Sanjay G. Gokhale

Transfusion-associated graft versus host disease (TAGVHD)-with reference to neonatal period

Abstract Transfusion-associated graft versus host disease [TAGVHD] results from the engraftment of transfused immuno-competent cells in blood transfusion recipients, whose immune system is unable to reject them. All blood products containing viable, immuno-competent T cells have been implicated in TAGVHD. Presence of a “one-way HLA match between donor and recipient” is associated with a significantly increased risk of TAGVHD. Though sharing of haplotype is the most probable explanation, it is far from adequate. Since TAGVHD is not seen in patients with AIDS, and an acute GVHD-like syndrome has been noted in some identical twins and autologous (self) transplants, some other processes, possibly of an “autoimmune” nature are responsible for TAGVHD. Most of the cases have been reported from Japan. This clustering in space and time is rather intriguing. We offer here alternative hypothesis. Foetal and then neonatal lymphocytes exhibit tolerance towards donor cytotoxic T lymphocytes; and consequently very few cases of TAGVHD have been reported in neonates than expected. This tolerance is a part of altered immunology of pregnancy. We feel that it is possible to use maternal blood for transfusion to her newborn baby by following certain protocol and procedure and TAGVHD is no barrier.

Maternal-neonatal transfusion compatibility irrespective of ABO mismatch – a prospective observational study

Abstract Objective: To determine transfusion compatibility of maternal RBCs for her neonate up to 4 weeks of age, irrespective of maternal-neonatal ABO mismatch. Methods: This was a prospective observational study involving eligible mothers with their neonates delivered in participating site from 1 July 2012 till 31 December 2012. Mother’s blood was collected before child birth. Neonatal blood sample was collected from placental end, shortly after birth. Blood Groups of mother–baby pair were individually tested for ABO and Rh-D groups. Pairs with negative Rh-D antigen/s or with same ABO blood groups were excluded. Thus, 28 pairs with both maternal and neonatal samples positive for Rh-D antigen and with different maternal neonatal ABO blood groups were included in the study. Blood samples were collected at birth and at 4 weeks. Cross matching was done at birth and at 4 weeks for each pair with standard blood bank protocols. Results: All 28 pairs showed positive compatibility with standard blood bank cross-matching protocols at birth and at 4 weeks. Conclusions: Maternal blood irrespective of ABO compatibility might be a viable and potentially acceptable option for her new born baby in neonatal period. This may be especially important in developing world with limited blood bank resources.

Explaining 'congenital malformations'.

About 2% of new born infants have a major malformation. The incidence is as high as 5% if one includes malformations detected later in childhood, such as structural anomalies of heart, spine, lungs and kidneys, etc. Minor anomalies are seen in 15% of new born babies. Infants with one minor anomaly have a 3% chance of having a major malformation; those with two anomalies have a 10% chance and those with three anomalies have a 20% chance. Association [Associated malformations] refers to the non-random appearance of two or more anomalies that occur together more frequently than by chance alone [namely VACTERL]. It is not determined whether the pattern of malformation is a sequence or a syndrome. These defects occur together in any combinations of two or more; and usually represent a sporadic occurrence in an otherwise normal family. Though etiology of congenital malformations is not precisely known, it can be explained considering evolution and the genetic control of embryogenesis. This is a new hypothesis which tries to explain the problems of associated malformations like VACTERL and other ones like Holt Oram’s Syndrome considering ‘Darwinian evolution’ and ‘genetic control of embryological morphogenesis’. The basic theme is that – the structures which have evolved together in evolution have shared the genetic control of embryological morphogenesis. This means that somewhere on the temporal axis of evolution – vertebral column, heart and kidneys have evolved together and have shared the genetic and evolutional control of embryogenesis [1]. Evolution of new regulatory pathways of mutations and gene duplications is an important aspect of vertebrate embryogenesis. The basic theme of evolution is spontaneous chance mutation in genes leading to altered morphological features as exemplified by transition from brachiopod crustaceans, to hexapod insects seen due to the mutation in Ultrabithorax Ubx protein [2]. Though in the early phase of development maternal gene staufen may be crucial for establishment of developmental precision and proportions in the Drosophila embryo [3]; Hox genes take over later in development. Segmentation mechanisms used by invertebrates and vertebrates have been conserved [4]; and there is evidence of a developmental clock linked to segmentation and somitogenesis of the paraxial mesoderm. The strict temporal regulation of somitogenesis is of critical developmental importance because many segmental structures adopt a periodicity based on that of the somites. Patterns of gene expression are under precise spatial and temporal control [5]. Studies of oligodendrocyte precursor cells (OPCs) in culture suggest that each OPC has a built-in timing mechanism that helps determine when the cell stops dividing and differentiates. Measurement of time in oligodendrocyte-type-2 astrocyte (O-2A) progenitors is a cellular process distinct from differentiation or division [6]. This intrinsic timer consists of at least two components: a timing component, which measures elapsed time; and an effector component, which stops cell division and initiates differentiation at the appropriate time. The timer seems to involve both transcriptional and post-transcriptional mechanisms, with some proteins progressively increasing and others progressively decreasing over time. Mutations in homeobox genes (encoding homeodomain proteins) have been described in a number of human disorders [7]. Direct evidence for the

Effect of two high dose vitamin D by parenteral route in treating vitamin D deficiency a prospective interventional study

Abstract Background: Vitamin D deficiency is recognized as a global public health problem. Despite ample sunshine, vitamin D deficiency is very common in the Middle East (15°–36°N) and African (35°S–37°N) countries; and in South Asian countries. Aim: To find a simple, affordable and practical plan to treat vitamin-d deficiency. Type of study: This was a prospective interventional study. Outcome variable: The primary outcome was typed as vitamin-D level more than 50 nanograms/ml as ‘yes’ and poor response or ‘no’ when it was less than 50 ng/ml. Participants: 80 Women participated in study. Laboratory tests: Vitamin D [25-OHD]-estimations were performed with LCMSMS-liquid chromatography tandem mass spectrometry. Corrective vitamin-D doses: All participants received TWO doses of Vitamin-D injections one ml at a time [600K IU/ml or 600,000 IU/ml]. All participants received their first dose; after collecting blood samples for Vitamin-D estimations. Second dose was given about a month after the first one [range 30–37 days]. These doses were given to correct the deficiency. Results: Even with this high dose treatment 60% woman had unsatisfactory Vitamin-D levels.

Neonatal Transfusion: Uncross-Matched “O” Negative Blood From Unrelated Donors in Emergency

Blood transfusion is the most commonly practised and successful tissue transplant. Though sick newborns often require urgent blood transfusions, there is lack of access to suitable blood products, especially in emergent situations. Early recognition and vigorous treatment is the key factor in early reversal of pediatricneonatal shock [1]. Blood for neonatal transfusion is often issued as group O packed RBCs with compatible infant Rh type. Alternatively, non-group O infants may receive non-group O RBCs if passive maternal anti-A or anti-B is not detected in an infant’s serum or plasma. In emergency situations, 10 20 mL/kg of O Rh-negative blood from unrelated donor may be used [2]. We retrieved data over 20 years (1997 2016), of neonates who received transfusion of “O” negative blood from unrelated donors as a part of treatment in emergent situations for different indications (Table 1). There were 10 neonates (four male and six female) with birth weight from 2,800 to 3,200 g. Nine babies were delivered in hospital and one was a home delivery. Two neonates with sepsis showed DIC. Since small transfusions of 20 mL or so do not require a pump, we administered it with a heparinised syringe by intermittent small bolus [3]. About 0.2 mL of heparin (1,000 U/mL) was taken in a 20 ml syringe; allowed to come in contact with the walls of the syringe by slowly moving the piston to and fro and then the heparin was thrown out of the syringe. About 25 mL of O negative donor’s blood was collected by peripheral venepuncture using this heparinized syringe. This whole fresh blood was directly injected into the recipient neonate slowly over next 30 min [4]. All neonates had uneventful recovery, normal growth and mental development over a period of observation of 1 to 20. Half life of plasma heparin is very short and it is eliminated within 1 h of injection. Since the blood is injected immediately and no handling is involved, the chances of microbial contamination are very low [4]. All the babies showed remarkable and sustained improvement with just one single small blood transfusion. We feel that 10 mL/kg of whole blood given to these babies helped them in different ways such as restoring intravascular volume, improving oxygen carrying capacity, improving low serum albumin levels and the fresh whole blood probably stimulated endogenous granulopoiesis [5]. Though certain rules in blood transfusion are meticulously followed, blood transfusion in neonatal period can be challenging and requires considering these issues: 1) Group “O” individuals can receive blood from “O” donors only. 2) “A” individuals can receive blood from “A” and “O” donors. 3) “B” individuals can receive blood from “B” and “O” donors. 4) “AB” individuals can receive blood from “AB” donors, and also from group A, B and O donors. We feel that compatibility and cross-matching in neonatal period is still a grey zone. As previously stated, these sick neonates need less blood but require it urgently. Though transfusing “O” negative blood saved 10 lives; further research is warranted. Our series may be the one with the longest period of observation establishing safety of this intervention.

Shuffling Adaptive Clinical Trials.

Clinical trials are interventional studies on human beings, designed to test the hypothesis for diagnostic techniques, treatments, and disease preventions. Any novel medical technology should be evaluated for its efficacy and safety by clinical trials. The costs associated with developing drugs have increased dramatically over the past decade, and fewer drugs are obtaining regulatory approval. Because of this, the pharmaceutical industry is continually exploring new ways of improving drug developments, and one area of focus is adaptive clinical trial designs. Adaptive designs, which allow for some types of prospectively planned mid-study changes, can improve the efficiency of a trial and maximize the chance of success without undermining validity and integrity of the trial. However it is felt that in adaptive trials; perhaps by using accrued data the actual patient population after the adaptations could deviate from the originally target patient population and so to overcome this drawback; special methods like Bayesian Statistics, predicted probability are used to deduce data-analysis. Here, in this study, mathematical model of a new adaptive design (shuffling adaptive trial) is suggested which uses real-time data, and because there is no gap between expected and observed data, statistical modifications are not needed. Results are obviously clinically relevant.

A Case of Spontaneous Extracranial Epidural Emphysema

Objective: To report a rare case of spontaneous extracranial epidural emphysema. Clinical Presentation and Intervention: An 18-year-old woman with a recent diagnosis of squamous cell carcinoma of the esophagus presented with acute onset of cough, dyspnea and subcutaneous emphysema. An esophageal endoscopy revealed an ulcerative lesion in the upper third of the esophagus that was diagnosed as squamous cell carcinoma. A computed tomographic scan of the chest showed spinal epidural emphysema in addition to pneumomediastinum and pneumoperitoneum. A few days later, the patient died of aspiration pneumonia and persistent epidural emphysema. Conclusion: The spontaneous extracranial epidural emphysema in our case resulted from a bout of cough with tracking of air from the pneumomediastinum through the emaciated tissue planes into the epidural space.

Four generations of rare familial lymphedema (Milroy disease).

Objective: To report a rare case of familial lymphedema (Milroy disease) affecting 4 generations of individuals. Clinical Presentation and Intervention: A 28-year-old woman presented with bilateral pedal edema which she had since birth. A detailed evaluation including blood counts, metabolic panel and imaging studies ruled out secondary causes of lymphedema. The family history revealed many affected individuals up to 4 generations. She was reassured about the potential benign yet familial nature of this condition. She was advised to wear compression stockings and to avoid scratches or skin breakdowns in the lower extremities to prevent cellulitis. Conclusion: This case showed the occurrence of asymptomatic progressive lymphedema in 4 generations of individuals.

Body segmentation went wrong but promptly corrected

The number of elements in the vertebral column has been reported to vary between 32 and 35 and the thoracolumbar vertebrae usually number seventeen. A baby presenting with thirteen dorsal vertebrae is reported herein, not for its rarity, but to highlight that it is repeat expression of one axial Hox code that is probably responsible for the extra dorsal vertebra and not extra genetic material; as if the body segmentation went wrong but was corrected. Baby MHR was mildly asphyxiated at birth due to meconium aspiration and needed resuscitation. A routine X-ray film showed thirteen dorsal vertebrae; the cervical, lumbar and sacral were normal in number. There was no evidence of any cardiopulmonary abnormality. The baby was given routine care as per protocol and the course was uneventful. The baby was seen again on day 5 and there was no evidence of any gross congenital malformations. Ultrasonographic examination of the abdomen and skull (through the anterior fontanel) showed no abnormality. Seen at the age of nine months, the baby showed normal physical and mental development. Repeat X-ray films showed thirteen dorsal vertebrae and thirteen ribs. There are usually seven cervical, 12 thoracic, five lumbar, five sacral, and four coccygeal vertebrae, but the total number may vary between 32 and 35. The cervical region is reported to be the most constant, the coccygeal being the most variable. Addition to a group is frequently seen, which occurs through the reduction in number of vertebrae of an adjacent group, the total number being unchanged (the thoracolumbar vertebrae usually number seventeen). The segmented or metameric aspect is a basic characteristic of many animal species ranging from invertebrates to man. Body segmentation usually corresponds to a repetition, along the anteroposterior (AP) axis, of similar structures consisting of derivatives from the three embryonic germ layers. Functionally, segmentation is critical to ensure the movements of a rod-like structure, such as the vertebral column. The segmented distribution of the vertebrae derives from the earlier metameric pattern of the embryonic somites. Segmentation of the embryonic body relies on a molecular oscillator called the segmentation clock, as proven in work performed on fish, chick and mouse embryos. The segmentation clock also acts during human embryonic development. In humans, metamerism or segmentation is most obvious at the level of the vertebral column and its associated muscles, and also in the peripheral nervous system (PNS) [1]. Segmentation facilitates movement and regionalization of the vertebrate body. The process of segmentation is controlled by specific genes. Genes controlling segmentation have been identified that are highly conserved in organisms belonging to different phyla [2] and segmentation mechanisms used by invertebrates and vertebrates have been conserved [3]. Though segmentation is the underlying principle of the body plan even in annelids and arthropods, the process of segmentation is more complex and more evolved in animals with a vertebral column. Morphology of individual vertebra is defined by an axial Hox code. The term ‘Hox code’ has been suggested to identify the functionally active set of genes involved for a given segment [4]. The incidence of extra dorsal vertebra with no reduction in lumbar elements is not known but is definitely a rare event. This baby showed thirteen dorsal and five lumbar vertebrae. Though even partial deletion of a vertebra (hemivertebra) is associated with cardiac or renal malformations, in spite of the one extra body segment there was no evidence of any major malformations in this case. During vertebrate embryogenesis The Journal of Maternal-Fetal and Neonatal Medicine, March 2007; 20(3): 259–260