Infected Non-union of Tibia Treated with Ilizarov External Fixator: Our Experience.

Introduction: Tibia is the most common long bone fractured due its vulnerable subcutaneous location and most often associated with acquired complications of delayed union or non-union due to infection. Amongst the various treatment options to treat them, the Ilizarov external fixator application is considered superior due to its multiple advantages. The objective of this study was to analyse the role of Ilizarov fixation in infected tibial non-union, as well as to assess bony union and associated functional outcomes. Materials and Methods: A retrospective review was conducted for the duration between 1st January 2005 to 31st December 2016. Total of fifty-one patients with tibial non-union associated with infection who treated with the Ilizarov fixator were included in the study. Patient records were reviewed for union of bone, bone and functional outcomes and complications. Results: The most common organism for infection was identified to be Staphylococcus Aureus. At the time of final follow-up all patients had achieved union except two, one of whom had to undergo amputation due to non-union and sepsis. Majority of the patients had an excellent score as per ASAMI grading system for bone and function results. The most common complication noted was pin track infections. Conclusion: In our experience, Ilizarov external fixator is better suited for infected non-union of tibia because it can provide a stable mechanical environment, bone transport, correct deformities, and enable weight bearing and hence we recommend its use for the same.

Long-term efficacy and safety of biosimilar infliximab (CT-P13) after switching from originator infliximab: open-label extension of the NOR-SWITCH trial.

BACKGROUND AND OBJECTIVES: The 52-week, randomized, double-blind, noninferiority, government-funded NOR-SWITCH trial demonstrated that switching from infliximab originator to less expensive biosimilar CT-P13 was not inferior to continued treatment with infliximab originator. The NOR-SWITCH extension trial aimed to assess efficacy, safety and immunogenicity in patients on CT-P13 throughout the 78-week study period (maintenance group) versus patients switched to CT-P13 at week 52 (switch group). The primary outcome was disease worsening during follow-up based on disease-specific composite measures. METHODS: Patients were recruited from 24 Norwegian hospitals, 380 of 438 patients who completed the main study: 197 in the maintenance group and 183 in the switch group. In the full analysis set, 127 (33%) had Crohn's disease, 80 (21%) ulcerative colitis, 67 (18%) spondyloarthritis, 55 (15%) rheumatoid arthritis, 20 (5%) psoriatic arthritis and 31 (8%) chronic plaque psoriasis. RESULTS: Baseline characteristics were similar in the two groups at the time of switching (week 52). Disease worsening occurred in 32 (16.8%) patients in the maintenance group vs. 20 (11.6%) in the switch group (per-protocol set). Adjusted risk difference was 5.9% (95% CI -1.1 to 12.9). Frequency of adverse events, anti-drug antibodies, changes in generic disease variables and disease-specific composite measures were comparable between arms. The study was inadequately powered to detect noninferiority within individual diseases. CONCLUSION: The NOR-SWITCH extension showed no difference in safety and efficacy between patients who maintained CT-P13 and patients who switched from originator infliximab to CT-P13, supporting that switching from originator infliximab to CT-P13 is safe and efficacious.

Correlation between intracerebral hemorrhage score and surgical outcome of spontaneous intracerebral hemorrhage.

Spontaneous intracerebral hemorrhage (ICH) comprises 10-15% of all strokes and has a higher risk of morbidity and mortality (40-45%). A simple and widely valid clinical grading scale, the Intracerebral Hemorrhage Score (ICH score) was developed to predict to outcome of spontaneous ICH. The aim of the present study was to assess the relation between the ICH score and the surgical outcome of ICH by Glasgow Outcome Scale (GOS) at the 30th post ictus day in our perspective. This prospective study was done during the period of April 2009 to October 2010 in Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka. Forty three cases were enrolled by set inclusion and exclusion criteria. Intracerebral Hemorrhage Score was calculated during admission and the surgical outcome of ICH was determined by GOS by face to face or telephone interview using structured questionnaire on their 30th post ictus day. Correlation between the ICH score and the surgical outcome of ICH was done by Pearson's correlation coefficient test. Value of r was found to be -0.635 which was statistically highly significant (p = .001) and the relation was found to be negative. Higher ICH score had unfavorable outcome As correlation between the ICH score and the surgical outcome of ICH was found statistically highly significant, it can be used widely as a grading scale in preoperative counseling. The use of ICH score could improve standardization of clinical treatment protocols and clinical research studies in ICH.

Preoperative use of granisetron plus dexamethasone and granisetron alone in prevention of post operative nausea and vomiting in tonsillectomy.

This prospective study was done for to see the efficacy of preoperative use of granisetron plus dexamethasone (Group A) & granisetron (Group B) alone for the postoperative prevention of nausea & vomiting after tonsillectomy operation. One hundred patients undergoing tonsillectomy & adenoidectomy operation under general anaesthesia who were admitted in the Mymensingh Medical College Hospital during the period from July 2008 to June 2009 with American Society of Anaesthesiologists (ASA) grade I & II with age 3-40 years, body weight 10-60 kgs, were studied. Observation of this study was analyzed in the light of comparison between the two groups. All results were expressed as mean±SEM. Age in Group A 15.98±1.028 & Group B 17.18±0.961 years; Weight in Group A 38.40±1.492 & Group B 39.76±1.561 kgs and operational duration in Group A 52.60±0.786 & Group B 52.70±0.823 minutes. The studied groups were statistically matched for age, weight, duration of surgery. We observed that the effects of combination of granisetron & dexamthasone are more than granisetron alone in prevention of nausea & vomiting after tonsillectomy operation. The frequency of vomiting was 4% in combination & 16% in single therapy which is statically significant (p<0.05).

Changes in cardiac parameters of renal allograft recipients: a compilation of clinical, laboratory, and echocardiographic observations.

INTRODUCTION: This study was undertaken to observe changes in cardiac parameters along with clinical and laboratory changes after renal transplantation. PATIENTS AND METHODS: Cardiac parameters were evaluated by M-mode 2-dimensional echocardiography before transplantation and at monthly intervals. All subjects had functioning grafts at the time of the evaluations. RESULTS: Fifty-two allograft recipients underwent pretransplant parameters for comparison to those at posttransplant months 1, 3, 6, and 12. When changes at month 1 and 3 were observed among 22 patients, improvements were evident at month 3. Comparisons of pretransplant versus month 3 showed systolic blood pressure (SBP), 161 +/- 16 to 133 +/- 26 mmHg (P < .002); diastolic BP (DBP), 101 +/- 9 to 86 +/- 11 mmHg, (P < .006); hemoglobin (Hgb), 7.3 +/- 1.6 to 11.2 +/- 3.9 g/dL (P < .006); left atrial diameter (LAD), 41 +/- 5 to 35 +/- 3 mm (P < .001); left ventricular muscle mass index (LVMI), 379 +/- 114 to 248 +/- 58 g/m2 (P < .001); and left ventricular end diastolic volume index (LVEDVI), 96 +/- 28 to 64 +/- 17 mL/m2 (P < .002). When changes at months 3, 6, and 12 were observed among 30 patients, improvements evident at month 3 were maintained. Comparisons of pretransplant and 3 and 12 months observations showed SBP, 157 +/- 17, 131 +/- 14, to 126 +/- 10 mm Hg (P < .001); DBP, 97 +/- 10, 83 +/- 16, to 85 +/- 6 mmHg (P < .001); Hgb, 7 +/- 1, 13 +/- 2, to 13 +/- 2 g/dL (P < .001); LAD, 39 +/- 7, 35 +/- 3, to 34 +/- 4 mm (P < .05); LVMI, 275 +/- 91, 191 +/- 38, to 159 +/- 26 g/m2 (P < .001); and LVEDVI, 87 +/- 29, 56 +/- 34, to 49 +/- 24 mL/m2 (P < .001). CONCLUSION: Significant improvements in cardiac parameters were evident by the third month post-renal transplantation; the changes were maintained over a longer period among patients with functional grafts.

Cardiac functional and morphologic changes of renal allograft recipients in the early posttransplant period.

UNLABELLED: After renal transplantation there is a substantial alteration in cardiac morphology and functions. This prospective study was undertaken to observe changes in different cardiac parameters in early months after transplantation. PATIENTS AND METHODS: Twenty-two allograft recipients (primary disease glomerulonephritis) were evaluated in the immediate pretransplant period (0 month) and 1 and 3 months after transplantation by clinical and echocardiographic (M mode, 2D) evaluations. RESULTS: Pretransplant echocardiogram showed left ventricular hypertrophy (LVH) in 100% subjects, LV dilation in 52%, and systolic dysfunction in 18%. By the third month, significant differences in systolic blood pressure (SBP-161 +/- 16 to 133 +/- 26 mm Hg, P < .002); diastolic BP (DBP-101 +/- 9 to 86 +/- 11 mm Hg, P < .006), and hemoglobin level (Hgb-7.3 +/- 1.6 to 11.2 +/- 3.9 g/dL, P < .006) were evident. Echocardiography showed decreased left atrial diameter (LADd-41 +/- 5 to 35 +/- 3 mm, P < .001); left ventricular internal diameter (LVIDd-54 +/- 6 to 47 +/- 6 mm, P < .02); left ventricular muscle mass index (LVMI-379 +/- 114 to 248 +/- 58 g/m(2), P < .001); and left ventricular end diastolic volume index (LVEDVI-96 +/- 28 to 64 +/- 17 ml/m2, P < .002). Bivariate correlations showed positive associations of mean blood pressure (MBP) and serum creatinine with LVMI, LVEDVI, and negative association of hemoglobin with MBP, serum creatinine, LVMI, and LVEDVI. CONCLUSION: From these observations, we concluded that cardiac morphological parameters start improving in the early posttransplant period. Improvements in renal function, anemia status, and lower blood pressure showed strong associations with these changes.

Association of HLA class I antigen matching and early graft outcome in living donor kidney transplantation.

INTRODUCTION: HLA antigen matching often plays an important role in organ transplantation. As for HLA class I antigen matching, there are differences of opinion regarding its influence on the outcome of renal transplantations. The aim of this study was to evaluate the association of HLA class I antigen matching with early graft outcomes in living donor kidney transplantation. PATIENTS AND METHODS: We evaluated graft outcomes in the first month of transplantation. Major events were slow graft function (serum creatinine > 250 micromol/L at the end of first week), delayed graft function (patients requiring dialysis in first week), and acute rejection episode. Graft outcomes were compared for normal renal function (NRF, serum creatinine < or = 175 micromol/L) impaired renal function (IRF, serum creatinine > 175 micromol/L) or impaired graft function due to an acute rejection episode (IGF). RESULTS: The 115 subjects had a mean age of 29 +/- 8 years and their donors 38 +/- 11 years (P < .01). Immunosuppression included prednisolone, azathioprine, and cyclosporine. Parents, siblings, and others were kidney donors in 46%, 33%, and 21%, respectively. Comparisons between NRF/IRF (serum creatinine 133 +/- 24 vs 201 +/- 36 micromol/L, P < .01) and NGF/IGF (serum creatinine 146 +/- 44 vs 161 +/- 39 micromol/L, P < .05) showed no difference in number or pattern of HLA matching. CONCLUSION: HLA class I antigen matching may not produce an added influence on early graft outcome among living donor kidney transplantations.

Effect rHuEpo on predialysis CRF patients: study of 45 cases.

Forty five (24 male & 21 female) moderate to severe degree of predialysis CRF patients were prospectively studied over a period of 6 months (July- December, 2004) to see the effect of Recombinant Human Erythropoietin (rHuEpo/EPO) therapy on renal anaemia, progression of renal excretory function & quality of life at 3 and 6 months intervals from the starting of EPO therapy. Mean +/- SD age of the patients was 56 +/- 12 (30-77 yrs) and causes of CRF were Diabetic Nephropathy (DN)=15 (33%), Chronic Glomerulonephritis (CGN) =14(31%), Hypertension (HTN)=11(21%), Chronic Pyelonephritis (CPN)=03 (6.5%) and Obstructive Uropathy (OU)=02 (4.5%). Doses of rHuEpo was 80-100 IU/k week subcutaneously (SC) until the target Hb 11gm% & Hct 30% were achieved; there after the dose was titrated as appropriate. Serum Iron & Ferritin levels were also kept within normal reference level by iron therapy during the study period. Mean +/- SD base line (before starting EPO therapy) level of haemoblobin were 8.4 +/- 0.81(gm%), Hct 27.86 +/- 1.6 (%), blood urea 21.72 +/- 10.5 (mmol/L), S. creatinine 431.93 +/- 228.79 (mmol/L) & Ccr. 21.25 +/- 10 mum respectively. The results showed that significant improvement of haemoglobin level occurred (gm%) from 8.4 +/- 0.81 (gm%) to 9.51 +/- 1.02 (p<0.001) at 3 months and 8.4 +/- 0.81 to 11.10 +/- 1.4, (p<0.001) at 6 months interval. Haematocrit (Hct%) value also significantly increased from 27.86 +/- 1.5 to 30.57 +/- 3.62, (p<0.001) at 3 months and 27.86 +/- 1.5 to 32.81 +/- 3.92 (p<0.001) at 6 months of EPO therapy. Mean blood urea and S. creatinine levels decreased from base line level during the study period but did not show any statistical significance. There was no significant side-effects like uncontrolled hypertension, seizure or hyperviscosity syndrome in any of the study population. The quality of life in terms of improvement of physical ability and sense of well being were also improved in all the study patients. In conclusion, this study showed that the effect of rHuEpo therapy is beneficial for the correction of renal anaemia, can delay the progression of renal failure and improvement of overall quality of life in predialysis CRF patients.

Assessment of renal insufficiency in gestational proteinuric hypertension in third trimester pregnancy.

This prospective study on assessment of renal insufficiency in pregnancy induced proteinuric hypertension was carried out on 104 cases, in Bangabandhu Sheikh Mujib Medical University (former IPGM&R), Dhaka during period of August 1997 to September 1998. The objective of this study, to find out the impairment of renal function in mild (<110 mmHg) and severe (>110 mmHg) hypertension. The frequency of mild hypertension was 96.29% and severe hypertension was 3.71% in third trimester of pregnancy. In this study mean age of the patient was 26.53+/-3.9 years, mean gestional age was 36.46+/-1.93 weeks and mean diastolic BP was 99.07 mmHg. The prevalence of hypertension was more in primigravida which was (72.23%) than multigravida (27.77%). Proteinuria was diagnosed as quantitative measurement of 24 hour urinary protein in photometric colorometer. The mean value of total urinary protein was 335+/-74.14 mg/24 hour (range 280-800 mg/24) hour). 1+Oedema was present in 48.14%, 2+ was 12.96% and 3+ was 14.81% of cases. There is a correlation of proteinuric hypertension with renal function which was done on the basis of laboratory investigations. Findings of parameters of renal function found to declined: Serum creatinine mean value 1.0+/-0.14 (P<0.001) (normal range 0.6-0.8 mg/dl.), Urinary creatinine mean 57.69+/-12 mg/dl., Creatinine clearance mean 53.72+/-11.63 ml/min, Total urinary protein mean 335.52+/-74.14 mg/24 hour. Total urinary volume mean 2985+/-49 ml/24 hr. All the patients and their babies were followed up till discharge from hospital. Cesarean section was done in 76% of cases and vaginal delivery was done in 24% cases. Mean hospital stay was prolonged in proteinuric hypertension 7+/-1 days than non proteinuric normotensive goup 3+/-1 days. All of those were average socio-economic status. Extreme low birth weight was 14.81% in 50% of IUGR cases.

IgA nephropathy in teaching hospitals of Dhaka.

A light and immunofluorescence microscopic study on renal biopsies were performed on 42 patients. Nephrotic syndrome with accompanying microhematuria and recurrent hematuria (Macroscopic/microscopic) with or without renal failure were the commonest indications for renal biopsy. Primary IgA nephropathy was diagnosed in five cases. Among the IgA nephropathy patients, the commonest light microscopic finding was mesangial proliferative glomerulonephritis. Macroscopic hematuria with proteinuria was the commonest feature. Three of the patients had hypertension at the time of renal biopsy. The age of the patients ranged from 19-38 years with a mean of 26 years. The high frequency of hypertension, degree of proteinuria and associated renal failure in one patient that it is a progressive disease. This preliminary study revealed that IgA nephropathy exists in Bangladesh. Larger samples need to be studied with a view to find out its prevalence and its peculiarities in this part of the world.

Identification of partial complementary DNA clones encoding a 59-kd protein with characteristics of a unique oncofetal antigen.

BACKGROUND: Oncofetal antigens (OFAs) are conserved tumor-associated autoantigens or transplantation antigens present on the surface of all major classes of rodent and human tumors and on midgestational fetal cells but not on normal neonatal or adult human and rodent tissues. A syngeneically derived monoclonal antibody, MAb-115, recognizes murine OFAs of 44 and 200 kd in molecular mass. PURPOSE: Our goal was to clone and characterize the complementary DNAs (cDNAs) that encode these murine OFAs. METHODS: Rabbit antiserum raised against purified 44-kd OFA glycoprotein was used to screen a mouse embryo cDNA-lambda phage expression library. Recombinant phage clones positive for the expression of OFAs were detected by immunohistochemical staining, then isolated and plaque purified. The presence of an OFA-encoding sequence in the recombinant phage was confirmed by specific reaction of the expressed protein with MAb-115. Recombinant fusion protein was purified from the extracts of corresponding lysogens. Rabbit antiserum against purified recombinant fusion protein was raised, and the capacity of this antiserum to detect the expression of OFA on rodent tumor and fetal cells was determined by flow cytometry. In addition, immunoreactivity of tumor bearer and hyperimmune murine sera to bacterially expressed recombinant OFA protein was evaluated by enzyme-linked immunosorbent assay. The OFA-expressing insert DNA from plaque-purified lambda clones was subcloned into phagemid vectors for sequencing analysis. RESULTS: Antiserum derived against the isolated recombinant mouse embryo polypeptide mimicked MAb-115 in its specific binding to all OFA-positive rodent tumor and fetal cell lines tested and likewise did not show reactivity to normal adult tissues. This antiserum specifically recognized the native 44- and 200-kd OFAs in extracts of murine lymphocytic lymphoma. Furthermore, sera of tumor-bearing mice or mice immunized with purified OFA or intact, irradiated OFA-positive lymphocytic lymphoma cells also reacted with the recombinant fusion protein. The characterization of the isolated clone included nucleotide sequence information followed by analysis of the deduced primary structure of the protein. CONCLUSIONS: These data suggest that the isolated cDNA clones encode a distinct gene product which is widely expressed on the surface of tumor and fetal cells and represents the first characterized sequence of a true OFA. IMPLICATIONS: The availability of this cDNA, encoding a protein expressed only on tumor and fetal cells, provides a direct means to assess biological characteristics of malignant tissue which can be assayed by biochemical, histochemical, and molecular methods.

44-kd oncofetal transplantation antigen in rodent and human fetal cells. Implications of recrudescence in human and rodent cancers.

OBJECTIVE: This article summarizes the phase-specific nature of a cell surface, 44-kd tumor-associated transplantation antigen glycoprotein expressed during early and middle gestation in a portion of rodent and human fetal cells during normal fetal tissue development and illustrates how this glycoprotein is consistently recrudesced in primary and established human squamous cell carcinomas and other human and rodent tumors. The oncofetal antigen was not detectable in any human or rodent term fetal tissue or normal adult tissues tested. The tumor-associated transplantation antigen was tumor specific, yet not germ-line specific (expressed in lymphomas, sarcomas, and carcinomas) in human or rodent cancers. Rodent model tumor studies have shown 44-kd oncofetal antigen can act as a tumor-associated autoantigen of potential use in cancer detection and therapy. DESIGN: The oncofetal antigen was detected by immunogenicity, flow cytometry, and Western blotting in syngeneic rodent tumor recipients and by the last two methods in humans with progressive cancer. Syngeneically derived mouse monoclonal antibody (MoAb 115) was used to identify 44-kd oncofetal antigen. Early to middle gestation, oncofetal antigen-positive, mouse embryo/fetal cells used to stimulate the hybridoma were tested for immunogenicity as a tumor-associated transplantation antigen in syngeneic hosts. SETTING AND PATIENTS: Patients presenting with head and neck squamous cell carcinoma (N = 25) and other carcinomas at the University of South Alabama Medical Center, Mobile, underwent a biopsy, and the tumors were mechanically dispersed and were then tested for oncofetal antigen expression directly in flow cytometry. The tumors were also cultured and tested as squamous carcinoma cell lines. Growing squamous carcinoma cells and uncultured tumor cells were stained with MoAb 115 or control MoAb. Extracts of the cells were banded by electrophoresis in gels, Western blotted, and reacted with MoAbs and enzyme-linked immunosorbent assay second antibody. Time-mated mouse fetus and human fetal cells were also stained with MoAb 115 or control antibody and analyzed in the flow cytometer. RESULTS: Eight- to 13-day mouse fetal cells conferred protection against syngeneic tumor challenge. Term 18- to 21-day fetal or neonate or adult mouse cells were nonprotective. All head and neck squamous cell carcinomas tested expressed 44-kd oncofetal antigen by flow cytometric analysis and in Western blots as did ATCC cell lines of these tumors, whereas normal control tissues were negative. Second trimester human fetal cells were 44-kd oncofetal antigen positive. A large spectrum of rodent sarcomas and lymphomas express the OFA. CONCLUSIONS: Shared 44-kd oncofetal antigen OFA offers promise as a tumor detection marker in human squamous cell carcinoma and other human carcinoma development, and syngeneic mouse tumors are good model systems to explore oncofetal antigen antigenicity.

Outcome of acute renal failure in adults in a teaching hospital in Bangladesh.

One hundred and twenty patients with a mean age of 38 years (range 12-85 years; M 91, F 37) were studied over a period of 5 years in a teaching hospital in Dhaka. Sixty-two patients presented with probable anuria with 1-4 days' duration, 63 patients presented with oliguria, and 3 were nonoliguric. The causes of acute renal failure were medical (94), surgical (22), obstetrical (13). Of the medical cases, the causes were gastroenteritis in 42 cases, gastroenteritis with CNS involvement in 11 cases, rapidly progressive glomerulonephritis in 10 cases, acute viral hepatitis in 8 cases, and septicemia in 8 cases. Of 22 surgical cases, postoperative acute renal failure was the cause in 9, road traffic accident in 6, and renal calculus disease in 7. There were 13 cases in the obstetrics group, of whom 9 were due to abortion, 2 were due to preeclampsia, and the other 2 were postoperative. The mean blood urea of all cases was 35 mmol/L and serum creatinine was 988 mumol/L. Dialysis was required in 105 cases; of these, 72 were medical cases, 21 were surgical cases, and 12 were obstetric cases. The overall survival rate was 75%. The improved survival is probably due to timely referral and prompt medical management.