancies is important as it will influence the use of DNA-based tests in the diagnosis, therapy and counseling of individuals affected with genetic disorders. This issue is pertinent to almost every aspect of medical practice and research in this post-genome era. In this article, we have tried to summarize those factors which are responsible for varied manifestations of lesion(s) in a single gene.

Status of HFE mutation in thalassemia syndromes in north India

Hereditary hemochromatosis is an autosomal recessive and most commonly inherited single gene disorder among Caucasians, with a prevalence of 5 per 1,000 and a carrier frequency of 1 in 10. Two point mutations were described and are referred as C282Y and H63D. In the present study, we have analyzed 729 north Indian samples for C282Y and H63D mutations. Of these, no allele of the C282Y mutation was seen, while 3 homozygous and 43 heterozygous for the H63D mutation were seen in the patients of thalassemia group. However, 47 cases were found heterozygous for the H63D mutation among the normal groups (11.16%).

The RD1-encoded antigen Rv3872 of Mycobacterium tuberculosis as a potential candidate for serodiagnosis of tuberculosis

Tuberculosis (TB) infections in India account for one-third of the global burden, making it important to develop speedy, cost-effective diagnostic tools. This study evaluated recombinant RD1-encoded antigens of Mycobacterium tuberculosis as tools for serodiagnosis by determining the immunological reactivity of these proteins against sera from healthy, bacille Calmette-Guérin (BCG)-vaccinated and TB-infected individuals from Kolkata. Rv3872, Rv3875 (ESAT-6) and Rv3878 were able to discriminate healthy BCG-vaccinated controls from TB patients. Rv3872 showed the highest level of antibody response in comparison with other antigens, and also showed statistically significant differences between pulmonary (p <0.0001) or extra-pulmonary (p <0.001) TB patients and healthy BCG-vaccinated individuals. The levels of antibody were measured using 20-mer overlapping peptides spanning the entire Rv3872 sequence. The immunological reactivity against a mixture of two peptides (P8 and P9) encompassing amino-acids 57-84 correlated well with that obtained using full-length Rv3872. This result was explained by the fact that two of the predicted regions of high antigenicity lie within amino-acid residues 57-85 of Rv3872. The high sensitivity and specificity of Rv3872, as well as the mixture of two synthetic overlapping peptides derived from Rv3872, highlight their potential and argue in favour of their use in serodiagnosis of both pulmonary and extra-pulmonary TB.

Study of clinical profile and antibiotic sensitivity pattern in culture positive typhoid fever cases

OBJECTIVES

The present study was designed to analyze the clinical profile and antibiotic sensitivity pattern in the cases of culture positive typhoid fever.

METHOD

The study was conducted over a period of 1 year. Total of 46 culture positive cases of Typhoid fever were included in the study. The sensitivity pattern of isolates from blood culture was recorded. The modes of presentation, clinical course, lab investigation reports were also recorded.

RESULTS

Out of 46 cases, 33 (71.7%) were males and 13 (28.3%) were females. Average age of presentation was 26.17 years. Fever was present in all patients. Resistance of S .typhi to amoxycillin, chloramphenicol and co-trimoxazole were significantly high. Ciprofloxacin showed resistance in 2 (4.3%) cases. Sensitivity to ceftriaxone was 100% in our study.

CONCLUSION

Typhoid fever is one of the most common health problem in Nepal. Various drugs are being used in the treatment of typhoid fever, in the mean time resistance to many of them are emerging. An appropriate antibiotic has to be initiated only after culture sensitivity in typhoid fever.

The spectrum of renal tubular acidosis in paediatric Sjögren syndrome

OBJECTIVES

Renal tubular acidosis (RTA) is a well-recognized extraglandular complication of adult Sjögren syndrome (SS) but has been reported only rarely in paediatric SS. We wished to describe the natural history of RTA in paediatric SS.

METHODS

We performed a chart and literature review. Inclusion criteria were primary or secondary SS with onset before 18 yr of age, complicated by RTA before 18 yr of age.

RESULTS

Twelve cases were identified: two from chart review and 10 from the literature. RTA was mostly associated with primary SS. RTA was detected at the onset of SS or up to 9 yr later. The clinical spectrum ranged from nearly silent to life-threatening, with plasma pH and serum potassium as low as 7.0 and 1.2 mEq/l, respectively. Hypokalaemia was present in 92%. Half the patients presented with profound weakness or paralysis, most likely from hypokalaemia. Proximal, distal and mixed RTA were detected, reflecting a diffuse 'tubulopathy' from interstitial nephritis, which was the predominant histopathological finding. Diabetes insipidus was the most frequent renal comorbidity. The RTA stabilized in 82% of the cases and resolved in one case. Only one patient had long-term unstable RTA.

CONCLUSIONS

RTA is an under-recognized complication of paediatric SS. It can be life-threatening in the acute phase but generally has a good long-term renal outcome. SS should be considered in the older child with otherwise unexplained RTA. Likewise, RTA should be excluded in children and adolescents with SS who develop weakness, fatigue or growth failure. Early recognition would reduce long-term complications such as growth failure.

Hemoglobin E-beta thalassemia: factors affecting phenotype

The phenotype of E-beta-thalassemia is affected by several genetic factors. The aim of this study was to analyze severity of E-beta-thalassemia and correlate with HbE, HbF, E/F ratios, beta-mutation and Xmn I polymorphism. Thirty cases of E-beta-thalassemia (23 with childhood onset) were studied. HbE levels were quantitated by HPLC. Xmn1 polymorphism and beta-mutations were studied by PCR-RFLP and ARMS respectively. Commonest features were pallor (100%), splenomegaly (74%), and hepatomegaly (65%), 43% (10/23) were on regular transfusions at diagnosis. One case presented with paraplegia. Patients heterozygous for Xmn I polymorphism (+/-) had later onset (>3 yrs) compared to homozygous (-/-) absence (0.5-2.8 yrs). Most (69.6%) showed beta-mutation IVS 1-5 (G-->C). Negative correlation was found between age of onset and HbE. Thus, presentation is similar to previously reported Thai cases. Heterozygosity of Xmn I polymorphism also delays disease onset. Early diagnosis facilitates appropriate management and prenatal diagnosis.

Spectrum of holoprosencephaly

OBJECTIVE

To conduct a clinical study of holoprosencephaly (HPE).

METHOD

Thirteen cases of HPE were studied regarding their clinical features, family history, and prenatal and imaging studies. Chromosomal analysis was done whenever fresh sample was available.

RESULTS

Six cases were antenatally detected by ultrasound; four cases were stillborn. Three cases were identified by neuroimaging done a part of evaluation of developmental delay or cleft lip. Eleven of them had facial anomalies characteristics of HPE. Two of these had subtle facial features and microcephaly. Karyotype was abnormal in 2 of 7 cases studied.

CONCLUSION

Most of the cases of HPE present antenatally or at birth. Milder forms like lobar and semilobar can present as developmental delay during infancy. Facial anomalies are usually associated with HPE. Chromosomal study of the case and clinical examination of the parents is essential for providing information regarding risk of recurrence to the family.

Case of Schizencephaly: a case report

Schizencephaly is a rare developmental disorder of neuronal migration, characterized by early focal destruction of the germinal matrix and surrounding brain before the cerebral hemispheres are fully formed at 1-5 months of gestation . The lesion is most likely related to multiple aetiologies including genetic, toxic, metabolic, vascular or infectious agents. This case is reported due to its rarity. The prevalence of schizencephaly is very uncommon internationally.

PRIMARY SQUAMOUS CELL CARCINOMA OF BREAST PRESENTING AS ABSCESS

Primary squamous cell carcinoma (SCC) of breast is a very rare neoplasm. SCC of breast presenting asabscess has been reported only occasionally. Treatment guidelines are usually similar to the guidelines forordinary ductal carcinoma, though firm conclusions have yet to be established. We report a case of primarySCC of breast presenting initially as breast abscess along with review of the literature.Key Words: Breast cancer, squamous cell carcinoma, breast abscess.

High frequency of hepatitis B virus infection in patients with beta-thalassemia receiving multiple transfusions

BACKGROUND AND OBJECTIVES

Hepatitis B virus (HBV) may occasionally be transmitted through transfusion of blood units that are hepatitis B surface antigen (HBsAg) negative but HBV DNA positive. Children with beta-thalassemia are particularly susceptible to HBV because they receive multiple blood transfusions. These children have high infection rates despite vaccination against HBV. Post-vaccination infections may be a result of viruses harbouring surface (S)-gene mutations (e.g. G587A) in a region critical for reactivity to antibody to hepatitis B surface antigen (anti-HBs). The true prevalence of HBV in individuals with beta-thalassemia has not been studied previously.

PATIENTS AND METHODS

Seventy patients with beta-thalassemia (median age 6 years; range 8 months to 22 years; 49 male), who had received seven to 623 (median 61) units of blood each and three doses (10/20 micro g) of HBV vaccine (Engerix B) before presentation to us, were included in the study; 50 of the 70 patients had received transfusions prior to vaccination. Enzyme-linked immunoassay for serological markers [HBsAg, antibody to hepatitis B core antigen (anti-HBc) and quantitative anti-HBs] and polymerase chain reaction (PCR) followed by Southern hybridization for molecular detection of hepatitis B, was performed on all samples. The PCR-amplified product was cloned, sequenced and the nucleotide and deduced amino acid sequences for the HBV S and polymerase (P) genes were analysed for mutations.

RESULTS

Four of 70 (5.7%) individuals with beta-thalassemia were HBsAg positive and 14 (20%) were anti-HBc positive. The prevalence of serological markers increased with number of transfusions (P < 0.01). Of 70 patients, 53 (75.7%) had an anti-HBs titre of > 10 IU/l following vaccination and 17 (24.3%) were non-responders (< 10 IU/l); 22 (31.4%) of the 70 were DNA positive. The frequency of HBV infection in beta-thalassemia was similar in vaccine responders and non-responders. The virus was of subtype ayw (genotype D) in the five DNA-positive samples in which a 388-nucleotide region of the S gene was sequenced. Mutations occurred at 13 positions in the S gene and at 10 positions in the P gene. Hydrophobicity plots revealed differences in amino acid regions 117-165 and 195-211. Some of these amino acid substitutions coincided with the putative cytotoxic T-lymphocyte epitopes of both S and P proteins.

CONCLUSIONS

A high frequency of HBV infection was seen using molecular methods in thalassemic patients. The frequency of infection was similar in vaccine responders and non-responders. A number of mutations were observed in the S gene, which could have implications for viral replication as well as virus-host cell interaction.

Setting priorities for patient safety

BACKGROUND

Current "flags" for adverse events (AEs) are biased towards those with serious outcomes, potentially leading to failure to address mundane common problems.

AIM

To provide a basis for setting priorities to improve patient safety by ranking adverse events by resource consumption as well as by outcome. This was done by classifying a set of AEs, according to how they may be prevented, into "Principal Natural Categories" (PNCs).

SETTING

AEs associated with a representative sample of admissions to Australian acute care hospitals.

DESIGN

AEs were classified into PNCs which were ranked by overall frequency, an index of resource consumption (a function of mean extended hospital stay and the number of cases in each PNC), and severity of outcome.

RESULTS

The 1712 AEs analysed fell into 581 PNCs; only 28% had more than two cases. Most resource use (60%) was by AEs which led to minor disabilities, 36% was by those which led to major disabilities, and 4% by those associated with death. Most of the events with serious outcomes fell into fewer than 50 PNCs; only seven of these PNCs had more than six cases resulting in serious outcomes.

CONCLUSIONS

If interventions for AEs are triggered only by serious outcomes by, for example, using recommended risk scoring methods, most problems would not be addressed, particularly the large number of mundane problems which consume the majority of resources. Both serious and mundane problems should be addressed. Most types of events occur too infrequently to be characterised at a hospital level and require large scale (preferably national) collections of incidents and events.

Computer simulations of lymph node metastasis for optimizing the pathologic examination of sentinel lymph nodes in patients with breast carcinoma

BACKGROUND

Many empiric protocols are used to detect metastases in sentinel lymph nodes (SLNs), but comparison of the efficacy of these methods is impractical because tissue is lost in processing, making reassessment with another policy difficult. Consequently, performance indicators of this test are largely unknown.

DESIGN

The authors retrospectively examined 112 SLNs removed from 89 patients with breast carcinoma treated at the authors' institution and used the histologic data to devise a mathematic model of a SLN with Matlab modeling software. The authors simulated examination of this computer-generated (virtual) lymph node according to several macroscopic and histologic sampling protocols and for each protocol assessed the probability of detecting micrometastases of specified sizes. The authors used published costing figures to estimate the cost of the policies.

RESULTS

Direct comparison of 6 sectioning strategies currently in use by pathology laboratories showed the chances of detecting a 500-microm metastasis ranged from 20% to 75%. Four of the 6 protocols had a less than 30% chance of detecting metastases of this size. The detection rate of smaller metastases was poorer. Cost was not a good discriminator because some policies were more efficient than others.

CONCLUSIONS

The detection of metastases is highly dependent on the methods used to look for them. The authors' simulations suggest that commonly used methods of examining lymph nodes have high false-negative rates, particularly for small metastases. There is an urgent need for pathologists and clinicians to agree on the minimum size of SLN metastases that will be sought by histology and set standard methods for examining these lymph nodes.

The intersection of health informatics and evidence-based medicine: computer-based systems to assist clinicians

Evidence-based medicine and health informatics may assist clinicians contend with the current barriers to the integration of evidence-based "best practice" into typical healthcare settings. Computer-based decision support systems can improve the process of care, but whether they improve patient outcomes in a cost-effective manner is uncertain.

Wegener granulomatosis--an atypical case

An unusual sequence of the clinical manifestations of microvascular disease is described in a 15 year-old girl. She initially presented with acute renal failure caused by a crescentic glomerulonephritis associated with positive tests for MPO-ANCA. Eighteen months later she had pulmonary hemorrhage and respiratory failure. An open lung biopsy showed granulomas that were diagnostic for Wegener granulomatosis. We discuss the diagnostic dilemmas faced in attempts to distinguish infective causes of pulmonary granulomas, such as tuberculosis or fungi, from granulomas associated with vasculitis, in a patient previously treated with immunosuppressive therapy.

Geographic and ethnic distribution of beta-thalassemia mutations in Uttar Pradesh, India

We have studied the geographic and ethnic distribution of mutations in 376 subjects who were carriers of beta-thalassemia, and identified the mutations in 365 chromosomes. The majority of the beta-thalassemia carriers were of Uttar Pradesh (India) origin. Their pattern of mutations differed from the other states of India and from those families who had migrated from Pakistan. The frequency of the IVS-I-5 (G-->C) and 619 bp deletion mutations were 64.3 and 2.5%, respectively, among families originating from Uttar Pradesh, compared to a prevalence of 37.5 and 27.5%, respectively in the population of Pakistani immigrants. Of the 10 common Asian Indian mutations, only eight were observed in subjects studied from different parts of India. By use of the amplification refractory mutation system along with DNA sequencing techniques, the mutations were successfully identified in 97.1% of subjects, while 11 cases (2.9%) still remain to be characterized by single strand conformation polymorphism and sequencing analyses. The application of this knowledge has facilitated the successful implementation of the program of genetic counseling and prenatal diagnosis of beta-thalassemia, thus helping to avoid the birth of an affected child in India.

Pachygyria/hypogenitalism: A monogenic syndrome

We describe the clinical and neuroimaging findings of two severely retarded boys born to consanguineous parents. This appears to be a monogenic condition of abnormal neuronal migration associated with hypogenitalism. Reports of other monogenic syndromes of neuronal migration abnormalities are reviewed.

Protein interactions of Src homology 2 (SH2) domain-containing inositol phosphatase (SHIP): association with Shc displaces SHIP from FcgammaRIIb in B cells

Our recent studies revealed that the inositol phosphatase Src homology 2 (SH2) domain-containing inositol phosphatase (SHIP) is phosphorylated and associated with Shc exclusively under negative signaling conditions in B cells, which is due to recruitment of the SHIP SH2 domain to the FcgammaRIIb. In addition, we reported that SHIP-Shc interaction involves both SHIP SH2 and Shc phosphotyrosine binding domains. These findings reveal a paradox in which the single SH2 domain of SHIP is simultaneously engaged to two different proteins: Shc and FcgammaRIIb. To resolve this paradox, we examined the protein interactions of SHIP. Our results demonstrated that isolated FcgammaRIIb contains SHIP but not Shc; likewise, Shc isolates contain SHIP but not FcgammaRIIb. In contrast, SHIP isolates contain both proteins, revealing two separate pools of SHIP: one bound to FcgammaRIIb and one bound to Shc. Kinetic studies reveal rapid SHIP association with FcgammaRIIb but slower and more transient association with Shc. Affinity measurements using a recombinant SHIP SH2 domain and phosphopeptides derived from FcgammaRIIb (corresponding to Y273) and Shc (corresponding to Y317) revealed an approximately equal rate of binding but a 10-fold faster dissociation rate for FcgammaRIIb compared with Shc phosphopeptide and yielding in an affinity of 2.1 microM for FcgammaRIIb and 0.26 microM for Shc. These findings are consistent with a model in which SHIP transiently associates with FcgammaRIIb to promote SHIP phosphorylation, whereupon SHIP binds to Shc and dissociates from FcgammaRIIb.

The role of pharmacists in HIV/STD prevention: evaluation of an STD syndromic management intervention in Nepal

OBJECTIVE

To evaluate the effects of a pilot sexually transmitted disease (STD) syndromic case management training for pharmacists in Nepal on STD drug dispensing behavior, HIV/STD prevention communication, and condom promotion and sales.

METHODS

Pre- and post-intervention interviews with samples of 160 pharmacists were conducted utilizing the simulated client method to collect data on pharmacists' response to men reporting urethral discharge. In order to assess the long-term effects, a sub-sample of 38 pharmacists trained 7-9 months before the follow-up survey was analysed separately.

RESULTS

There were no significant differences in the percentages of pharmacists who suggested taking medications, dispensed medications, or referred clients to a physician. The proportion of pharmacists who recommended an injection declined from 27% to 14%. Prior to the intervention, only one pharmacist (0.8%) dispensed the correct drugs and regimen for the syndromic treatment of urethritis. This increased to 45% immediately following the training. In a sub-sample of pharmacists who were interviewed 7-9 months after the training, the correct drugs and regimen were dispensed by 26%. The proportion of pharmacists who recommended to clients to have their sex partners treated increased from 5% to 21%. Although the proportion of pharmacists who suggested condom use increased from 14% to 24%, the proportion of pharmacists actually selling a condom or giving advice on HIV testing remained low and unchanged pre- and post-intervention. Over one-third of pharmacists mentioned HIV or AIDS in their interactions with clients, compared to 9% prior to the intervention.

CONCLUSIONS

The findings suggest that STD services provided by pharmacists can be significantly improved through a short-term training intervention, although the improvements are modest and probably time-limited. Interventions must be more intensive and combined with regular follow-ups if they are to meet their desired goals of improving STD treatment in a pharmacy setting.