Validation of dried blood spot for serological diagnosis of Hepatitis B and C: a multicentric study

The present study aimed to determine diagnostic performance of dried blood spot (DBS) for the detection of Hepatitis B surface antigen (HBsAg) and Hepatitis C virus antibodies (anti-HCV) using CLIA at 3 different laboratories across India. DBS can serve as a simple and convenient alternative to plasma/serum for HBsAg detection. However for anti-HCV, site-specific validation of the assay is warranted.

Facilitators and barriers to the uptake of COVID-19 vaccine precaution dose among adult population: qualitative analysis across six different states of India

Introduction

India launched the COVID-19 vaccination drive on 16th January 2021 by vaccinating the adult population above 18 years of age. This was followed by the introduction of an additional precaution dose. As on 18th October 2022, 1,02,66,96,808 (1.02 Billion) first dose and 94, 95, 39,516 (949 Million) second doses of COVID-19 vaccine were administered. However, when compared to the uptake of the primary doses, the precaution dose uptake lagged behind with only 21,75, 12,721 (217 million) doses administered. Even though, the uptake of the primary doses remained optimal, irrespective of different interventions by the Government of India, the uptake of the precaution dose remained poor. In this context, the Ministry of Health & Family Welfare wanted to understand the facilitators and Barriers for precaution dose uptake among adults so that future immunization campaigns could address these issues.

Methods

An exploratory qualitative study was conducted to assess the facilitators and barriers for COVID-19 precaution dose uptake at community level across 6 different states in India. From each of the states, two districts with the highest and lowest rates of COVID-19 vaccine precaution dose uptake were selected. In each of these districts, 2 block Primary Healthcare Centres (PHCs), one with high and one with low uptake were identified. Within these block PHCs, a PHC field area with high and low precaution dose uptakes was identified. From the identified sites a minimum of four IDIs, four FGDs were conducted among the community members. KIIs of the State Immunization Officers, District Immunisation Officers, PHC Medical Officers, healthcare workers like Accredited Social Health Activist/Auxiliary Nurse Midwife were also conducted. The data was audio recorded and it was transcribed, translated and analysed using framework approach.

Results

It was observed that rise in COVID-19 cases prompted the community to take the precaution dose, this along with the cost of hospitalization and the number of productive days being lost as a result of being infected resulted in vaccine uptake. The fear of non-availability of COVID-19 vaccines latter on also prompted people for vaccine uptake. While the barriers were, poor accessibility to vaccination centers, long hours of travel, poor road connectivity and lack of transportation facilities. However, the most prominent barriers observed across all study sites was that a sense of pandemic fatigue and complacency had developed both among the providers as well as the beneficiaries. Other barriers include differences in vaccination schedules and longer duration between the primary doses of some vaccines. Media was identified to be both a barrier and facilitator for Covid-19 Precaution dose uptake. Even though media played an important role in disseminating information in the beginning of the campaign, it was soon followed by the circulation of both misinformation and disinformation.

Discussion

The study identified that dissemination of accurate information and community involvement at each stage of planning and implementation are crucial for the success of any campaign. Efforts should be constantly made to address and re-invent strategies that will be most suitable for the needs of the community. Therefore, in order to ensure successful vaccination campaigns, it is crucial that along with political will it is also important to have a decentralized approach with inter-sectoral coordination with different stakeholders such as healthcare workers, community members and the different departments such as the local self-governments, education department, law & order department etc. These lessons learnt from COVID-19 vaccination campaigns must not be forgotten and must be applied in future vaccination campaigns and while framing public health policies.

Antiretroviral Treatment-Induced Galectin-9 Might Impact HIV Viremia in Addition to Contributing to Inflammaging

BACKGROUND

Galectin-9 induces HIV reactivation and also contributes to non-AIDS events through inflammaging. Hence, it is important to assess its levels in HIV-infected individuals to determine their association with HIV viremia and other comorbidities.

METHODS

Plasma galectin-9 levels were estimated in viremic (n = 152) and aviremic (n = 395) individuals on first-line antiretroviral therapy (ART). They were assessed for correlation with HIV-1 viral load (VL), CD4 count, and ART duration, as well as for receiver operating characteristic curve analysis.

RESULT

Plasma galectin-9 levels correlated positively with VL (r = 0.507, p < 0.0001) and ART duration (r = 0.308, p = 0.002) and negatively with CD4 count (r = -0.186, p < 0.0001). Area under the curve for galectin-9/CD4 count ratio for identifying viremic individuals was 0.906. Sensitivity and specificity of the ratio at a cutoff of 14.47 were 90.13% and 70.05%, respectively, for detecting viremic individuals. Further, galectin-9 levels correlated with cystatin C (r = 0.239, p = 0.0183), IL-18 (r = 0.311, p = 0.006), and systolic blood pressure (r = 0.220, p = 0.0355). Galectin-9-induced HIV reactivation was significantly lower in individuals on long-term ART than those on short-term ART.

CONCLUSION

The galectin-9-to-CD4 count ratio indicated the potential of galectin-9 as a cheaper monitoring tool to detect HIV viremia. Strategies for countering the effects of galectin-9 for controlling HIV viremia and non-AIDS events are urgently warranted.

Prevention of recurrence of bacterial vaginosis using lactobacilli-containing vaginal tablets among women with HIV: a randomized, placebo-controlled, double-blinded phase IV trial

OBJECTIVES

The effectiveness of lactobacilli-containing vaginal tablets (VT) in bacterial vaginosis (BV) recurrence prevention among women infected with HIV treated with standard oral metronidazole in Pune, India was studied.

METHODS

Women infected with HIV with confirmed BV diagnosis (Nugent score ≥7 and Amsel criteria >3) were enrolled in a 12-month, double-blind, randomized, placebo-controlled, phase IV study between 2018 and 2021. After a standard course of oral metronidazole for 7 days (400 mg three times a day), women were randomly assigned to either lactobacilli-containing or placebo VT arms to receive VTs for 4 months. BV recurrence was assessed after the initial cure from BV.

RESULTS

Of the 464 women infected with HIV, 80 women with confirmed BV were enrolled. The retention was affected due to the COVID-19 pandemic (6-month retention rates 78%). The cure was seen in 85% and 93.5% of participants from the treatment and placebo arms, respectively, after four VT cycles. BV recurrence was seen in 41.4% and 44.8% in the treatment and placebo arm, respectively, with no significant difference in the two groups.

CONCLUSION

The lactobacilli-containing VT was acceptable and safe; however, the addition of VT over standard oral metronidazole did not show any additional benefit in the prevention of BV recurrence in women infected with HIV, indicating the need for long-term randomized trials among them. Registered at Clinical Trials Registry- India, (CTRI) Number: CTRI/2018/04/013298.

Challenges faced by ethics committee members in India during COVID-19 pandemic: A mixed-methods exploration

Background & objectives

The COVID-19 pandemic had a distinct impact on scientific research and Ethics Committees (ECs). We conducted a mixed-methods investigation to understand the issues faced and solutions identified by ECs during this pandemic in India.

Methods

A quantitative online survey form (30 members) and qualitative in-depth interviews (10 members) from various ECs were conducted. Thematic content analysis for qualitative and proportion analysis for quantitative data was carried out.

Results

During the online survey, an average difficulty score, which was measured using the Visual Analogue Scale, was 5.3 (SD 2.1). Pressure for expedited approvals was felt by EC members with a drastic increase in the number of submission of research projects. The scarcity of information on investigational products (IPs) and requisite consent process posed major hurdles. Ongoing non-COVID studies and post-graduate dissertations were badly hit due to the shift in attention towards COVID-related research. Non-familiarity with virtual technology and lack of face-to-face interactions were highlighted as demerits. However, a few of the EC members welcomed newer methods, being time-saving, convenient and reducing travel hassles. Site monitoring and severe adverse event-related analyses were also negatively impacted upon. Solutions included the alternate methods of consenting (virtual, abbreviated), a detailed explanation of the protocol and IPs and benefits versus risk assessment.

Interpretation & conclusions

Despite various challenges posed by the COVID-19 pandemic, the ECs in India steered well through the hurdles. Moreover, adapting a hybrid mode, technical training and updating guidelines were perceived as urgent by EC members.

980Quantifying inadvertent data-duplication- findings from validation of antenatal-registration and HIV-testing data-sets from an Indian state

Background

India plans elimination of HIV-Mother-to-Child-Transmission in 2020. Targets include &gt;95% coverage of Antenatal-care (ANC) and HIV-testing. In 2015-16, while 43% of the estimated Indian pregnant-women (PW) received HIV-tests, one state reported &gt;95% testing. Indian public-health-care is a three-tiered system from primary-level sub-centres (population-5000) to tertiary-level hospitals. ANC involves multiple-visits per pregnancy at different care-levels and data are aggregated in the Health-Management-Information-System (HMIS) at all levels. We validated (public and private-sector data from this state, for duplication in ANC registration and HIV-testing using mixed methods.

Methods

In the absence of guidelines for assessing aggregate-data duplication, we used mixed-methods, including surveys among 9845 PW and providers from 240 facilities in 10/36 representative districts; in-depth-interviews; case-studies and analysis of HMIS and HIV-program data (April 2015-Mar 2017). Interviews and case-studies highlighted inadvertent duplicate data-capture. Surveys quantified levels of duplication and adjustment factors (public and private-sector) were developed.

Results

Twenty-four% PW, visited multiple facilities for ANC, while 81% providers reported all the PW coming to their facilities as new ANC registrations (irrespective of lower-tier registration); identifying a minimum duplication of 19% (24%*81%) in ANC coverage. Twenty-nine% and 28% PW from public and private-facilities reported &gt;1 HIV-test; while 75% and 36% reported visiting another public-facility where HIV test was likely to be reported again. Minimum duplication of 22% and 10% in HIV testing was noted in public and private-sectors respectively.

Conclusions

We report methods to quantify repeat HIV-testing and duplicate-reporting, due to inherent processes in ANC in public-healthcare in India. Modification of data-capture was recommended and adopted across India.

Key messages

Assessing duplication in aggregate health data is key to developing robust datasets for disease elimination

Detection of Immunoglobulin M and Immunoglobulin G Antibodies Against Orientia tsutsugamushi for Scrub Typhus Diagnosis and Serosurvey in Endemic Regions

OBJECTIVE

To estimate the regional cutoff of optical density (OD) values for immuno-globulin M (IgM) antibodies against Orientia tsutsugamushi in serum and cerebrospinal fluid (CSF) for clinical diagnosis of scrub typhus and immunoglobulin G (IgG) antibodies in serum for sero-epidemiology in Gorakhpur, Uttar Pradesh, India.

METHODS

We used data from a serological investigation of acute encephalitis syndrome patients (n=407) during the 2016 outbreak in Gorakhpur, India to determine the cutoff for OD values for IgM antibodies, and from community-based serosurveys (n=1991) to estimate the cutoff for OD values for IgG antibodies.

RESULTS

We determined regionally relevant cutoff for OD values of 0.76 for IgM antibodies in serum and 0.22 in cerebrospinal fluid for scrub typhus diagnosis. For serosurveys, IgG antibody cutoff was 1.5.

CONCLUSION

We have proposed locally relevant cutoffs for scrub typhus endemic regions, which may be useful for correctly classifying infected population.

Seroprevalence & seroincidence of Orientia tsutsugamushi infection in Gorakhpur, Uttar Pradesh, India: A community-based serosurvey during lean (April-May) & epidemic (October-November) periods for acute encephalitis syndrome

Background & objectives

In India, acute encephalitis syndrome (AES) cases are frequently reported from Gorakhpur district in Uttar Pradesh. Scrub typhus is one of the predominant aetiological agents for these cases. In order to delineate the extent of the background of scrub typhus seroprevalence and the associated risk factors at community level, serosurveys during both lean and epidemic periods (phase 1 and phase 2, respectively) of AES outbreaks were conducted in this region.

Methods

Two community-based serosurveys were conducted during lean (April-May 2016) and epidemic AES (October-November 2016) periods. A total of 1085 and 906 individuals were enrolled during lean and epidemic AES periods, respectively, from different villages reporting recent AES cases. Scrub typhus-seronegative individuals (n=254) during the lean period were tested again during the epidemic period to estimate the incidence of scrub typhus.

Results

The seroprevalence of Orientia tsutsugamushi during AES epidemic period [immunoglobulin (Ig) IgG: 70.8%, IgM: 4.4%] was high as compared to that of lean AES period (IgG: 50.6%, P <0.001; IgM: 3.4%). The factors independently associated with O. tsutsugamushi positivity during lean AES period were female gender, illiteracy, not wearing footwear, not taking bath after work whereas increasing age, close contact with animals, source of drinking water and open-air defecation emerged as additional risk factors during the epidemic AES season. IgM positivity was significantly higher among febrile individuals compared to those without fever (7.7 vs. 3.5%, P=0.006). The seroincidence for O. tsutsugamushi was 19.7 per cent, and the subclinical infection rate was 54 per cent.

Interpretation & conclusions

The community-based surveys identified endemicity of O. tsutsugamushi and the associated risk factors in Gorakhpur region. The findings will be helpful for planning appropriate interventional strategies to control scrub typhus.

Amebic Liver Abscess and Kawasaki Disease

BACKGROUND

Co-occurrence of amebic hepatitis and Kawasaki disease has not been reported previously.

CASE CHARACTERISTICS

We describe two children (aged 4 y and 5 y) with Kawasaki disease and coexisting liver abscess. They were treated with intravenous immunoglobulins with/without percutaneous drainage in combination with amebicidal agents.

OUTCOME

Both the children were completely cured of the amebic hepatitis, and had normalization and regression of coronaries at follow-up.

MESSAGE

We report the co-existence of amebic hepatitis with Kawasaki disease.

GeneXpert HIV-1 quant assay, a new tool for scale up of viral load monitoring in the success of ART programme in India

BACKGROUND

Recent WHO guidelines identify virologic monitoring for diagnosing and confirming ART failure. In view of this, validation and scale up of point of care viral load technologies is essential in resource limited settings.

METHODS

A systematic validation of the GeneXpert® HIV-1 Quant assay (a point-of-care technology) in view of scaling up HIV-1 viral load in India to monitor the success of national ART programme was carried out. Two hundred nineteen plasma specimens falling in nine viral load ranges (<40 to >5 L copies/ml) were tested by the Abbott m2000rt Real Time and GeneXpert HIV-1 Quant assays. Additionally, 20 seronegative; 16 stored specimens and 10 spiked controls were also tested. Statistical analysis was done using Stata/IC and sensitivity, specificity, PPV, NPV and %misclassification rates were calculated as per DHSs/AISs, WHO, NACO cut-offs for virological failure.

RESULTS

The GeneXpert assay compared well with the Abbott assay with a higher sensitivity (97%), specificity (97-100%) and concordance (91.32%). The correlation between two assays (r = 0.886) was statistically significant (p < 0.01), the linear regression showed a moderate fit (R² = 0.784) and differences were within limits of agreement. Reproducibility showed an average variation of 4.15 and 3.52% while Lower limit of detection (LLD) and Upper limit of detection (ULD) were 42 and 1,740,000 copies/ml respectively. The misclassification rates for three viral load cut offs were not statistically different (p = 0.736). All seronegative samples were negative and viral loads of the stored samples showed a good fit (R² = 0.896 to 0.982).

CONCLUSION

The viral load results of GeneXpert HIV-1 Quant assay compared well with Abbott HIV-1 m2000 Real Time PCR; suggesting its use as a Point of care assay for viral load estimation in resource limited settings. Its ease of performance and rapidity will aid in timely diagnosis of ART failures, integrated HIV-TB management and will facilitate the UNAIDS 90-90-90 target.

Neutralizing Antibody Response and Efficacy of Novel Recombinant Tetravalent Dengue DNA Vaccine Comprising Envelope Domain III in Mice

BACKGROUND

Dengue is a global arboviral threat to humans; causing 390 million infections per year. The availability of safe and effective tetravalent dengue vaccine is a global requirement to prevent epidemics, morbidity, and mortality associated with it.

METHODS

Five experimental groups (6 mice per group) each of 5-week-old BALB/c mice were immunized with vaccine and placebo (empty plasmid) (100 µg, i.m.) on days 0, 14 and 28. Among these, four groups (one group per serotype) of each were subsequently challenged 3 weeks after the last boost with dengue virus (DENV) serotypes 1-4 (100 LD₅₀, 20 µl intracerebrally) to determine vaccine efficacy. The fifth group of each was used as a control. The PBS immunized group was used as mock control. Serum samples were collected before and after subsequent immunizations. EDIII fusion protein expression was determined by Western blot. Total protein concentration was measured by Bradford assay. Neutralizing antibodies were assessed by TCID₅₀-CPE inhibition assay. Statistical analysis was performed using Stata/IC 10.1 software for Windows. One-way repeated measures ANOVA and Mann-Whitney test were used for neutralizing antibody analysis and vaccine efficacy, respectively.

RESULTS

The recombinant EDIII fusion protein was expressed adequately in transfected 293T cells. Total protein concentration was almost 3 times more than the control. Vaccine candidate induced neutralizing antibodies against all four DENV serotypes with a notable increase after subsequent boosters. Vaccine efficacy was 83.3% (DENV-1, -3, -4) and 50% (DENV-2).

CONCLUSION

Our results suggest that vaccine is immunogenic and protective; however, further studies are required to improve the immunogenicity particularly against DENV-2.

HIV and cancer registry linkage identifies a substantial burden of cancers in persons with HIV in India

We utilized computerized record-linkage methods to link HIV and cancer databases with limited unique identifiers in Pune, India, to determine feasibility of linkage and obtain preliminary estimates of cancer risk in persons living with HIV (PLHIV) as compared with the general population.Records of 32,575 PLHIV were linked to 31,754 Pune Cancer Registry records (1996-2008) using a probabilistic-matching algorithm. Cancer risk was estimated by calculating standardized incidence ratios (SIRs) in the early (4-27 months after HIV registration), late (28-60 months), and overall (4-60 months) incidence periods. Cancers diagnosed prior to or within 3 months of HIV registration were considered prevalent.Of 613 linked cancers to PLHIV, 188 were prevalent, 106 early incident, and 319 late incident. Incident cancers comprised 11.5% AIDS-defining cancers (ADCs), including cervical cancer and non-Hodgkin lymphoma (NHL), but not Kaposi sarcoma (KS), and 88.5% non-AIDS-defining cancers (NADCs). Risk for any incident cancer diagnosis in early, late, and combined periods was significantly elevated among PLHIV (SIRs: 5.6 [95% CI 4.6-6.8], 17.7 [95% CI 15.8-19.8], and 11.5 [95% CI 10-12.6], respectively). Cervical cancer risk was elevated in both incidence periods (SIRs: 9.6 [95% CI 4.8-17.2] and 22.6 [95% CI 14.3-33.9], respectively), while NHL risk was elevated only in the late incidence period (SIR: 18.0 [95% CI 9.8-30.20]). Risks for NADCs were dramatically elevated (SIR > 100) for eye-orbit, substantially (SIR > 20) for all-mouth, esophagus, breast, unspecified-leukemia, colon-rectum-anus, and other/unspecified cancers; moderately elevated (SIR > 10) for salivary gland, penis, nasopharynx, and brain-nervous system, and mildly elevated (SIR > 5) for stomach. Risks for 6 NADCs (small intestine, testis, lymphocytic leukemia, prostate, ovary, and melanoma) were not elevated and 5 cancers, including multiple myeloma not seen.Our study demonstrates the feasibility of using probabilistic record-linkage to study cancer/other comorbidities among PLHIV in India and provides preliminary population-based estimates of cancer risks in PLHIV in India. Our results, suggesting a potentially substantial burden and slightly different spectrum of cancers among PLHIV in India, support efforts to conduct multicenter linkage studies to obtain precise estimates and to monitor cancer risk in PLHIV in India.

Predictors of bisexual behaviour among MSM attending intervention sites may help in prevention interventions for this bridge to the heterosexual epidemic in India: data from HIV sentinel surveillance

Background

Indian cultural tradition demanding marriage, many MSM howsoever they self-identify are likely to be married or have sex with women. To consolidate India's HIV prevention gains, it is important to understand and address the interaction between the MSM and heterosexual epidemics in India and create specific interventions for bisexual MSM. The challenge is to identify and intervene this hard to reach population. Data from HIV Sentinel Surveillance 2011 among MSM in four Indian states were analyzed to assess predictors and prevalence of bisexual behaviour in MSM.

Methods

Between March-May 2011, 4682 men (15–49 years) who had anal/oral sex with a male partner in the past month, attending intervention sites and consenting for an un-linked anonymous survey answered an 11- item questionnaire and provided blood for HIV test by finger stick at 19 designated surveillance sites.

Results

Of 4682 MSM tested overall, 5% were illiterate, 51% reported only receptive anal intercourse, 21% only penetrative and 28% both. 36% MSM had ever received money for sex. Overall 6.8% were HIV infected. 44% MSM were bisexual in the last six months. On multivariate analysis, ‘being bisexual’ was found to be independently associated with ‘older age’: 26–30 years [AOR = 3.1, 95% CI(2.7, 3.7)], >30 years [AOR = 6.5, 95% CI(5.5, 7.7)]; ‘reporting penetrative behaviour alone’ with other men [AOR = 5.8, 95% CI(4.8, 7.0), p<0.01] and ‘reporting both penetrative and receptive behaviour’ [AOR = 2.7, 95% CI(2.3, 3.1) p<0.01]. Those who both paid and received money for sex [AOR = 0.49, 95% CI (0.38, 0.62)] were significantly less likely to be bisexual.

Conclusions

A substantial proportion of men receiving services from Targeted Intervention programs are bisexual and the easy opportunity for intervention in this setting should be capitalised upon. Focusing on older MSM, as well as MSM who show penetrative behaviour with other men, could help in reaching this population.

Ubiquitin-like (UBX)-domain-containing protein, UBXN2A, promotes cell death by interfering with the p53-Mortalin interactions in colon cancer cells

Mortalin (mot-2) induces inactivation of the tumor suppressor p53's transcriptional and apoptotic functions by cytoplasmic sequestration of p53 in select cancers. The mot-2-dependent cytoprotective function enables cancer cells to support malignant transformation. Abrogating the p53-mot-2 interaction can control or slow down the growth of cancer cells. In this study, we report the discovery of a ubiquitin-like (UBX)-domain-containing protein, UBXN2A, which binds to mot-2 and consequently inhibits the binding between mot-2 and p53. Genetic analysis showed that UBXN2A binds to mot-2's substrate binding domain, and it partly overlaps p53's binding site indicating UBXN2A and p53 likely bind to mot-2 competitively. By binding to mot-2, UBXN2A releases p53 from cytosolic sequestration, rescuing the tumor suppressor functions of p53. Biochemical analysis and functional assays showed that the overexpression of UBXN2A and the functional consequences of unsequestered p53 trigger p53-dependent apoptosis. Cells expressing shRNA against UBXN2A showed the opposite effect of that seen with UBXN2A overexpression. The expression of UBXN2A and its apoptotic effects were not observed in normal colonic epithelial cells and p53-/- colon cancer cells. Finally, significant reduction in tumor volume in a xenograft mouse model in response to UBXN2A expression was verified in vivo. Our results introduce UBXN2A as a home defense response protein, which can reconstitute inactive p53-dependent apoptotic pathways. Inhibition of mot-2-p53 interaction by UBXN2A is an attractive therapeutic strategy in mot-2-elevated tumors.

The Effect of High-Fidelity Simulation on the Confidence and Decision-Making Ability of Anaesthesia Trainees in Managing Subsequent Simulated ‘Can't Intubate, Can't Oxygenate’ scenarios

The decision to attempt a percutaneous airway in a recognised ‘Can't Intubate, Can't Oxygenate’ (CICO) situation may occur too late to avoid a poor outcome. Our study was designed to investigate the effect of high-fidelity simulation on the confidence and decision-making ability of anaesthesia trainees in managing CICO scenarios in subsequent simulation. Nine anaesthesia trainees from Logan Hospital participated. Pre-study questionnaires surveying confidence levels in various anaesthetic crises were completed. All participants underwent an education session based on algorithms developed for failed intubation and ventilation, and techniques for securing percutaneous airway access. However, only four of the nine participated in a high-fidelity simulation session. All nine participants were then filmed during ‘mini-simulation’ assessment sessions and completed post-study questionnaires identical to those at the commencement of the study. The four trainees who had undertaken the initial high-fidelity simulation had a lower median time to laryngeal mask airway attempt (60 versus 115 seconds) and time to percutaneous airway attempt (111 versus 172 seconds) in the subsequent simulation. The median number of deviations from the Difficult Airway Society algorithm was 0 for the simulation group compared to 1 for the non-simulation group. This small study suggests that high-fidelity simulation shortens the decision-making time of anaesthesia trainees in subsequent simulated CICO scenarios. This observation warrants follow-up in larger prospective trials.

Heterosexual anal sex among female sex workers in high HIV prevalence states of India: need for comprehensive intervention

Introduction

Role of vaginal sex in heterosexual transmission of HIV has been investigated but that of heterosexual anal sex (HAS) is not fully understood. This paper examines practice of HAS among Female Sex Workers (FSWs) and its correlates in India where the HIV epidemic is being primarily driven by core groups like FSWs.

Methods

Data for this paper are drawn from Round I survey of 9667 FSWs in the Integrated Biological and Behavioral Assessment (IBBA) from 23 districts of 4 high HIV prevalent states of India. Bivariate and multivariate analysis identified factors associated with HAS.

Results

Ever having anal sex was reported by 11.9% FSWs (95% CI: 11.3%–12.6%). Typology (AOR 2.20, 95% CI 1.64–2.95) and literacy (AOR 1.28, 95% CI 1.10–1.49) were positively associated with practice of HAS. Longer duration in sex trade (AOR 1.69, 95% CI 1.44–1.99), entertaining larger number of clients the previous week (AOR 1.78, 95% CI 1.47–2.15), alcohol consumption (AOR 1.21, 95% CI 1.03–1.42) and inability to negotiate condom use (AOR 1.53, 95% CI 1.28–1.83) were also correlated with HAS. Self-risk perception for HIV (AOR 1.46, 95% CI 1.25–1.71) did not impede HAS. Although symptoms of sexually transmitted infections (STIs) in the last 12 months were associated with anal sex (AOR 1.39, 95% CI 1.13–1.72) there was no significant association between laboratory confirmed HIV and other STIs with HAS.

Conclusion

Practice of HAS by FSWs might significantly contribute to HIV transmission in India. This study also shows that despite self-risk perception for HIV, even literate FSWs with longer duration in sex work report HAS. General messages on condom use may not influence safe HAS. FSWs need to be targeted with specific messages on HIV transmission during anal sex. Women controlled prevention methods, such as rectal microbicides and vaginal microbicides are needed.

Association of plasma viremia with HIV-1 RNA levels in cervicovaginal lavage secretions in HIV-1 seropositive ART naïve women from Pune, India

BACKGROUND

Coherent drug/microbicide/vaccine development research would benefit through a precise knowledge of HIV dissemination and its persistence in the female genital tract. Understanding relationship between plasma viremia and cervicovaginal HIV shedding may help to unveil mechanisms underlying transmission, compartmentalization and pathogenesis.

OBJECTIVES

To study the association between HIV-1 RNA levels in the plasma and CVL specimens.

STUDY DESIGN

Whole blood, plasma and CVL specimens were collected from 36 ART naïve HIV-1 seropositive women qualifying the study inclusion criteria. Absolute CD4 counts, plasma and CVL HIV-1 RNA levels were estimated using commercially available kits (BD MultiSET™ Kit, Becton Dickinson, US and Abbott RT, Abbott Molecular, Germany). Correlation between plasma and CVL viral load was estimated by the Spearman's rank correlation coefficient. Additionally, the correlation between CVL viral load and absolute CD4 counts was studied.

RESULTS

HIV-1 viral load in the CVL specimens was successfully quantified using the Abbott RT. Twenty-seven of 36 women (75%) had detectable HIV-1 RNA levels in plasma and CVL specimens. The CVL viral load did not show any correlation with plasma viral load (ρ=0.281, p=0.096) and showed a 'moderate correlation' (ρ=-0.563, p=0.0004) with absolute CD4 counts.

CONCLUSIONS

Albeit, the Abbott RT is designed for estimating plasma HIV-1 RNA levels, the study reports its use for estimating HIV-1 RNA levels in the CVL specimens as well. In accordance with the previous studies, our results suggest that plasma and CVL viral load are not correlated and plasma viremia might not solely predict cervico vaginal HIV shedding.

Correlates of sex initiation among school going adolescents in Pune, India

OBJECTIVE

To identify the correlates of sex initiation among school going adolescents in Pune, India.

METHODS

A study among 910 school going adolescents was conducted in five schools and one junior college in and around Pune, Maharashtra (India) between 2003-2006. Case control analysis (n = 205) was performed among 41 cases who reported ever having sex and 164 controls matched for gender, location and type of school. Correlates of sex initiation were identified using conditional logistic regression.

RESULTS

Adolescents studying in vernacular schools, accessing pornography and having unfriendly relationship with parents had higher likelihood of sex initiation. Adolescents who reported sexual abuse, Sexually Transmitted Diseases (STDs) symptoms, smoking habit and those who had not read scientific literature on reproductive and sexual health were more likely to have initiated sex early. In the multivariate model, unfriendly relationship with parents and reported symptoms of STDs were found to be independently associated with 'early initiation of sex' among school going adolescents in this study.

CONCLUSIONS

Premarital sexual activity, both consensual and non-consensual, was reported indicating a need for school based adolescent reproductive and sexual health education (ARSHE) programs in Maharashtra, India. The program in India should focus on specialized interventions for young adolescents. Routine health check-ups and probing on symptoms of STDs, non-consensual sex and other risky practices should be implemented in schools.

Enteric pathogens in HIV infected and HIV uninfected individuals with diarrhea in Pune

BACKGROUND

Diarrhea in HIV infected individuals is a common complication seen in about 90% of patients in developing countries. The objective of this study was to identify enteric pathogens in HIV infected and HIV uninfected individuals in Pune.

METHOD

This study was conducted from January 2009 to May 2010 on 331 consecutive patients presenting with diarrhea admitted at Naidu Municipal Corporation Hospital, Pune and processed using conventional methods.

RESULTS

Intestinal parasitic pathogens were detected in 60% (39/65) of HIV infected and 14.3 (38/266) of HIV uninfected individuals. Bacterial pathogens were detected in 34% (22/65) of HIV infected individuals and 28.2% (75/266) of the HIV uninfected individuals. The common enteric pathogens detected in HIV infected individuals were Cystoisospora belli (28%, 18/65) followed by Cryprotosporidium parvum (12%, 8/65). In HIV uninfected individuals Entamoeba histolytica (7.1%, 19/266) followed by Shigella flexnari (4.9%, 13/266) were the most common pathogens. The difference in detection of enteric parasites in HIV infected individuals and HIV uninfected individuals was found to be significant (p < 0.01).

CONCLUSIONS

Intestinal parasitic pathogens are more common in HIV infected antiretroviral therapy naïve patients. Early detection of enteric pathogens by routine examination of stool samples will help in the management and to improve the quality of life for HIV infected individuals.

CD4 estimating reagents in dry format are compatible with conventional flow cytometer; FACSCalibur for estimation of absolute CD4 count & percentages

BACKGROUND & OBJECTIVES

Reliable CD4 counts are important for successful implementation of antiretroviral treatment (ART). Availability of dry CD4 reagents can eliminate cold chain requirement reducing shipment and storage cost. An attempt was made in this study to validate the ReaPan and Rea T Count dry reagents developed by ReaMetrix against the original BD Biosciences liquid reagents.

METHOD

Absolute counts and percentages of CD4, CD8 and CD3 + T cells obtained in 100 HIV infected individuals using the test and reference reagents were analyzed for correlation and agreement using Pearson's correlation and Bland Altman bias analysis . The stability of the reagents and of the stained samples was analyzed at ambient temperature and at 37 °C.

RESULTS

The absolute CD4 + T cell count and percentages obtained using test and reference reagents showed correlation coefficients ranging from 833 to 981. A mean bias between dry and reference reagents ranged from 0.8 to 26.4. The ReaPan and Rea T Count reagents were stable up to one month at 37 °C also. The samples stained with ReaPan reagents were stable at ambient temperature till day 7 whereas the samples stained with Rea T Count reagents were stable at ambient temperature and at 37° C for 10 days.

INTERPRETATION & CONCLUSIONS

The ReaPan dry reagents can be used on existing FACSCalibur machines with additional training on Cell Quest Pro software without incurring any additional equipment cost and this can eliminate the requirement of cold chain during transport and on site storage. The stability of the stained samples has great clinical significance preventing redrawing of the blood samples from the patients.

Initial virologic response and HIV drug resistance among HIV-infected individuals initiating first-line antiretroviral therapy at 2 clinics in Chennai and Mumbai, India

Human immunodeficiency virus drug resistance (HIVDR) in cohorts of patients initiating antiretroviral therapy (ART) at clinics in Chennai and Mumbai, India, was assessed following World Health Organization (WHO) guidelines. Twelve months after ART initiation, 75% and 64.6% of participants at the Chennai and Mumbai clinics, respectively, achieved viral load suppression of <1000 copies/mL (HIVDR prevention). HIVDR at initiation of ART (P <.05) and 12-month CD4 cell counts <200 cells/μL (P <.05) were associated with HIVDR at 12 months. HIVDR prevention exceeded WHO guidelines (≥ 70%) at the Chennai clinic but was below the target in Mumbai due to high rates of loss to follow-up. Findings highlight the need for defaulter tracing and scale-up of routine viral load testing to identify patients failing first-line ART.

Mutations in the gyrA and parC genes of quinolone-resistant Neisseria gonorrhoeae isolates in India

A dramatic increase in the number of quinolone-resistant Neisseria gonorrhoeae isolates in India and worldwide has been reported recently. This study was undertaken to identify and characterise mutations in the gyrA and parC genes of N. gonorrhoeae resistant to six different quinolone antibiotics. In total, 64 N. gonorrhoeae clinical isolates were obtained during 2007-2009 from patients attending sexually transmitted diseases clinics (New Delhi, 35; Pune, 16; Mumbai, 6; Hyderabad, 6; and Nagpur, 1). Antimicrobial susceptibility was determined by Etest and mutation patterns in gyrA and parC were determined by sequencing analysis. All strains showed varying resistance to different quinolone analogues, ranging from 17.2% (gatifloxacin) to 98.4% (ofloxacin and norfloxacin). Sequencing of gyrA and parC revealed that 100% of strains showed mutations in gyrA and 46.9% showed mutations both in gyrA and parC. All strains showed single or double mutations at Ser-91→Phe, Ser-91→Thr and Asp-95→Gly/Asn in gyrA and at Glu-91→Gly in parC. Asp-95→Asn mutation was the most prevalent in strains isolated from New Delhi, whilst Asp-95→Gly was prevalent in strains isolated from Pune. Strains were categorised into eight different mutation patterns. Resistant strains with high minimum inhibitory concentrations (≥8 μg/mL) showed mutations both in gyrA and parC. The difference in the proportion of strains showing mutations in gyrA and parC was found to be significant (P<0.001). The mutation Asp-95→Asn was restricted to Pune strains only. These results indicate that mutations in quinolone target enzymes may have resulted in the high-level resistance seen in these isolates.

Utility of the point of care CD4 analyzer, PIMA, to enumerate CD4 counts in the field settings in India

BACKGROUND

In resource limited settings non-availability of CD4 count facility at the site could adversely affect the ART roll out programme. Point of care CD4 enumerating equipments can make the CD4 count available at the site of care and improve the patients' management considerably. This study is aimed at determining the utility of a Point of Care PIMA CD4 analyzer (Alere, Germany) in the field settings in India.

METHOD

The blood samples were collected from 1790 participants at 21 ART centers from different parts of the country and tested using PIMA and the reference methods (FACSCalibur, FACSCount and CyFlow SL3). The paired finger prick and venous blood samples from 175 participants were tested by the PIMA CD4 Analyzer and then by FACSCalibur.

RESULT

The CD4 counts obtained by PIMA CD4 analyzer showed excellent correlation with the counts obtained by the reference methods; for venous blood the Pearson's r was 0.921, p < 0.001 and the relative bias was 0.2% (range: -42 to 42%) and for finger prick samples, the Pearson's r was 0.856 and the relative bias was -9.1% (range: -46% to 27%). For CD4 ranges; <250, 251-350, 351-500 and >500 cells/mm3, the differences in the median CD4 counts obtained by the reference method and the PIMA analyzer were not significant (P > 0.05) and the relative bias were low (-7 to 5.1%). The Intermachine comparison showed variation within the acceptable limit of%CV of 10%.

CONCLUSION

In the field settings, the POC PIMA CD4 analyzer gave CD4 counts comparable to the reference methods for all CD4 ranges. The POC equipment could identify the patients eligible for ART in 91% cases. Adequate training is necessary for finger prick sample collection for optimum results. Decentralization of CD4 testing by making the CD4 counts available at primary health centers, especially in remote areas with minimum or no infrastructure would reduce the missed visits and improve adherence of the patients.

Neutralizing antibody responses in recent seroconverters with HIV-1 subtype C infections in India

The longitudinal heterologous neutralization response against two HIV-1 subtype C isolates was studied in 33 ART-naive individuals recently infected with HIV-1 subtype C from India. Seven of 33 (21%) seroconverters demonstrated a consistent response against both isolates (65-100% neutralization), whereas the remaining 26 (79%) were nonresponders. Four of the seven responders demonstrated a neutralization response (>75% neutralization) within 2-3 months of infection and in the remaining three, the response was demonstrated between 22 and 38 months after infection. In the past, HIV vaccines targeted the V3 region for the development of neutralizing antibodies. However, recent studies have shown that anti-V3 antibodies are generated after HIV-1 infection, but are not effective in neutralizing virus. In this study, the V3 sequences of HIV-1 from seven responders were analyzed and compared with those from nonresponders. The V3 region sequences from early and late responders did show certain mutations that were not found in the nonresponders; however none of these mutations could explain the neutralization responses. This suggested that HIV-1 envelope regions other than the V3 domain may be involved in generating a neutralization response. This is the first report that describes the pattern of emergence and persistence of the heterologous neutralization response in recently HIV-1 subtype C-infected individuals from India and studies its association with sequence variation in the V3 region.

An attempt to measure the spread of emergency medicine internationally

OBJECTIVE

To determine the feasibility of using the internet to track the spread of emergency medicine internationally.

OVERVIEW

This was an attempt to perform a descriptive cross-sectional study employing a web-based survey.

SUBJECTS

Potential respondents were identified from multiple sources.

OBSERVATIONS

The primary outcome was the response to 16 questions about EM care and the setting in which it was delivered for acute cardiac, paediatric, obstetrical illnesses and trauma. The questions were divided into six general areas and elicited for urban, semi-urban and rural settings. A series of four e-mails soliciting completion of the survey were sent to potential respondents.

ANALYSIS

Simple descriptive statistics.

RESULTS

We identified 358 potential respondents with valid e-mail addresses over a period of three years. Overall, 145 (41%) responded and 117 (33% 95% CI 28-38%) of them were complete and interpretable. There was one response from 54 and two responses from 29 countries, representing an overall response rate by country surveyed of 65% (95% CI 57-73%), but of all existing countries of only 43% (95% CI 36-50%). Based on sparse data, it appears that in urban areas, 47% (obstetrics) to 65% (paediatric) of acutely sick or injured patients are taken to an ED-equivalent. For rural areas, this range was 19% (obstetrical) to 40% (trauma). CT scans are available in 78% of urban ED-equivalents but 12% of rural ones. Haematocrits are available in 72% of rural settings. In 60% of responding nations, some type of EM training was available, and in 42% physicians went abroad to study EM.

CONCLUSIONS

A survey of international EM is challenging to achieve because of difficulty in both identifying and in contacting potential respondents. Based on sparse data, population density (urban, rural) appears to be related to both the location to which acutely ill patients are taken for their care and to the level of technology available. The specialty of EM is now recognised internationally and education in EM is common.

Correlates of anxiety and depression among HIV test-seekers at a Voluntary Counseling and Testing facility in Pune, India

OBJECTIVE

We assessed the extent of anxiety/depression/distress using Hospital Anxiety and Depression Scale (HADS) among a cross-section of HIV test-seekers at a Voluntary Counseling and Testing (VCT) facility in Pune, India.

METHODS

HADS has 14 items for uniscale with 7 items each for anxiety and depression rated on a four-point Likert scale. Between September 2002 and March 2003, HADS was administered to 150 consecutive HIV tests-seekers attending NARI-Talera VCT facility. Subsequently, HIV testing was done after obtaining informed consent.

RESULTS

HADS showed strong internal consistency (Cronbach-alpha 0.77). The prevalence of risk behavior (73.3%) and HIV (45.5%) were high. Education levels influenced anxiety (p = 0.033; 0.008), more so in women (p = 0.044). Repeat test-seekers exhibited significant depression (AOR: 2.9; 95% CI: 1.4-6.1; p = 0.004) and distress (AOR: 2.5; 95% CI: 1.2-5.3; p = 0.017). Marital status influenced the uniscale scores. The HIV positive repeat test-seekers were more anxious (p = 0.035) and depressed (0.037).

CONCLUSIONS

Existence of emotional distress among HIV test-seekers, particularly among repeat test-seekers, possibly 'AIDS-anxious' individuals indicates additional counseling needs specifically by introducing gender and education sensitive interventions. VCT staff can be trained to assess emotional distress among HIV test-seekers to formulate long-term intervention.

Modification of medical outcome study (MOS) instrument for quality of life assessment & its validation in HIV infected individuals in India

BACKGROUND & OBJECTIVE

Several instruments have been developed specifically to assess the quality of life (QOL) in HIV infected individuals. No information is available in this aspect from India. The present study was thus carried out to assess the QOL among HIV infected persons, to study their relationship with socio-demographic characteristics and stages of disease progression, and to examine change in QOL over time.

METHODS

One time assessment of QOL on 100 and repeat evaluation on 20 HIV infected persons enrolled in an ongoing longitudinal prospective study of clinical progression was done. Medical Outcome Study (MOS-QOL) core instrument was modified to suit the Indian cultural settings and interview-administered.

RESULTS

The overall scale had Cronbach alpha 0.75. Instrument showed significant positive inter-domain correlations and linear association between QOL scores and CD4 counts. QOL was markedly affected in the domains of physical health, work and earnings, routine activities, and appetite and food intake. Women had significantly lower QOL scores despite having less advanced disease. The QOL scores decreased with drop in CD4 counts mainly in the physical health domains. Generally, the QOL scores were high in the follow up visit compared to baseline.

INTERPRETATION & CONCLUSION

The modified MOS scale with Cronbach alpha of more than 0.7 and linear relationship between CD4 counts and the QOL scores indicated that the instrument was reliable and valid for evaluation of QOL in HIV infected persons in India. Comparative lower scores in the domains of physical health indicate medical intervention to greatly benefit the HIV infected persons. Longitudinal studies need to be undertaken to assess the impact of introduction of anti retroviral therapy (ART) through the national programme on disease progression and changes in QOL.

Correlates of HIV vaccine trial participation: an Indian perspective

Successful conduct of HIV vaccine trials in a population of great cultural diversity like India could be a challenge. Concerns, knowledge gaps and willingness to participate in future HIV vaccine trials were studied among 349 patients attending three sexually transmitted infections clinics and one reproductive tract infections clinic. Overall willingness to volunteer for HIV vaccine trials was 48%. Women and men at risk of HIV infection were willing to participate in the HIV vaccine trials. Factors associated with increased willingness to participate in these trials were awareness of current HIV vaccine efforts, realization of importance of vaccine for self, concern about adverse events and altruism.

Assessment of quality of life among HIV-infected persons in Pune, India

OBJECTIVE

To study dimensions of Quality of Life (QOL) amongst HIV infected persons, their relationship with socio-demographic characteristics and disease progression.

DESIGN

Cross-sectional study with one time assessment of QOL.

METHODS

Modified Medical Outcome Study (MOS) core instrument [The Medical Outcome Study 116 core set of Measures of functioning and well being, Appendix A, core survey instrument (internet)] was interview--administered to 100 HIV infected individuals.

RESULTS

The instrument showed significant positive inter-domain correlations and desired linear association between QOL scores and the CD4 counts. The scale had a Cronbach alpha value of 0.75. QOL was markedly affected in the domains of physical health, work and earnings, routine activities and appetite and food intake. Women had significantly lower QOL scores than men despite having less advanced disease. The QOL scores were significantly lower among persons with lower CD4 counts mainly in different domains of physical health.

CONCLUSIONS

The modified MOS scale had the desired reliability and validity for evaluation of QOL in the HIV-infected persons in India. Low scores in the domains of physical health compared to other domains suggest a strategy to focus on medical intervention. A need for psychosocial intervention for women was perceived. Longitudinal studies must be done to assess the impact of anti-retroviral therapy being rolled out through the national programme on QOL.

Accelerated germ cell apoptosis in sex chromosome aneuploid fetal human gonads

The purpose of the study was to examine the occurrence of programmed cell death (apoptosis) in normal and chromosomally aneuploid testis and ovaries during the second trimester of human development. Such information may be useful in understanding normal and abnormal germ cell development and disorders associated with infertility in adult life. Apoptosis was studied by terminal deoxynucleotidyl transferase-mediated dUTP nick-end labelling (TUNEL) analysis in human fetal ovaries (n = 16) and testis (n = 14) between 9 and 23 weeks of development, in ovaries of four Turner's syndrome fetuses (45X) and in the gonad of an XO/XY fetus. In normal fetal testis, a small proportion of germ cells, Sertoli cells and Leydig cells undergo apoptosis. In normal fetal ovaries, some developing oocytes and granulosa cells were detected as TUNEL positive. Semiquantitative analysis of fetal ovaries revealed that approximately 3-7% of oocytes were apoptotic. In abnormal fetal testis (XO/XY genotype). TUNEL analysis revealed that only germ cells not enclosed in seminiferous tubules undergo apoptosis. TUNEL analysis of the Turner's syndrome (45X) ovaries studied at 15 and 20 weeks of development revealed massive apoptosis of the oocytes. Nearly 50-70% of the oocytes were TUNEL positive in these ovaries. These results suggest that germ cell apoptosis is a common event occurring during development of human gonads. Chromosomal defects by some means accelerates apoptosis that probably leads to gonadal dysgenesis later in life.

Spontaneous expulsion of unusual tracheobronchial foreign body

An extremely rare case of long, thin and sharp pin in a young boy which was inhaled initially and defied removal at branchoscopy was eventually recovered in stool after a long and variable course through alimentary tract has been reported.

Relation between effective utilization of exogenous fat emulsion as energy substrate and oxygen metabolism after surgery

It is known that fat oxidation is increased in patients who have sustained surgical stress, but it is not clear whether fat emulsion should be administered during the early postoperative period. The aim of this study was to evaluate the utilization of exogenous fat emulsion after major surgery. Total parenteral nutrition composed of glucose/amino acids or glucose/amino acids/fat was administered for 6 days to 18 patients who had undergone esophagectomy. The caloric intake was significantly less than the resting energy expenditure (REE), and there was no difference in substrate utilization in either group up to postoperative day (POD) 2. After POD 4, fat utilization was significantly increased in the fat group. The total ketone body concentration was higher in the fat group than in the glucose group on POD 1 and 2. The arterial ketone body ratio (AKBR), which reflects the rate of turnover of the Krebs cycle, was positively correlated with the caloric intake/REE ratio. It was negatively correlated with the oxygen delivery index, oxygen consumption, and lactate concentration between POD 0 and POD 2. The lactate concentration was decreased and the AKBR was increased by POD 4. Fat emulsion was effectively utilized as energy substrate after POD 4, after the relative tissue hypoxia had improved and the AKBR had increased. The utilization of exogenous fat emulsion was closely related to deficient caloric intake and oxygen metabolism.

Eicosapentaenoic acid reduces pulmonary edema in endotoxemic rats

BACKGROUND

Recently, eicosapentaenoic acid (EPA) was found to have an anti-inflammatory effect attributable to diminished synthesis of arachidonic acid metabolites that initiate acute lung injury. We evaluated the ability of dietary EPA supplementation to prevent endotoxin-induced acute lung injury in rats.

MATERIALS AND METHODS

Rats fed a standard diet were divided randomly into two groups: for 2 weeks one group additionally was fed 1000 mg/kg/day of EPA ethyl ester emulsion (EPA rats), while in the other group the diet was supplemented with vehicle alone (control rats). Fatty acid components of alveolar macrophages (AM) were measured, as well as leukotriene (LT) B(4) and LTB(5) production by AM exposed in vitro to calcium ionophore A23187. Plasma concentrations of thromboxane (Tx) B(2), a stable metabolite of TxA(2), were examined 1 h after inducing lung injury with endotoxin (2 mg/kg iv). At 6 h, wet/dry (W/D) weight ratios were calculated for the lungs to assess pulmonary edema, and neutrophils were counted in pulmonary parenchyma and peripheral blood.

RESULTS

Arachidonic acid content and LTB(4) generation in AM were significantly lower in EPA rats than in controls; conversely, EPA content and LTB(5) generation in AM were significantly higher in the EPA group. Neutrophil counts in lung parenchyma and peripheral blood did not differ between groups, but W/D and plasma TxB(2) concentrations were significantly lower in EPA rats.

CONCLUSIONS

EPA supplementation depressed arachidonic acid content and LTB(4) generation in AM and plasma TxB(2) in our model, leading to decreased pulmonary edema.

Effect of surgery on neutrophil leukotriene B4 generation and arachidonic acid content

The effect of surgery on neutrophil leukotriene B₄ (LTB₄) generation and arachidonic acid content was examined in 9 patients undergoing major surgery for esophageal cancer and 10 patients undergoing lesser surgery. Plasma IL-8 and neutrophil LTB₄ generation was increased significantly 6 h after surgery regardless of the extent of surgery. This finding was associated with a decrease in neutrophil arachidonate content. In patients who underwent major surgery, neutrophil LTB₄ generation decreased progressively on the 1st, 2nd, and 4th postoperative days, and this decrease paralleled a further decrease in neutrophil arachidonate content. These findings suggest that neutrophils are activated by surgery, thereby consuming their arachidonic acid, and that neutrophil LTB₄ generation is influenced by postoperative arachidonate levels.

Punctate thymic calcification in infants with untreated Langerhans' cell histiocytosis: report of four new cases

Four new cases of punctate thymic calcification in infants with untreated Langerhans' cell histiocytosis (LCH) are added to the four previously reported cases. All cases were shown on CT scans; plain films were rarely diagnostic. Pathologic correlation remains elusive since the usual biopsies of the LCH have been on skin or bone biopsies. A single prior pathologic study of the thymus in untreated LCH showed microscopic calcospherites. The thymic punctate calcific densities in patients with LCH may represent further accretion so that the calcospherites become macroscopic. The finding of such punctate calcific densities in an enlarged thymus of an infant with skin or bone or lung disease is strongly suggestive of LCH.

Fat emulsion administration in the early postoperative period in patients undergoing esophagectomy for carcinoma depresses arachidonic acid metabolism in neutrophils

The aim of this study was to evaluate the effect of fat emulsion administration on neutrophil arachidonic acid and leukotriene B4 (LTB4) generation in surgically stressed patients. Total parenteral nutrition was administered to 17 patients for 2 wk after esophagectomy for carcinoma. Eight patients received fat with glucose (fat group, 30% of total calories) and 9 patients received glucose (glucose group) as a non-protein calorie source from the day of the operation to the seventh postoperative day (POD), and they gradually were converted to enteral nutrition during the second postoperative week. The arachidonic acid in the fat group decreased in the serum from POD 4 to 14. and in neutrophils from 12 h after the beginning of surgery to POD 14, compared to preoperative levels. LTB4 production by A23187-stimulated neutrophils was highest 6 h after the beginning of surgery, when neutrophil arachidonic acid concentration was decreasing, and then fell below the preoperative value from POD 4 to 14 in both groups. LTB4 production on POD 14 was lower in the fat group than in the glucose group. Biosynthesis of arachidonic acid from linoleic acid is inhibited in surgically stressed patients receiving fat emulsion, resulting in the diminished synthesis of LTB4 by neutrophils. The decrease in LTB4 may diminish chemotactic and chemokinetic signals to other leukocytes.

Massive hemorrhage after biopsy of an esophageal polyp

Esophageal vascular malformations are very rare. Herein, we describe a rare polyp formed by an abnormally large vessel that bled profusely after biopsy. Despite endoscopic procedures, the patient continued to bleed and underwent emergency surgery. Histopathological examination revealed an abnormally large blood vessel with a thick wall in the upper part of the lamina propria mucosae and covered by squamous cell epithelium. The elevated lesion, which was endoscopically diagnosed a small polyp, was in fact an abnormally large artery covered by squamous cell epithelium. Massive bleeding after biopsy of an esophageal polyp is apparently so rare that it has not, as yet, been described.

Oxygen delivery as a factor in the development of fatal postoperative complications after oesophagectomy

BACKGROUND

This study was designed to assess the impact of oxygen transport variables on outcome in 115 patients undergoing elective surgery for oesophageal carcinoma.

METHODS

Haemodynamic parameters were determined using a Swan-Ganz catheter in all patients on the day before operation, 6 h after operation, and daily for the first 4 days after operation.

RESULTS

Oxygen delivery and consumption at 6 h were significantly higher in survivors than in non-survivors. However, oxygen delivery and consumption in both groups did not differ significantly after postoperative day 1. Of 17 patients with oxygen delivery levels lower than 445 ml min-1 m-2 at 6 h, eight died in hospital. Oxygen delivery in patients who developed either an anastomotic leak or severe pneumonia was significantly lower 6 h after surgery. Lower levels of oxygen delivery preceded postoperative complications.

CONCLUSION

Oxygen delivery 6 h after oesophagectomy correlates with postoperative complications and may be a determinant of hospital mortality.

The efficacy of podiatric orthoses as an adjunct to the treatment of plantar ulceration in leprosy

This study examines the outcome of a management approach to plantar ulceration secondary to leprotic neuropathy. Locally-available resources were used to produce podiatric orthoses which were supplied to an experimental group. The effects on healing time and quality of healing were compared with a control group. Both groups were ambulant (the programme sought not to interfere with socioeconomic independence). Using standard nonparametric methods of analysis, it was demonstrated that the effects on healing rate, attributed to the experimental intervention, were highly significant. Over a 7-month period, 57% of the experimental group ulcers healed, while only 12.5% of the control group ulcers healed. The experimental intervention also demonstrated a positive effect on the quality of ulcer healing. This effect was not reflected in the control group.

Segmental spinal dysgenesis. A disorder different from spinal agenesis

We reviewed the clinical and roentgenographic findings, treatment, and results for seventeen patients (six male and eleven female) who had segmental spinal dysgenesis, a disorder frequently confused with, but distinct from, lumbar and lumbosacral agenesis. The average age at the time of presentation to the Minnesota Spine Center or the Gillette Children's Hospital was two and a half years (range, newborn to twenty-one years), and the average duration of follow-up was eight years (range, five months to twenty-two years). At the time of the diagnosis, eight patients had neurological deficits: seven had a neurogenic bladder and four had weakness of the lower extremities. An average of 2.6 procedures (range, one to five procedures) was needed to obtain a solid fusion. Decompression of the stenotic canal was performed in ten patients, and it was followed by an improvement in neurological function in two of them. A solid fusion of the spine, arrest of the progressive kyphosis, and stabilization of neurological function were obtained in all patients. We recommend early anterior and posterior arthrodesis in patients who have segmental spinal dysgenesis, as the progressive kyphosis that inevitably develops often results in neurological deficits.