Considering Culture and Conflict: A Novel Approach to Active Bystander Intervention.

Introduction: Workplace microaggressions are prevalent in clinical settings and contribute to poorer mental health outcomes, as well as to higher rates of burnout for physicians and students experiencing them. While bystander workshops customarily provide guidance on direct interventions to a general audience, the literature does not yet address workshops in an academic setting that consider the individual's motivations and behavior patterns. We implemented a psychologically informed approach to microaggression training to increase participants' understanding and willingness to undergo behavioral change. Methods: We created a survey that included 10 distinct scenarios of discrimination in the clinical setting. Participants' willingness to intervene was assessed on a Likert scale prior to, then following, a 1-hour active bystander intervention workshop conducted virtually. The workshop outlined the role of culture and conflict management style in willingness to intervene. Four modes of intervention were outlined, including direct and indirect methods. Results: A total of 78 medical students, graduate students, residents, and faculty members participated in the workshop. Of those, we compared 68 individuals' pre- and postworkshop responses to our questionnaire. We then focused on the 54 participants with no previous training in psychiatry or psychology. Utilizing a Wilcoxon signed rank test, we compared the average pre/post scores of willingness to intervene and found scores to have improved following workshop attendance (Z = -6.339, p < .001). Discussion: Our findings suggest that a psychiatrically informed and culturally sensitive approach to active bystander intervention workshops may promote upstanding more effectively in academic medicine.

ABO incompatibility: A cause for neonatal alloimmune thrombocytopenia.

ABO antibodies are naturally occurring antibodies. The ABO antibodies found in the Group O individuals include anti-A and anti-B. In Group O individuals, it tends to be predominantly immunoglobulins G (IgG), although immunoglobulins M and IgA components are also present. Infants of Group O mothers are at higher risk for hemolytic disease of the fetus and new-born than those born to mothers with Group A or B because IgG readily cross the placenta. At the same time, abnormal high concentration of ABO antibody in mother can lead to destruction of platelets in neonates and leads to development of neonatal alloimmune thrombocytopenia as human platelets carry detectable quantities of A and B blood group antigens on their surface. Proper and early diagnosis combined with treatment with intravenous immunoglobulins or transfusion with compatible platelets, may be from mother, can save the neonate from bleeding episodes.

Clinical features, severity and outcome of acute pancreatitis in systemic lupus erythematosus.

Acute pancreatitis (AP) is a rare but life threatening manifestation of Systemic Lupus Erythematosus (SLE). The current study aims to study the clinical characteristics, severity, mortality, and outcome of SLE-related AP in Indian population. We retrospectively reviewed medical records of patients with SLE who had AP in the past. Data from 13 rheumatology centers across India were compiled. All patients satisfied SLICC criteria for SLE and ATLANTA criteria for AP. AP was classified in to mild, moderate and severe using revised Atlanta classification. Patients with known risk factors like gall stone and alcohol were excluded.Sixty-six patients (six, children) were studied. Majority of patients were females (82%). The median age of presentation was 24 (11-63) years and most patients (57.5%) presented within first year of diagnosis of lupus. AP occurred mostly in the setting of active lupus (89%). Active nephritis was seen in 39% while a fourth had CNS disease. Patients with severe AP had lower C3. Ascites and sepsis were most common local and systemic complications, respectively. Mortality was 17%. Hypocalcemia, presence of sepsis and shock predicted mortality. In the multivariate analysis, only presence of shock remained as independent predictor of death (OR 63.0, 95% CI: 5.2-760.3). Pancreatitis is an early manifestation of SLE and is associated with active disease. Significant mortality is seen particularly with severe pancreatitis.

Molecular characterization of rare D--/D-- variants in individuals of Indian origin.

BACKGROUND: Rh antigens are critical in haemolytic disease of the foetus and newborn (HDFN). The D-- phenotype is a rare blood group characterised by the lack of expression of C, c, E and e antigens at the surface of red blood cells because of mutations in both RHCE alleles inactivating the expression of a "normal" protein. The aim of the study was to determine the molecular basis of D-- individuals of Indian origin. MATERIALS AND METHODS: Ten Rh D-positive postnatal women who had produced antibodies against all Rh antigens, except D, leading to HDFN and foetal loss, were investigated. Extensive serological and molecular (polymerase chain reaction [PCR] using sequence-specific primers), quantitative multiplex PCR of short fluorescent fragments (QMPSF), and Sanger sequencing analyses were carried out. RESULTS: Serological testing with anti-C, anti-c, anti-E, and anti-e reagents showed absence of the four antigens in all ten index cases, as well as in three siblings. Flow cytometry indicated absence of these antigens with a typical exalted expression of the D antigen, thus confirming the rare D-- phenotype. Molecular analysis by QMPSF suggested homozygous CE-D hybrid alleles causing the D-- phenotype: RHCE-D(3-9)-CE (n = 11), RHCE-D(3-8)-CE (n=1), and RHCE-D(2-6)-CE (n=1). DISCUSSION: For the first time, we report the molecular basis of the D-- phenotype in the Indian population. Identification and characterisation of RHCE-null variants by molecular methods can help resolve transfusion-related problems in these individuals. Family studies of index cases helped to identify rare blood donors and offer counselling to females of child-bearing age on the complications involved in such pregnancies.

Anti-Emm, a rare specificity to the high-incidence antigen Emm in an Indian patient defining the new blood group system EMM (ISBT042).

A transfusion recipient lacking a high-incidence antigen (HIA) and has corresponding alloantibody pose a problem in providing compatible blood unit. We encountered a patient with an antibody to an HIA that required identification to assess if compatible blood could be organized. A 65-year-old male was posted for coronary artery bypass grafting surgery. His blood specimen collected in EDTA was referred to the blood bank to provide blood for transfusion. The patient, grouped AB RhD+, had an antibody reacting in saline and antiglobulin phases. It agglutinated all the red blood cells (RBCs) of the 11-cell panel and random donors, indicating specificity to an HIA, though one of his siblings was compatible. After ruling out specificity to HIAs such as H, Inb, and INRA (IN5), the specimen was referred to the New York Blood Centre for further work-up. The antibody reacted with examples of red cells lacking HIA, except those with the Emm- phenotype. The patient's RBCs were typed as Emm-. Anti-Emm in the patient appeared to be naturally occurring as there was no history of transfusion. Naturally occurring alloantibody to an HIA, identified as anti-Emm in phenotype Emm-, is rare and the first of its kind to be reported from India. The case was instrumental in recognizing the Emm as the new blood group system assigned with the symbol ISBT042.

PIGG defines the Emm blood group system.

Emm is a high incidence red cell antigen with eight previously reported Emm- probands. Anti-Emm appears to be naturally occurring yet responsible for a clinically significant acute hemolytic transfusion reaction. Previous work suggests that Emm is located on a GPI-anchored protein, but the antigenic epitope and genetic basis have been elusive. We investigated samples from a South Asian Indian family with two Emm- brothers by whole genome sequencing (WGS). Additionally, samples from four unrelated Emm- individuals were investigated for variants in the candidate gene. Filtering for homozygous variants found in the Emm- brothers and by gnomAD frequency of < 0.001 resulted in 1818 variants with one of high impact; a 2-bp deletion causing a frameshift and premature stop codon in PIGG [NM_001127178.3:c.2624_2625delTA, p.(Leu875*), rs771819481]. PIGG encodes for a transferase, GPI-ethanolaminephosphate transferase II, which adds ethanolamine phosphate (EtNP) to the second mannose in a GPI-anchor. The four additional unrelated Emm- individuals had various PIGG mutations; deletion of Exons 2-3, deletion of Exons 7-9, insertion/deletion (indel) in Exon 3, and new stop codon in Exon 5. The Emm- phenotype is associated with a rare deficiency of PIGG, potentially defining a new Emm blood group system composed of EtNP bound to mannose, part of the GPI-anchor. The results are consistent with the known PI-linked association of the Emm antigen, and may explain the production of the antibody in the absence of RBC transfusion. Any association with neurologic phenotypes requires further research.

Acne fulminans in a young man with granulomatosis with polyangiitis (Wegener's granulomatosis): A chance association or marker of serious systemic disease?

A 19-year-old man with granulomatosis with polyangiitis (Wegener's disease) presented with hemorrhagic facial nodules mimicking severe inflammatory acne (acne fulminans) as one of the first symptoms of the disease. The lesions were earlier treated as nodulocystic acne with isotretinoin without any benefit. Complete resolution was seen with pulsed methylprednisolone and oral prednisolone and mycophenolate mofetil thereafter. He also developed acute onset of severe pustular eruption of the face and a destructive ulcer of the auricle on two separate occasions. Facial lesions mimicking severe inflammatory acne, not responsive to standard treatment, may be a marker for more severe systemic disease such as Wegener's disease/granulomatosis with polyangiitis.

Intrinsic and Antipsychotic Drug-Induced Metabolic Dysfunction in Schizophrenia.

For decades, there have been observations demonstrating significant metabolic disturbances in people with schizophrenia including clinically relevant weight gain, hypertension, and disturbances in glucose and lipid homeostasis. Many of these findings pre-date the use of antipsychotic drugs (APDs) which on their own are also strongly associated with metabolic side effects. The combination of APD-induced metabolic changes and common adverse environmental factors associated with schizophrenia have made it difficult to determine the specific contributions of each to the overall metabolic picture. Data from drug-naïve patients, both from the pre-APD era and more recently, suggest that there may be an intrinsic metabolic risk associated with schizophrenia. Nevertheless, these findings remain controversial due to significant clinical variability in both psychiatric and metabolic symptoms throughout patients' disease courses. Here, we provide an extensive review of classic and more recent literature describing the metabolic phenotype associated with schizophrenia. We also suggest potential mechanistic links between signaling pathways associated with schizophrenia and metabolic dysfunction. We propose that, beyond its symptomatology in the central nervous system, schizophrenia is also characterized by pathophysiology in other organ systems directly related to metabolic control.

A comprehensive analysis on Symplocos racemosa Roxb.: Traditional uses, botany, phytochemistry and pharmacological activities.

ETHNOPHARMACOLOGICAL RELEVANCE: Symplocos racemosa Roxb. belongs to a unigeneric family Symplocaceae, known as lodhra in Sanskrit; is a small evergreen tree, found throughout the tropical and sub-tropical countries. Ethnobotanical literature indicates use of S. racemosa in treatment of eye disease, skin diseases, ear diseases, liver and bowel complaints, tumors, uterine disorders, spongy and bleeding gums, asthma, fever, snake-bite, gonorrhea and arthritis. The main aim of this review is to provide detailed phytopharmacological profile on S. racemosa in support with the traditional practices and ethnomedicinal uses. MATERIALS AND METHODS: All relevant worldwide accepted databases have been searched for the name "S. racemosa" along with other literature from Indian Classical texts and Pharmacopoeias. The accessible literatures available on S. racemosa, were collected through electronic search on Pub med, Scopus, Science direct and traditional reports. RESULTS: S. racemosa is important Indian traditional drug used in many Ayurvedic and herbal formulations for treatment of liver as well as uterine disorders and leucorrhea. Majority of phytopharmacological reports are on stem bark of the plant which include anti-cancer, hepatoprotective, anti-oxidant, anti-androgenic effect, anti-inflammatory, wound healing activity and anti-diabetic effects. Phytochemical studies indicated presence of many phenolic glycosides like symplocoside, triterpenoids like betulinic acid, acetyloleanolic acid and oleanolic acid and flavonoids like quercetin which might have contributed to the observed protective effects. CONCLUSION: Many ethnobotanical claims have been confirmed through systematic in-vitro and in-vivo pharmacological studies on different extracts of stem bark and isolated constituents. However, systematic studies on the bio-markers are desirable to establish mode of action and to validate the traditional claim in clinical practice after proper safety assessment. The conservation data of genus Symplocos showed risk of extinction due to restricted distribution in the wild hence systematic techniques should be developed for the maintenance of this plant.

Efficacy of pamidronate therapy in children with chronic non-bacterial osteitis: disease activity assessment by whole body magnetic resonance imaging.

OBJECTIVE: The aim of this study was to describe the efficacy of pamidronate therapy on disease activity in children with chronic non-bacterial osteitis (CNO) using whole body MRI (WB-MRI). METHODS: Clinical assessment and WB-MRI were obtained in 11 children before and after 1 year of pamidronate therapy using a 1.5 T MRI scanner and short tau inversion recovery sequences. The images were reported by a paediatric radiologist. RESULTS: WB-MRI identified 75 lesions in 11 patients; 16 of these lesions had not been detected by clinical examination. Follow-up MRI after 1 year of pamidronate showed complete resolution of inflammation in 45 lesions, moderate improvement in 10 lesions and no change in 20 lesions. Two new lesions developed while on treatment. CONCLUSION: WB-MRI allows a more accurate assessment of the disease extent in CNO than clinical examination alone and is useful in the objective measurement of treatment efficacy. Pamidronate appears to be an effective treatment in children with CNO unresponsive to NSAIDs.

Hexamers of the type II secretion ATPase GspE from Vibrio cholerae with increased ATPase activity.

The type II secretion system (T2SS), a multiprotein machinery spanning two membranes in Gram-negative bacteria, is responsible for the secretion of folded proteins from the periplasm across the outer membrane. The critical multidomain T2SS assembly ATPase GspE(EpsE) had not been structurally characterized as a hexamer. Here, four hexamers of Vibrio cholerae GspE(EpsE) are obtained when fused to Hcp1 as an assistant hexamer, as shown with native mass spectrometry. The enzymatic activity of the GspE(EpsE)-Hcp1 fusions is ∼20 times higher than that of a GspE(EpsE) monomer, indicating that increasing the local concentration of GspE(EpsE) by the fusion strategy was successful. Crystal structures of GspE(EpsE)-Hcp1 fusions with different linker lengths reveal regular and elongated hexamers of GspE(EpsE) with major differences in domain orientation within subunits, and in subunit assembly. SAXS studies on GspE(EpsE)-Hcp1 fusions suggest that even further variability in GspE(EpsE) hexamer architecture is likely.

Analysis of efforts to maintain safe donor in main donor pool after completion of temporary deferral period.

BACKGROUND: Voluntary blood donation is not satisfactory all over India. In India, about 55% of donation is through voluntary non-remunerated blood donors (VNRBD). However, about one third already motivated blood donors are deferred due to stringent screening criteria, either temporarily or permanently. The temporarily deferred donors could be a good source of blood donation after deferral period. AIMS: The present study is carried out to know retrieval of blood donors those who are deferred temporarily. DESIGN: The present study is carried out in the Regional Blood Transfusion Centre of Western India. All donors screened as per the guideline and deferred donors are categorized as temporary and permanently deferred donors. MATERIALS AND METHODS: From temporarily deferred donors, reason for deferral is considered. As per reason of deferral, time duration for recalling the donor is defined. Based on this, donor is called back to donate again. STATISTICAL ANALYSIS: Chi-square test is applied. RESULT: A total of 33% donors were deferred either temporarily or permanently. In the repeat donors (5.32%) deferral rate was significantly higher than first time (1.32%) donors. Significant female preponderance was observed (15.05% vs 2.51%). Majority of temporarily deferred donors were less than 40 years of age (80.80%), graduate (82.90%), from low income group (62.90%) and profession was service (48.10%). CONCLUSION: Low hemoglobin (78.30%) was the most common reason of temporary deferral, both in first time and repeat donors (71.00%). Efforts to increase the hemoglobin in the repeat donors will improve the donor retention and overall blood safety can be increased.

True positivity of anti-Hepatitis C Virus Enzyme-linked immunosorbent assay reactive blood donors: A prospective study done in western India.

BACKGROUND: A significant number of safe donations are removed from the blood supply, because of the reactive anti-HCV screening test results. This study aimed to assess if the HCV (Hepatitis C Virus) seropositive donors were confirmed positive or not. MATERIALS AND METHODS: More than 68,000 blood donors' samples were routinely screened and 140 samples were found to be anti-HCV ELISA reactive. These 140 samples were tested by NAT. The NAT negative samples were tested by RIBA. Analysis of samples reactive in single ELISA kit vs. two ELISA kits was done. RESULTS: Out of 140 anti-HCV ELISA reactive samples, a total of 16 (11.43%) were positive by NAT. The results of 124 RIBA showed 6 (4.84%) positive, 92 (74.19%) negative, and 26 (20.97%) indeterminate results. None of the sample which was reactive in only single ELISA kit was positive by NAT or RIBA. CONCLUSION: Only a minority of blood donors with repeatedly reactive anti-HCV screening test is positive by confirmatory testing, but all these blood units are discarded as per existing legal provisions in India. Efforts should be made to retain these donors and also donor units.

Deferral pattern in voluntary blood donors on basis of low hemoglobin and effect of application of digital hemoglobinometer on this pattern.

BACKGROUND: One of the responsibilities of blood center is to provide safety to blood donors. It is mandatory to screen a blood donor for hemoglobin (Hb) or hematocrit which should not be less than 12.5 g/dl or 38% Hct. Most commonly applied method for hemoglobin estimation is copper sulphate method, but this method has chances of false acceptance as well as false deferral. In order to avoid this chance of error, digital hemoglobinometer is used. This study was planned to analyze effect of application of digital hemoglobinometer for detection of Hb on donors, who are deferred by copper sulphate method. MATERIALS AND METHODS: Total 35,339 voluntary non renumareted altruistic donors were included in this study between the periods of September 2005 to July 2006. Total deferred donors were 8622 (24.39%) and donors deferred due to hemoglobin by copper sulphate method were 4391 (50.92%). Digital hemoglobinometer was applied on 3163 deferred donors (72.03%). Results of digital hemoglobinometer were validated by known controls. RESULT: Digital hemoglobinometer was applied on 3163 donors who were deferred by copper sulphate method. Out of this, donors accepted by digital hemoglobinometer were 1196 (37.01%). Total repeat donors were 629 (52.50%) and first time were 567 (47.40%). Male donors were 891 (74.44%) and females were 305 (25.50%). Donors deferred with digital hemoglobinometer were 2135, out of them 1097 (51.14%) were repeat, 1038 (48.38%) were first time, 1349 (60.79%) were male, 786 (34.47%) donors were female donors. Range of hemoglobin in deferred donors was 7.0 to 12.4 and in accepted donors 12.5 to 16.4. CONCLUSION: By the application of digital hemoglobinometer 37.81% donors were found hemoglobin >12.5 which were deferred with copper sulphate method and unnecessary deferral of donors can be reduced to a great extent. In country like India, where blood supply is always less than the requirement, this new technique may be helpful to increase donor population but cost benefit ratio should be analyzed.

Primary cardiac lymphoma diagnosed by multiphase-gated cardiac CT and CT-guided percutaneous trans-sternal biopsy.

We present a case of a primary cardiac B-cell lymphoma where a multiphase-gated cardiac CT exam helped to successfully guide trans-sternal needle biopsy to establish a tissue diagnosis.

Serial follow-up of repeat voluntary blood donors reactive for anti-HCV ELISA.

BACKGROUND: Voluntary non-remunerated repeat blood donors are perceived to be safer than the first time blood donors. This study was planned for follow-up of previous hepatitis C virus (HCV) test results of anti-HCV enzyme-linked immunosorbent assay (ELISA) reactive repeat blood donors. The aim was to suggest a protocol for re-entry of the blood donors who are confirmed HCV negative by nucleic acid test (NAT) and recombinant immunoblot assay (RIBA). A group of repeat voluntary donors were followed retrospectively who became reactive on a cross sectional study and showed HCV reactivity while donating blood regularly. MATERIAL AND METHODS: A total of 51,023 voluntary non remunerated blood donors were screened for anti-HCV ELISA routinely. If anybody showed positivity, they were tested by two ELISA kits (screening and confirmatory) and then confirmed infection status by NAT and or RIBA. The previous HCV test results of repeat donors reactive by anti-HCV ELISA were looked back from the records. Data of donors who were repeat reactive with single ELISA kit (in the present study) were analyzed separately from those reactive with two ELISA kits (in the present study). RESULTS: In this study, 140 (0.27%) donors who were reactive by anti HCV ELISA were included. Out of them, 35 were repeat voluntary donors and 16 (11.43%) were reactive with single ELISA kit. All 16 donors were reactive by single ELISA kit occasionally in previous donations. Their present ELISA positive donations were negative for HCV NAT and RIBA. A total of 19 (13.57%) donors were reactive with two ELISA kits. In their previous donations, the donors who were reactive even once with two ELISA kits were consistently reactive by the same two ELISA kits in their next donations also. CONCLUSION: Donor sample reactive by only single ELISA kit may not be considered as infectious for disposal as they were negative by NAT and or RIBA. One time ELISA positivity was found probably due to ELISA kit specificity and sensitivity. Donors reactive with two ELISA kit should be discarded as there is a high positivity with NAT/ RIBA. However, donors reactive by two ELISA kits and negative by NAT and RIBA should be followed up and may not be deferred permanently.