Evaluation of total Lymphocyte Count and Absolute Lymphocyte Count as a Surrogate Marker for CD4 Count to Initiate ART

INTRODUCTION: The burden of HIV remains high for patients and their families especially in resource limited settings. It is estimated that 40 million people with human immunodeficiency virus (HIV) reside in resource limited settings. Among them it is reported that 6 million require highly active anti retroviral therapy (HAART). Ideally the WHO recommends regular combined immunological and virological monitoring for all HIV infected patients. Analysis for viral loads and CD4 counts require not only sophisticated equipment, but in addition, highly skilled laboratory personnel. The initiation of antiretroviral therapy is based on CD4 counts of less than 350 cells/mm3 according to the World Health Organization (WHO) and National AIDS Control Organisation (NACO). The determination of CD4 count however in resource-limited localities is difficult. A total lymphocyte count (TLC) of <1200 cells/mm3 has been recommended in addition to WHO staging (stage II) of the disease, for the initiation of antiretroviral therapy in such localities. The use of absolute lymphocyte count as a marker for HIV progression has been argued in many quarters over the years . Studies have suggested that when the absolute lymphocyte count is used in conjunction with blood hemoglobin, gives a more sensitive marker for HIV progression. Also studies have demonstrated the usefulness of absolute lymphocyte count (ALC) or total lymphocyte count (TLC), in identifying patients who would benefit from initiating prophylaxis for acquired immunodeficiency syndrome (AIDS)-related opportunistic infections. This study is being conducted to evaluate the correlation of TLC and ALC to CD4 count for initiating HAART in HIV-infected patients, as there are fewer published studies on this subject, from resource-limited settings. AIMS AND OBJECTIVES: 1. To evaluate the correlation of CD4 counts with the TLC and ALC to suggest that these can be used as a surrogate for CD4 count to initiate ART in resource limited settings. 2. To determine a range of TLC and ALC cut-offs for predicting CD4 count <350 cells/μl, which is important for the initiation of ART and for CD4 count 200CELLS/μL. MATERIALS & METHOD: The present study was conducted on HIV seropositive patients admitted in any wards or attending outpatient departments of Government Rajaji Hospital, Madurai during the period of Jan 2016 to June 2016. The study included 100 cases of newly detected HIV positive patients. All subjects fulfilled eligibility criteria, and none of the exclusion criteria were included in the study. METHODOLOGY: A previously designed proforma is used to collect the demographic and clinical details of the patients. All the patients underwent detailed clinical evaluation, appropriate investigations. History was taken on details of unprotected sexual intercourse, blood transfusion ,IV drug abuse, repeated respiratory infections, fever, recurrent diarrhoea and unexplained weight loss. Presence of lymphadenopathy, oral ulcers, splenomegaly and peripheral neuropathy will be noted. Hemoglobin, complete blood count including total WBC count and differential count, blood urea, serum creatinine, blood glucose, liver function tests including serum bilirubin, serum transaminases, will be estimated. CD4 count, Total lymphocyte count and absolute lymphocyte count are also estimated .The study group was divided on the basis of CD4 count into >350 cells / cu.mm, 200 to 350 cells/cu.mm 100 to 200 cells/cu.mm and <100 cells/cu.mm amd mean for absolute lymphocyte count and total lymphocyte count and haemoglobin was studied in these groups. RESULTS: In our study 100 patients were randomly selected of which 67% were males and 33% were females. Majority of patients in our study were in reproductive age group (21 to 50 years). This indicates a trend of young and productive generation being affected; a reflection of the devastating effects India will face as the younger generation work force is affected. Most common mode of HIV transmission was heterosexual. Also there is a rise in transmission through male to male sexual contact. In our study TLC<1100 cells/cu.mm correlates with CD4 count <200 cells/μL and TLC < 1300 cells/ cu.mm correlates with CD4 count <350 cells /μL. In our study using WHO clinical staging 4 when correlated with CD4 count < 200 cells/μL we get a significant statistical p value. Patients with stage 4 had mean CD4 count 155.86 cells/μL and patients with CD4 count < 200 cells/μL were in stage 3 or stage 4(93%).The mean Hemoglobin for CD4 count <350 cells/μL is 6.26 gm% and the mean haemoglobin for CD4 count <200 cells/μL is 5.6 gm%. The mean ALC for CD4 count <350 cells/μL is 1066.56 cells/cu.mm. and the mean ALC for CD4 count <200 cells/μL is 978.75 cells/cu.mm. CONCLUSION: In all the patients various clinical and inexpensive laboratory measures such as WHO clinical staging, Total lymphocyte count, Hemoglobin, Absolute lymphocyte count were done and correlated with CD4 count. It was analysed that these parameters can used as a surrogate marker for CD4 count to initiate HAART

Exploring Societal Perplexes & Cultural Quandary in Amulya Malladi’s The Mango Season

Literature is a work of art blended with an aesthetic and artistic creation specifically in the written form. There are indeed many different kinds of literature around the globe, but Indian English Literature has its special qualities that make it stand out to readers. Indian English Literature is an amalgamation of various themes such as socio-historical, multicultural, and multilingual objectives. Amulya Malladi is an Indian women diasporic writer, she brings the concept of cultural dilemmas in her work. This paper investigates Amulya’s second fiction ‘The Mango Season’ and highlights the societal complications/ cultural confusions faced by the protagonist Priya Rao. Due to religious and cultural differences, the protagonist suffers a lot to decide between her love for her family and her love for her beloved. Cultural dilemmas are primarily the result of two living experiences that develop in one’s own country and in the host land. ‘The Mango Season’ is very naturalistic in its depiction of cultural confusions & societal norms faced by the protagonist who is well educated and graduated in the West while her parents are down-rooted in the Orient culture

INDUCED PHENOLOXIDASE PROFILES IN SILKWORM Bombyx mori (L.) UNDER BIOTIC STRESS

Phenol oxidase (PO) is one of the stress enzyme protein in living organism. The conversion of Pro-PO into an activation form of PO required a stress protein. In the present study has emerged with the novel finding of induced phenoloxidase was identified under bacterial endotoxin viz., Lipopolysaccharide (LPS) activity using silkworm Bombyx mori as an animal model. The PO enzyme plays an important role for insect survival during pathophysiological conditions. The enzyme activity was analyzed from ten different silkworm races with two phenolic substrates viz., L-Dopa and Dopamine by Native-PAGE. The bacterially induced PO was found in hemolymph and midgut of silkworm, PO3 were induced by LPS injection. In control PO1 & PO2 are non-bacterially induced protein having the molecular weight of 72 and 71. The results shown that there is no substrate specificity and similar functional activity was found in hemolymph and midgut under pathogenic condition. It was observed that bacterially inducible PO clearly differed from non-inducible PO (control). At final observation of induced isozymes of PO in the haemolymph and midgut system of tolerant silkworm races points out the existence of biochemical immunity against biotic stress of LPS. This is the first report to document the silkworm immunity under the LPS toxin in different silkworm races to identify the tolerant and susceptibility against a biotic stress

A Study on the Coagulation Profile and Its Clinicopathological Correlation of the Haemophilia Patients at the Day Care Centre of Tirunelveli Medical College

BACKGROUND: Haemophilia is a commonest hereditary bleeding disorder . It includes Haemophilia A ,Haemophilia B. It occurs due to deficiency of clotting factors Factor VIII and Factor IX respectively. People with Haemophilia bleed continuously as blood is unable to clot due to deficiency of clotting factors. They present with haemarthrosis, soft tissue hematomas or prolonged bleeding after trauma. Functional Independence Score in Haemophilia (FISH) is used to assess the degree of disability. Basic laboratory investigations like CBC and APTT can be used to assess the severity of the disease. METHODOLOGY: This study was done as a prospective study at Haemophilia day care centre Tirunelveli Medical college hospital from March 2017 to September 2018(18 months). The study population included 35 cases. Detailed history regarding onset and progression of the disease, family history,age of diagnosis of the disease, treatment history were asked. Patients were examined for physical disability, Disability assessment is done using Functional Independence Score in Haemophilia (FISH) in which every patient is examined for 7 activities under 3 categories for a total score of 28. Basic laboratory investigations like CBC and APTT are done using semi automated analyser. APTT values are correlated with the FISH scores and the severity of the disease is assessed. RESULTS: In our study out of 35 cases 33 cases were severe haemophilia, 2 cases were mild haemophilia. FISH score was low in patients with severe haemophilia 99 was noted in 2 patients and they had a mean FISH score of 16. 1 patient had APTT within normal range (i.e.,) below 38 sec and his FISH score was 25. It was found that for progressive increase in APTT values the mean FISH score was decreasing indicating that increase in APTT is associated with the increasing severity of the disease. CONCLUSION: Though FISH score has been a vital tool in assessing the severity of the disease, haemoglobin and APTT could help in effective management of haemophilic patients on regular therapy

Chlorhexidine-alcohol versus Povidone-Iodine-alcohol for surgical site antisepsis in caesarean section

Background: Caesarean section is one of the most common procedures performed. Recent studies found that surgical-site infection (SSI) was the most common healthcare-associated infection. Authors hypothesized that optimization of preoperative skin antisepsis may decrease postoperative infections. The objective was to establish the efficacy of chlorhexidine-based antiseptic protocol versus povidone-iodine protocol in reducing SSI for patients undergoing caesarean deliveries.Methods: This is a randomized prospective study conducted from April 2017 to September 2017 at a tertiary care center in India. Women who underwent caesarean sections were allocated into either group. Enrolled patients were randomly assigned to have the surgical site painted with chlorhexidine-alcohol preparation or painted with a solution of 10% povidone-iodine and then with surgical spirit. The outcomes were any SSI occurring within a week or during the 30 day follow up period of the surgery including any of: superficial or deep surgical site infection, or endometritis, according to Centers for Disease Control and Prevention definitions.Results: A total of 560 subjects (273 in the chlorhexidine group and 287 in the iodine group) qualified for the study. The number of surgical-site infection was significantly lower in the chlorhexidine group than in the iodine group (6.95% vs. 14.28%; P=0.005). Chlorhexidine–alcohol was significantly more protective than iodine-alcohol against both superficial incisional infections (5.49% vs. 10.10%, P=0.03) and deep incisional infections (1.46% vs. 4.18%, P=0.04).Conclusions: This study highlighted that Chlorhexidine-alcohol provided superior skin antisepsis in comparison to povidone iodine-alcohol

Crystal structural studies of ethyl-5-(4-chlorophenylsulfonyl)-4-hydroxy-2, 6-dip-tolyl-1, 2, 5, 6-tetrahydropyridine-3-carboxylate and diethyl 4-hydroxy-2-(4-nitrophenyl)-5-(phenylsulfonyl)-6-(phenylsulfonylmethyl)cyclohexa-3,6-diene-1,3-dicarboxylate

The crystal structures of trans,trans-Ethyl-5-(4-chlorophenylsulfonyl)-4-hydroxy-2,6-dip-tolyl-1,2,5,6-tetrahydropyridine-3-carboxylate (Ia) and cis-Diethyl 4-hydroxy-2-(4-nitrophenyl)-5-(phenylsulfonyl)-6-(phenylsulfonylmethyl)cyclohexa-3,6-diene-1,3-dicarboxylate (Ib) were elucidated by single crystal X ray diffraction. Compound (Ia) C28H28Cl NO5S, crystallizes in the monoclinic system, space group P 21/c, with a = 9.4530(7) Å, b = 25.366(2) Å, c = 11.4353(8) Å, β = 103.092(7)°, V = 2670 (3) Å3 and   Z = 4. The compound (Ib), C31H29N1O11S2, crystallizes in the monoclinic system, space group P 21/c, with a = 21.179(4) Å, b = 8.4998(16) Å, c = 17.347(3) Å, β = 102.563(3)°, V = 3048.0(10) Å3 and Z = 4. The central piperidine ring of compound (Ia) adopts the sofa conformation and the central cyclohexadiene ring of compound (Ib) adopts the boat conformation.  Details of the compounds preparation, crystal structures and hydrogen bonding interactions of the compounds are discussed

Spectral analysis and crystal structure of two substituted spiro acenaphthene structures

The crystal structure of spiro[2.2"]acenaphthene-1"-onespiro[3.3']-5'-(2-bromophenylmethylidene)-1'-methylpiperidin-4'-one-4-(2-bromophenyl)octahydroindolizine (Ia) and spiro[2.2"]acenaphthene-1"-onespiro[3.3']-5'-(4-bromophenylmethylidene)-1'-methylpiperidin-4'-one-4-(4-bromophenyl)octahydroindolizine (Ib) were elucidated  by single crystal X ray diffraction. Compound (Ia), C37H32Br2N2O2, crystallizes in the Orthorombic  system, space group  P212121 with a = 9.6989(5) Å, b = 16.3615(9) Å, c = 19.8997(11) Å and Z = 4. Compound (Ib), having the same molecular formula, crystallizes in the monoclinic system, space group P 21/n with a = 8.3169(5) Å, b = 16.9397(9) Å, c= 22.2466(13) Å, β = 96.943(3)° and Z = 4. The central piperidine ring adopts twisted conformation, the piperidine of octahydroindolizine ring is in half chair conformation and the pyrrole ring is in twisted envelope conformation in both the compounds (Ia) and (Ib). Details of the preparation, NMR and crystal structure determination and intra- and inter- molecular interactions of the compounds are given

Piperine Modulates High Fat Diet - Induced Renal Damage by Regulating Kim-1 and Igf-1 Beta Signaling Molecules in Male Wistar Rats

Diabetes mellitus is a chronic metabolic disorder characterized by hyperglycemia and other symptoms which ultimately cause various other complications like retinopathy , micro angioplasty and nephropathy . piperine shows antidiabetic activity by improving insulin level, signifying its usage in the management of hyperglycemia. IGF-1 is the insulin-like growth factor receptor . KIM-1 has proved to be an outstanding early indicator of kidney injury in the rats. Induction of type 2 diabetes to male wistar albino rats , they were divided into four groups , one group were treated with piperine , fasting blood glucose was analysed. Biochemical analysis and mRNA expression analysis of KIM-1 and IGF-1 by RT-PCR is done. Fasting blood glucose and the serum insulin was elevated in diabetes induced rats . piperine-treated animals exhibited a significant decrease in the level of FBG and serum insulin from the above study, it could show that piperine possesses antidiabetic activity

Effect of Piperine on an Nrf2/Keap 1 Signalling Mechanism in Adipose Tissue of High Fat Diet and Sucrose-Induced Experimental Diabetic Rats

Piperine, an alkaloid compound found in black pepper has been shown to have various health benefits such as anti-oxidants, anti-inflammatory, and anticancer activities. But mechanisms underlying the anti-diabetic activity are unclear. Keap1-Nrf2 is an anti-oxidant stress signal pathway and it is considered to be an intracellular defence mechanism to countered oxidative stress. The study was aimed at assessing antidiabetic activity of piperine against high fat diet and sucrose-induced (HFD) type-2 diabetic rats by regulating the expression of Nrf2/Keap 1 signalling. Healthy adult male albino rats of wistar strain were grouped in to 5. Considering healthy control (group-1), HFD-induced type-2 diabetes (group2), Diabetic rats treated with piperine (group 3), diabetic rats metformin (group 4) and control +Piperine treated rats ( group 5) respectively. After 30 days of treatment, fasting blood glucose (FBG) checked and adipose tissue from control and treated groups was used to determine the role of piperine on the expression of NrF2/Keap 1 mNRA in adipose by Real Time-PCR analysis. Data were analysed by one-way ANOVA and p&lt;0.01 was considered to be statistical significance among the groups. HFD-induced T2DM showed a significant increase in the levels of FBG and altered levels of Nrf-2 and Keap-1 gene expression (2 fold) compared to normal control animals. Piperine at a dose of 40mg, fascinatingly improved the glycemic control and normalised the mRNA expression of both Nrf-2 and Keap-1 whose effects were near to that of standard drug metformin level (p&lt;0.05) proving its potential mechanism of action. Conclusion: Our current study clearly indicates that piperine controls hyperglycemia in type-2 diabetic rats by facilitating the expression of antioxidant signalling (Nrf-2/Keap-1) in the adipose. In addition, this is the first of its kind to show the role of piperine in reducing hyperglycemia against high fat diet and sucrose –induced type-2 diabetic rats as an invivo experimental model. Hence, piperine could be considered as an important health supplement and potential drug candidate for the treatment of diabetes

Maternal and perinatal outcome of Evan’s syndrome: a 5 years study in a tertiary care centre

Background: Evans syndrome is a rare autoimmune disorder characterized by simultaneous or sequential presence of a positive antiglobulin test, autoimmune haemolytic anemia (AIHA), and immune thrombocytopenia (ITP). It is characterised by frequent exacerbations and remissions within a chronic course. It was first described by Robert Evans in 1951.  Incidence of AIHA is 1 per 75 - 80,000 and ITP is 5.5 /100000 per general adult population.  Incidence of Evans syndrome is 1.8% to 10% of patients with ITP. Objective was to study the maternal and perinatal outcome of women with Evans syndrome (E).Methods: About 4 antenatal mothers were identified with Evans syndrome at St. Johns medical college and hospital, Bengaluru during the study period of 5 years from July 2013-July 2017. They were followed up during their antenatal, intra natal and postnatal period and outcomes were studied. All patients included in the study fulfilled the criteria for Evans syndrome.Results: There were 4 cases of Evans syndrome, with a total number of deliveries of 11859, during this 5 year study. Incidence was 0.09 per 1000 births. All patients presented with bleeding manifestations ranging from mucosal haemorrhage to subarachnoid haemorrhage (SAH) at the time of diagnosis. All patients were on treatment with either 1st or 2nd line of management with corticosteroids/ azathioprine. None had bleeding during pregnancy after the initiation of treatment. Patients had antenatal complications like preeclampsia 25%, IUGR 25%, oligohydraminos 50%, IUD 25%. 2 patients received platelet transfusions intrapartum. None had intrapartum or postpartum haemorrhage. There were no maternal and neonatal mortality.Conclusions: Evans syndrome in pregnancy is a rare condition and requires multi disciplinary approach involving specialists from obstetrics, neonatology, and hematology. Close maternal and fetal surveillance and management during pregnancy is essential to increase the possibility of a favourable pregnancy outcome in these women