AIM: Local anesthetic toxicity remains one of the most dreaded complications of the intravenous regional anesthesia (IVRA) technique. It results from the sudden release of a large amount of local anesthetic (LA) into the systemic circulation. This release can occur when the tourniquet deflates accidentally during the procedure or when it is deflated intentionally at the end of the procedure to terminate the anesthesia. The forearm tourniquet IVRA technique may offer distinct advantages over the conventional upper arm tourniquet IVRA technique. Use of a forearm tourniquet allows the dosage of local anesthetic to be decreased to almost half of what is required with an upper arm tourniquet, and the incidence of tourniquet pain has been reported to be less with forearm tourniquet. In this study, authors assessed the clinical efficacy of administering IVRA with lidocaine plus ketorolac using either a forearm or upper arm tourniquet. METHODS: Upper arm IVRA was established using 0.5% lidocaine at a dose of 3 mg/kg with ketorolac at 0.3 mg/kg. Forearm IVRA was established using 0.5 % lidocaine at a dose of 1.5 mg/kg with ketorolac at 0.15 mg/kg. Quality of surgical anesthesia, onset and duration of sensory block and postoperative surgical pain and analgesic use were recorded and assessed. The incidence of local anesthetic toxicity and local complications due to the tourniquet were also recorded. RESULTS: Surgical anesthesia was assessed as excellent or good (grade 0/1) in all 20/20 patients who received IVRA using an upper arm tourniquet and in 19/20 patients who received IVRA using a forearm tourniquet (P=1.00). Onset as well as regression of sensory block was similar in both the groups. Post operative VAS scores at 30 min and 60 min were statistically comparable between the two groups, as was the analgesic use in the first 24 h. CONCLUSIONS: In conclusion, forearm IVRA provides effective perioperative anesthesia and analgesia. The technique results in a similar clinical profile as upper arm IVRA while using half the dose of both lidocaine and ketorolac.

BACKGROUND: Studies on incidence of childhood mental disorders are extremely rare globally and there are none from India. Incidence studies though more difficult and time consuming, provide invaluable information on the pattern and causes of occurrence of mental disorders allowing opportunity for early intervention and primary prevention. AIM: This study aimed at estimating the incidence of psychiatric disorders in school children. MATERIALS AND METHODS: A representative sample of school children was assessed through a two stage evaluation process involving teacher's rating (N=963) and parent rating (N=873). Children who scored below the cut-off for psychiatric disorder (N=727) on both the screening instruments were re-contacted six years later. 186 children and their families were personally available for reevaluation. All the children and their parents were re-assessed on Parent Interview Schedule; Strengths and Difficulties Questionnaire: and detailed clinical assessment by a psychiatrist. Psychiatric diagnosis was made as per ICD 10 criteria. Data on children who were found to have psychiatric disorder were compared with those who did not have psychiatric disorders. RESULTS: 20 children out of 186 followed up had psychiatric disorder giving the annual incidence rate of 18/1000/yr. Children who had disorder at follow-up did not differ from those who did not on age, gender and psychological (temperament, parental handling, life stress and IQ) parameters at baseline. DISCUSSION: Incidence figures cannot be compared due to lack of any comparable studies. Factors associated with occurrence of new cases of psychiatric disorder and implications for future studies are discussed.

BACKGROUND: Knowledge of normal tibial torsion is mandatory during total knee replacement (TKR), deformity correction and fracture management of tibia. Different values of tibial torsion have been found in different races due to biological and mechanical factors. Value of normal tibial torsion in Indian limbs is not known, hence this study to determine the norm of tibial torsional value in normal Indian population. MATERIALS AND METHODS: Computer tomography (CT) scans were performed in 100 non-arthritic limbs of 50 Indian adults (42 males, eight females; age 26-40 years). Value of tibial torsion was measured using dorsal tangent to tibial condyles proximally and bimalleolar axis distally. RESULTS: Normal tibial torsion was found to be 21.6 +/- 7.6 (range 4.8 to 39.5) with none of the values in internal rotation. Right tibia was externally rotated by 2 degrees as compared to the left side (P 0.029). No significant difference was found in male and female subjects. Value of tibial torsion was less than in Caucasian limbs, but was comparable to Japanese limbs when studies using similar measurement technique were compared. CONCLUSIONS: Indian limbs have less tibial torsion than Caucasian limbs but the value of tibial torsion is comparable to Japanese limbs.

PURPOSE. To measure the angular relationships of distal femoral rotational axes in 100 normal Indian knees. METHODS. 42 men and 8 women aged 26 to 40 (mean, 31) years, with 100 normal non-arthritic knees were recruited. Anatomic landmarks were measured using computed tomography. They included the posterior condylar axis, the transepicondylar axis, the anteroposterior axis (Whiteside's line), the posterior condylar angle (PCA), the Whiteside-epicondylar angle (W-EP), and the Whiteside-posterior condylar angle (W-PC). RESULTS. The mean PCA, W-EP, and W-PC were 5, 90.8, and 95.8 degrees, respectively. The mean femorotibial alignment was 179.6 degrees. The differences between the left and right sides were significant only for the WEP and W-PC. Only the PCA and W-EP were weakly correlated (r=0.338, p=0.001). CONCLUSION. There are differences in distal femoral rotational axes among Indian, Caucasian, and Japanese knees. Our data can be used to evaluate changes in those axes in ageing or arthritic patients.

We measured the circular dichroism (CD) and absorption spectra of the B-band region of microperoxidase 11 (MP11) as a function of temperature and peptide concentration. At micromolar concentrations, small MP11 dimers or trimers lead to excitonic coupling between low-spin and high-spin heme groups, to which the NH(2) group of the MP11 N-terminal and H(2)O are bound as a sixth ligand, respectively. These aggregates convert into monomers with hexacoordinated high-spin heme groups with increasing temperature. This transition can be described by a two-state model. Aggregation becomes more extended at 50 muM concentration and causes some B-band hyperchromism, which reflects a J-type arrangement of heme groups linked together in the aggregates formed. At near-millimolar concentration, the CD and absorption spectra of the B-band region suggest the existence of even more extended and thermally stable aggregates, which might involve mu-oxo dimers of the heme groups. The degree of aggregation at 50 and 500 muM concentration increases substantially if the sample is freed from most of its oxygen in a N(2) atmosphere. The CD spectrum of the monomeric high-spin species is reminiscent of that observed for the unfolded alkaline conformation of the intact protein. Finally, we investigated the binding of acetylmethionine (AcM) ligands to the heme at aggregation-supporting conditions (500 muM concentration). The data suggest that the ligand prevents any substantial aggregation. As a surprising result, our data reveal that AcM-MP11 complexes exhibit a high-spin/low-spin mixture, with the high-spin configuration being stabilized at high temperatures.

Mutations can accumulate in the protease and gag genes of HIV in patients who fail therapy with protease inhibitor drugs. Mutations within protease, the drug target, have been extensively studied. Mutations in gag have been less well studied, mostly concentrating on cleavage sites. A retroviral vector system has been adapted to study full-length gag, protease and reverse transcriptase genes from patient derived viruses. Patient plasma derived mutant full-length gag, protease and gag-protease from a multi drug resistant virus were studied. Mutant protease alone lead to a 95% drop in replication capacity that was completely rescued by co-expressing the full-length co-evolved mutant gag. Cleavage site mutations have been shown to improve the replication capacity of mutated protease. Strikingly, in this study matrix and part of capsid from the co-evolved mutant gag was sufficient to achieve full recovery of replication capacity due to the mutant protease, without cleavage site mutations. The same region of gag from a second, unrelated, multi-drug resistant clinical isolate also rescued the replication capacity of the original mutant protease, suggesting a common mechanism that evolves with resistance to protease inhibitors. Mutant gag alone conferred reduced susceptibility to all protease inhibitors, and acted synergistically when linked to mutant protease. The matrix and partial capsid region of gag sufficient to rescue replication capacity also conferred resistance to protease inhibitors. Thus the amino terminus of Gag has a previously unidentified and important function in protease inhibitor susceptibility and replication capacity.

Event-related-potentials (especially P300) and cognitive functioning as potential endophenotypes have not been studied in opioid dependence. We compared auditory P300 and cognitive functions in opioid-dependent men, their brothers and normal controls in an exploratory study with a view to find shared genetic factors in the development of opioid dependence. Twenty abstinent opioid-dependent males, their brothers and twenty matched controls were administered Wisconsin card sorting test (WCST), digit span test, trail making test-B, and auditory event-related potentials (P300) from an oddball task were recorded. The opioid dependent group performed the worst, the brothers group was intermediate, and the control group performed the best on tests of WCST, digit span and trail making test-B. The opioid dependent group had the smallest amplitudes and longest latencies of P300, and was followed by the brothers group who had an intermediate position and the control group who had the largest amplitudes and the shortest latencies. P300 and executive neurocognitive functions can be considered endophenotypes for the genetic study of vulnerability to opioid dependence. These are reflective of executive dysfunction and disrupted behavioral inhibition and the intermediate position of brothers suggests a common genetic substrate as a component of the etiology.

OBJECTIVE: To describe and compare sexual and injecting risk behaviours and sexually transmitted infections (STI), hepatitis C virus (HCV) and HIV prevalence in injecting drug users (IDU) in six districts in three states of India: Manipur, Nagaland, and Maharashtra. METHOD: The respondent-driven sample consisted of 2075 IDU. Consenting participants were administered a structured questionnaire and samples of blood and urine were collected to test for HIV and STI. Data were analysed using RDSAT. RESULTS: In two districts in Manipur, 77 and 98% of IDU injected heroin, whereas the main injecting drug in Nagaland was dextropropoxyphene (99%). In Mumbai/Thane, Maharashtra, the majority of respondents reported using chlorpheniramine (87%) and heroin (99%). In all districts, almost half of IDU reported generally sharing needles and syringes; consistent condom use with non-paid female partners was also low. Approximately one-quarter of IDU in Mumbai/Thane visited a paid partner in the past year. IDU with reactive syphilis serology were higher in Nagaland (7 and 19%) than in Manipur and Maharashtra. HIV in two districts of Manipur (23%, 32%) and Mumbai/Thane (16%) was greater than Nagaland (<2%). HCV prevalence was more than 50% in Mumbai/Thane and Manipur. CONCLUSION: Irrespective of regional differences, high-risk behaviour of needle sharing and low condom use makes IDU a critical subpopulation for HIV prevention interventions. Interventions need to address the differing drug use patterns in the regions and transmission prevention among non-paid regular and casual female partners of IDU in the northeast districts and paid female partners in Mumbai/Thane.

OBJECTIVE: To describe the sociodemographic characteristics, prevalence of high-risk sexual behaviours, HIV, sexually transmitted infections (STI), and perception of risk in self-identified men who have sex with men (MSM) in four south Indian states. METHODS: A cross-sectional probability-based survey of 4597 self-identified MSM in selected districts from four states in south India was undertaken. Self-defined sexual identity, sexual behaviour, and STI/HIV knowledge were assessed using a structured questionnaire. Blood and urine samples were tested for HIV and STI. Recruitment criteria differed slightly across states. RESULTS: When grouped by self-identity, the HIV prevalence was: hijra (transgender) 18.1%; bisexuals 15.9%; kothis (anal-receptive) 13.5%; double-deckers (both anal-insertive/anal-receptive) 10.5%; and panthis (anal-insertive) 7.6%. Reported condom use with last paid male partner was over 80% in all states and categories. Consistent condom use was overall low among self-identified MSM, with less than 29% with non-commercial non-regular male partners and less than 49% with regular male partners. The percentage of self-identified MSM with regular female partners was 4-43% and with commercial female partners was 14-36% across states, and consistent condom use differed by self-identity. Syphilis prevalence was high among kothis and hijras (15.8 and 13.6%, respectively). Urethral gonorrhoea prevalence was less than 1% and chlamydia prevalence ranged from 0.4 to 4.0%. CONCLUSION: HIV prevalence and risk behaviour within these self-identified MSM communities in south India is high. Moreover, a significant proportion of them had female partners, both regular and commercial. The national programme's focus on HIV prevention services for these high-risk MSM is justified.

OBJECTIVES: To describe formal, external to programme methods for size estimation of high-risk populations and compare execution challenges and validity of results. DESIGN: A cross-sectional HIV risk behavioural and biological survey was implemented among 24, 10 and five female sex workers, high-risk men who have sex with men and injecting drug user survey groups, respectively. Size estimates were calculated using three formal methods: capture-recapture, the multiplier method and the reverse tracking method (RTM), a new method. METHODS: Estimates were compared with each other and programme data. RESULTS: In general, when appropriately executed, formal methods produced smaller estimates to programme data, although the RTM tended to be closer to programme estimates. CONCLUSIONS: Capture-recapture requires some knowledge of site location. It can be used as a community mobilization measure at the initiation of a programme. The multiplier method presumes the existence of high quality external data and requires care in selecting the appropriate multiplier. All size estimation methods require careful planning and a full understanding of population dynamics and limitations of data. Before selecting a size estimation method, one must be aware of the strengths, weaknesses and applicability of each method. Use of size estimation methods in large-scale programmes should be considered carefully with adequate importance given to planning and implementation.