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.

Contexte : Centre de traitement antirétroviral (ART) du district de Tumkur dans l'état de Karnataka, Inde. Il n'y a pas de document publié sur les perdus de vue avant le traitement ART en Inde.Objectif : Evaluer la proportion de perdus de vue (définis comme l'absence de visite au centre d'ART dans l'année suivant l'enregistrement) et les variables sociodémographiques et immunologiques qui y sont associées.Schéma : Etude rétrospective de cohorte impliquant une revue des dossiers médicaux des patients adultes infectés par le VIH (âge ⩾15 ans) enregistrés en soins pré-ART entre janvier 2010 et juin 2012.Résultats : Sur 3238 patients enregistrés, 2519 (78%) étaient éligibles pour le traitement ART tandis que 719 (22%) ne l'étaient pas. Quatre de ces derniers ont été transférés. Parmi les 715 individus enrôlés en soin pré-ART, 290 (41%) ont été perdus de vue. Les facteurs associés avec le fait d'être perdus de vue en analyse multivariée incluaient la tranche d'âge ⩾45 ans, un niveau d'instruction faible, le célibat, le stade 3 ou 4 de l'OMS et la résidence en milieu rural.Conclusion : Près de quatre individus sur 10 en soins pre-ART ont été perdus de vue dans l'année suivant leur enregistrement. Ceci requiert une attention urgente. L'analyse de cohorte en routine du programme national devrait inclure les patients en soins pré-ART afin d'améliorer la revue des cas, leur suivi et leur supervision. Une recherche qualitative ultérieure afin de cerner les raisons des pertes de vue est nécessaire pour concevoir les interventions futures.

Marco de referencia: El centro de tratamiento antirretrovírico (ART) en el distrito de Tumkur del estado de Karnataka en la India. Hasta el momento no existen publicaciones sobre la pérdida de vista de los pacientes seropositivos durante el seguimiento antes de comenzar el ART en la India.Objetivo: Se buscó definir la proporción de pacientes perdidos de vista durante el seguimiento (definidos como los pacientes que no habían acudido al centro de ART hasta un año después de haberse registrado) y evaluar las variables socioeconómicas e inmunitarias que se asociaban con esta situación.Método: Se llevó a cabo un estudio retrospectivo de cohortes a partir del examen de las historias clínicas de los adultos (⩾15 años de edad) infectados por el virus de la inmunodeficiencia humana (VIH), que se inscribieron a la atención clínica previa al ART de enero del 2010 a junio del 2012.Resultados: De los 3238 pacientes registrados, 2519 cumplían con los requisitos para iniciar el ART (78%) y 719 de ellos no eran aptos (22%); cuatro pacientes de este último grupo se remitieron a otro centro. De las 715 personas restantes, inscritas en la atención previa al ART, 290 se perdieron de vista durante el seguimiento (41%). El análisis multifactorial puso en evidencia que los factores asociados con la pérdida de vista de los pacientes fueron el grupo de edad de ⩾45 años, una baja escolaridad, el hecho de ser solteros, el estado 3 o 4 de la enfermedad según la clasificación de la Organización Mundial de la Salud y la residencia en zona rural.Conclusión: Cerca de cuatro de cada diez pacientes inscritos en la atención clínica previa al ART se perdieron de vista durante el seguimiento en el primer año después de haberse registrado. Esta situación exige una atención urgente. Es importante que los análisis sistemáticos de cohortes del programa nacional incluyan a las personas infectadas que reciben atención antes de comenzar el ART, a fin de mejorar la evaluación, el seguimiento y la supervisión de los pacientes. Es preciso fomentar la realización de nuevas investigaciones cualitativas que determinen las razones de la pérdida de vista durante el seguimiento y contribuyan a la planificación de las intervenciones futuras.

Embryonic motoneuron-skeletal muscle co-culture in a defined system.

This paper describes a significant biotechnological advancement by creating a minimalist serum-free defined system to co-culture rat mammalian nerve and muscle cells in order to form functional neuromuscular junctions. To date, all the known in vitro nerve and muscle co-culture models use serum containing media; and while functional neuromuscular junctions (NMJ) are described, they failed to detail or quantify the minimum factors needed to recreate the NMJ in vitro. In this work, we demonstrate the development of a defined motoneuron and muscle co-culture system resulting in the formation of NMJs including: 1) a new culture technique, 2) a novel serum-free medium formulation and 3) a synthetic self-assembled monolayer (SAM) substrate N-1 [3-(trimethoxysilyl) propyl] diethylenetriamine (DETA). We characterized the culture by morphology, immunocytochemistry, electrophysiology and videography. This model system provides a better understanding of the minimal growth factor and substrate interactions necessary for NMJ formation and provides a basic system that can be utilized for nerve-muscle tissue engineering, regenerative medicine and development of limb prosthetics.

Signet ring cell carcinoma of ampulla of Vater in a young adult.

Signet ring cell carcinoma of the ampulla of Vater is extremely rare. The 7 cases reported earlier have been in older patients. We report a 32-year-old lady with this condition, who also had metastases in the bone marrow, vertebrae, lungs and liver.

Low circulating estradiol and adrenal androgens concentrations in men on glucocorticoids: a potential contributory factor in steroid-induced osteoporosis.

Reductions in circulating estradiol concentrations could be implicated in the pathogenesis of steroid-induced osteoporosis (SIOP) in men. We assessed serum estradiol and adrenal androgens (dehydroepiandrosterone sulfate [DHEAS] and androstenedione) in 77 men (group A: idiopathic osteoporosis [IOP], n = 38, aged [mean +/- SD] 57.7 +/- 12.1 years; group B: SIOP, n = 39, aged 55.3 +/- 13.1 years). We also studied the relationship between bone mineral density (BMD) and serum estradiol in the group of men with SIOP. In group B, we observed a higher prevalence of low serum testosterone concentrations (<9.0 nmol/L) (P =.0052), which was significantly correlated with steroid dosage (r = -0.42, P =.0089) and estradiol concentrations (r = 0.42, P =.012). There was a significant positive association between BMD at the lumbar spine and serum estradiol (P =.004) in the men with SIOP (group B). A high proportion of subjects had low serum estradiol concentrations (<48 pmol/L) in both groups (group A: 44.7 %, group B: 36 %). Serum adrenal androgens concentrations were also significantly suppressed in group B (serum androstenedione-group A: 4.99 +/- 1.8; Group B: 2.1 +/- 1.6 nmol/L; P =.0001). Serum DHEAS was undetectable in 59% of patients in group B versus 6% in group A (P =.001). Reductions in androstenedione also correlated with steroid dosage (r = -0.35, P =.01). In conclusion, the data show that adrenal androgens synthesis is markedly suppressed in men with SIOP. The clinical relevance of this finding remains to be determined. This study also shows a positive association between serum estradiol and BMD and a high prevalence of low serum estradiol in men with SIOP. Low serum estradiol may contribute to bone loss in men with SIOP.

High-frequency oscillatory ventilation of the perfluorocarbon-filled lung: dose-response relationships in an animal model of acute lung injury.

OBJECTIVE: To examine dose-response relationships regarding the efficiency of gas exchange and hemodynamic function during high-frequency oscillation and partial liquid ventilation (HFO-PLV) of the perfluorocarbon (PFC)-treated lung in a model of acute lung injury. SETTING: An animal research laboratory in a university medical center. DESIGN: A prospective, randomized study comparing animals receiving varying doses (0, 5, 15, and 20 mL/kg) of perflubron during high-frequency oscillatory ventilation (HFOV) with mean airway pressure (Paw) optimized to achieve a minimal percutaneous oxygen saturation (Spo2). SUBJECTS: Nineteen healthy swine (mean weight 28.9 kg) with saline lavage-induced acute lung injury. METHODS: Animals were treated with repetitive saline lavage to achieve a uniform degree of acute lung injury (Spo2 < or =90% on an Fio2 of 1.0). After lung injury, subjects were converted to HFOV, and lung volume was optimized. HFO-PLV was initiated by instillation of perflubron at a rate of 0.5 mL.kg-1.min-1 to achieve total doses of 5, 15, and 20 mL/kg. After PFC dosing, the only experimental manipulation consisted of adjustment of Paw to achieve an Spo2 of 90% +/- 2% with Fio2 of 0.6. Gas exchange, hemodynamic variables, and pulmonary mechanics data were collected over a 1-hr period. Five control animals were not dosed with perflubron and remained on HFOV for the 1-hr period of data collection. MEASUREMENTS AND MAIN RESULTS: After lung volume recruitment with HFOV, the initiation of HFO-PLV was best tolerated with the two lower doses in our protocol. There were essentially no changes in Paco2 or pH between groups over the dosing interval. After dosing, analysis of variance demonstrated a PFC dose-dependent effect for oxygenation index (p =.01) only; the lowest oxygenation index was found in the 15 mL/kg group (p =.01). In the 15 mL/kg group, the Paw decreased steadily from 20.6 +/- 3.4 cm H2O at the end of dosing to 18.0 +/- 4.9 cm H2O at 60 mins. The Pao2 increased from 113 +/- 51 torr (15.06 +/- 6.79 kPa) to 134 +/- 49 torr (17.86 +/- 6.53 kPa) during this period and was associated with a decreasing oxygenation index (from 11.4 +/- 2.0 to 9.3 +/- 1.5). The cardiac index and pulmonary vascular resistance did not change significantly during the dosing period and were relatively stable after the completion of dosing. CONCLUSIONS: The combination of HFOV and perflubron administration was well tolerated hemodynamically and was not associated with deterioration of gas exchange during dosing. Our data suggest that the optimal dose of perflubron to achieve the lowest oxygenation index during HFO-PLV is between 5 and 15 mL/kg. The combination of HFOV and perflubron administration is a novel strategy in the treatment of acute lung injury that shows some promise and merits additional investigation. We hope in future studies to address the histopathologic effects of varying perflubron doses during HFOV in a long-term study of the lung-protective effects of HFO-PLV.

Cerebral chromoblastomicosis--a rare case report of cerebral abscess and brief review of literature--a case report.

A rare case of Cerebral Chromomycosis caused by chromogenic fungus Cladosporium trichoides in a 35 year old male with classical presentation of cerebral abscess is being presented. The case report lays emphasis on the histological diagnosis of chromogenic fungus in the wall of the abscess cavity, surgically removed from a well delineated circumscribed lesion in the frontal lobe of the cerebrum. The causative fungus could be detected even in unstained paraffin sections. The diagnosis could be made only after surgical removal and histopathological examination. The mycological culture could not be made as the material was received in formaldehyde fixative. The unique features of the case is its recurrence free uneventful survival five years after surgical excision. This is probably the fifth reported case of cerebral chromomycosis from India and first of its type from arid zone of Rajasthan.

Conventional versus intensive diabetes therapy in children with type 1 diabetes: effects on memory and motor speed.

OBJECTIVE: Severe hypoglycemia may impair medial temporal-mediated cognitive skills, such as the ability to recall past events explicitly (delayed declarative memory). The objective of this study was to determine whether delayed declarative memory deficits are present in a group of diabetic children with an increased risk of severe hypoglycemia. RESEARCH DESIGN AND METHODS: Nondiabetic children (n = 16) and children with type 1 diabetes who had been randomly assigned to either intensive (IT) (n = 13) or conventional (CT) (n = 12) diabetes therapy at the time of diagnosis participated in the study. All episodes of severe hypoglycemia were prospectively ascertained. All children were tested on memory tasks that have been closely linked to medial temporal functioning and on reaction time measures. RESULTS: Our results demonstrated that the IT group had a threefold higher rate of severe hypoglycemia, performed less accurately on a spatial declarative memory task, and performed more slowly, but not less accurately, on a pattern recognition task than did the CT group or control subjects. In addition, both groups of type 1 diabetic children were significantly impaired on a motor speed task compared with their nondiabetic peers. CONCLUSIONS: These results indicate a selective relative memory impairment associated with IT that is consistent with the effects of severe hypoglycemia and medial temporal damage or dysfunction. If larger prospective studies determine that severe hypoglycemia is the mediating factor for this memory impairment, extreme caution in imposing overly strict standards for glucose control in young patients with type 1 diabetes would be indicated because of the increased risk of hypoglycemia associated with IT regimens.

Memory and insulin dependent diabetes mellitus (IDDM): effects of childhood onset and severe hypoglycemia.

Previous studies of the neuropsychological consequences of insulin dependent diabetes mellitus (IDDM) have had mixed and often contradictory results, possibly due to the heterogeneity of the samples and neuropsychological measures, and a lack of specific hypotheses. In order to address this problem, we focused on the effect of severe hypoglycemia on memory functioning in a relatively homogeneous sample of childhood-onset IDDM patients. Given the deleterious effects of hypoglycemia on medial temporal lobe structures (e.g., hippocampus) and the relationship between medial temporal damage and declarative memory functioning, we hypothesized that those patients who had experienced severe hypoglycemia would demonstrate impaired declarative memory and spared nondeclarative memory functioning. Results of the study were generally consistent with this hypothesis, although some impact of hypoglycemia was observed on perceptual priming ability.

Mucocutaneous disorders in Hiv positive patients.

Twenty eight HIV positive patients were included in this study. They were evaluated for their mucocutaneous disorders, sexually transmitted diseases and other systemic disorders between 1994-95 in the department of Dermatology and STD Dr R M L Hospital of New Delhi. The heterosexual contact with commercial sex workers (CSWs) was the most common route of HIV transmission. Chancroid, syphilis and genital warts were common STDs found in HIV positive patients. Oral thrush (67.9%) was the commonest mucocutaneous disorder found in these patients followed by herpes zoster (25%) and seborrhoeic dermatitis (21.4%). There was no unusual clinical presentation seen in mucocutaneous disorders and STDs.

Effect of oral erythromycin on colonic transit in patients with idiopathic constipation. A pilot study.

Erythromycin, a motilin receptor agonist has been shown to have prokinetic effects on the upper gastrointestinal tract and gallbladder. Colonic effects of the drug are controversial, and it is debated whether human colon contains motilin receptors. In this study we evaluated the effects of erythromycin on colonic transit and stool frequency in 11 patients with idiopathic constipation over a 1-month period in an open study. The dose used was 1 g/day for two weeks followed by 500 mg/day for another two weeks. The mean (SE) total and segmental colonic transit was measured before and seven days after therapy in seven of these patients. A daily record of stool frequency was maintained in all 11 patients. Erythromycin shortened the total colonic transit from 86.2 (14.6) to 44.8 (8.99) hr (P < 0.01); however, segmental transit studies revealed a significant effect (P < 0.01) only in the right colon and rectosigmoid region. No significant side effects were observed with short-term therapy. These preliminary results suggest that erythromycin is of therapeutic value in patients with idiopathic constipation.

Colonization by Helicobacter pylori and its relationship to histological changes in the gastric mucosa in portal hypertension.

In order to investigate the relationship between Helicobacter pylori infection of the gastric mucosa and mucosal changes in portal hypertension, gastric fundic and antral biopsies were obtained from 66 patients with portal hypertension and 49 controls with non-ulcer dyspepsia (NUD). Gastric mucosa from portal hypertensive patients exhibited typical vascular dilatation and congestion, while mild dilatation of lamina propria blood vessels was not uncommon in NUD patients with histological evidence of gastritis. Colonization of the gastric mucosa by H. pylori infection was significantly less in portal hypertension (51.5%) compared to controls (75.5%; P < 0.01). The difference was more apparent in patients with marked vascular dilatation (18.8% colonization) compared to patients with minimal vascular dilatation (66.7%). H. pylori infection was significantly associated with active superficial gastritis (P < 0.001), and with atrophic gastritis (P < 0.001), in both study groups. H. pylori-negative superficial gastritis was significantly more common in portal hypertension (25/66 patients) than in controls (7/49; P < 0.05). H. pylori infection was not more common in patients who had undergone repeated sclerotherapy. The results suggest that the gastric mucosa of portal hypertension does not provide a hospitable environment for H. pylori colonization, particularly when mucosal congestion is marked. H. pylori infection does not add significantly to the gastropathy of portal hypertension.

Jejunal perforation: a complication of colonoscopy.

Perforation of a hollow viscus following fibreoptic endoscopy is rare. Perforation following colonoscopy has been reported to occur in the large intestine. We report a case. Small bowel perforation subsequent to colonoscopy.

Ischemic lesions in basal ganglia in children after minor head injury.

Twenty-three children under the age of 6 1/2 years developed immediate unilateral weakness after an apparently minor head injury. Computed tomography disclosed a hypodense lesion in the basal ganglia. The lesion appeared to be caused by an infarct in the basal ganglia. All but one of the children recovered completely within 4 months.

Endoscopic variceal ligation: an effective method of variceal obliteration.

Endoscopic variceal ligation was performed in 20 patients with portal hypertension of varied etiology. Variceal obliteration was achieved in 18 patients (90%) while recurrence of bleeding occurred in two patients (10%). The average number of bands required was four per patient and average number of sessions required for variceal obliteration was two. We found the procedure to be cheap, safe and effective in achieving early variceal obliteration.

Usefulness of immunoperoxidase test for serodiagnosis of genital chlamydial infections.

An immunoperoxidase test detecting Chlamydia trachomatis specific serum IgG and IgA antibodies, was carried out to determine its efficacy in establishing chlamydial etiology in 104 clinically diagnosed patients attending a major STD Clinic in Delhi. The patients consisted of 58 with nonspecific urethritis/cervicitis (NSU/NSC), 11 with pelvic inflammatory disease (PID), 23 with primary infertility in either male or female and 12 with lymphogranuloma venereum (LGV). IgG antibodies were tested at a dilution of 1:64 and 1:128 and IgA antibodies at 1:16. Although 27.7 per cent (5 of 18) of the controls had IgG antibodies (> or = 1:128), none had IgA, showing the IgA marker as 100 per cent specific. In 80.8 per cent of all the patients, active infection was detected, 81.0 per cent in NSU/NSC, 81.8 per cent in PID, 76.9 per cent in female infertility, 80 per cent in male infertility and 83.3 per cent in LGV patients. The immunoperoxidase test was found to be an extremely simple and rapid test especially suited for laboratories where facilities are limited.

Colonic sonography: preliminary observations.

Transrectal instillation of water is a recently described technique for improved sonological imaging of the lumen and wall of the colon. In order to assess the accuracy of this technique, termed colonic sonography (CS), in the detection of abnormalities of the large bowel, 100 consecutive patients were subjected to colonic sonography and the results were compared with the results of colonoscopy and surgery. The technique showed a sensitivity of 91% for the detection of colonic tuberculosis, 89% for ulcerative colitis and 83% for colonic cancers. Small mucosal ulcers, polyps less than 7 mm in diameter and the changes of non-specific colitis were not detected. Sonography displayed the entire colon more consistently than colonoscopy. The extent and extra-colonic spread of disease were better appreciated. The procedure was not adversely influenced by the presence of faecal material within the colon and was well tolerated. Colonic sonography is a promising new technique for detecting significant colonic pathology and merits further comparison with existing modalities.