Extradigital glomus tumor as a cause of chronic perianal pain.

Glomus tumor is a rare perivascular benign tumor arising from the Sucquet-Hoyer canal of the normal glomus body, most commonly in the digital areas. We report a serving soldier with such a tumor in an atypical site, the perianal region, presenting with episodic shooting pain. Total surgical excision was performed. Histopathology revealed a well-circumscribed tumor composed of clusters of monotonous polygonal cells surrounding capillary-sized blood vessels. Tumor cells also showed immunopositivity for smooth muscle antigen and vimentin. Following excision, the patient was completely relieved of pain and there was no recurrence on follow-up for 6 months.

Investigation of an outbreak of chikungunya in Malegaon Municipal areas of Nasik district, Maharashtra (India) and its control.

BACKGROUND & OBJECTIVES: An outbreak of chikungunya fever occurred in Malegaon town of Nasik district of Maharashtra state, India during February and March 2006. A total of 4530 fever cases were reported during this period including 1781 cases which were admitted in different hospitals of the town. An entomological and epidemiological investigation was carried out in the affected villages during the outbreak to study the possible causes of the outbreak and to isolate the virus responsible. METHODS: Entomological evaluation was done as per WHO guidelines. Sera samples were collected by venipuncture from clinically suspected chikungunya patients in hospitals and also during house-to-house survey in affected villages. IgM antibodies to dengue virus were detected using IgM capture ELISA (PANBIO) and by "Haemagglutination inhibition test" for detection of antibodies against Chikungunya virus. Acute sera samples were inoculated in cell lines for virus isolation. The isolates were confirmed by RT-PCR. RESULTS: On investigation, it was found that water storage containers like cement tanks, plastic containers or earthen pots placed in front of the individual houses were the potential breeding sites for Aedes aegypti. Entomological survey carried out in the most affected areas revealed high Aedes indices. House, container and breteau indices were found to be 27.2, 16.19 and 35.1, respectively. Out of the 13 acute sera samples collected, virus was isolated in 10 samples. The isolates were confirmed by RT-PCR and sequencing using primers from nsP1 gene of Chikungunya virus (CHIKV, Accession No. EF077609, EF077610). Of the 17 convalescent sera tested, significant level of HI antibodies to CHIKV was detected in five samples. One sample was positive for IgM antibodies against dengue virus. Based on clinico-epidemiological features and laboratory findings, the illness was confirmed to be of chikungunya viral disease. CONCLUSION: Control measures targeting the vector population and personal protective measures against the mosquito bites were instituted. Extensive IEC campaign with the involvement of community and religious leaders helped in containment of the disease.

Reconstruction of Complex Abdominal Wall Defects.

INTRODUCTION: Reconstruction of large abdominal wall defects not amenable to primary closure remains a challenging problem. These defects result from trauma, previous surgery, infection and tumour resection. The primary objectives of abdominal wall reconstructions are to protect abdominal contents and provide functional support. The abdominal wall reconstruction aims at providing basic component parts, i.e. skin, soft tissue and fascia. For large soft tissue defects, pedicled or free flap closure can be used. In clean wounds, fascial replacement is accomplished with synthetic mesh provided there is adequate soft tissue coverage. METHODS: We treated a total of 20 consecutive patients with complex abdominal wall defects utilizing various reconstructive procedures. There were 15 males (75%) and 5 females (25%). The aetiology included dehiscence of laparotomy wounds in eight (40%), following ablative surgery for malignant tumours in seven (35%), trauma in three (15%) and congenital defects in two (10%) cases. The reconstructive procedures consisted of onlay prolene mesh in seven (35%), Gore-Tex (PTFE) dual mesh both as inlay and onlay in five (25%), facial partition release technique in three (15%), inlay prolene mesh covered with omentum and split skin graft in two (10%), inlay prolene mesh covered with expanded skin in two (10%), and Gore-Tex dual mesh covered with latissimus dorsi myocutaneous flap in one (5%) case. Postoperatively none developed mesh infection or extrusion. Three patients with malignant aetiology received postoperative radiotherapy. During follow up, one patient developed ventral hernia cephalad to the repair and one died due to recurrence of abdominal wall malignancy. CONCLUSION: The reconstruction of an abdominal wall defect requires a comprehensive plan of preoperative and post operative care of the patient and aims toward restoration of abdominal structural integrity by a variety of procedures. The use of new biomaterials and tissue expanders provides reliable and durable abdominal wall closure along with good aesthetic results.

Massive lower intestinal bleeding--a decade of experience.

BACKGROUND: Lower gastrointestinal bleeding is defined as hemorrhage orginating distal to the ligament of Treitz. Its diagnosis is difficult, often requiring endoscopy, angiography and isotope scans. METHODS: All patients with massive lower gastrointestinal bleeding seen in three gastroenterology centers of Armed Forces during an 11 year period between 1988 and 1999 were retrospectively analysed. RESULTS: A total of 91 patients with massive lower gastro intestinal bleeding were seen during 11 years. The mean age of the patients was 38.9 years and 64 were males. Aetiological diagnosis was: Non-specific ulcers--11, Ileal tuberculosis--8, NSAID enteropathy--8, Enteric fever--7, Meckel's diverticulum--7, Polyps--6, Ulcerative colitis--5, Carcinoma colon--5, Colonic diverticulosis--5, No cause found--5, Polyposis coli--5, Jejunal diverticulae--3, Angiodysplasia colon--3, Radiation colitis--3, Ischaemic colitis--3, Ileal tumor--2, Ileal angiodysplasia--2, Intestinal Lymphoma--2, Bechet's syndrome--1. Bleeding stopped on conservative therapy in 18 patients (including 5 where no diagnosis could be made). Diagnosis was made in 36 patients on fiber-optic colonoscopy done during active bleeding. Remaining patients were subjected to emergency laparotomy and diagnosis was obvious on inspection of abdominal contents in 25 cases. The diagnosis was finally made in remaining 12 cases by intraoperative endoscopic examination through an ileotomy. Four patients died, only one of them due to rebleed after surgery from an additional lesion. CONCLUSIONS: Compared with experience in Western countries, massive lower gastro-intestinal hemorrhage in India affects younger patients, has different causes and carries a lower mortality. Colonoscopy is useful in making diagnosis during active lower intestinal bleeding in about one-third cases. Exploratory laparotomy and Intra-operative endoscopy are complimentary to above examination and can make the diagnosis in most of the remaining cases.

HARTMANN'S PROCEDURE REVISITED.

Between July 1991 and June 1999 out of 176 patients undergoing colonic surgery (elective and emergency), Hartmann's procedure was performed in 63. There were 39 males and 24 females. Mean age was 43 years (range 12 to 81). To assess the utility of Hartmann's procedure the documents of all these 63 patients were retrospectively analysed. In 47 bowel continuity was reestablished. The over all mortality in first stage operation (Hartmann's procedure) was 12.7% and mortality in the second stage procedure (reestablishing bowel continuity) was nil. Complication rate was drastically less in second operation. The authors conclude that Hartmann's procedure is safe and effective while dealing with colorectal pathologies as resection and primary anastomosis is fraught with danger.

Plasmodium chabaudi-infected erythrocytes adhere to CD36 and bind to microvascular endothelial cells in an organ-specific way.

Adherence of erythrocytes infected with Plasmodium falciparum to microvascular endothelial cells (sequestration) is considered to play an important role in parasite virulence and pathogenesis. However, the real importance of sequestration for infection and disease has never been fully assessed. The absence of an appropriate in vivo model for sequestration has been a major barrier. We have examined the rodent malaria parasite Plasmodium chabaudi chabaudi AS in mice as a potential model. Erythrocytes infected with this parasite adhere in vitro to purified CD36, a critical endothelium receptor for binding P. falciparum-infected erythrocytes. P. c. chabaudi-infected erythrocytes adhere in vitro to endothelial cells in a gamma interferon-dependent manner, suggesting the involvement of additional adhesion molecules in the binding process, as is also the case with P. falciparum-infected cells. Furthermore, plasma or sera from infected and hyperimmune mice, respectively, have the ability to block binding of infected erythrocytes to endothelial cells. In vivo, erythrocytes containing mature P. c. chabaudi parasites are sequestered from the peripheral circulation. Sequestration is organ specific, occurring primarily in the liver, although intimate contact between infected erythrocytes and endothelial cells is also observed in the spleen and brain. The results are discussed in the context of the use of this model to study (i) the relationship between endothelial cell activation and the level of sequestration and (ii) the primary function of sequestration in malaria infection.

NASOGASTRIC DECOMPRESSION IN CHOLECYSTECTOMY, IS IT NECESSARY?

Nasogastric decompression seems to be widely employed in cholecystectomies despite evidence to the contrary. Based on a questionnaire given to 100 surgeons routinely doing cholecystectomies we found decompression being employed by the majority. 43% were unwilling to change their protocol. Our prospective randomised controlled trial of 162 cholecystectomies was done to assess intubation morbidity, related complications and influence on recovery. The objective was to determine if nasogastric decompression was scientifically based or conjectural. 130 patients underwent elective surgery and 32 required surgery for acute cholecystitis or associated common bile duct exploration. Both groups were randomised into tube and no-tube groups. The incidence of nausea, vomiting, distension and respiratory complications were noted and revealed no statistically significant group differences. No tube groups had earlier return of bowel motility, required lesser parenteral support and were discharged earlier compared to intubated patients. Out of 81 patients without decompression, only 7(8.6%) needed intubation due to vomiting whereas 2(3%) intubated cases required reinsertion of the tube due to ileus. Detailed analysis of these patients did not reveal any predictive criteria for selective intubation. We conclude that nasogastric decompression is used indiscriminately without scientific reasoning. Our prospective randomised trial does not favour intubation in elective or emergency setting for cholecystectomies. Intubation is needless in 92% cases and delays recovery. No criteria could be identified to preselect patients for intubation.

Progress towards elimination of leprosy as a public health problem in India and role of modified leprosy elimination campaign.

India (population 943 million) has seen a highly significant decrease in the prevalence of leprosy since the introduction of multi-drug therapy (MDT) in 1981. From a prevalence rate of 57/10,000 of the population in March 1981, the figure has declined to 5.2/10,000 in March 1999. This was possible due to the creation of a completely vertical (specialized) infrastructure for leprosy control in the 218 endemic districts of the country and skeleton vertical staff in the remaining districts, coupled with the recruitment of additional staff on contract basis to provide MDT through vertical staff in endemic districts and mobile treatment units in the moderate and low endemic districts. Despite all efforts, however, new case detection has not shown a decline over the last 14 years due to the presence of hidden (and undiagnosed) cases. Therefore, in order to intensify and hasten progress towards elimination (less than 1 case per 10,000 of the population) in the whole country, it was decided to implement a massive leprosy elimination campaign (LEC) in all the States/Union Territories (UTs). The reports of 22 States/UTs indicate that 415 out of the total of 490 districts in the country were covered by modified LEC (MLEC), with 85% coverage of the population. The campaign used in India was modified from the pattern previously described by the World Health Organization. The detection of hidden or suspected cases took place within a short, intensive period of 6-7 days and relied heavily on house-to-house searches by General Health Care staff trained in leprosy detection and confirmation was made by appropriately trained staff. This MLEC received widespread Government and public support, resulting in the detection of 454,290 hidden cases of leprosy, whilst providing training to a large number of General Health Care staff and volunteers and creating widespread awareness about leprosy and the availability of treatment free of charge for all cases. This programme proved to be one of the most successful health care interventions undertaken in India in recent years, particularly in the states of Bihar and Orissa. Although a few states in India are unlikely to reach the current WHO goal of elimination before end of the year 2000, the results of the MLEC strongly support the possibility that elimination levels will be achieved in the majority of states by the end of the year 2000 and at national level by the end of the year 2002.

Modified leprosy elimination campaign (MLEC) in the State of Orissa, India.

As part of a country-wide modified leprosy elimination campaign (MLEC) carried out in 21 selected States in India in 1998, the State of Orissa launched activities in early January of that year, during which 28.9 million people were examined, giving 85% coverage of the enumerated population. Using general health care staff and volunteers, 416,604 suspect cases were identified and 62,804 of these were confirmed as leprosy by experience observers. The period of intensive search activity lasted 1 week only, but this was preceded by several months of community mobilization and involvement, health education, training of government and voluntary staff, media messages and the involvement of all relevant health departments, officials and politicians. Both this and the intensive search period were characterized by a high level of interest and cooperation by all concerned. The total of new cases detected and put on treatment (multi-drug therapy; MDT) during the period of only 7 days was approximately equal to that which, on routine population survey by the leprosy services, would be recorded over a period of 2 years. The MLEC in Orissa is judged to have been not only an historic step forward in the control of leprosy in a State previously classified as highly endemic for leprosy, but also one of the most successful State health interventions ever mounted. In the 5 months after completion of the campaign, the voluntary reporting rate increased from 50 to 90%. As a direct result of the campaign, facilities for the diagnosis and treatment of leprosy are now available daily in an additional 1639 institutions, over and above those in existence before the campaign was launched. The achievements in terms of detecting hidden (and thus undiagnosed and untreated) cases exceeded the outset predictions, underlining the importance of continued vigilance and the need to maintain involvement of general health care staff. It is anticipated that the rise in prevalence due to the addition of 62,884 cases will be reduced by the implementation of MDT by 80% by about March 1999. Overall the results of the MLEC in Orissa strongly support the likelihood that an elimination level of less than 1 case per 10,000 of the population will be reached in this State by the year 2000.

Selection of donors and organization of a donor system for liver transplantation in India.

Organ transplantation has been a major scientific advance of this century. There is an attempt to start liver transplantation (LTx) in India in the near future. Donor selection is an integral part of the transplantation programme. Donor organs are a scarce resource and optimising their use will not only contribute to the success of the programme but also will ensure a steady flow of donors in the long term. Various factors essential for consideration while selecting a donor for liver transplantation are discussed. I have suggested guidelines for organising a viable donor system in the Indian setting to make the transplant programme long lasting.

Studies with artificial extrachromosomal elements in trypanosomatids: could specificity in the initiation of DNA replication be linked to that in transcription?

Historically, artificial replicons have served as useful models for the definition of regulatory elements involved in chromosomal replication and transmission in yeast and DNA replication in bacteria. Here, Pradeep Patnaik examines what we have learnt so far from the replicative behaviour of various artificial extrachromosomal elements available for trypanosomatids. He highlights the involvement of transcription regulatory elements in virtually every eukaryotic origin of replication analysed in detail and, by drawing upon the extensive literature supporting a close association between DNA replication and transcription, he speculates that the nature and organization of origins of replication on a chromosome also may hold clues to the manner by which an organism regulates gene expression.

The contribution of "cure by dapsone monotherapy' to the reduction of prevalence of leprosy in the State of Orissa, India, 1983-1993.

The implementation of multiple drug therapy (MDT) in the State of Orissa, India, started in early 1983 and was extended in a phased manner to nine out of the then total of 13 districts by 1993. As part of a programme to bring the remaining four districts under MDT, an intensive screening of the registers was carried out in early 1993. From a total of 28,855 cases registered in these districts, 26,113 (90.5%) were examined and 18,008 (69.9%) deleted. The deleted included patients who had died, emigrated, double (or occasionally treble) entries for the same patient and those in whom careful re-assessment suggested that the original diagnosis of leprosy had been wrong. In addition, however, 8,260 (45.8%) of the 18,008 cases deleted were considered to have been cured by dapsone monotherapy. This figure, from districts with a relatively poor development of services for leprosy control, prompted a retrospective examination of data from the other (more privileged) nine districts. This revealed that from a total of 264,000 patients screened, prior to the implementation of MDT from 1983 onwards, 75,590 (28.6%) were removed from the registers, and that of these, 63,562 (84.0%) were considered to have been cured by dapsone monotherapy. Thus from a total of 93,598 patients removed from registeres in this State since 1983, 71,822 (76.7%) have been assessed as cured by dapsone monotherapy. The significance of this finding and its apparently considerable contribution to the overall reduction in the prevalence of leprosy in Orissa, 1983-1993, is discussed.

Artificial linear mini-chromosomes for Trypanosoma brucei.

We have constructed artificial linear mini- chromosomes for the parasitic protozoan Trypanosoma brucei. These chromosomes exist at approx. 2 copies per cell, are indefinitely stable under selection but are lost from 50% of the transformed population in approx. 7 generations when grown in the absence of selective pressure. Consistent with results obtained earlier with natural chromosomes in T.brucei, the telomeres on these artificial chromosomes grow, adding approx. 1- 1.5 telomeric repeats per generation. The activity of a procyclic acidic repetitive protein (parp) gene promoter on these elements is unaffected by its proximity to a telomere, implying the lack of a telomere-proximal position effect (TPE) in procyclic trypanosomes. Among other things, these autonomously replicating dispensable genetic elements will provide a defined system for the study of nuclear DNA replication, karyotypic plasticity and other aspects of chromosomal behavior in this ancient eukaryotic lineage.

The region encompassing the procyclic acidic repetitive protein (PARP) gene promoter plays a role in plasmid DNA replication in Trypanosoma brucei.

We have previously reported the construction and characterization of an autonomously replicating plasmid in Trypanosoma brucei. In this plasmid the procyclic acidic repetitive protein (PARP) gene promoter drives the transcription of a selectable marker. Deletion of this promoter incapacitates the plasmid, suggesting its utilization as a promoter-trap. Three independent libraries were created by inserting variously digested T.brucei genomic DNA into this promoterless construct. Transfection of these libraries into procyclic T.brucei and the subsequent isolation of episomes led only to the reisolation of the PARP promoter. Additionally, a ribosomal RNA promoter failed to keep the construct as an episome, although it can sustain mRNA transcription in T.brucei and was shown to be an efficient promoter in this construct. Finally, by using a transient replication assay involving the methylation-sensitive restriction endonuclease DpnI to distinguish between input and replicated DNA, we showed that the PARP promoter-bearing construct could replicate autonomously in procyclic T.brucei, but the corresponding construct with the rRNA promoter could not. The close association between elements that sustain transcription and DNA replication in T.brucei mirrors results observed in several higher eukaryotes and their viruses and suggests an ancient origin of this feature.