Demographics and appropriateness of cellular blood component irradiation practices: Ambispective analysis from a tertiary care center.

BACKGROUND: Transfusion-associated graft versus host disease (TA-GVHD) is often underreported. There may also be lapses in TA-GVHD prevention practices due to lack of revision of some of the existing clinical guidelines as well as limited audits on practices of blood component irradiation. This study was undertaken to highlight these shortcomings, and generate data for development of institutional guidelines. METHODS/MATERIALS: Study cohort was selected from patients requiring transfusion support during June 2019 to May 2020. Transfusion history of these patients were followed, both retrospectively and prospectively till July 2021. Transfusion requisitions were categorized as IR (with request for irradiation) or NIR (with no request for irradiation) and justified or unjustified according to published international guidelines. RESULTS: Total 6963 requisitions for cellular blood components were received from 255 patients included in the study cohort. Of these, 3690 (54.9 %) were IR requisitions, while remaining 3029 (45.1 %) requisitions were NIR. Overall, 4242 (63.1 %) requisition were justified for their irradiation status as per published guidelines and 1595 (23.8 %) were found to be Unjustified while justification could not be assessed for remaining 882 (13.1 %) of the requisitions. The highest proportion of Unjustified demands in NIR requisitions was observed in patients with Severe Aplastic anemia (59.4 %). CONCLUSION: Many units were unnecessarily irradiated (7.7 %) while irradiation was missed in 16 % of the requisitions included in analysis which may be attributed to lack of institutional guidelines. We recommend that every centre should adopt a published well-researched guideline including amendments based on review of practices at their center.

Statistical model for prediction of ABO hemolytic disease of the fetus and newborn in India.

ABO incompatibility is the most common cause of immune hemolytic disease of the fetus and newborn (HDFN). The American Academy of Pediatrics lists blood group incompatibility as one of the major risk factors for severe hyperbilirubinemia in newborns. We have estimated the risk of ABO HDFN to determine the need for its routine screening. Blood group data from all blood donors who donated in the last 10 years were collected and analyzed. The population prevalence of ABO blood group genes using the phenotype data of blood donors was estimated. This information was further used to calculate an incidence of ABO HDFN requiring intervention in the population. ABO blood group typing was analyzed in 425,743 blood donors. The ABO phenotypes of A, B, O, and AB were 22.48, 36.73, 31.59, and 9.2 percent, respectively. The gene frequencies were 0.1733, 0.2647, and 0.5620 for A, B, and O, respectively. It was estimated that 13.84 percent of group O women would give birth to a non-group O baby and that approximately 2.77 percent of deliveries would likely have ABO HDFN in the study population. In India, the estimated risk of ABO HDFN is 2.9 percent, with a daily 2196 babies at risk of ABO HDFN requiring intervention. This analysis estimates the overall burden of ABO HDFN in the population, which could aid in the decision-making of policymakers, physicians, and community health practitioners to improve neonatal care.ABO incompatibility is the most common cause of immune hemolytic disease of the fetus and newborn (HDFN). The American Academy of Pediatrics lists blood group incompatibility as one of the major risk factors for severe hyperbilirubinemia in newborns. We have estimated the risk of ABO HDFN to determine the need for its routine screening. Blood group data from all blood donors who donated in the last 10 years were collected and analyzed. The population prevalence of ABO blood group genes using the phenotype data of blood donors was estimated. This information was further used to calculate an incidence of ABO HDFN requiring intervention in the population. ABO blood group typing was analyzed in 425,743 blood donors. The ABO phenotypes of A, B, O, and AB were 22.48, 36.73, 31.59, and 9.2 percent, respectively. The gene frequencies were 0.1733, 0.2647, and 0.5620 for A, B, and O, respectively. It was estimated that 13.84 percent of group O women would give birth to a non­group O baby and that approximately 2.77 percent of deliveries would likely have ABO HDFN in the study population. In India, the estimated risk of ABO HDFN is 2.9 percent, with a daily 2196 babies at risk of ABO HDFN requiring intervention. This analysis estimates the overall burden of ABO HDFN in the population, which could aid in the decision-making of policymakers, physicians, and community health practitioners to improve neonatal care.

Platelet-rich plasma and microneedling improves hair growth in patients ofandrogenetic alopecia when used as an adjuvant to minoxidil.

BACKGROUND: Platelet-rich plasma (PRP) is a popular procedure for the treatment of androgenetic alopecia (AGA). AIM: To ascertain the role of minoxidil 5% lotion alone versus minoxidil 5% lotion and PRP versus minoxidil 5% lotion, PRP with microneedling in AGA. MATERIAL AND METHODS: Ninety-three AGA patients with Hamilton-Norwood score 1-5 were grouped into three groups A, B, and C. Patients in group A (control group) were treated with minoxidil 5% lotion twice daily (n = 31), whereas patients in group B underwent treatment with minoxidil 5% lotion twice daily and PRP (n = 31), and group C patients received minoxidil 5% lotion twice daily, PRP, and microneedling (n = 31). Baseline and post-treatment photographs were taken along with dermoscopic evaluation. Selection of the dermoscopic variables included in the evaluation process was based on the published literature and dermoscopists' expertise and experience. Hair pull test was performed before and during follow-up. RESULTS: Post-treatment, hair pull test was negative in 27 patients (87.1%, P < 0.01) of group C, 20 patients (64.5%, P < 0.05) of group B, and 15 patients (48.4%) of group A. Hair growth was better appreciated in group C (26/31) compared to groups B (17/31)and A (10/31).The patients' self-satisfaction score on a Likert scale was more than seven (high satisfaction) in 24/31 patients in group C. There was a statistically significant difference between three groups in terms of hair pull test, terminal-to-vellus hair ratio, and patient satisfaction score as determined by one-way ANOVA. CONCLUSION: PRP with microneedling is better in comparison with PRP alone or minoxidil monotherapy in patients with AGA.

Differentiation of pityriasis rubra pilaris from plaque psoriasis by dermoscopy.

BACKGROUND: Diagnosing and differentiating pityriasis rubra pilaris (PRP) from other disorders can be a challenging task. Although histopathology remains the gold standard, it may not be feasible at times, especially in children. Being noninvasive, dermoscopy can be of great diagnostic importance in such a scenario. Dermoscopy overcomes the refractive properties of stratum corneum by interface medium or cross-polarization enabling easier visualization of lesions. OBJECTIVE: To study the dermoscopic features of PRP and compare them with dermoscopic features of psoriasis. PATIENTS AND METHODS: Retrospective observational analysis of dermoscopic characteristics of 28 patients with PRP (16) and psoriasis (12). Polarized dermoscopy at 10× magnification was performed and photographs were captured by Apple iPhone 7. The selection of dermoscopic variables was based on preexisting literature on the dermoscopic patterns of the 2 entities. RESULTS: The most frequent dermoscopic criteria of PRP were the presence of a central hair (16/16; 100%), follicular plugs (11/16; 68.7%), and perifollicular yellow/orange halos (9/16; 56.2%). No vascular structures were seen in our cases of PRP. Psoriasis was characterized by regularly distributed dotted vessels (12/12; 100%) and white scales (8/12; 66.6%). CONCLUSIONS: Round-to-oval yellowish areas surrounding a central hair with or without follicular plugs represents the most frequent dermoscopic pattern of PRP.

Bimatoprost in Dermatology.

Bimatoprost is a prostamide analogue used for treatment of glaucoma in ophthalmology. Surprisingly, the side effects such as increased pigmentation of eyelids and hypertrichosis in patients being treated with prostaglandin analogues for glaucoma have opened new areas of application in various dermatological disorders such as alopecia mainly affecting eyelashes, eyebrows, and vitiligo.

Olmsted Syndrome with Lateral Supraciliary Madarosis and Clubbing: A Rare Case Report.

Olmsted syndrome (OS) is a rare congenital, mutilating palmoplantar keratoderma first described by Olmsted in 1927. It starts in the neonatal period or in childhood, and has a slow but progressive disabling course. We report the case of a 16-year-old boy who presented with keratoderma of the palm and soles since childhood with lateral supraciliary madarosis and clubbing. The patient was started on oral retinoids and topical keratolytics and had partial improvement in 2 months. Keratoderma of the palms and soles along with lateral supraciliary madarosis and clubbing in our case is a very rare finding, and to the best of our knowledge, has not been reported so far.

Original article: Platelet-rich plasma with microneedling in androgenetic alopecia along with dermoscopic pre- and post-treatment evaluation.

BACKGROUND: Platelet-rich plasma has shown beneficial effects in the treatment of androgenic alopecia with its growth factor properties in accelerating the dermal papilla. Dermoscopy is a noninvasive method that allows the in vivo evaluation of microstructures not visible to the naked eye. OBJECTIVE: To ascertain the role of platelet-rich plasma (PRP) with microneedling, and to compare the pre- and post-treatment dermoscopic features in androgenetic alopecia. (AGA). METHOD: Patients with mild to moderate AGA, aged 18-45 years with Hamilton-Norwood score 1-5 were included in both study and control group. Dermoscopy was performed using Dermlite II hybrid m; 3Gen dermoscope at 10× magnification in polarized mode, and photographs were taken. Those not responding or those not having any new hair growth to conventional therapy for at least 1 year were included. The study group were given autologous platelet-rich plasma injections with microneedling over a period of 3 months at 3 weekly interval. Baseline and post-treatment photographs were taken. RESULT: Hair growth started after the first session. The patients' satisfaction was more than 75% in 18 patients, on patients' subjective hair growth assessment scale. In post-PRP-treated patients of AGA, increase in the number of vellus and total hairs, increased hair shaft diameter, and reduction in yellow dots were appreciated after 3 sessions. Hair pull test was negative after treatment in 14 patients (70%). CONCLUSION: This study reinforces the importance of dermoscopy in not only aiding in the diagnosis, but also in evaluation of pre- and post-treatment response of AGA.

Dermoscopy in vitiligo: diagnosis and beyond.

BACKGROUND: Vitiligo is essentially a clinical diagnosis, and dermoscopy may aid in noninvasive confirmation of diagnosis by excluding other clinically simulating hypopigmentary conditions. More importantly, dermoscopy is rapidly gaining ground as an important adjunct tool to evaluate disease activity. AIM: To study the dermoscopic features of vitiligo and ascertain their correlation with disease activity. METHODS: Retrospective analysis of dermoscopy of 60 cases suffering from vitiligo was undertaken. Dermoscopy was performed using Dermlite II hybrid m dermatoscope at 10× magnification in polarized mode, and photographs were captured by Apple iphone 6. Variables assessed in the dermoscopic evaluation included perifollicular changes, perilesional changes, altered pigmentary network, and presence of specific features such as the starburst appearance, comet tail appearance, leukotrichia, telangiectasia, and any new findings. RESULTS: Sixty patients with stable, progressive, or repigmenting vitiligo were retrospectively studied. While perifollicular depigmentation (PFD) was predictive of stable vitiligo, perifollicular pigmentation (PFP) was characteristic of active disease. Starburst appearance, altered pigment network, and comet tail appearance, were also noted, and these were typical of progressive vitiligo. A new dermoscopic feature, the 'tapioca sago' appearance (sabudana), was observed in the skin adjacent to the vitiligo lesion only in patients with progressive vitiligo. CONCLUSION: Dermoscopy is useful in assessing the stage of evolution and the status of disease activity in vitiligo. The most useful dermoscopic clues are observed in the perifollicular region, since progressive lesions display perifollicular pigmentation and stable/remitting lesions display perifolliclar depigmentation.

Dermoscopy of alopecia areata-a retrospective analysis.

BACKGROUND: Dermoscopy devices can overcome the refractive properties of stratum corneum by interface medium or cross polarization such that the lesion can be easily seen. AIM: To examine the dermoscopic feature in alopecia areata and correlate the severity of disease with dermoscopic features. MATERIALS AND METHODS: Retrospective analysis of 72 patients suffering from alopecia areata (AA), irrespective of age and sex, who visited the dermatology outpatient department of a tertiary care center in Eastern India was carried out. The most recently developed cases of AA were examined dermoscopically. Variables included yellow dots (YDs), black dots (BDs), broken hair (BH), short vellus hair (SVH), and exclamation mark hair (EMH) on the basis of available literature and expertise. RESULTS: Yellow dots was the most common finding seen in 57 cases (79.16%), black dots in 51 cases (70.8%). Short vellus hair was seen in 32 cases (44.44%), broken hair was seen in 31 cases (43.05%), and exclamation mark hair in 23 cases (31.9%). YDs per field of vision was considered as the most common finding with increased severity of AA. CONCLUSION: YDS, in increased number per field of vision, is the most consistent finding seen in severe cases of AA, as they are in progressive AA and alopecia universalis. An increased number of SVH and terminal hairs were seen in patients who were being treated.

Patterns of Orthopaedic Injuries among Motorbike Accident Admissions Presenting to a Tertiary Care Hospital in Kathmandu.

BACKGROUND: The anecdotal burden of morbidity secondary to motorbike accidents is thought to enormous by personnel involved in trauma care. The objective of the present study is to ascertain patterns and association of injuries and causes of mortality in a cohort of motorbike accident victims. METHODS: A retrospective chart review of 1337 motorbike accident admissions B and B Hospital in Kathmandu between January 2009 and December 2010 was undertaken. RESULTS: Majority of victims were between 20 to 50 years [1230 (92%) males]. Lower extremity injuries comprised on 816 (61% of total admissions). Tibia fractures were the most common injury in isolation, multiple injury, as well as polytrauma, and a vast majority of these were open fractures. Multiple injuries were seen in 82 (6.1%) patients and 33 (2.5% of Total) patients were polytraumatized. An amputation was necessary in 16 (1.2%) patients and emergent fasciotomy for compartment syndrome was necessary in 23 (1.7%) cases of tibia fractures and 39 (2.2%) of foot and ankle injuries. A floating joint injury was present in 24 (1.8%) patients.. A fat embolism syndrome (FES) was diagnosed in 8 (0.6%) patients. The overall mortality was 0.45% (6 patients). CONCLUSIONS: Motorbike accident is an important cause of morbidity and mortality in Kathmandu, and often involves a very productive age group. There is an imminent need to address this public health problem.

Extra and Intra-articular Synovial Chondromatosis.

Synovial chondromatosis is not so rare intra-articular condition secondary to synovial metaplasia, that affects the knee joint. Extra-articular synovial chondromatosis however is an extremely rare condition that usually involves the synovial sheath or bursa of the foot or hand. We present two cases of synovial chondromatosis, one intra and one extra-articular. The first case was a 25 year old lady who presented with pain, swelling and restricted range of motion of left knee and was found to have an intra-articular synovial chondromatosis which was treated successfully by joint debridement. The second case was that of a 22 year old man who presented with right knee pain and was diagnosed to have an extra-articular synovial chondromatosis of his right medial hamstring tendon sheath, excision of which resulted in complete relief of symptoms.

Autoimmune hemolytic anemia: From lab to bedside.

Autoimmune hemolytic anemia (AIHA) is not an uncommon clinical disorder and requires advanced, efficient immunohematological and transfusion support. Many AIHA patients have underlying disorder and therefore, it is incumbent upon the clinician to investigate these patients in detail, as the underlying condition can be of a serious nature such as lymphoproliferative disorder or connective tissue disorder. Despite advances in transfusion medicine, simple immunohematological test such as direct antiglobulin test (DAT) still remains the diagnostic hallmark of AIHA. The sensitive gel technology has enabled the immunohematologist not only to diagnose serologically such patients, but also to characterize red cell bound autoantibodies with regard to their class, subclass and titer in a rapid and simplified way. Detailed characterization of autoantibodies is important, as there is a relationship between in vivo hemolysis and strength of DAT; red cell bound multiple immunoglobulins, immunoglobulin G subclass and titer. Transfusing AIHA patient is a challenge to the immunohematologist as it is encountered with difficulties in ABO grouping and cross matching requiring specialized serological tests such as alloadsorption or autoadsorption. At times, it may be almost impossible to find a fully matched unit to transfuse these patients. However, transfusion should not be withheld in a critically ill patient even in the absence of compatible blood. The "best match" or "least incompatible units" can be transfused to such patients under close supervision without any serious side-effects. All blood banks should have the facilities to perform the necessary investigations required to issue "best match" packed red blood cells in AIHA. Specialized techniques such as elution and adsorption, which at times are helpful in enhancing blood safety in AIHA should be established in all transfusion services.

Evaluation of health care workers' knowledge and functioning of blood centres in north India: a questionnaire based survey.

For quality, safety and efficacy of blood components, adequate infrastructure and trained manpower are essential requirements. Objective of this study is to analyse existing systems of transfusion services in north India, various testing methodologies practiced and to assess the level of knowledge of health care professionals working at these centres. Participants included laboratory technicians and nurses whose knowledge and various practices at blood centres were assessed using a questionnaire. Knowledge of those having more experience, working at urban blood centres and received an additional training was significantly higher. Only a few blood centres are performing all mandatory tests on donors' samples.

Root cause analysis of transfusion error: identifying causes to implement changes.

BACKGROUND: As part of ongoing efforts to improve transfusion safety, an error reporting system was implemented in our hospital-based transfusion medicine unit at a tertiary care medical institute. This system is based on Medical Event Reporting System-Transfusion Medicine (MERS-TM) and collects data on all near miss, no harm, and misadventures related to the transfusion process. Root cause analyses of one such innocuous appearing error demonstrate how weaknesses in the system can be identified to make necessary changes to achieve transfusion safety. STUDY DESIGN AND METHODS: The reported error was investigated, classified, coded, and analyzed using MERS-TM prototype, modified and adopted for our institute. RESULTS: The consequent error was a "mistransfusion" but a "no-harm event" as the transfused unit was of the same blood group as the patient. It was a high event severity level error (level 1). Multiple errors preceded the final error at various functional locations in the transfusion process. Human, organizational, and patient-related factors were identified as root causes and corrective actions were initiated to prevent future occurrences. CONCLUSION: This case illustrates the usefulness of having an error reporting system in hospitals to highlight human and system failures associated with transfusion that may otherwise go unnoticed. Areas can be identified where resources need to be targeted to improve patient safety.

Knowledge and practices of general practitioners regarding psychiatric problems.

BACKGROUND: Mental health problems account for 12% of global disease burden and non-psychiatrist medical practitioners deal with a large proportion of this burden. This study was planned to assess the knowledge, attitude and treatment practices of non-psychiatrist medical practitioners regarding mental health problems. MATERIALS AND METHODS: One hundred Allopathic and 25 each of Homeopathic and Ayurvedic medical practitioners were interviewed and assessed using a semi-structured performa. RESULTS: Majority (95%) of them were aware regarding etiology, increasing incidence and treatment facilities available for mental health problems. Treatment modalities include counseling and medication but 69.9% of them had not received any formal training in administering them. CONCLUSIONS: 98.5% practitioners providing mental health services at the primary level feel the need to be properly trained and oriented in the management of these patients to improve quality of healthcare.

Multicenter evaluation of individual donor nucleic acid testing (NAT) for simultaneous detection of human immunodeficiency virus -1 & hepatitis B & C viruses in Indian blood donors.

BACKGROUND & OBJECTIVE: India has a high prevalence of HIV-1, hapatitis C and B virus (HCV and HBV) in the blood donors but has yet to implement nucleic acid testing (NAT) in blood screening. We undertook a multicentre evaluation of blood donor testing by NAT for simultaneous detection of HIV-1, HBV and HCV in a single tube and also to determine the feasibility of NAT implementation in India's low volume setting. METHODS: A total of 12,224 unlinked samples along with their serological results were obtained from representative eight blood banks in India and were individually manually tested by the Procleix Ultrio Assay (Chiron Corp. Emeryville, CA) for simultaneous detection of HIV-1, HCV, and HBV. RESULTS: Of the 12,224 samples tested, 209 (1.71%) were seroreactive. One hundred thirty three samples (1.09%) were reactive by Ultrio assay, 84 samples were seroreactive but NAT non reactive. There were eight NAT yield cases: 1 HIV, 1 HIV-HCV co-infection, and 6 HBV. INTERPRETATION & CONCLUSION: Our observed NAT yield for all three viruses was 1 in 1528 (0.065%). We estimate NAT could interdict 3272 infectious donations a year among our approximate 5 million annual donations.

Application of gel technology in the serologic characterization of autoantibody in DAT-positive autoimmune diseases.

Gel tests are now available for the determination of immunoglobulin classes and subclasses and complement fractions coating RBCs. These tests simplified serologic characterization of autoantibodies in various autoimmune diseases. The aim of this study was to evaluate the use of gel cards in the serologic characterization of autoantibody with regard to the immunoglobulin classes, complement fractions, and IgG subclasses, and the influence of these characteristics on hemolysis. Gel cards were used to characterize the RBC-bound autoantibodies in 66 DAT-positive patients. Hematologic and biochemical parameters such as Hb, reticulocyte count, serum bilirubin, and serum LDH were obtained from the patient files. Of the 49 patients carrying IgG on their RBCs, 21 (42.8%) were suffering from connective tissue disorders and another 16 patients (32.7%) had autoimmune hemolytic anemia. A total of 19 of these 49 patients had evidence of hemolysis. Thirteen of the 17 patients (76.5%) whose RBCs were coated with more than one type of immunoglobulin and complement were experiencing hemolysis (p < 0.05). Seventy-five percent (21 of 28) of patients having IgG1, IgG3, or both on their RBCs showed hemolysis (p < 0.05). Thus, it is important to serologically characterize autoantibodies in autoimmune disorders to effectively predict the prognosis and disease outcome. This characterization can be performed effectively with the gel test, which can be introduced in blood centers as a replacement to the conventional tube technique.

The CT appearances of gallbladder perforation.

Perforation of the gallbladder is an uncommon complication of acute cholecystitis that is associated with relatively high mortality. Symptoms and clinical signs can be indistinguishable from those of uncomplicated acute cholecystitis, leading to delayed diagnosis. We reviewed the clinical and imaging findings in 17 patients with gallbladder perforation confirmed at surgery.