A Time Motion Study in the Immunization Clinic of a Tertiary Care Hospital of Kolkata, West Bengal

Background:

A time and motion study is used to determine the amount of time required for a specific activity, work function, or mechanical process. Few such studies have been reported in the outpatient department of institutions, and such studies based exclusively on immunization clinic of an institute is a rarity.

Materials and Methods:

This was an observational cross sectional study done in the immunization clinic of R.G. Kar Medical College, Kolkata, over a period of 1 month (September 2010). The study population included mother/caregivers attending the immunization clinics with their children. The total sample was 482. Pre-synchronized stopwatches were used to record service delivery time at the different activity points.

Results:

Median time was the same for both initial registration table and nutrition and health education table (120 seconds), but the vaccination and post vaccination advice table took the highest percentage of overall time (46.3%). Maximum time spent on the vaccination and post vaccination advice table was on Monday (538.1 s) and nutritional assessment and health assessment table took maximum time on Friday (217.1 s). Time taken in the first half of immunization session was more in most of the tables.

Conclusion:

The goal for achieving universal immunization against vaccine-preventable diseases requires multifaceted collated response from many stakeholders. Efficient functioning of immunization clinics is therefore required to achieve the prescribed goals. This study aims to initiate an effort to study the utilization of time at a certain health care unit with the invitation of much more in depth analysis in future.     

Objective grading of the loss of pain and touch sensations in leprosy patients

Two new instruments named Pain/Touch Sensation Testing and Grading devices, which provide standardized and graded stimuli of pain and touch, respectively, were employed to grade the sensory loss at the center of 110 lesions in 97 patients. The grades of sensory loss for pain were 0 (no sensory loss) in 8 lesions, 1 in 6 lesions, 2 in 14 lesions, 3 in 26 lesions, 4 in 19 lesions, and 5 (complete loss) in 37 lesions (total 110 lesions). Grades of sensory loss for touch were 0 in 12 lesions, 1 in 3 lesions, 2 in 5 lesions, 3 in 9 lesions, 4 in 15 lesions, and 5 in 22 lesions (total 66 lesions). Reevaluation done after 2-40 weeks in 46 of these lesions revealed that the grade for pain had decreased in 17 lesions, increased in 4, and remained the same in 25. The grade for loss of touch sensation had decreased in 10, increased in 1, and remained the same in 35. Grading of the sensory loss in most of the 1-cm-square areas of the entire lesion, done in 19 patients (26 lesions), revealed that the sensory loss was not uniform all over the lesion and it was also not maximum at the center of the lesion, though generally it was less at the margin in comparison with the central area. Follow up of 11 of these lesions revealed a decrease in the grades in 7 lesions for both pain and touch sensations, while 2 lesions showed a decrease in the grades for touch sensation only.(ABSTRACT TRUNCATED AT 250 WORDS)     

Minimum temperature felt as hot (MTH)--a new concept for grading the loss of temperature sensation in leprosy patients

In order to grade the loss of the temperature sensation in the skin of leprosy patients, a newly designed instrument called the Temperature-Sensation-Testing-and-Grading device has been employed to determine the minimum temperature felt as hot (MTH) at the skin area. The MTH in normal subjects was observed to vary from one region of the body to another; it was generally higher on the distal parts of the extremities compared to the proximal parts; and it was also higher on the lower extremities compared to the upper ones. The abdomen and the back generally had the lowest values. There were no variations according to age (11-80 years) or sex and no differences on symmetrical sites of the body. The MTH value, however, showed a dependence on the environmental temperature, the values being lower at low environmental temperatures and higher at high environmental temperatures. But at the same site and the same environmental temperature, the MTH value was found to be almost constant. Different individuals had different MTH values at the same body site and even at the same environmental temperature. The unaffected skin of leprosy patients showed values comparable to the controls. At the leprosy lesions, however, the degree of sensory loss could easily be determined in comparison with the MTH at the contralateral/adjoining unaffected skin. Out of 54 leprosy patients, 7 patients had no sensory loss; in 27 patients the loss varied between 1 degree C and 20 degrees C; while in 20 patients the loss was complete--they could not perceive even 50 degrees C as hot.(ABSTRACT TRUNCATED AT 250 WORDS)     

Recurrence of kala-azar after PKDL: role of co-factors

Recurrence of kala-azar after post kala-azar dermal leishmaniasis (PKDL) has remained uncommon. We report here two patients with recurrence of kala-azar (KA) after development of PKDL. In one case the second attack of KA was preceded by repeated attacks of malaria and tuberculosis, and in the other the recurrence of KA followed an attack of measles. While measles has earlier been suggested as co-factor in inducing transformation from sub-clinical to clinical kala-azar, malaria was demonstrated to enhance the virulence and invasiveness of Leishmania in an experimental model as well as under natural condition. We propose that in our cases, measles and repeated attacks of malaria or tuberculosis led to immunosuppression and recurrence of visceral leishmaniasis (VL).     

Unusual cause of acute mitral regurgitation: idiopathic hypereosinophilic syndrome

Idiopathic hypereosinophilic syndrome (HES) is a rare multisystem condition characterized by dysregulated overproduction of eosinophils. Cardiac involvement in HES is characterized by necrosis from infiltration of eosinophils and thrombus formation and, in the late stage, by fibrosis and chronic valvular regurgitation. We report a very unusual presentation of idiopathic HES with acute mitral regurgitation due to papillary muscle rupture. The transesophageal echocardiogram was suggestive of a flail posterior leaflet and suspicious for endocarditis. Intraoperatively, papillary muscle rupture was seen and the patient underwent mitral valve replacement. The pathologic examination of the valve revealed eosinophilic infiltration of the papillary muscle. The patient was treated with steroids and responded well clinically.     

Cod glycopeptide with picomolar affinity to galectin-3 suppresses T-cell apoptosis and prostate cancer metastasis

Cancer metastasis and immune suppression are critical issues in cancer therapy. Here, we show that a β-galactoside–binding lectin [galectin-3 (gal3)] that recognizes the Thomsen-Friedenreich disaccharide (TFD, Galβ1,3GalNAc) present on the surface of most cancer cells is involved in promoting angiogenesis, tumor-endothelial cell adhesion, and metastasis of prostate cancer cells, as well as evading immune surveillance through killing of activated T cells. To block gal3-mediated interactions, we purified a glycopeptide from cod (designated TFD₁₀₀) that binds gal3 with picomolar affinity. TFD₁₀₀ blocks gal3-mediated angiogenesis, tumor-endothelial cell interactions, and metastasis of prostate cancer cells in mice at nanomolar levels. Moreover, apoptosis of activated T cells induced by either recombinant gal3 or prostate cancer patient serum-associated gal3 was inhibited at nanomolar concentration of TFD₁₀₀. Because the gal3–TFD interaction is a key factor driving metastasis in most epithelial cancers, this high-affinity TFD₁₀₀ should be a promising antimetastatic agent for the treatment of various cancers, including prostate adenocarcinoma.     

In Vivo Therapeutic Efficacy of Chloroquine Alone or in Combination with Primaquine against Vivax Malaria in Kolkata,West Bengal,India, and Polymorphism in pvmdr1 and pvcrt-o Genes

Plasmodium vivax malaria, though benign, has now become a matter of concern due to recent reports of life-threatening severity and development of parasite resistance to different antimalarial drugs. The magnitude of the problem is still undetermined. The present study was undertaken to determine the in vivo efficacy of chloroquine (CQ) and chloroquine plus primaquine in P. vivax malaria in Kolkata and polymorphisms in the pvmdr1 and pvcrt-o genes. A total of 250 patients with P. vivax monoinfection were recruited and randomized into two groups, A and B; treated with chloroquine and chloroquine plus primaquine, respectively; and followed up for 42 days according to the WHO protocol of 2009. Data were analyzed using per-protocol analyses. We assessed polymorphisms of the pvmdr1 and pvcrt-o genes by a DNA-sequencing method. Out of the 250 patients recruited, 204 completed a 42-day follow-up period, 101 in group A and 103 in group B. In group A, the non-PCR-corrected efficacy of CQ was 99% (95% confidence interval [CI], 0.944 to 1.00), and in group B, all cases were classified as adequate clinical and parasitological response (ACPR). Day 3 positivity was observed in 11 (5.3%) cases. No specific mutation pattern was recorded in the pvcrt-o gene. Eight nonsynonymous mutations were found in the pvmdr1 gene, three of which were new. The Y976F mutation was not detected in any isolate. Chloroquine, either alone or in combination with primaquine, is still effective against P. vivax malaria in the study area. (The study protocol was registered in CTRI [Clinical Trial Registry-India] of the Indian council of Medical Research under registration no. CTRI/2011/09/002031.)     

A human transferrin-vascular endothelial growth factor (hnTf-VEGF) fusion protein containing an integrated binding site for (111)In for imaging tumor angiogenesis.

Our objective was to synthesize a recombinant protein (hnTf-VEGF [VEGF is vascular endothelial growth factor]) composed of VEGF(165) fused through a flexible polypeptide linker (GGGGS)(3) to the n-lobe of human transferrin (hnTf) for imaging angiogenesis. The hnTf domain allowed labeling with (111)In at a site remote from the VEGF receptor-binding domain. METHODS: DNA encoding hnTf, peptide linker (GGGGS)(3), and VEGF(165) genes were cloned into the Pichia pastoris vector pPICZalphaB to generate the pPICZalphaB-hnTF-VEGF plasmid. The expression vector was transformed into P. pastoris KM71H strain. The protein was purified using Co(2+) metal affinity resin. The growth-stimulatory effects of hnTf-VEGF on human umbilical vascular endothelial cells (HUVECs) and its binding to porcine aortic endothelial cells (PAECs) transfected with VEGF receptors were evaluated. hnTf-VEGF protein was labeled with (111)InCl(3) in 10 mmol/L HEPES/15 mmol/L NaHCO(3) buffer, pH 7.4 (HEPES is N-(2-hydroxyethyl)piperazine-N'-(2-ethanesulfonic acid). The loss of (111)In in vitro from (111)In-hnTf-VEGF to transferrin in human plasma and to diethylenetriaminepentaacetic acid (DTPA) in buffer was determined. Tumor and normal tissue distributions of (111)In-hnTf-VEGF were evaluated in athymic mice implanted subcutaneously with U87MG human glioblastoma xenografts. Tumor imaging was performed. RESULTS: Sodium dodecylsulfate-polyacrylamine gel electrophoresis under reducing and nonreducing conditions showed bands for hnTf-VEGF monomer (M(r) of 65 kDa) and dimer (M(r) of 130 kDa). hnTf-VEGF stimulated the growth of HUVECs 3-fold and demonstrated binding to PAECs displaced by a 50-fold excess of VEGF(165) but not by apotransferrin. There was 21.3% +/- 3.4% loss of (111)In per day from (111)In-hnTf-VEGF to transferrin in plasma, but <5% loss to DTPA over 4 h. (111)In-hnTf-VEGF accumulated in U87MG tumors (6.7% injected dose per gram at 72 h after injection) and its tumor uptake decreased 15-fold by coadministration of a 100-fold excess of VEGF but not by apotransferrin. The tumor-to-blood ratio was 4.9:1 at 72 h after injection and tumors were imaged at 24-72 h after injection. CONCLUSION: (111)In-hnTf-VEGF is a promising radiopharmaceutical for imaging tumor angiogenesis and represents a prototypic protein harboring the metal-binding site of transferrin for labeling with (111)In without introducing DTPA metal chelators.     

Self-replantation of an avulsed tooth in torsoversion: a 10-year follow-up

Abstract –  A 15-year-old moderately built boy reported to the dental outpatient department with a complaint of pus discharge from the upper front teeth. There was a clear history of traumatic avulsion followed by self-replantation 6 years earlier. No dental treatment was taken by the child. On clinical examination the left upper central incisor was in torsoversion (anatomical labial surface on palatal side and vice versa). The child had probably self-replanted in torsoversion. Endodontic treatment was successfully completed, and final rehabilitation was done by a porcelain crown. The case highlights the excellent results of immediate replantation even when it is done by a child. It also highlights the value of school level dental education.