Overview of the serologic and molecular basis of D variants with a focus on D variants in the Indian population.

Complexities of D within the Rh blood group system have long been recognized, initially using basic serologic testing and, more recently, using advanced and sensitive typing reagents. Discrepancies may arise when an individual carries a D antigen showing altered D antigen expression. These D variants are clinically important, since they may lead to production of anti-D in the carrier and induce alloimmunization in D- recipients, making their correct identification imperative. For clinical purposes, D variants can be classified into three groups: weak D, partial D, and DEL. The problem surrounding proper characterization of D variants exists because routine serologic tests are sometimes inadequate to detect D variants or resolve discrepant or ambiguous D typing results. Today, molecular analysis has revealed more than 300 RH alleles and is a better method for investigating D variants. Global distribution of variants differs, as observed in European, African, and East Asian populations. Discovery of the novel RHD*01W.150 (weak D type 150) with a nucleotide change of c.327_487-4164dup is proof. This variant, the result of an insertion of a duplicated exon 3 between exons 2 and 4 in the same orientation, was detected in more than 50 percent of Indian D variant samples in a 2018 study. The outcome of studies worldwide has led to the recommendation to manage D variant individuals as D+ or D- according to RHD genotype. The policies and workup with respect to D variant testing in donors, recipients, and prenatal women differ among blood banks, depending on type of variants predominantly encountered. Thus, a general genotyping protocol cannot be followed globally, and an Indian-specific RHD genotyping assay (multiplex polymerase chain reaction) designed to detect D variants frequently found in the Indian population was developed to save time and resources. This assay is also helpful for detecting several partial and null alleles. Identification of D variants by serology and characterization by molecular testing need to go hand-in-hand for better and safer transfusion practices.

Manipulation of distal radius fractures: a comparison of Bier's block vs haematoma block.

INTRODUCTION: Displaced distal radius fractures often require manipulation under anaesthesia. Many anaesthetic techniques are described, with the two most commonly used being Bier's block (BB) and haematoma block (HB). Despite national guidance preferring a BB, an HB is often performed instead. This study aims to compare the analgesic properties of a BB with those of an HB when manipulating distal radius fractures. METHODS: This is an observational cohort study comparing the management of displaced distal radius fractures requiring reduction across two National Health Service trusts. Patients aged over 18 with isolated, displaced distal radius fractures were recruited. Patient demographics, AO fracture classification and grade of clinician performing the procedure were recorded. A numeric rating scale (NRS) pain score was obtained for each patient after manipulation. The quality of reduction was judged against standardised anatomical parameters. RESULTS: Some 200 patients were recruited (100 HB, 100 BB). There were no differences in age (BB: median 66.5 years, interquartile range [IQR] 55-74; HB: median 67 years, IQR 55-74; p = 0.79) or fracture characteristics (p = 0.29) between cohorts. Patients undergoing BB had significantly lower pain scores with a lower IQR than those undergoing HB (p < 0.005). Patients undergoing BB manipulation were more likely to have the fracture reduced and normal anatomy restored (p < 0.005). BBs were performed mainly by Foundation Year 2 junior doctors, whereas HB manipulations were performed by a range of clinicians from emergency nurse practitioners to consultants. CONCLUSIONS: BB provides better analgesia than an HB. This can be performed successfully and reliably by Senior House Officer-level junior doctors.

A unique approach to screen for blood donors lacking high-prevalence antigen Inb of the Indian blood group system.

The Inb antigen of the Indian blood group system is a high-prevalence antigen. The presence of alloanti-Inb in a recipient may pose a problem in finding compatible blood for transfusion. The aim of this study was to screen blood donors for Inb and to include individuals found to be In(b-) in our rare donor registry. To save resources, a unique study design was constructed. Blood group O donors were tested for Inb because their red blood cell (RBC) units could serve recipients across all ABO groups. EDTA blood samples were used for serologic and genomic testing. These samples were first tested serologically for Ina, and samples typed as In(a+) were then tested both serologically and molecularly for Ina and Inb to find homozygous IN*01/01 [i.e., the predicted In(b-) phenotype]. A cost-conservative approach in using recycling of antibody was adopted to economize available resources. Of 6300 donors, 196 donor samples typed as In(a+) and were also found to be In(b+) when tested by serologic and genomic methods. Although none of the donors typed as In(b-), the statistical analysis suggests the expected prevalence for this rare phenotype to be 0.02 percent among the total number of donors tested. In conclusion, this report presents a unique cost-conservative approach using limited reagents to screen a large number of donors for the rare In(b-) phenotype.The Inb antigen of the Indian blood group system is a high-prevalence antigen. The presence of alloanti-Inb in a recipient may pose a problem in finding compatible blood for transfusion. The aim of this study was to screen blood donors for Inb and to include individuals found to be In(b­) in our rare donor registry. To save resources, a unique study design was constructed. Blood group O donors were tested for Inb because their red blood cell (RBC) units could serve recipients across all ABO groups. EDTA blood samples were used for serologic and genomic testing. These samples were first tested serologically for Ina, and samples typed as In(a+) were then tested both serologically and molecularly for Ina and Inb to find homozygous IN*01/01 [i.e., the predicted In(b­) phenotype]. A cost-conservative approach in using recycling of antibody was adopted to economize available resources. Of 6300 donors, 196 donor samples typed as In(a+) and were also found to be In(b+) when tested by serologic and genomic methods. Although none of the donors typed as In(b­), the statistical analysis suggests the expected prevalence for this rare phenotype to be 0.02 percent among the total number of donors tested. In conclusion, this report presents a unique cost-conservative approach using limited reagents to screen a large number of donors for the rare In(b­) phenotype.

Gait Speed and Grip Strength Are Associated With Dropping Out of the Liver Transplant Waiting List.

INTRODUCTION: Frailty measures can predict perioperative surgical risk in liver transplant patients. The 5-meter walk test (5MWT) and hand grip strength (HGS) are easy and reproducible frailty measures. We hypothesized that they could capture frailty in liver transplant listed patients and would be associated with dropping out of the waiting list. METHODS: We conducted a retrospective analysis of patients undergoing outpatient liver transplant listing at the University of Pittsburgh Medical Center from 2013 to 2016. We compared demographics, baseline laboratory markers, 5MWT, and HGS between patients who were dropped from the waiting list for medical reasons and those who remained or were successfully transplanted. Bivariate statistical analysis was performed using Fisher exact or χ2 tests. RESULTS: We reviewed 197 patients listed for liver transplant. Average age was 57.1 years (range 20-74), and patients were predominantly white (90.4%). Patients' most common etiology of liver disease was hepatitis C (32.5%), 14 (7.1%) had a previous liver transplant, and average Model for End-Stage Liver Disease score upon listing was 16.0. Of the cohort, 38 (19.3%) were ultimately dropped from the waitlist due to non-hepatocellular carcinoma-related reasons. Patients dropped from the waiting list had weaker HGS (46.14 lb vs 59.6 lb; P < .005) and slower 5MWT speed (5MWT: 0.92 m/s vs 1.03 m/s; P < .005). CONCLUSION: The 5MWT and HGS can easily measure frailty in patients being evaluated for liver transplant. These tests are associated with waiting list dropout, indicating that they can be valuable tools in the evaluation of these patients.

Potential of ozonated sesame oil to augment wound healing in rats.

The hypothesis that ozonated oil has wound healing property was investigated in an excision wound model using Sprague Dawley rats. The animals were divided into four groups, which were treated with sesame oil (vehicle), framycetin (standard), or two doses of ozonated sesame oil (peroxide values 500 and 700 mEq/1000 g, respectively). The formulations were topically applied on the excision wounds once daily for 11 consecutive days and the animals were euthanized on the 12(th) day. Wound healing was assessed by measuring the wound contracture, tensile strength, collagen content and superoxide dismutase activity of skin of the excised wound area. On the terminal day, areas of the wounds of the group receiving high dose ozonated oil were significantly smaller than those of the group treated with vehicle. Ozonated oil treated wounds had significantly higher tensile strength, collagen content and superoxide dismutase activity than that of the vehicle treated wounds. Histopathological analysis of skin of the excised wound area treated with ozonated oil revealed better healing activity vis-à-vis vehicle-treated wounds. Thus, it can be concluded that ozonated oil can be of potential therapeutic use for healing wounds.

Molecular analysis of α-synuclein gene in Parkinson's disease in North Karnataka, India.

BACKGROUND: Parkinson's disease (PD) is a disabling neurological disorder characterized by progressive degeneration of dopaminergic neurons. Mutations analysis within the α-synuclein gene (SNCA) on chromosome 4 has been reported in the last decade. OBJECTIVE: To elucidate the possible role of SNCA gene in the pathogenesis of PD in Indian population specifically in north Karnataka. MATERIALS AND METHODS: The study subjects included 100 clinically diagnosed PD patients and 100 ethnically matched healthy controls. Isolated deoxyribonucleic acid (DNA) samples from both were subjected to exon-specific polymerase chain reaction (PCR) amplification and amplicons were subjected to capillary-based direct DNA sequencing. RESULT: No mutations were observed in SNCA gene of PD samples in comparison with control samples. CONCLUSION: These findings support the hypothesis that the SNCA gene mutations might be population specific and may not be playing role in causing PD in all the populations.

Ruptured uterine artery pseudoaneurysm: an overlooked cause of late postpartum haemorrhage.

We report an exceptional case of secondary postpartum hemorrhage (PPH) twenty days after cesarean delivery, resulting from a ruptured uterine artery pseudoaneurysm (UAP). The diagnosis was initially confounded by a septic shock necessitating inotropic support in the intensive care unit. Intense vaginal bleeding occurred eleven days after uterine curettage. Doppler ultrasound showed an anechoic focus in the inferior part of the uterus with turbulent flow. Bilateral internal iliac artery angiograms revealed a left uterine artery pseudoaneurysm that was successfully embolized. UAP is a rare cause of unexplained PPH that requires a high index of suspicion for diagnosis. This first report in the anesthesia literature serves to focus our awareness on its possible occurrence, and gives track to its management. Pitfalls in UAP diagnostic are highlighted (delayed presentation, possibility of spontaneous hemostasis, and lack of typical findings on colour Doppler sonography in hypotensive patients). These pitfalls may further be confounded by a concomitant sepsis. Angiography and selective uterine artery embolization is the treatment of choice.

Second-generation platelet concentrate (PRF) as a pulpotomy medicament in a permanent molar with pulpitis: a case report.

AIM: To discuss the clinical and radiographic success of a pulpotomy with second-generation platelet concentrate (PRF), in a human mature permanent molar tooth. SUMMARY: A 19-year-old female patient reported to the Department of Conservative Dentistry and Endodontics with established pulpitis in tooth 36. The tooth had a carious pulp exposure, with a history of lingering pain. After isolation, caries removal and pulp exposure, pulpotomy with PRF was performed and a permanent restoration was placed immediately. At the first recall (+1 day), no postoperative pain was reported. At 6, 12, 18 and 22 months recall, the tooth responded positively to pulp sensibility tests, and radiographic examination revealed a normal periodontal ligament space. Positive results of this case imply the need for more studies with larger sample sizes and a longer recall period to justify the use of this novel material for the treatment of pulpitis in human permanent molar teeth. KEY LEARNING POINTS: Pulpotomy with PRF could be an alternate treatment to mineral trioxide aggregate or other materials in mature permanent teeth with pulpitis.

Hemifacial mass with extensive intralesional ossification and fat.

The imaging appearance of neurofibromas is well described; however, macroscopic fat in a neurofibroma has been sparsely reported and intralesional ossification has only been documented twice in the literature. We describe a diffuse neurofibroma presenting as a hemifacial mass, atypical for the presence of extensive intralesional ossification and fat; the diagnosis was suggested on identification of other associated radiological features of neurofibromatosis.

Evolutionary reduction of developmental plasticity in desert spadefoot toads.

Organisms vary their rates of growth and development in response to environmental inputs. Such developmental plasticity may be adaptive and positively correlate with environmental heterogeneity. However, the evolution of developmental plasticity among closely related taxa is not well understood. To determine the evolutionary pattern of plasticity, we compared plasticity in time to and size at metamorphosis in response to water desiccation in tadpoles among spadefoot species that differ in breeding pond and larval period durations. Like most tadpoles, spadefoot tadpoles possess the remarkable ability to accelerate development in response to pond drying to avoid desiccation. Here, we hypothesize that desert spadefoot tadpoles have evolved reduced plasticity to avoid desiccation in ephemeral desert pools compared to their nondesert relatives that breed in long-duration ponds. We recorded time to and size at metamorphosis following experimental manipulation of water levels and found that desert-adapted species had much less plasticity in larval period and size at metamorphosis than nondesert species, which retain the hypothetical ancestral state of plasticity. Furthermore, we observed a correlation between degree of plasticity and fat body content that may provide mechanistic insights into the evolution of developmental plasticity in amphibians.

Failures of the Dual Articular knee prosthesis due to fracture of the polyethylene post.

The Dual Articular (DA) total knee replacement was designed for revision and complex primary knee arthroplasty. A number of these knees failed due to fracture of the polyethylene post. We aimed to identify the proportion of DA prostheses that failed in this manner in our hospital. The hospital database was interrogated to identify all patients undergoing revision total knee replacement under the care of one surgeon from 1995 to 2007. Case notes were then reviewed to collect information about the history surrounding the knee surgery, and determine the patient's weight at the time of surgery. Telephone follow-up was carried out to obtain complete contemporary data. Forty-eight prostheses were implanted into 39 patients (21 male, 18 female). Thirty-two of the prostheses were DA and of these, 7 underwent arthroscopy or arthrotomy to reveal a fracture of the polyethylene post (22%). T-tests showed no statistical difference in age (p=0.73) or weight (p=0.79) between the group of DA patients with fractured posts and those without. Six of the 7 fractures were in male patients (Chi-squared; p=0.01). Patients complained of pain, clicking and instability at a mean of 7 years post-surgery. Sixteen DA2000 prostheses were implanted, but none of these had failed due to a fractured polyethylene post. A high proportion of DA prostheses failed due to post fracture. We recommend that patients with DA prostheses be kept under review to detect failures early. Pain, clicking and instability should be investigated with arthroscopy and the tibial insert exchanged as appropriate.

Varied distribution of RhD epitopes in the Indian population.

BACKGROUND: Inhabited by more than 4000 caste and tribal groups, India has an extremely heterogenous population. For thousands of years many tribal groups have practised endogamy and are practically genetically isolated. Traditionally, polyclonal anti-D reagent has been used for RhD typing; though monoclonal antibodies are increasingly being used. As a result, blood banks find it difficult to assign the RhD status to an increasing number of people. As monoclonal anti-D typing reagents may not detect all RhD antigen epitopes, we studied the RhD antigen epitope heterogeneity in different population groups in India. METHODS: Red cells of 5315 RhD-positive individuals belonging to different castes and tribes of India were tested with 30 different epitope-specific monoclonal anti-D antibodies. RESULTS: No single monoclonal antibody could detect all RhD-positive red cells detected by polyclonal antisera. The highest proportion of D antigen was detected by LHM 76/55 and BRAD-8 (98%) monoclonal antibodies. CONCLUSION: We need to determine the correct mix of monoclonal antibodies that will detect nearly all RhD antigens detected by polyclonal anti-D sera. Similarly, before accepting monoclonal anti-D for therapeutic use, it would be necessary to determine the appropriate ones for use in the Indian population.

A multi-disciplinary approach in the management of a traumatized tooth with complicated crown-root fracture: A case report.

A 13-year-old boy had fractured his maxillary right central incisor. The fracture line involved 2/3rd of the crown, compromising the pulp and extended subgingivally on the palatal aspect invading the biologic width. The procedure used to manage this case included endodontic treatment of residual tooth orthodontic extrusion to move the fracture line above the alveolar bone. Finally the tooth was restored prosthodontically.

Disseminated histoplamosis.

A case of disseminated histoplasmosis in a 45-year-old male patient with acquired immunodeficiency syndrome (AIDS) from Pune is reported. The patient presented with high-grade fever and pain in hypochondrium. Clinical signs were pallor and hepatosplenomegaly. Bone marrow and splenic aspirate revealed numerous intracellular oval shaped yeast forms. Histoplasma capsulatum was isolated from the bone marrow and splenic aspirate. H. capsulatum infection is an opportunistic infection usually reported from patient with AIDS in areas endemic for H. capsulatum. The present case highlights the fact that histoplasmosis could be an emerging opportunistic infection in India.

Dental caries prevalence among preschool children of Hubli: Dharwad city.

The prevalence of dental caries and treatment needs in the age group of 3-5 years was estimated among 1500 children of Hubli-Dharwad city. The attitude of mothers towards their children's oral health and its relation with caries prevalence was noted among 200 subjects. The prevalence of dental caries was 54.1%. The attitude of mothers towards children's oral health made a statistical difference in the mean dmft levels.

Low HIV-1 incidence among married serodiscordant couples in Pune, India.

Unlike commercial sex workers and patients attending sexually transmitted infection (STI) clinics, married couples are not typically targeted for HIV risk reduction programs in India. Thus, married partners of HIV-infected persons are at particularly high risk for HIV infection. Between September 2002 and November 2004, 457 HIV-1 sero-discordant, married couples were enrolled in a one-year prospective study of HIV transmission in Pune, India. The HIV incidence among uninfected partners was 1.22 per 100 person-years (95% CI 0.45-2.66), which is much lower than what has been previously reported among discordant couples in Africa. This may be due to higher rates of condom use, lower rates of STIs and higher CD4 T lymphocyte counts, among the Indian HIV sero-discordant couples.

Idiopathic gingival fibromatosis - a case report.

A case of 4 a year old girl with the complaint of delayed eruption of teeth is presented. She had moderate to severe, diffuse gingival enlargement in the maxilla and mandible. No deciduous teeth had erupted even at the age of five years except for incisal edges of upper, and lower anterior teeth. The diagnosis was made based on clinical examination and after ruling out drug and family history. Surgical removal of the hyperplastic tissue was done under general anesthesia.