Prevalence of delayed initiation of rabies postexposure prophylaxis and factors influencing it among animal bite victims from Eastern Uttar Pradesh, India.

BACKGROUND: In a rabies-endemic country like India, every animal bite is potentially taken as rabid exposure and timely and appropriate postexposure prophylaxis (PEP) is crucial as rabies is an almost 100% fatal disease. METHODS: A retrospective record-based study was conducted at an anti-rabies clinic (ARC) in Eastern Uttar Pradesh, India. Data of the animal bite victims attending the ARC for PEP from January to December 2022 were extracted from the records. A semistructured questionnaire was used for collecting information regarding the interval between exposure and the initiation of anti-rabies PEP, age, gender, residence, the bite site on the body, category of exposure and other risk factors associated with the delay in PEP. RESULTS: Most of the victims were male (67.6%), from an urban background (61.3%) and aged up to 20 y (43.9%). Out of the 222 victims, 62 (27.9%) had delayed initiation of PEP (>48 h after exposure). Factors found to be significantly associated with delayed initiation of PEP were residence (p=0.01), age (p=0.04) and the type of biting animal (p=0.002). CONCLUSIONS: Delayed initiation of PEP is common among animal bite victims in this region of India, although PEP is affordable. Educational programmes and awareness-raising campaigns for timely administration of PEP should be a priority, especially targeting rural residents, those aged<18 y and those bitten by animals other than dogs.

Porcine reproductive and respiratory syndrome virus induces concurrent elevation of High Mobility Group Box-1 protein and pro-inflammatory cytokines in experimentally infected piglets.

Porcine Reproductive and Respiratory Syndrome (PRRS), caused by PRRS virus (PRRSV), is one of the most important devastating diseases of pigs, characterized by reproductive failure in sows, and respiratory disease with heavy mortality in piglets. PRRS virus has been reported to elevate the levels of proinflammatory cytokines in the serum of infected pigs. High Mobility Group Box-1 (HMGB-1) protein is a cellular biomolecule belonging to the Danger Associated Molecular Patterns (DAMP) family, which stimulates immune cells to release pro-inflammatory cytokines upon release out of cells. The role of HMGB-1 in the pathogenesis of PRRSV remains largely unknown. In the present study, HMGB-1 levels in serum samples collected from six-week-old piglets infected intra-nasally with 2 × 105.75 TCID50/mL of Indian PRRSV (Ind-297221/2013) was estimated by ELISA up to 21 days post infection (dpi). Pro-inflammatory cytokine mRNA (IL-1ß, IL-6 and TNF- α) expression in PBL was estimated by SYBR green based real time PCR. Mean HMGB-1 concentration in serum was found to be significantly elevated in PRRSV infected piglets on 6 dpi as compared to uninfected control piglets. At mRNA level, significant increase in expression of HMGB-1 was observed from 4 to 5 dpi and from 11 to 13 dpi. IL-1ß and IL-6 mRNA were significantly upregulated between 4 and 6 dpi. Significant increase in TNF-α gene expression was seen only on 7 and 9 dpi. Higher levels of pro-inflammatory cytokines and HMGB-1 could be correlated with fever which was observed within 7 dpi in all the infected piglets and additionally around 13 dpi in the animal that died on 17 dpi. Thus, elevated HMGB-1 level in PRRSV infected piglets could be correlated with concurrent increase in pro-inflammatory cytokine (IL-6) mRNA. In-vitro studies were conducted in PRRSV infected Porcine Pulmonary Alveolar Macrophages (PAM) to ascertain HMGB-1 role in PRRS pathogenesis. The results of both in-vivo and in-vitro studies showed that HMGB-1 plays an important role in mediating the pro-inflammatory cytokine responses in PRRS pathogenesis.

Pediatric robotic-assisted laparoscopic pyeloplasty: Does age matter?

BACKGROUND: Although shown to be safe in infancy, robotic-assisted laparoscopic pyeloplasty (RALP) for ureteropelvic junction obstruction (UPJO) is most commonly performed in older children and adolescents. OBJECTIVE: This study examined a contemporary RALP experience at a single tertiary pediatric center and compared outcomes in infants aged ≤1 year with an older cohort. METHODS AND DESIGN: All RALP procedures were entered into an Institutional Review Board-approved data registry from 2012 to 2016. Patients were retrospectively grouped according to age. The primary outcome was success rate. Secondary outcomes included complications and length of hospital stay. Failure was defined as the need for secondary surgical intervention for UPJO or worsening urinary tract dilation on imaging. Statistical analysis was performed using SPSS version 20. Mann-Whitney U testing was used for comparison. RESULTS: A total of 138 patients underwent RALP during 2012-2016, with a median age of 6 years (IQR 1, 13.25) and a male:female ratio of approximately 2:1. Of these, 34 (24.6%) were aged ≤1 year. Of all patients, 60 (43.5%) presented with a history of prenatal hydronephrosis, and 32% had a crossing vessel causing obstruction. An indwelling stent was placed in antegrade fashion in 71% of cases, and 18% had a percutaneously placed externalized stent. There were six (4%) failures requiring reoperation. Multivariate and comparative analysis demonstrated that the infant cohort utilized less morphine equivalents and more often had a percutaneous stent placed compared to the older cohort. Of the complications that occurred, 60% were minor (Clavien grades 1 and 2) and 40% were Clavien grade 3 in the infant cohort, and 70.1% and 29.9% in the older cohort, respectively. No studied criteria predicted failure in either cohort. CONCLUSION: This study presented one of the largest contemporary series of consecutive pediatric RALPs, and showed an overall success rate of 96%. There were no significant differences in length of hospital stay, and complications or failure rates in infants compared to older children. This study substantiated the ongoing trend towards the adaptation of robotic-assisted surgery for the entire pediatric patient population.

Pathogenic characterization of porcine reproductive and respiratory syndrome virus of Indian origin in experimentally infected piglets.

Porcine reproductive and respiratory syndrome (PRRS) is an economically important transboundary viral disease of pigs confronting the swine industry worldwide. This study was aimed to assess the pathogenic potential of PRRS virus belonging to genotype 2 that emerged in India in 2013. Nine 6-week-old piglets were inoculated intranasally with 2 × 105.75  TCID50 /ml of PRRSV (Ind-297221/2013). Three piglets were kept as uninfected controls. Blood and nasal swabs were collected daily up to 7 days post-infection (dpi) and on alternate days subsequently. Piglets were necropsied for tissue sample collection either on death or after euthanasia on 7, 14 or 21 dpi (one uninfected control and three PRRSV-infected piglets per interval). The virus caused high fever, typical blue ear, weight loss, respiratory distress, diarrhoea and leucopenia between 2 and 8 dpi. Two infected piglets died (on 3 and 17 dpi) during the course of study. The presence of virus in serum and nasal secretion was observed up to 19 and 17 dpi, respectively, with the maximum load between 4 and 7 dpi. Seroconversion started 6 dpi and the mean PRRSV antibody titre reached up to 640 by 21 dpi. Virus load was highest in tonsils at all the intervals, whereas in spleen and lymph nodes load was higher in later intervals. Major microscopic lesions in PRRSV-infected piglets included moderate to severe interstitial pneumonia, lymphoid depletion in tonsils and lymph nodes (cystic), thymic atrophy, reactive hyperplasia followed by lymphoid depletion in spleen. PRRSV antigen was consistently demonstrated by immunoperoxidase test in the lungs, spleen, tonsils and lymph nodes. Antigen distribution was more widespread on 7 and 14 dpi than on 21 dpi. The findings establish that the Indian PRRSV is highly pathogenic to piglets.

Outcomes of externalized pyeloureteral versus internal ureteral stent in pediatric robotic-assisted laparoscopic pyeloplasty.

INTRODUCTION: After pyeloplasty, urinary drainage options include internal double-J (DJ) ureteral stents or externalized pyeloureteral (EPU) stents, which can avoid bladder symptoms and additional anesthetic exposure from stent removal. Comparative outcome studies, however, are lacking following primary pediatric robotic-assisted laparoscopic pyeloplasty (RALP). OBJECTIVE: To compare operative success, operative time, hospitalization, and postoperative complications of EPU versus DJ stents following RALP. STUDY DESIGN: Consecutive children undergoing primary RALP from 10/2013 to 9/2015 were retrospectively identified. Data collected included patient demographics, stent type and duration, postoperative complications, and operative success. To control for confounding by indication for EPU stent, propensity score weighting was used to balance baseline covariates. Weighted regression analyses compared between-group differences in study outcomes. RESULTS: At median follow-up of 12.3 months, 44 and 17 patients underwent DJ and EPU stenting, respectively. At baseline, DJ stent patients were older than EPU stent patients (median 7.7 vs 1.2 years, P = 0.01) and were less likely to be on postoperative antibiotic prophylaxis (25 vs 76%, P < 0.001). After weighting, these differences disappeared. All EPU stents were removed in the outpatient clinic; all DJ stents were removed under anesthesia. On weighted regression analyses (Summary Fig.), EPU stents had no different associations than DJ stents with operative success (95 vs 94%, between-group difference 1%, 95% CI -11, 13; P = 0.86), complications, or operative time, but did have 0.6 of a day more hospitalization (95% CI 0.04, 1.2; P = 0.04). DISCUSSION: Patients receiving EPU stents were different at baseline from those receiving DJ stents. After propensity score weighting balanced these covariates, EPU stents were associated with similar operative success, complications, and operative time to DJ stents. Further study is warranted in larger prospective cohorts. CONCLUSION: Use of EPU stents provided a viable alternative, particularly in younger patients, to DJ stenting with comparable success and complications, while avoiding the need for an additional anesthetic.

Mmp-9 responsive PEG cleavable nanovesicles for efficient delivery of chemotherapeutics to pancreatic cancer.

Significant differences in biochemical parameters between normal and tumor tissues offer an opportunity to chemically design drug carriers which respond to these changes and deliver the drugs at the desired site. For example, overexpression of the matrix metalloproteinase-9 (MMP-9) enzyme in the extracellular matrix of tumor tissues can act as a trigger to chemically modulate the drug delivery from the carriers. In this study, we have synthesized an MMP-9-cleavable, collagen mimetic lipopeptide which forms nanosized vesicles with the POPC, POPE-SS-PEG, and cholesteryl-hemisuccinate lipids. The lipopeptide retains the triple-helical conformation when incorporated into these nanovesicles. The PEG groups shield the substrate lipopeptides from hydrolysis by MMP-9. However, in the presence of elevated glutathione levels, the PEG groups are reductively removed, exposing the lipopeptides to MMP-9. The resultant peptide-bond cleavage disturbs the vesicles' lipid bilayer, leading to the release of encapsulated contents. These PEGylated nanovesicles are capable of encapsulating the anticancer drug gemcitabine with 50% efficiency. They were stable in physiological conditions and in human serum. Effective drug release was demonstrated using the pancreatic ductal carcinoma cells (PANC-1 and MIAPaCa-2) in two-dimensional and three-dimensional "tumor-like" spheroid cultures. A reduction in tumor growth was observed after intravenous administration of the gemcitabine-encapsulated nanovesicles in the xenograft model of athymic, female nude mice.

Robot-assisted laparoscopic ureteroureterostomy for proximal ureteral obstructions in children.

OBJECTIVE: Ureteropelvic junction obstruction is a common presentation in the pediatric population, but proximal ureteral obstructions are rare. In this setting, robot-assisted laparoscopy (RAL) offers a minimally invasive option to open or traditional laparoscopic repair. The present study demonstrates successful RAL in two children with proximal ureteral obstructions: one with a right retrocaval ureter and one with a left ureter entrapped between two lower-pole crossing vessels. METHOD: After retrograde placement of a double-J ureteral stent, the child was secured in a lateral decubitus position exposing the affected side. A three-port RAL system was used to dissect free the obstructed ureter. A spatulated watertight ureteroureterostomy was then fashioned after transposition of the ureter into an anatomic position. Sutures and free instruments were passed into the peritoneal cavity via the 5-mm instrument ports, thus obviating the need for a separate assistant port. RESULTS: RAL provided for crisp visualization, meticulous dissection, and precise approximation of the reconstructed ureter. In both patients, blood loss was negligible, narcotic use was minimal, and length of stay was roughly 30h. Follow-up imaging at 1 month showed excellent hydronephrosis resolution for both reconstructions. CONCLUSION: These two cases demonstrate the feasibility of RAL for proximal ureteral anomalies in the pediatric population.

Spontaneous resolution of delayed onset, posttraumatic high-flow priapism.

Priapism is an uncommon but serious condition with major long-term sequelae. The commoner, ischemic variety is a medical emergency requiring immediate intervention in order to avoid erectile dysfunction. However,the high flow variety is non-ischemic and the patient may not seek immediate therapy. The options of management for this rare, painless form of priapism vary from conservative therapy to embolization of the internal pudendal artery or, in some cases, surgery that may result in subsequent erectile dysfunction. We present a case of a 24-year-old man who presented with priapism of six-day duration, 10 days after perineal injury. Doppler ultrasonogram of the penis revealed a cavernosal artery pseudoaneurysm. Pudendal artery angiogram done four days later revealed no leak and the priapism subsided spontaneously with subsequent return of normal erections.

The efficacy of erythropoietin in human immunodeficiency virus-infected end-stage renal disease patients treated by maintenance hemodialysis.

The superimposition of human immunodeficiency virus (HIV) infection, associated opportunistic infections, and anti-retroviral therapy further worsens the severity of anemia in patients also suffering from end-stage renal disease. A major cause of anemia in renal failure is a deficiency of erythropoietin. The causes of anemia in HIV disease include direct and indirect stem cell inhibition by the virus, increased peripheral destruction of red blood cells, and bone marrow suppression by various opportunistic infections and therapeutic drugs, particularly zidovudine. We compared the efficacy of recombinant human erythropoietin (rHuEPO) therapy in improving the anemia in HIV-infected end-stage renal disease patients (group I) with that in nondiabetic (group II) and diabetic (group III) hemodialysis patients without HIV infection. All three groups of patients were comparable in dialysis prescription and serum iron studies. Iron supplementation was prescribed to all patients, and none received blood transfusions. After 8 weeks of rHuEPO therapy (administered intravenously in a dose of 100 U/kg body weight thrice weekly), the mean increase in hematocrit was similar in all responders (5.8% increase in hematocrit in 23 of 30 HIV patients and 6.7% increase in 24 of 30 non-HIV patients). Response in hematocrit was noted in HIV patients despite the presence of opportunistic infections in 15 and zidovudine administration in 11. Seven HIV-positive patients and six non-HIV patients failed to respond to rHuEPO. Irrespective of the HIV status, the baseline serum EPO levels in patients responding to rHuEPO were significantly lower than those in nonresponders.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute lung disease after exposure to fly ash.

A 48-year-old man with no history of pulmonary disease developed acute lung disease after the intensive exposure of fly ash. He subsequently had progressive worsening of shortness of breath and hypoxemia to the point of requiring mechanical ventilation. Fly ash is a compound consisting of silicon dioxide and various other substances and is used in industrial settings to generate electricity. Exposure to fly ash may cause irritation to the mucous membrane of the respiratory tract and even pulmonary fibrosis in humans. To our knowledge, this is the first case report described in the medical literature of acute lung disease developing after fly ash exposure.

Salvage of clotted jugular vein hemodialysis catheters.

Jugular venous catheters (JVC) provide rapid, vascular access for both emergency and maintenance hemodialysis in both acute and end-stage renal disease. Clotting and occlusion of JVC is a common problem necessitating alternate vascular access. Urokinase will declot 80-90% of central venous catheters; however, recurrence of catheter occlusion is frequent. We successfully employed a guide wire insertion technique to salvage occluded JVC after failed urokinase infusion. In 24 patients JVCs, inserted for either temporary or permanent vascular access, clotted within 6-55 days of initiating hemodialysis. Urokinase (5,000 IU) instilled into both arterial and venous limbs of the catheter had been unsuccessful in restoring patency. In these patients, we inserted a soft-tipped guide wire into both lumina. In 21 of 24 patients (87.5%), guide wire insertion opened the occluded JVC, permitting immediate initiation of hemodialysis. We conclude that for clotted JVC unresponsive to urokinase infusion, guide wire insertion can salvage most catheters thereby facilitating hemodialysis.

Income distribution in rural Sagar.

"The study makes an attempt to identify the pattern of household income distribution in rural areas, based on the socio-economic surveys in Sagar district [in India]." Factors affecting family income include "occupational structure, distance from nearby urban centers and general accessibility.... The rural settlements under urban influence or with proper accessibility have a greater percentage of high-income families. The major source of income for over a third of the rural families of the district is agricultural labour, while another third earns its living by other agricultural work and the rest are either petty businessmen or are engaged in services."

Determination of bone width in malnourished children under 5, and its inter relationship with mid arm muscle thickness, subcutaneous fat thickness and the mid upper arm girth.

The mid upper arm of 516 malnourished children (one to five years) were studied radiographically for changes in bone width, muscle mass and subcutaneous fat, of malnutrition at different ages. The data was studied by statistical analysis, determining the correlation coefficients of each of the factors. The findings indicate that previous assumptions about the components and the changes of the mid upper arm girth (MUG) in chronic severe malnutrition, were perhaps too simplistic.

Changing trends in mortality and morbidity in a teaching hospital in central India.

A comparison of mortality and morbidity pattern of hospital admissions of children under 14 years during 1966-68 and 1977-81 has been made. Annual admission rate has increased from 1515 to 2515, which is in proportion to the population increase of 3 lacs from 1966 to 1981. Recently more than 70% were discharged within a week as against 52% during 1966-68, indicating a faster turnover and a need for more beds. Protein energy malnutrition, infections and diarrhoea with dehydration were main killers. The pattern of mortality and morbidity has not much changed from 1966 to 81 but mortality rates at all ages have considerably declined in recent years (neonatal, post neonatal, preschool and school). Measures to decline it further have been discussed. The data should be of interest to those engaged in planning health strategies and to teachers in defining priorities in Medical education.

PIP: A comparison of mortality and morbidity patterns of hospital admissions for children under age 14 between 1966-68 and 1977-81 has been made. Annual admission rate has increased from 1515 to 2515, which is in proportion to the population increase of 3 lacs from 1966-81. Recently, more than 70% were discharged within 1 week as compared to 51% during 1966-68, indicating a faster turnover and a need for more beds. Protein energy malnutrition, infections, and diarrhea with dehydration were the main causes of death. The pattern of mortality and morbidity has not changed much from 1966-81, but mortality rates at all ages have declined considerably in recent years (neonatal, postneonatal, preschool and school-age). Measures to decrease it even further have been discusses. the data should be of interest to those engaged in planning health strategies and to teachers in order to help define priorities in medical education.

Infant feeding with commercial milk formula in an urban community of central India.

PIP: A study group composed of mothers of 250 infants who were being fed only commercial milk formula were observed in an urban Indian community. Most mothers estimated the amount of powder and water as they could not understand the directions for use of the commercial milk formula. The mothers were also purchasing daily or weekly feeding needs from open tins as they could not afford the price of full tins. The sterilization of bottles was not prevalent. Christians, as compared with Jain and Muslim communities, were more inclined to practice breast feeding. Many mothers used formula feeds because they believed they more easily digestible and better nutritionally. As well, many perceived, erroneously, that there was a greater economy to using formula feeds. Others believed that breast feeding caused liver trouble or recurring diarrhea in their infants and therefore switched to formula milk. Most of the women were influenced primarily by health personnel with only 14% being influenced by advertising. Thus, education of the benefits of breast feeding and the risks of commercial milk formula must begin within the medical schools of India and finally reach the affected population: mothers and infants.^ieng

Knowledge, attitudes and practice regarding infant feeding among mother substitutes.

PIP: With more women entering the workforce, the issue of infant nutrition has become more complex. Mother surrogates, or substitutes, are increasingly taking over the responsibility of infant care. 80 mother substitutes, aged 7-70, were interviewed in Jabalpur town, India, from October 1983-July 1984. Substitutes originated from nuclear families consisting of grandmothers, aunts, elder sisters, brothers, and servants. They were questioned concerning breast feeding, top milk initiation, feeding technique, and weaning. Results pointed to a variety of opinions on feeding practices and nutrition. 50% of younger mother substitutes and the majority of older, uneducated ones believed in initiating breast feeding from the 2nd day onward. 50% of young and 64% of older substitutes did not consider giving colostrum, and various reasons why are cited. 20% of all and 42% of highly educated substitutes were aware of the advantages of breast feeding. 65% of young and 60% uneducated did not know age of initiation of top milk. 45% advocated bottle feeding, with 25% preferring spoon feeding. With regard to "tinned milk" 40% did not use it, 25% were unaware of it, and of 30% using tinned milk, only 1/3 knew the correct technique of reconstitution. The majority of young and uneducated substitutes thought proper weaning age to be after 6 months. 50%, aged 21-40 years, believed in adding solid food from below 6 months. 90% of the young mother substitutes were against solids being introduced by the age of 4 months. A majority of the substitutes suggested weaning foods such as dal, rice, roti, and biscuits with a few considering tinned cereals as proper weaning foods. This response may point to the reason why protein and energy deficiency may be observed around weaning age in many infants throughout the 3rd world.^ieng