Acute mixed cellular and humoral rejection of renal allograft with leucopenia.

Diagnosis and management of acute renal allograft dysfunction often pose challenge to nephrologists during practice. Acute rejection is a major cause of acute graft dysfunction but is rare in patients with leucopenia. Acute rejection can have either humoral or cellular components or sometimes mixed components. Mixed acute cellular and humoral rejection often present as steroid resistant rejection. Here we report a patient with live related renal transplant recipient with acute graft dysfunction with leucopenia who was found to have mixed acute cellular and humoral rejection.

Surgical innovation revisited: A historical narrative of the minimally invasive "Agarwal sliding-clip renorrhaphy" technique for partial nephrectomy and its application to an Australian cohort.

Objective: To evaluate local clinical outcomes of sliding clip renorrhaphy, from inception to current utilization for open, laparoscopic, and robotically assisted partial nephrectomy. Methods: We reviewed prospectively maintained databases of three surgeons performing partial nephrectomies with the sliding-clip technique at teaching hospitals between 2005 and 2019. Baseline characteristics, operative parameters, including surgical approach, RENAL Nephrometry Score, and post-operative outcomes, including Clavien-Dindo classification of complications, were recorded for 76 consecutive cases. We compared perioperative and 90-day events with patient and tumor characteristics, stratified by operative approach and case complexity, using Wilcoxon rank-sum test for continuous variables and the Chi-squared or Fisher's exact test, for binary and categorical variables, respectively. Results: Open surgery (n = 15) reduced ischemia time and operative time, but increased hospital admission time. Pre- and post-operative estimated glomerular filtration rates did not change significantly by operative approach. Older patients (P = .007) and open surgery (P = .003) were associated with a higher rate of complications (any-grade). Six grade ≥3 complications occurred: these were associated with higher RENAL Nephrometry Score (P = .016) and higher pathological tumor stage (P = .045). Limits include smaller case volumes which incorporate the learning curve cases; therefore, these data are most applicable to lower volume teaching hospitals. Conclusion: The sliding-clip technique for partial nephrectomy was first described by Agarwal et al and has low complication rates, acceptable operative time, and preserves renal function across open and minimally invasive surgeries. This series encompasses the initial learning curve with developing the technique through to present-day emergence as a routine standard of practice.

Histology of the terminal end of the distal rectal pouch and fistula region in anorectal malformations.

OBJECTIVE: Until recently, surgeons have been posed with a dilemma---whether or not they should preserve the terminal end of the distal rectal pouch and the fistula region in anorectal malformations (ARMs). A detailed histological study of this region was conducted to establish a consensus for preserving or excising this region for reconstruction of ARMs. METHODS: Histopathological examination using haematoxylin and eosin-stained sections of the terminal portion of the distal rectal pouch and proximal portion of the rectourogenital or rectoperineal connection was performed in 60 cases of high, intermediate and low ARMs. RESULTS: Distorted internal sphincter was present in 93.3% of high, 90% of intermediate and 100% of low ARMs. The proximal fistula region was lined by transitional epithelium in 50% of cases, and anal glands were present in 83.3% and anal crypts in 68.3% of cases. The rectal pouch in the region of the internal sphincter and fistula was aganglionic in all cases. CONCLUSION: This study shows that the terminal end of the distal rectal pouch and proximal fistula region possess distorted anal features with aganglionosis, and contradicts the recommendation that this region should be reconstructed in patients with malformations.

Diagnosis of acute myocardial infarction: CK-MB versus cTn-T in Indian patients.

The comparative diagnostic efficacy of two cardiac markers: CK-MB and cTn-T, has scarcely been investigated in Indian patients of acute myocardial infarction. The present study was conducted for the same objective. The present study comprised of 59 patients. Males were 44 (75%) and females were 15 (25 %). The age of patients ranged from 32-84 years with mean age of 62.8 yrs. The mean age of males and females were 60 and 63 yrs respectively. All patients presented with history of chest pain with a 12 leads ECG proven MI (ST Elevation, discordant T-waves). CK-MB was estimated in peripheral blood samples at 0,24,48 and 72 hours by an autoanalyzer. Following 12 hours of admission bed side Troponin-T test was done employing cTn-T marker kit. Initially (0 hr), in 50% patients CK-MB was elevated. By end of 24 hours all the patients were CKMB positive and peak level was attained at 24 hrs. Then it tended to decline over next 48 hrs. There were no false positive or negative results. The cTn-T test was positive only in 22 % of ECG positive infarctions. However, the cTn-T positive cases were always accompanied by a higher CK-MB levels. A significantly lower cTn-T positive cases in Indian patients can only be attributed to some difference in amino acid sequence of Indian cTn-T and occidental cTn-T. A larger study from other Indian cardiac centers can either substantiate or contradict our results.

Prevalence of anaemia in pregnant & lactating women in India.

BACKGROUND & OBJECTIVES: The prevalence of anaemia during pregnancy and lactation was significantly lower in the National Family Health Survey 1998-1999 (NFHS-2), using the hemocue method for haemoglobin estimation compared to earlier surveys. The present study selected seven States and used the same districts and villages studied in the NFHS-2, to see if the reported reduction in prevalence of anaemia was due to health and nutrition inputs and/or due to a different method for haemoglobin estimation. METHODS: A total of 1,751 women (1,148 pregnant and 603 lactating- exclusively breastfeeding up to 3 months of age), from seven States- Himachal Pradesh and Haryana in north; Assam and Orissa in east; Kerala and Tamil Nadu in south and Madhya Pradesh in central India, were selected. Haemoglobin was estimated by the cyanmethaemoglobin method, so that comparison was possible with earlier studies. Data on socio-demographic characteristics, pregnancy, nutritional status and dietary intakes were collected. RESULTS: Prevalence as well as severity of anaemia was significantly higher in the present study as compared to the NFHS-2 study data. The difference could be due to haemocue method, which gives higher haemoglobin values. The contributing factors found on multiple regression analysis for anaemia in pregnancy and lactation were: literacy, occupation and standard living index of the study women; their awareness about anaemia, its prevention by regular consumption of ironfolate tablets and increase in food intake. Maternal height, age of marriage, parity and foetal loss also contributed to haemoglobin level. There were interstate differences; lower fertility, higher literacy and better diet was observed in Himachal Pradesh as compared to Haryana. The literacy and nutritional status of women in Tamil Nadu was lower than Kerala. The remaining 3 states had poor fertility, lower social living index and nutritional status with >90 per cent women being anaemic in pregnancy and lactation. Low prevalence of severe anaemia in Orissa as compared to Assam was due to availability and consumption of iron folate tablets. The antenatal services in the first trimester and checkup by a doctor, along with availability and consumption of iron folate tablets over 3 months in all the States influenced haemoglobin levels. INTERPRETATION & CONCLUSION: Despite the measures taken to control anaemia in pregnancy and lactation in the last two decades, the severity of nutritional anaemia continues to remain a public health issue of great magnitude, suggesting that these measures have been largely ineffective. The present findings also showed interstate differences particularly in fertility, women education, nutrition status and occupation; availability of antenatal services and iron folate tablets as possible factors responsible for differences in prevalence of anaemia.

Peak expiratory flow rate of children working in lock factories.

Peak expiratory flow rate (PEFR) of 106 children working in different units of lock factory was measured and compared with age and sex matched control group of same socio-economic status children. All the children worked for about ten hours per day. It was observed that there was a significant decrease in PEFR of children working in the different units of lock factories i.e. Hand press, Polishing, Lock fitting, Lock packing units as compared to control group (P>0.001). The reduction percentage of PEFR was maximum in children working in polishing unit (25.48%).

Biochemical changes in saliva of malnourished children.

The protein concentration and activity of arginase enzymes in serum and saliva was estimated in a total of 94 children out of which 52 were suffering from protein-energy malnutrition (PEM) and 42 served as controls. The salivary ferritin was also estimated in 41 children (control eight and PEM 33). There was a progressive fall in serum and salivary arginase activity and levels of salivary protein and ferritin with severity of PEM. The salivary ferritin showed very significant fall even in PEM grade I. In PEM grade III the mean ferritin value was 3.28 +/- 0.75 micrograms/L as compared to 169.3 +/- 21.9 micrograms/L for normal children. The changes in salivary protein, arginase activity, and ferritin in PEM may be used in recognizing severity as well as early stage of the disease.

Interaction of di-(2-ethylhexyl) phthalate with the pharmacological response and metabolic aspects of ethanol in mice.

The interactions of di-(2-ethylhexyl) phthalate (DEHP) with the pharmacological response and metabolic aspects of ethanol in mice were investigated at oral doses of DEHP of 1.5, 3.0 and 7.5 g/kg or intraperitoneal doses of 3.7, 7.5 and 18.9 g/kg, administered once or daily for 7 days. A single oral or intraperitoneal administration of DEHP resulted in a significant increase in the ethanol-induced sleeping time, associated with an inhibition of alcohol dehydrogenase activity in liver; the effect of intraperitoneal administration was significant only at the highest dose. The activities of high and low Km aldehyde dehydrogenases in mouse liver were not affected by a single dose of DEHP by either route. Repeated oral doses of DEHP produced significant reductions in the ethanol-induced sleeping time and increases in the activities of alcohol and aldehyde dehydrogenases, whereas repeated intraperitoneal doses of DEHP significantly increased the sleeping time and decreased the activity of alcohol dehydrogenase, without any perceptible effect on the activities of aldehyde dehydrogenases. In vitro studies with mouse liver preparations revealed significant inhibition of alcohol dehydrogenase activity by mono-(2-ethylhexyl) phthalate and 2-ethylhexanol and of high and low Km aldehyde dehydrogenase activities by DEHP and mono-(2-ethylhexyl) phthalate at concentrations ranging from 0.03 to 1.00 mM. In all cases, in vitro enzyme inhibition by mono-(2-ethylhexyl) phthalate was most pronounced.

Effects of di(2-ethylhexyl) phthalate on the gonadal pathophysiology, sperm morphology, and reproductive performance of male rats.

Dietary exposure of adult male F344 rats to 0, 320, 1250, 5000, or 20,000 ppm DEHP for 60 consecutive days resulted in a dose-dependent reduction in total body, testis, epididymis, and prostate weights at 5000 and 20,000 ppm. Degenerative changes were observed in testis, along with decreased testicular zinc content, reduced epididymal sperm density and motility, and increased occurrence of abnormal sperm at 20,000 ppm. There was a trend towards reduced testosterone and increased luteinizing hormone and follicle stimulating hormone in serum at 5000 and 20,000 ppm. The mean percentage of fertile animals was unchanged and reduction in fertility parameters, although not marked in severity, were correlated with gonadal effects. Average litter size was reduced at 20,000 ppm, but initial pup weights and growth were unaffected. There were no grossly observed abnormalities in the offspring and the rate of neonatal deaths was similar in control and DEHP treated groups. Characteristic toxicity manifestations of DEHP included dose-dependent enlargement of liver and reduced sperm triglycerides and cholesterol. Additionally, serum albumin and total proteins were dose dependently increased upon treatment with DEHP. Cessation of exposure to DEHP initiated partial to complete recovery from toxicity in most cases. The magnitude of recovery were variable with that of the gonads being slower than other systems. These data suggest a lack of reproductive dysfunction in F344 male rats at DEHP doses below 20,000 ppm which produced measurable testicular degeneration and afflicted epididymal sperm morphology under the present experimental conditions.

Effect of Di-(2-ethylhexyl) phthalate (DEHP) on chemical constituents and enzymatic activity of rat liver.

Effect of Di(2-ethylhexyl) phthalate (DEHP), was investigated on chemical constituents and activity of certain enzymes of rat liver. A significant increase in liver weight; total and relative to body weight; decrease in total, free and esterified cholesterol; and no change in dry weight, moisture; RNA, DNA, total lipids, phospholipids, pyruvic acid and lactic acid contents was observed in liver of DEHP-treated rats as compared to controls. Activity of 3 mitochondrial enzymes, malic dehydrogenase, cytochrome-c-oxidase and diaphorase were significantly decreased while that of NADH-cytochrome c reductase, RNAase and DNAase remained unaltered upon treatment. The results suggest that DEHP exerts its hepatotoxic effects by interfering with bioenergetics of the cell.

Effect of di-2-ethylhexyl phthalate on the activity of succinic dehydrogenase and adenosine triphosphatase of some vital organs of rat.

Succinic dehydrogenase (SDH) and adenosine triphosphatase (ATPase) activity measured 21 days after 3 intraperitoneal injections of di-2-ethylhexyl phthalate (DEHP) was decreased in heart, lung and kidney while it remained unaltered in brain. Under in vitro conditions, only SDH was sensitive to DEHP, degree of inhibition being concentration-dependent. DEHP solubilized with Tween 80 inhibited the SDH activity significantly at small concentrations of 5 to 25 ppm. ATPase activity was not modified.

Adverse effects of butyl benzyl phthalate on the reproductive and hematopoietic systems of male rats.

A 14-day dietary study was conducted in adult, male, Fischer 344 rats at levels of 0.0, 0.625, 1.25, 2.5 and 5.0% butyl benzyl phthalate (BBP) to evaluate potential effects of this plasticizer on the male reproductive and hematopoietic systems. Total body, thymus, testis, epididymis, prostate and seminal vesicle weights were reduced in the 2.5% and 5% BBP dose groups, while pituitary weight was unaffected. Histological evaluations revealed dose-dependent atrophy of the testis, prostate and seminal vesicles at 2.5% and 5%, atrophy of the thymus and epididymis at 5%, and the presence of immature sperm cells in the tubular lumens and necrosis of the tubular epithelium in the epididymis at 2.5% and 5% BBP. Plasma testosterone concentration was decreased at 5%, while follicle stimulating hormone (FSH) and luteinizing hormone (LH) concentrations were increased at 2.5% and 5.0% BBP. The circulating components of blood, and clotting times (prothrombin time, activated partial thromboplastin time), were unaffected although bone marrow cellularity was reduced at 2.5% and 5%. Changes in non-reproductive organs included enlargement of liver and kidneys, thymic atrophy and associated morphological abnormalities in these organs. These data indicate a direct toxic effect of BBP on the testis with secondary effects on other reproductive organs. Pituitary and hypothalamic responses did not appear to be affected. The reduced bone marrow cellularities suggest that prolonged exposures to BBP could affect circulating blood components or compromise clotting ability.

Positive life orientation and recovery from myocardial infarction.

The study examined the relationship between positive life orientation (PLO) and recovery from a recent myocardial infarction (MI), i.e. heart attack. PLO was defined as a predisposition to selectively focus one's attention on the brighter side of any situation. An 11-item measure of PLO was developed. Seventy male patients of first MI receiving treatment at a local government hospital were interviewed twice, 4-5 days after their first heart attack (time 1) and a month after their first heart attack (time 2). The interview schedule consisted of measures of PLO, perceived recovery, expected recovery, helplessness, personal control and mood state. At time 1 all these measures were administered but at time 2 measures of only PLO, personal control, perceived recovery and mood state were administered. In addition, the attending doctor assessed the patients' medical recovery at time 1. Results showed positive correlation of patients' PLO scores with their medical recovery, perceived recovery, expected recovery, personal control and mood state but negative with helplessness. PLO scores were not influenced by patients' age, education, or income. Patients' scores on PLO at two time points were not significantly different and were positively correlated. Their scores on sense of personal control and perceived recovery increased significantly at time 2. Significant intercorrelations among variables, under study, often reduced to insignificance on partialling out PLO. PLO, thus emerged as an important factor in recovery from MI.

Efficacy of amphipathic dithiocarbamates in intracellular cadmium mobilization and in modulation of hepatic and renal metallothionein in cadmium pre-exposed rat.

Forty-eight hours after an intraperitoneal injection of cadmium chloride (1.5 mg Cd/kg) to female albino rats, Cd was mainly localized in the hepatic and renal supernatant cytosolic fraction (SCF). Seventy-two hours later, the total hepatic burden remained unchanged but the total renal burden was enhanced, showing its tendency to accumulate in the kidney. A single dose (0.4 mmol/kg, i.p.) of sodium N-benzyl-D-glucamine dithiocarbamate (BG.DTC) or sodium N-(4-methoxybenzyl)-D-glucamine dithiocarbamate (MeO.BG.DTC), 24 h after Cd injection, efficiently mobilized Cd from hepatic SCF, apparently from cadmium-metallothionein (Cd-MT); MeO.BG.DTC also removed Cd from hepatic nuclear mitochondrial fraction. This treatment, however, increased the renal burden of Cd, indicating that the chelating agents, at least partly, transport Cd from the liver and possibly from other sites into the kidney. Three doses of the chelators further enhanced mobilization of Cd from hepatic as well as renal SCF, as corroborated by its enhanced urinary and, to a greater extent, fecal excretion. Hepatic and renal MT were induced several-fold above normal after a single dose of Cd as well as single or repeated doses of BG.DTC or MeO.BG.DTC. Seventy-two hours after a Cd injection, the hepatic MT declined to half of the induced level while the renal MT remained elevated. Administration of BG.DTC or MeO.BG.DTC in Cd pre-treated rats produced an additive response in hepatic MT, but the response in renal MT was less than additive at one dose and slightly declined after three doses. Hepatic Zn and Cu and renal Zn increased on treatment with Cd but were depleted after a single or repeated injection of BG.DTC or MeO.BG.DTC in normal as well as in Cd pre-exposed animals. The results indicate that intracellular access of amphipathic dithiocarbamates effectively mobilizes MT-bound Cd, which is preferentially excreted in the feces, and helps avoid further burden on the kidney and consequent nephrotoxicity. Additionally, MeO.BG.DTC was a better inducer of hepatic MT to help increased capture of toxic metal from the initial circulation and consequent toxicity.

In vivo induction of sister chromatid exchange in mouse bone marrow following oral exposure to commercial formulations of alpha-cyano pyrethroids.

In vivo genetic toxicity potential of cypermethrin and deltamethrin, two alpha-cyano pyrethroid insecticides was evaluated through induction of sister chromatid exchange in mouse bone marrow cells. Groups of four healthy, adult, male albino mice were each administered with a single oral dose of 10.6, 21.1 and 32 mg cypermethrin a.i./kg b.w. or 6.6, 13.2 and 20 mg deltamethrin a.i./kg b.w. in peanut oil. For reference, a peanut-oil vehicle control and cyclophosphamide (20 mg/kg, i.p.) positive control group of animals were run in parallel. Sister chromatid exchange (SCE) analysis in bone marrow metaphase chromosomes, 24 h post-treatment, revealed modest induction with statistical significance at the highest test dose of both insecticides as compared to the vehicle control group. Further, the SCE induction by cypermethrin was more prominent than by deltamethrin. Marked induction of SCE frequency by exposure to cyclophosphamide, an alkylating mutagen, lent authenticity to these observations which, together with earlier evidence of mitotic and chromosomal abnormalities by these pyrethroids, substantiated their genetic toxicity potential and susceptibility of mammals to consequent risks.

Cytogenetic effects of deltamethrin on rat bone marrow.

Deltamethrin, a synthetic pyrethroid insecticide, was administered to adult female albino rats as a single i.p., s.c., or oral dose of 5.6, 8.4, or 11.2 mg/kg b.w. or repeated i.p. doses of 2.24 mg/kg b.w. for five consecutive days (cumulative dose 11.2 mg/kg b.w.). This treatment inhibited the mitotic index in a dose-dependent manner and increased the frequency of chromosome aberrations in the bone marrow at 24 h post exposure. The parenterally (i.p. and s.c.) administered deltamethrin appeared more effective than the oral gavage for eliciting its cytotoxicity and genetic toxicity potential. The frequency of micronucleated erythrocytes in the bone marrow was also increased at 30 h following a single i.p. dose of 5.6, 8.4, or 11.2 mg/kg b.w. The most prevalent abnormality observed in this study was endomitotic reduplication of chromosomes which, along with mitotic inhibition and micronucleus induction, indicated microtubular/mitotic spindle poisoning by deltamethrin. The increased frequency of chromosome aberrations and micronucleated erythrocytes also suggests a clastogenic potential of deltamethrin. These observations indicate the in vivo susceptibility of mammals to the genetic toxicity potential of deltamethrin.

Complex ruptured amebic liver abscesses: the role of percutaneous catheter drainage.

The failure of medical therapy for amebic liver abscess may be followed by its perforation, a complication associated with high mortality. We assessed the role of percutaneous catheter drainage in management of the sequelae of ruptured amebic abscesses in 13 critically ill patients; 22 intrahepatic lesions, three of which were multiloculated, were drained. Catheters were also placed in 17 extrahepatic collections: pleural space (n = 5), subphrenic (n = 7), perihepatic/subhepatic (n = 3), greater sac of peritoneum (n = 2). No attempt at percutaneous drainage failed. Prompt resolution of clinical features following drainage was a uniform feature. Successful resolution of the abscesses occurred within 20 days in 11 patients. In the remaining two, catheters needed to be retained in situ for 35 and 50 days. The mean hospital stay was 15 days (range 10-20 days). 100% patient survival was achieved, without a single morbid episode. Our results suggest that patients with ruptured amebic abscesses can be effectively and safely managed by percutaneous catheter drainage irrespective of the extent of extrahepatic contamination.

Laparoscopic condom dissection: new technique of retroperitoneoscopy.

The laparoscopic condom dissection is an advancement on the recently described balloon dissection technique of retroperitoneoscopy. It allows a simultaneous balloon dissection and retroperitoneal laparoscopic dissection using a telescope placed inside a condom balloon. In spite of a mild masking effect by the balloon, the clarity of vision was satisfactory, and adequate dissection could be carried out in all five patients in whom the condom was placed deep to the fascia transversalis or Gerota's fascia.

PIP: The laparoscopic condom dissection technique is an advancement on the recently described Gaur balloon technique for retroperitoneal dissection. The condom device allows for controlled expansion into the required operative area. The authors describe their experience using this technique. Under general anesthesia the patient is placed in a lateral position with the kidney bridge elevated. Two techniques are then described. Using technique 1, the condom cannula is inserted deep to the fascia transversalis through a 2-cm incision, after creating a retroperitoneal space by digital dissection. In technique 2, an 11-mm trocar-cannula is inserted into the retroperitoneal space. The cannula with attached condom is then introduced through this channel. A 10-mm telescope is then inserted. The condom is then inflated to 300 mL. A fiberoptic light source may be inserted through the cannula. Superficial dissection of the retroperitoneal structures may be performed through the balloon itself. Technique 1 was performed on 5 patients with success. Technique 2 was performed on 3 patients with unsatisfactory results. In summary, laparoscopic condom dissection is a new technique that requires further evaluation.

Percutaneous catheter drainage of amebic liver abscesses with and without intrahepatic biliary communication: a comparative study.

Influence of communication with the intrahepatic biliary system on the clinical picture of amebic liver abscesses in 33 consecutive patients resistant to medical therapy, and their response to percutaneous catheter drainage was evaluated. Abscess-biliary communication was found in 27% of the sample. Patients with abscesses communicating with the biliary tree presented more frequently with jaundice (67% vs. 0%, P < 0.005), with a longer duration of illness (median 20 vs. 12 days, P < 0.001), had larger lesions (median 600 vs. 320 ml, P < 0.001) and required catheter drainage for longer periods (median 17 vs. 6.5 days, P < 0.000001). However the presence of a biliary communication did not materially affect the cure rate with catheter drainage (89% vs 100%, P > or = 0.05). In conclusion, an abscess-biliary communication is not uncommon in refractory amebic liver abscesses, and can be clinically detected by the presence of jaundice. Though a prolonged period of drainage may be necessary in the presence of this complication, catheter drainage can be expected to result in cure.