P-079 INCIDENCE AND RISK FACTORS OF ABDOMINAL FASCIAL DEHISCENCE AFTER EXPLORATORY LAPAROTOMY- AN AUDIT OF 282 CASES

Background

An audit was performed to identify the incidence and risk factors of post-operative abdominal fascial dehiscence after Exploratory laparotomy.

Methods

The prospectively maintained database of a single unit was reviewed.The demographic parameters, comorbidities, degree of contamination, type of procedures, and the types of suture & needles were reviewed.We analyzed the relation of the type of sutures, type of surgery and degree of contamination on the development abdominal fascial dehiscence within 30 days of surgery .Difference between the groups were analyzed by t tests for continuous variables and Chi squared tests for categorical variables.

Results

50 (17.7%) patients developed fascial dehiscence.Mean Albumin was 2.45 +/- 0.69 g/dl in the dehiscence group, compared to 2.97 +/- 0.86 g/dl in those without dehiscence (p= 0.00).The prevalence of diabetics, smokers and incidence of postoperative surgical site infection were significantly more in the patients with dehiscence (p value - 0.045, 0.043 and 0.00 respectively).Prevalence of class 4 wounds was higher in the group with dehiscence (70% vs 44%, p value 0.001).Type of suture used (Loop PDS No. 1 vs PDS 2–0) did not significantly influence development of facial dehiscence within 1 month.

Conclusion

Results of our study are consistent with existing literature. Important preoperative/intraoperative parameters such as smokingr, diabetics, preoperative hypovolemic shock, albumin are significant predictors of fascial dehiscence in the post operative period. This will enable surgeons to take corrective measures before the surgery

Nasopharyngeal teratoma, congenital diaphragmatic hernia and Dandy-Walker malformation - a yet uncharacterized syndrome

An association of congenital diaphragmatic hernia, dandy walker malformation and nasopharyngeal teratoma is very rare. Here, we report a fourth case with this association where chromosomal microarray and whole exome sequencing (WES) was performed to understand the underlying genetic basis. Findings of few variants especially a novel variation in HIRA provided some insights. An association of congenital diaphragmatic hernia, dandy walker malformation and nasopharyngeal teratoma is very rare. Here, we report a fourth case with this association where chromosomal microarray and whole exome sequencing (WES) was performed to understand the underlying genetic basis. Findings of few variants especially a novel variation in HIRA provided some insights.

Accuracy of conventional cytology: results from a multicentre screening study in India

Objective: We conducted a multi-centre cross-sectional study in India to evaluate the accuracy of conventional cytology to detect high-grade squamous intraepithelial lesions (HSIL).

Setting: Cross-sectional studies in Jaipur, Kolkata, Mumbai and Trivandrum, India, during 1999-2003.

Methods: A common protocol and questionnaire were used to test 22,663 women aged 25-65 years with conventional cytology in five cross-sectional studies. Three thresholds were used to define test positivity: atypical squamous cells of uncertain significance (ASCUS), low-grade squamous intra-epithelial lesion (LSIL), or HSIL. All screened women were investigated with colposcopy, and biopsies were taken when necessary. The reference standard for final disease status was histology or negative colposcopy. Data from the studies were pooled to evaluate the test characteristics for the detection of histologically confirmed HSIL.

Results: The test positivity rates of cytology were 8.8% at ASCUS, 6.2% at LSIL and 1.8% at HSIL thresholds, and 355 women had histologically confirmed HSIL while 74 had invasive cancer. The pooled sensitivity, specificity, positive and negative predictive values at ASCUS threshold were 64.5%, 92.3%, 11.8% and 99.4% respectively. The corresponding values at LSIL threshold were 58.0%, 94.9%, 15.2% and 99.3%, while at the HSIL threshold they were 45.4%, 99.2%, 46.3% and 99.1%. The sensitivity varied between 37.8-81.3% at ASCUS , 28.9-76.9% at LSIL and 24.4-72.3% at HSIL thresholds. A significantly low sensitivity was observed in women aged 25-39 years (p<0.001). The wide variation in sensitivity across study sites persisted even after age standardisation.

Conclusion: The sensitivity of cytology varied widely between the study sites. Findings from our study and other reviews indicate that sustained efforts in improving sampling, preparation and reading of cytological specimens and improvements in clinical judgement are essential to achieve concurrently high sensitivity and specificity.

Retention in pre-antiretroviral treatment care in a district of Karnataka, India: how well are we doing?

SETTING

Antiretroviral treatment (ART) Centre in Tumkur district of Karnataka State, India. There is no published information about pre-ART loss to follow-up from India.

OBJECTIVE

To assess the proportion lost to follow-up (defined as not visiting the ART Centre within 1 year of registration) and associated socio-demographic and immunological variables.

DESIGN

Retrospective cohort study involving a review of medical records of adult HIV-infected persons (aged ⩾15 years) registered in pre-ART care during January 2010-June 2012.

RESULTS

Of 3238 patients registered, 2519 (78%) were eligible for ART, while 719 (22%) were not. Four of the latter were transferred out; the remaining 715 individuals were enrolled in pre-ART care, of whom 290 (41%) were lost to follow-up. Factors associated with loss to follow-up on multivariate analysis included age group ⩾45 years, low educational level, not being married, World Health Organization Stage III or IV and rural residence.

CONCLUSION

About four in 10 individuals in pre-ART care were lost to follow-up within 1 year of registration. This needs urgent attention. Routine cohort analysis in the national programme should include those in pre-ART care to enable improved review, monitoring and supervision. Further qualitative research to ascertain reasons for loss to follow-up is required to design future interventions.

HIV-1 discordant couples in Karnataka, South India: is the sex ratio of index cases changing?

India has an estimated 2.5 million HIV infections, most of which are heterosexually transmitted. Women comprise 40% of infected adults. In India, 90% of women between the ages of 15 and 45 years are married. Previous literature has suggested that sexual intercourse with an HIV-infected husband represents a married woman's greatest risk for being infected. However, a recent meta-analysis of discordant couples from sub-Saharan Africa reported that women were the index case in half of all couples. Similar data are not available from India. This cross-sectional study describes the epidemiology of 925 discordant couples from five districts in Karnataka province, one of the high HIV prevalence provinces in India. Men were the index case in 74% of couples. However, in young couples (where the index case was aged <30 years), women were more likely to be the infected partner (64% of couples). Condom use was reported by 46% of these discordant couples. These results suggest an emerging predominance of female index case infections among younger discordant couples in India, and point to the need for focusing HIV preventive messages on youth and couples before marriage.

Cystic fibrosis in India

Cystic fibrosis (CF) was considered to be non-existent in Indian subcontinent. Reports in last one decade have suggested that cystic fibrosis occurs in India but its precise magnitude is not known. Studies on migrant Indian population in United States and United Kingdom estimate frequency of CF as 1:10,000 to 1:40,000. The clinical features are similar to that reported in Caucasian population. CF in Indian children is usually diagnosed late and in advanced stage. Children are more malnourished and may have clinically evident deficiency of fat soluble vitamins. The frequency of clubbing, colonization with Pseudomonas, and laboratory evidence of pseudo-Bartter syndrome is relatively more at the time of diagnosis. Diagnostic facilities in form of sweat chloride estimation and genetic studies are not available readily. Mutation profile is different. The frequency of common mutation F508del in Indian children is between 19% and 34%. Other mutations are heterogeneous. Management of CF in India is difficult due to less number of trained manpower, limited availability, and high cost of pharmacologic agents. The determinants of early death include: severe malnutrition and colonization with Pseudomonas at the time of diagnosis, more than four episodes of lower respiratory infection per year and age of onset of symptoms before 2 months of age. To conclude, CF does occur in India; however, precise magnitude of problem is not known. There is need to create awareness amongst pediatricians, developing diagnostic facilities, and management protocols based on locally available resources.

Diagnosing and managing cystic fibrosis in the developing world

Cystic fibrosis (CF), earlier believed to be non existent in non Caucasians, is now a pan ethnic disease, having being reported from various regions of the world over last one decade. Apart from limited resources, the major problems in diagnosis and management of CF in developing countries include: lack of awareness among pediatricians, absence of facilities for diagnosis (sweat chloride estimation and genetic studies), lack of trained manpower for care of specific problems, and non availability of appropriate drugs. Care of children with CF may not be a priority for governments in countries where childhood mortality rates are high, predominantly due to acute infections. An indigenously developed and relatively inexpensive method of sweat collection and chloride estimation using pilocarpine iontophoresis and titration, respectively, may be an alternative to the commercially available costly equipment. Having a team of trained nurse, physiotherapist, and dietician for optimal care of CF patients may not be feasible due to inadequate resources. Training a single person (e.g. nurse) to deliver comprehensive CF care may be a feasible alternative. To overcome problems of non availability of appropriate drugs (enzymes, inhaled antibiotics, DNAse, etc), locally available drugs may be used. Examples include use of hypertonic saline in place of DNAse, enteric coated enzyme tablets in place of enteric coated spherules, etc. Factors that are associated with decreased survival in CF patients from developing countries are age of onset of symptoms <2 months, severe malnutrition at the time of diagnosis, colonization with Pseudomonas at the time of diagnosis and frequency of pneumonia >4 episodes/year. All these factors can be modified except onset of symptoms before 2 months of age, by early diagnosis and appropriate treatment. Many of the above mentioned hurdles have been successfully overcome by us to establish CF services in a resource-limited setting. We conclude that education of pediatricians about the disease, early diagnosis using indigenous technology and aggressive physiotherapy with nutritional management and judicious use of antibiotics can improve the quality of life and survival in CF patients in resource-limited settings.

Clinical profile and frequency of delta f508 mutation in Indian children with cystic fibrosis

OBJECTIVE

To document clinical profile of cystic fibrosis (CF) in Indian children and the prevalence of delta F508 mutation in these patients.

DESIGN

Observational study.

SETTING

Pediatric chest clinic in an urban tertiary care center in north India.

PERIOD OF STUDY

July 1995 to June 2002.

METHODS

Clinical features of 120 children diagnosed as CF by quantitative pilocarpine iontophoresis were recorded. A polymerase chain reaction based test for identification of delta F 508 mutation was performed on all children.

RESULTS

Out of 3500 new cases registered in Pediatric Chest Clinic during this period 120, (3.5%) children were diagnosed as CF. Origin of parents of patients traced from almost all the States of north India. Family history suggestive of CF was present in 41 (34%) and consanguinity in 19 (61%) patients. Common clinical manifestations at the time of presentation included recurrent or persistent pneumonia in 118 (98%), failure to thrive in 108 (90%), malabsorption in 96 (80%), history of meconium ileus in 10 (8%), and rectal prolapse was present in 16 (13%). History of salt craving, salty taste on kissing and skin rashes was present in 5 patients each. 49(41%) patients were severely malnourished. Nasal polyposis was present in 5 (4%) patients. Examination of chest revealed evidence of hyperinflation in 100 (83%), kyphosis 20 (17%), crepitations 110 (92%), wheezing 40 (25%) and bronchial breathing in 20 (17%) patients. Average clinical CF scores were 51 (95%; CI 20-80). 48 (40%) patients had a CF score of LT40. Pseudomonas spp was cultured from respiratory secretions of 51 (42%), Staphylococcus spp in 18 (15%), Klebsiella spp in 8 (7%) and Hemophilus influenzae in 2 (2%) patients. Delta F508 mutation was positive in 45 chromosomes out of 240 tested. Patients originated from Pakistan had more frequency of delta F508 mutations.

CONCLUSIONS

Cystic fibrosis does occur in Indian children; clinical features are classical. Diagnosis is often delayed and the disease is advanced in most patients at the time of diagnosis. Frequency of Delta F508 mutation is 19% i.e., less than that seen in Caucasian population. There is need to create awareness about occurrence of CF in Indian children.

Early detection of cervical cancer with visual inspection methods: a summary of completed and on-going studies in India

India is a high-risk country for cervical cancer which accounts a quarter (126,000 new cases, 71,000 deaths around 2,000) of the world burden. The age-standardized incidence rates range from 16-55 per 100,000 women in different regions with particularly high rates in rural areas. Control of cervical cancer by early detection and treatment is a priority of the National Cancer Control Programme of India. There are no organized cytology screening programmes in the country. The technical and financial constraints to organize cytology screening have encouraged the evaluation of visual inspection approaches as potential alternatives to cervical cytology in India. Four types of visual detection approaches for cervical neoplasia are investigated in India: a) naked eye inspection without acetic acid application, widely known as 'downstaging'; b) naked eye inspection after application of 3-5% acetic acid (VIA); c) VIA using magnification devices (VIAM); d) visual inspection after the application of Lugol's iodine (VILI). Downstaging has been shown to be poorly sensitive and specific to detect cervical neoplasia and is no longer considered as a suitable screening test for cervical cancer. VIA, VIAM and VILI are currently being investigated in multicentre cross-sectional studies (without verification bias), in which cytology and HPV testing are also simultaneously evaluated, and the results of these investigations will be available in 2003. These studies will provide valuable information on the average, comparative test performances in detecting high-grade cervical cancer precursors and cancer. Results from pooled analysis of data from two completed studies indicated an approximate sensitivity of 93.4% and specificity of 85.1% for VIA to detect CIN 2 or worse lesions; the corresponding figures for cytology were 72.1% and 91.6%. The efficacy of VIA in reducing incidence of an mortality from cervical cancer and its cost-effectiveness is currently being investigated in two cluster randomized controlled intervention trials in India. One of these studies is a 4-arm trial addressing the comparative efficacy of VIA, cytology and primary screening with HPV DNA testing. This trial will provide valuable information on comparative detection rates of CIN 2-3 lesions by the middle of 2003. The expected outcomes from the Indian studies will contribute valuable information for guiding the development of public health policies on cervical cancer prevention in countries with different levels of socio-economic and health services development and open up new avenues of research. This paper is available too at: http//www.insp.mx/salud/index.html.

An indigenously developed method for sweat collection and estimation of chloride for diagnosis of cystic fibrosis

An indigenously developed method for sweat collection and titration method for estimation of chloride was validated. The mean difference in estimated chloride value from the known strength of saline in 50 samples was -1.04 +/- 4.13 mEq/L (95% CI: -0.07 to 2.28). The mean difference in the estimated chloride values between two observers when the test was performed on known strengths of saline solution was -2.5 +/- 4.24 mEq/L (95% CI: -3.67 to 1.33). The inter observer variability between two observers when the test was performed on sweat samples obtained from 50 individuals was -1.12 +/- 4.34 mEq/L (95% CI: -2.23 to 0.8 ). Sweat weight of more than 100 mg could be collected in first attempt in 602 of 757 (80%) patient with an average sweat weight of 230 mg. This inexpensive method of sweat collection and chloride estimation has acceptable accuracy and repeatability and can be used in resource poor setting for making a diagnosis of cystic fibrosis.

Prenatal diagnosis of haemoglobinopathies

BACKGROUND

Haemoglobinopathies constitute a major health problem in the Indian subcontinent. In the absence of any method for achieving complete cure and treatment being expensive, prenatal diagnosis and selective termination of an affected foetus is a feasible option to decrease the disease load. We report our experience with prenatal diagnosis of haemoglobinopathies over a two-and-a-half year period in 257 pregnancies.

METHODS

Amplification refractory mutation system (ARMS) was used to detect beta-thalassaemia, haemoglobin E and sickle cell mutations.

RESULTS

Five mutations in the beta-globin gene which are common in the Indian population were detected in 92.3% of mutant chromosomes, whereas 3.1% of chromosomes carried rare mutations followed by 0.8% haemoglobin E and 0.4% sickle cell mutations. Mutations in 3.3% chromosomes were uncharacterized. The prenatal procedure, carried out early in pregnancy, was a chorionic villus sampling in most cases. A confirmed diagnosis based on ARMS-PCR was given in 241 (93.8%) cases. In 10 cases (3.9%) linkage analysis was required to confirm the foetal status, as mutations in both parents were not identified or the chorionic villus sample carried the single identified mutation. Four families with haemoglobin E-beta thalassaemia and one family with sickle cell disease were also included. Of the study population, 91.25% of the couples had a previous child with haemoglobinopathy, whereas 8.75% of the couples came before the birth of the first affected child.

CONCLUSION

We conclude that ARMS-PCR is a highly sensitive technique for detecting mutations in the beta-globin gene and its efficacy in the prenatal diagnosis of haemoglobinopathies is proven.

Cysteinyl leukotrienes mediate enhanced vasoconstriction to angiotensin II but not endothelin-1 in SHR

We assessed whether cysteinyl leukotrienes mediate the vasoconstrictor responses to angiotensin II and endothelin-1 in the mesenteric vascular bed of Wistar-Kyoto (WKY) and spontaneously hypertensive rats (SHR) perfused ex vivo at a constant flow rate of 5 ml/min with Krebs buffer. Maximal perfusion pressure response (E(max)) but not EC(50) values to angiotensin II (P < 0.001) and endothelin-1 (P < 0.01) were significantly higher in the SHR, whereas the responses to potassium chloride remained unchanged. Inclusion of the selective 5-lipoxygenase inhibitor AA-861 or the cysteinyl leukotriene receptor antagonist MK-571 significantly reduced the vasoconstrictor responses to angiotensin II but not to endothelin-1 and potassium chloride. The reduction in E(max) to angiotensin II was more pronounced in SHR (P < 0.001) than in WKY (P < 0.05) rats. Cysteinyl leukotrienes LTC(4)-, LTD(4)-, and LTE(4) (1 microM)-evoked vasoconstrictor responses were significantly higher in SHR (P < 0.05), whereas LTB(4) failed to evoke any response in either strain. These data suggest that 5-lipoxygenase metabolites, particularly cysteinyl leukotrienes, contribute to the exaggerated vasoconstrictor responses to angiotensin II but not to endothelin-1.

Prevalence of astroviruses in a children's hospital

An enzyme immunoassay for astrovirus was used to screen 357 stool samples from 267 symptomatic inpatients at a tertiary-care children's hospital. Thirty stool samples from 26 patients contained astrovirus antigen, while rotavirus was found in 34 samples and Clostridium difficile toxin was found in 40. Half of the astrovirus infections were nosocomial. Additional pathogens were identified in six of the astrovirus antigen-positive stool samples. Most (80%) of the astroviruses recovered were of serotype 1. Astrovirus infections were significantly more common than rotavirus or C. difficile infections in very young infants and in those with surgical short-bowel syndrome.

Relationship among particle size distribution, dissolution profile, plasma values, and anthelmintic efficacy of oxfendazole

Three mean particle sizes of oxfendazole raw material (1.65 micron, lot A; 3.2 micron, 10t B; 12.0 micron, lot C) were prepared and identically formulated as corresponding (A, B, and C) suspensions at 2.26% (W/V) concentration. Studies involving microscopic examination, scanning electron microscope analysis, particle size distribution, and surface area measurement were carried out on raw materials. In vitro dissolution profiles were obtained for the suspensions. A comparative bioavailability study of these 3 suspensions was performed in 12 sheep with each sheep given each formulation in a Latin square crossover study design; oxfendazole was dosed at rate of 5 mg/kg of body weight. Plasma-value measurements were made followed by an analysis of various bioavailability studies. Plasma area values indicated that suspension C (dw = 12.0 micron) was significantly (P less than 0.05) less bioavailable than was suspension A (dw = 1.65 micron); there was no difference between suspension A and suspension B. Significant differences were not seen in biological half-life and maximum plasma concentrations. The term dw refers to that particle diameter (determined by Coulter counting) at which 50% of the oxfendazole mass was in the form of particles having a lesser diameter and 50% was in the form of particles having a greater diameter. In a separate study involving 20 Merino weaner sheep infected with benzimidazole-resistant Haemonchus contortus larvae, oxfendazole's anthelmintic efficacy was demonstrated in the 2.26% suspension dosage form (90% particles less than 10 micron) at a dosing rate of 5 mg/kg. A correlation was found between its anthelmintic activity and plasma area values when compared in individual sheep. Data demonstrated that substantial differences in particle size distribution of oxfendazole could influence its dissolution rate, plasma concentrations, and absorption characteristics, thus indicating that oxfendazole's absorption could be dissolution-rate limited.

Distribution Of Abo And Rh Blood Groups In Hiv Seropositives At An Integrated Counseling And Testing Centre In Karnataka, India

Introduction: ABO blood group system was the fi rst human blood group system to be discovered. Subsequent to the discovery of blood groups by Landsteiner and advancement in its study many workers tried to fi nd out associations between blood groups and the incidence of various diseases. The objective of the study was to create a blood group database which would probably help in transfusion services and fi nd out the distribution of blood groups in the seropositive population. Methodology: Blood groups were ascertained for 1809 patients who were HIV seropositive enrolled at ICTC in a tertiary care teaching hospital in Karnataka, India from April 2004 to January 2010 using the simple tile method. The results were compiles and statistically analyzed. Results: Blood grouping was done for 1809 patients, out of which 1749 (96.68%) were adults and 60(3.32%) were paediatric patients. O Rhesus positive was the most prevalent blood group in both adult (40.13%) and paediatric (43.33%) seropositives. B Rhesus positive was next commonest group in adults (26.12%) and A Rhesus positive in paediatric(30.0%). AB Rhesus negative (Adults-0.34% and Paediatric-0%) blood group was the least prevalent in the study population. Conclusion: It is important to create blood group database for the Indian seropositives population, to know any probable association between blood group and HIV infection. This study is an attempt to create a blood group database in a modestly large seropositive which would play a vital role in transfusion services and future research . Larger nation-wide studies would be required to substantiate any association between blood groups and HIV infection. DOI: http://dx.doi.org/10.3126/saarctb.v8i2.5901 SAARCTB 2011; 8(2): 42-45