Pk Gupta

Transfusion Transmitted Infections in Armed Forces: Prevalence and Trends

BACKGROUND This study presents data on the prevalence rate of infectious markers among voluntary and replacement donors in the blood transfusion service in Armed Forces from 2000 to 2004. METHODS 39,646 units of blood were collected from donors during the period from 2000 to 2004. All the samples were screened for hepatitis B surface antigen (HBsAg), human immunodeficiency virus (HIV) 1&2, hepatitis C virus (HCV), and by venereal disease research laboratory test (VDRL). RESULTS 24,527 (61.9%) were voluntary donations and 15,119 (38.1%) replacement donations. Prevalence of HBsAg had decreased, amongst voluntary donors from 1.67% to 0.77% but the positivity rate has not showed significant change. Seropositivity of HIV had decreased both in voluntary and replacement donors to 0.22% and 0.86% respectively. The seropositivity for anti-HCV showed steady decrease amongst voluntary donors from 0.46% to 0.20% in 2004, but in replacement donors, there was an increase in reactivity rate from 0.43% to 0.65%. CONCLUSION The increased seropositivity for HCV, HIV and HBsAg could be decreased by introduction of nucleic acid amplification testing (NAT) in minipools for HCV and HIV and introduction of anti-HBcAg (IgM) for hepatitis B virus (HBV) infection. But this may not be possible in near future in developing countries due to financial constraints. At present implementation of strict donor criteria and with use of sensitive laboratory screening tests it is possible to reduce the incidence of transfusion transmitted infections (TTI) in Indian scenario.

Is seroprevalence of anti-IGM CMV among blood donors relevant in India?

BACKGROUND Infection with cytomegalovirus (CMV) is more common in developing nations and the people belonging to the lower socioeconomic section of the society. The immunosuppressed population for whom CMV-seronegative blood products are requested is increasing due to advances in medical care. AIM To study the prevalence of CMV antibodies among the different sexes and age groups in healthy blood donors. MATERIALS AND METHODS A retrospective study was done on 5600 serum samples stored frozen in a repository for CMV antibodies using the ELISA technique. RESULTS Five thousand three hundred and fifty (95.5%) were male and 250 (4.5%) were female. Four cases (0.071%) out of 5600 samples were positive for anti-IgM CMV with 95% Confidence Interval (95% C.I) of 0.02 - 0.17. CONCLUSION In a developing country like India, screening for IgM antibody on a routine basis may not be feasible, given the likely positive yield to be low and the cost being high. It is recommended that in a tertiary care hospital, blood units to be transfused to neonates, organ transplant recipients, those suffering from malignancies and other immunocompromised patients should be screened for anti-IgM CMV or preventive strategies like universal leucodepletion to be implemented to decrease the transmission of CMV in these groups of patients.

Mollison's Blood Transfusion in Clinical Medicine – 11th Edition

It is a beautifully produced book, has great clarity and has most of the recent advances in its latest edition. Highly respected, long-established book that has become the “bible” in transfusion medicine. This book provides a sound basis for understanding modern transfusion medicine. It is a definitive reference source for any clinician involved with patients requiring transfusion and for staff working in transfusion services, immunohaematology laboratories and blood banks. It also gives advice on management issues for the clinician. The latest edition is completely revised and updated to reflect the rapid pace of changes in transfusion medicine. Transfusion medicine now involves mobilization and selection of haematopoietic progenitor cells for transplantation, storage of umbilical cord blood, and manipulation of mononuclear cells by culture and gene insertion to offer potential therapies for a wide range of diseases. The edition has been revised to reflect this progress. Enormous advances in protein structure determination have occurred since the last edition and these are reflected in the revised edition. Mollisons textbook has traditionally been used as a source of ‘classic’ studies and information not available elsewhere, and the authors have been careful to retain this information in this edition. In conclusion it is recommended that no hospital transfusion laboratory should be without its “Mollison” and most haematologists should possess their own copy.

Real Time-PCR HBV-DNA Analysis: Significance and First Experience in Armed Forces.

BACKGROUND HBV DNA quantitation is used extensively world wide for the diagnosis and monitoring of treatment of Hepatitis B virus (HBV) infection. However, it has still to be popular in India. The aim of this study was to quantitate HBV - DNA by Real time - PCR method in Hepatitis B and in immuno-compromised patients, to compare the results with HBeAg detection and to monitor the response to therapy of chronic Hepatitis B patients to antivirals. METHODS Ninety one serum samples of Hepatitis group of patients (all HBsAg positive), 41 samples from immuno-compromised patients (all HBsAg negative) and 49 patients of Chronic Hepatitis B group (all HBsAg positive) were the subjects of this first ever study in Armed Forces. Twenty serum samples from healthy volunteers and non-hepatitis B patients served as negative controls. The amplification detection was carried out in a Rotor-Gene 2000-sequence detector. RESULTS Amongst Hepatitis B group, 33% (30/91) of the samples were positive for HBV-DNA and 26% (24/91) of samples were positive for HBeAg. In the immuno-compromised group of patients 14.6% (6/11) of samples were positive for HIV-DNA and 9.7% (4/41) were positive for HBeAg. Of the Chronic Hepatitis B patients on treatment, all (100%) were positive by HBV-DNA, whereas 29/49 (59.2%) were positive by HBeAg before treatment. After treatment with antivirals, 06/49 (12.2%) were positive by both tests and 11/49 (22.5%) were positive only by HBV-DNA. 32/49 (65.3%) patients became negative serologically after therapy. CONCLUSION HBeAg status did not necessarily reflect HBV-DNA level in the serum, as 10/91 (11%) in the Hepatitis B group, 2/41 (4.9%) in the immuno compromised group and 20/49 (40.8%) patients in the Chronic Hepatitis B group were positive for HBV-DNA but negative for HBeAg. HBV-DNA was not found to be positive amongst any of the negative controls. Real time - PCR is a sensitive and reproducible assay for HBV-DNA quantitation and may be started in Armed Forces referral centers in the near future.

Evaluation of Suspected Monoclonal Gammopathies: Experience in a Tertiary Care Hospital

BACKGROUND Monoclonal gammopathies occurs in patients with malignant diseases of plasma cells and lymphocytes and in few benign conditions. The objective of this study was to assess the precision, accuracy and confirmation of monoclonal gammopathies on serum protein electrophoresis (SPE) and the clinical relevance of detection and characterization of M component. METHODS All samples received for serum electrophoresis in the last 3 years were analysed for data on M band positivity and correlating it with clinical profile of the patients. Immunofixation (IFE), Immunoelectrophoresis (IEP) and IgG, IgM estimation were carried out in few cases. The follow up of cases was done by serial monitoring of SPE and β2 microglobulin levels. RESULTS 1155 samples were received during the 3 years period. 282 (24.4%) samples were positive for M component on SPE. Of these, 239 (84.8%) patients had M spike in λ region and 43 patients had M spike in β region. The mean load of the M protein band in the λ region was 37.8% and in β region was 35.8%. IgG with κ chain was seen in 40%, IgG with λ chain was seen in 50%, 5% patients each had IgM with κ and IgA with λ light chain. 246 samples (96.5%) had high levels of β2 microglobulin. Of the 116 cases of multiple myeloma, IgG levels was more commonly raised (5%) as compared to IgA (6.9%) and IgM (5.2%). CONCLUSION It is recommended that SPE should be performed in patients having unexplained weakness, anaemia, back pain, osteoporosis, osteolytic lesions, fractures, renal insufficiency or recurrent infections.

Perinatal outcomes among children born by assisted reproductive techniques—a hospital-based case control study

BACKGROUND Widespread use of assisted reproductive techniques (ART) has raised major concern about the outcome of resulting pregnancies, as well as about the health of the newborn children. The ART conceived pregnancies have an increased risk for prematurity and low birth weight (LBW). The risk of congenital malformations among children conceived via ART is contemplated to be high. The present case control study was conducted with an aim of analysing perinatal outcomes of children born by ART in the Indian context. METHODS The case control study was conducted in the Army Hospital (Research and Referral), New Delhi. It included 82 cases and 164 controls. The data was collected on maternal and newborn characteristics among cases and controls. Perinatal outcomes were compared between ART conceived and spontaneously pregnant women in terms of birth weight, preterm, multiple pregnancies, and neonatal complications. RESULTS Significant difference was observed in terms of the preterm delivery, birth weight, neonatal complications between the cases and the controls. The adjusted odds ratio (OR) was 21.6 (95% confidence interval [CI] 4.3, 112.9) for preterm delivery; 6.0 (95% CI 1.1, 43.8) for multiple pregnancy and 3.2 (95% CI 1.5, 7.0) for caesarean section. The risk of LBW and neonatal complications was heavily confounded by preterm delivery and multiple pregnancies, the adjusted OR being 0.9 and 1.0, respectively. CONCLUSION Increased risk of preterm delivery, multiple pregnancies and caesarean section was associated with ART. The LBW was confounded by preterm delivery and multiple pregnancies.

PNH revisited: Clinical profile, laboratory diagnosis and follow-up.

BACKGROUND Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by intravascular hemolysis, marrow failure, nocturnal hemoglobinuria and thrombophila. This acquired disease caused by a deficiency of glycosylphosphatidylinositol (GPI) anchored proteins on the hematopoietic cells is uncommon in the Indian population. MATERIALS AND METHODS Data of patients diagnosed with PNH in the past 1 year were collected. Clinical data (age, gender, various presenting symptoms), treatment information and follow-up data were collected from medical records. Results of relevant diagnostic tests were documented i.e., urine analysis, Hams test, sucrose lysis test and sephacryl gel card test (GCT) for CD55 and CD59. RESULTS A total of 5 patients were diagnosed with PNH in the past 1 year. Presenting symptoms were hemolytic anemia (n=4) and bone marrow failure (n=1). A GCT detected CD59 deficiency in all erythrocytes in 4 patients and CD55 deficiency in 2 patients. A weak positive PNH test for CD59 was seen in 1 patient and a weak positive PNH test for CD55 was seen in 3 patients. All patients were negative by sucrose lysis test. Hams test was positive in two cases. Patients were treated with prednisolone and/or androgen and 1 patient with aplastic anemia was also given antithymocyte globulin. A total of 4 patients responded with a partial recovery of hematopoiesis and 1 patient showed no recovery. None of the patients received a bone marrow transplant. CONCLUSION The study highlights the diagnostic methods and treatment protocols undertaken to evaluate the PNH clone in a developing country where advanced methods like flowcytometry immunophenotyping (FCMI) and bone marrow transplants are not routinely available.

Spectrum of Haemoglobinopathies in a Tertiary Care Hospital of Armed Forces

BACKGROUND Thalassaemia and other structural haemoglobinopathies are the major genetic disorders prevalent in certain parts of the world including India. This study presents the pattern of haemoglobinopathies amongst the referred patients of anaemia in a two-year period. METHODS A total of 1032 patients were studied during a two-year period for anaemia investigation. Haematological indices, sickling test and haemoglobin electrophoresis with quantification of the bands was done in all cases. RESULT Out of 1032 cases, 774 (75%) were normal and 258 (25%) cases had abnormal haemoglobin pattern. Of the 258 abnormal cases, 136 (53%) were males and 122 (47%) were females. Of all cases of anaemia 370 (36%) were microcytic hypochromic, 237 (23%) macrocytic, 151 (15%) were dimorphic and the rest (26%) had normocytic normochromic picture. 82% of microcytic hypochromic anaemias had reduced serum iron and elevated total iron binding capacity (TIBC), whereas 85% had decreased serum ferritin levels. Spectrum of haemoglobinopathies prevalent were β-Thalassemia trait (17%), followed by sickle cell trait (2.3%). Other haemoglobinopathies in descending order of frequency were sickle cell disease (1.7%), Hb D trait (1%), Hb E trait (0.8%), sickle cell - β thalassemia, Hb E disease, E - β thalassemia (0.6% each) and thalassemia major (0.4%). CONCLUSION This study provides a comprehensive database on the spectrum of haemoglobinopathies in the Armed Forces. It is suggested that detection of HbA2 should be carried out in all the high-risk groups with anaemia.

Hereditary Factor X (Stuart-Prower Factor) Deficiency

Inherited deficiency of Factor X was first reported way back in mid 1950s by workers who were studying patients with a haemorrhagic disease resembling factor VII deficiency. It is also known by the surnames of the patients who were first found to manifest the defect (Stuart and Prower). Congenital Factor X deficiency is inherited as an autosomal recessive condition [1]. The exact frequency of the defect has not been established although a homozygous incidence of 1:1,000,000 has been described [2]. About 50 affected families have since been described [3]. Factor X is one of the vitamin K dependent factors, which is synthesized in the liver parenchymal cell and found in the plasma in a concentration of about 1 mg/dl [4]. It is a rare coagulation disorder in which both males and females are equally affected. We present a case that manifested with bleeding diathesis at 20 years of age post-operatively.