Genetic polymorphisms associated with sulphadoxine-pyrimethamine drug resistance among Plasmodium falciparum field isolates in malaria endemic areas of Assam

Background:

The emergence of antimalarial drug resistance malaria parasite is widespread in North eastern region of India. During January 2012-December 2013, we conducted active surveillance for detection of antifolate resistance-associated genetic polymorphisms in Plasmodium falciparum malaria parasite from different malaria endemic areas of Assam.

Materials and Methods:

A total of 281 field samples were collected from suspected malaria patients of which 106 malaria P. falciparum positive cases were detected in microscopic slide examination. A nested PCR was done for amplification of a 648 bp portion of the dhfr gene and 710 bp portion of the dhps gene.

Results:

Mutation analysis revealed existence of three different haplotypes of the P. falciparum dhfr gene of which ANRNI was highly prevalent (90%). Triple mutant haplotypes AIRNI (N51I + C59R + S108N) of the dhfr gene associated with pyrimethamine resistance were prevalent in Chirang district of Assam. Whereas, dhps mutation study revealed that triple mutant haplotype AGEAA (S436A + A437G + K540E) associated with Sulphadoxine resistance was found among 26% of P. falciparum field isolates. However, P. falciparum dhfr-dhps two locus mutation analysis showed that there were a total of nine dhfr-dhps genotypes.

Conclusion:

It was noticed that 93.62% (88/94) isolates had mutations in the sequences of both enzymes, which is an indication of prevalence of high grade of Sulphadoxine — pyrimethamine resistance in P. falciparum malaria parasites in Assam.

Acute Pulmonary Embolism after Cesarean Section

Pregnancy is a well-known state of hypercoagubality, increasing the risk of venous thromboembolism (VTE). It is more common with cesarean delivery than vaginal delivery. Pulmonary Embolism (PE) is under diagnosed during pregnancy and postpartum period as majority of signs and symptoms of PE are non-specific. We describe a case of 35-yearold obese female who suffered a syncopal attack following caesarean delivery and was diagnosed to have pulmonary embolism. A high index of suspicion is required for the timely diagnosis and treatment of PE as most of the signs and symptoms of PE are nonspecific. It is important to consider VTE prophylaxis especially in patients with risk factors.

Population genetic study of Plasmodium falciparum parasites pertaining to dhps gene sequence in malaria endemic areas of Assam

Plasmodium falciparum malaria parasite had developed resistance to almost all the currently used antimalarial drugs. The purpose of the study was to come across the genetic distances in P. falciparum dhps gene sequences circulating in Assam. A partial fragment of P. falciparum dhps gene containing major single nucleotide polymorphisms associated with sulphadoxine resistance were amplified and sequenced. Thereafter specific bioinformatics tools like BioEdit v7.0.9, ClustalW in Mega 5, DnaSP version v.5.10.01 etc were used for the analysis. A total of 100 P. falciparum positive cases in different malaria endemic areas of Assam were included for the study. Based upon the mutation analysis, a total of seven different P. falciparum dhps genotypes were observed with five variable sites. Maximum five haplotypes were found in the P. falciparum isolates from Jorhat district of Assam. Four polymorphic sites were observed in the P. falciparum dhps gene sequences in Karbi Anglong, NC Hills, Chirang and Jorhat whereas the isolates from other study areas had three polymorphic sites. A statistically significant positive value of Tajima's D were observed among the P. falciparum field isolates in Assam indicating that there is an excess of intermediate frequency alleles and can result from population bottlenecks, structure and/or balancing selection. Extensive gene flow took place among the P. falciparum population of Jorhat with Sivasagar, Chirang with Sivasagar and Chirang with Karbi Anglong. However, large genetic differentiation was observed among the P. falciparum isolates of NC Hills with Lakhimpur, Tinsukia, Dibrugarh and Golaghat and also the parasite population of Karbi Anglong with Lakhimpur and Tinsukia signifying little gene flow among the population. This finding has shown that mutant Pfdhps gene associated with sulphadoxine resistance is circulating in Assam. It is believed that, the parasite population may have undergone high level of breeding.

Image registration under translation and rotation in two-dimensional planes using Fourier slice theorem

Image recognition in the presence of both rotation and translation is a longstanding problem in correlation pattern recognition. Use of log polar transform gives a solution to this problem, but at a cost of losing the vital phase information from the image. The main objective of this paper is to develop an algorithm based on Fourier slice theorem for measuring the simultaneous rotation and translation of an object in a 2D plane. The algorithm is applicable for any arbitrary object shift for full 180° rotation.

Intravenous Iron Sucrose Therapy in Iron Deficiency Anemia in Antenatal and Postnatal Patients

INTRODUCTION

Iron deficiency anemia is the most common nutritional deficiency in pregnancy and more common in developing countries which is aggravated due to increased demand and blood loss during delivery. Though there are different methods for treating iron deficiency anemia. Iron sucrose is being used because of its minimal side effects. This study was undertaken to evaluate the response and effect of intravenous iron sucrose given to patient in antenatal and postnatal period with moderate iron deficiency anemia.

METHODS

A hospital based prospective study was conducted 1st Jan 2013-30th Dec 2014 in the department of obstetrics and gynecology Kathmandu Medical College, Teaching Hospital Kathmandu, Nepal. Antenatal and postnatal patients with hemoglobin between 5-9 gm% with diagnosed iron deficiency anemia were included in the study. The aim was to bring her hemoglobin level to 11gm%.

RESULTS

All together 37 patients were enrolled out of which two patient were dropped due to allergic reaction and 35 patients were included in study. Iron sucrose therapy is effective in achieving target hemoglobin of 11gm/dl in 80% of patients. It showed that intravenous iron sucrose significantly (P < 0.001) increase hemoglobin level within two weeks of therapy without any major adverse effects.

CONCLUSIONS

Iron sucrose therapy is safe, effective and well tolerated for the treatment of iron deficiency anemia. Parental iron therapy was effective in increasing hemoglobin, serum ferritin and other hematological parameters in antenatal and postnatal patients with anemia. The treatment will help to reduce the risk of maternal complication during pregnancy and postpartum and its adverse effect to fetus.

Factors influencing elevated serum apolipoprotein B48 in diabetic and control participants

Factors influencing the concentration of apolipoprotein B48 (apo B48) at fasting and post-prandial time frames are still being elucidated. This study assesses some possible contributing factors including the presence of type 2 diabetes and gender using an established enzyme-linked immunosorbent assay (ELISA) method. Apo B48 and triglyceride (TG) levels were measured before and for two, four and six hours post-prandially in 49 poorly controlled participants with type 2 diabetes and in 60 apparently healthy participants (controls). Apo B48 levels in the control participants increased post-prandially, peaking at four hours (14.81 ± 7.72 μg/mL) with similar responses demonstrated in TG concentrations. Post-prandial apo B48 levels were significantly higher in male control participants as demonstrated by apo B48 area under the curve (AUC); similar responses were also confirmed in triglyceride AUC. Post-prandial apo B48 concentrations in control participants correlated with HOMA-IR (P < 0.05). Apo B48 continued to increase throughout the six hours in participants with type 2 diabetes (17.73 ± 13.46 μg/mL), when levels were significantly greater than in the control participants (13.04 ± 7.67 μg/mL) (P < 0.05) despite a decrease in accompanying TG levels in participants with type 2 diabetes. Using an ELISA method, this study demonstrated that gender, insulin resistance (as evidenced by HOMA-IR) and diabetes status influence serum apo B48 levels. These effects were only apparent post-prandially.

Obstetric Hysterectomy and Maternal Survival

Aims: This study was done to analyze the cases of obstetric hysterectomy and maternal complications and survival after that. Methods: A retrospective study was carried out from the review of records   of the near miss, maternal mortality, cesarean audit and operation theater record of the Department of Obstetrics and Gynaecology, Tribhuvan University Teaching Hospital (TUTH), Kathmandu from 2057-2071 BS. Results: Fourteen maternal survival resulted following total of 19 obstetric hysterectomy, subtotal hysterectomy being the procedure of choice in 11 cases, emergency peripartum hysterectomy (EPH) being performed in abundance (18/19) in comparison to an elective peripartum hysterectomy, which was undertaken in a single case of placenta percreta, and inclusive of latter were four cases of morbid placental adhesion, a placenta increta and two placenta accreta. Eight out of 19 cases had vaginal delivery and rest had cesarean section. Among seven cases of cesarean hysterectomy 3 were done for placenta previa with accreta one case each done for abruptio placentae  and placenta accreta and two cases were done for extra placental causes. Among four cases of emergency peripartum hysterectomy (EPH), which were relaparotomy followed by hysterectomy, three cases were done for complication of cesarean section and one done for uterine atonicity. Four cases of spontaneous vaginal deliveries needed peripartum hysterectomy two of them were complicated by morbid placental adhesion placenta increta (1), placental percreta (1), two cases were vaginal birth after cesarean (VBAC). Seven cases of uterine rupture had undergone peripartum hysterectomy.   Conclusions: Obstetric hysterectomy is a lifesaving surgical procedure for maternal survival whenever necessary and mandates a quick decision making process, however in consideration of younger age and low parity or nulliparity, the best obstetric governance and services must foresee not to let mothers meet such situation necessitating organ removal and to enjoy potential reproductive life cycle.DOI: http://dx.doi.org/10.3126/njog.v9i2.11759    

Factors Influencing Perception of Labor Pain among Parturient Women at Tribhuvan University Teaching Hospital

Aims: This study was done to understand the severity of labor pain in parturients of Kathmandu and to determine factors affecting it. Methods: A descriptive study was conducted in Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal where 300 term parturientsin active labor (cervical dilatation of 3-5 cm with three uterine contractions in 10 minutes each lasting for ≥ 30 seconds) were analysed for socio-demographic data, clinical profile and pain assessment.Visual analog scale was used for pain assessment. Results: The intensity of labor pain was graded as severe by 32%, moderateby 57% and mild by 11% of parturients.Almost half ofthe parturients in the age group of ≤19years described labor pain as severe as compared to women between 20-34years (30.4%) and ≥35years (20%). Among the nulliparous parturients, 37% described it as severe compared to only 20.7% in≥Para1.In those with≥higher secondary leveleducation, 35.9% described labor pain as severe as compared to those women who had education of ≤primary level(26.9%) and upto secondary level (27.1%). Labor pain was seen to be more severe in advanced labor withmore than half describingit as severe when the cervix was dilated to 5 cm, as compared to only 25.9% and 29.4% of the parturients at 3 and 4cm cervical dilatation respectively. Conclusions: This study concluded that the labor pain was moderate to severe for majority of the parturients.Adolescents, nullipara, patients with higher education and those in advanced laborwere more likely to perceive labor pain of higher intensity. Nepal Journal of Obstetrics and Gynaecology / Vol 8 / No. 1 / Issue 15 / Jan- June, 2013 / 26-30 DOI: http://dx.doi.org/10.3126/njog.v8i1.8857

Feasibility and acceptability of gentamicin in the Uniject prefilled injection system for community-based treatment of possible neonatal sepsis: the experience of female community health volunteers in Nepal

OBJECTIVE

Explore feasibility and acceptability of gentamicin in the Uniject prefilled injection system, in combination with oral cotrimoxazole-p and an appropriate newborn weighing scale, for treatment of possible neonatal sepsis when administered in the community by female community health volunteers.

STUDY DESIGN

In a community-based program in Nepal, 45 volunteers recorded 422 live births. Among these, 82 infants were identified as having possible severe bacterial infection. In all, 67 of these infants were treated with gentamicin in Uniject and 15 were referred to the health facility. Mixed methods were used to collect data about Uniject performance, acceptability and safety.

RESULT

Volunteers successfully treated 67 infants with gentamicin in Uniject. Gentamicin in Uniject performed well and was acceptable.

CONCLUSION

Gentamicin in Uniject, in combination with cotrimoxazole-p and an appropriate newborn weighing scale, is a feasible and acceptable option for treatment of possible neonatal sepsis in the community by female community health volunteers.

Development and characterization of a cell line TTCF from endangered mahseer Tor tor (Ham.)

Tor tor is an important game and food fish of India with a distribution throughout Asia from the trans-Himalayan region to the Mekong River basin to Malaysia, Pakistan, Bangladesh and Indonesia. A new cell line named TTCF was developed from the caudal fin of T. tor for the first time. The cell line was optimally maintained at 28°C in Leibovitz-15 (L-15) medium supplemented with 20% fetal bovine serum (FBS). The propagation of TTCF cells showed a high plating efficiency of 63.00%. The cytogenetic analysis revealed a diploid count of 100 chromosomes at passage 15, 30, 45 and 60 passages. The viability of the TTCF cell line was found to be 72% after 6 months of cryopreservation in liquid nitrogen (-196°C). The origin of the cell lines was confirmed by the amplification of 578- and 655-bp sequences of 16S rRNA and cytochrome oxidase subunit I (COI) genes of mitochondrial DNA (mtDNA) respectively. TTCF cells were successfully transfected with green fluorescent protein (GFP) reporter plasmids. Further, immunocytochemistry studies confirm its fibroblastic morphology of cells. Genotoxicity assessment of H₂O₂ in TTCF cell line revealed the utility of TTCF cell line as in vitro model for aquatic toxicological studies.

Tricuspid Valve Repair: Devega’s Tricuspid Annuloplasty in Moderate Secondary Tricuspid Regurgitation

Background Moderate secondary tricuspid incompetence has variable natural history if left unattended during mitral valve surgery. Recent data suggest progression of the secondary tricuspid incompetence over time. Secondary moderate tricuspid regurgitation in rheumatic mitral valve disease may regress after mitral valve surgery without direct intervention. Objectives: The present retrospective comparative hospital based tudy was done to assess early result of DeVega tricuspid valve annuloplasty amongst those with moderate tricuspid regurgitation due to rheumatic mitral valve disease. Methods: Group I (mitral valve replacement with tricuspid repair) and Group II (mitral valve replacement only) were compared regarding functional class, heart rate, rhythm, cardiac dimensions, function and valve pathology. The two groups were followed up at three months post-operatively and evaluated for their functional class and echocardiography variables. The data was analyzed with SPSS 16.0 Results: There were 43 patients who underwent mitral valve replacement with moderate tricuspid regurgitation. Twenty three underwent mitral valve replacement with tricuspid repair group (Group 1). Most of the patients were women (28/43). The mean age was 31.4 + 14.8 and 25.13 + 9.4 years. Group I had 21(91.3%) and Group II had 17 (85%) in NYHA class III & IV. The pre-operative echocardiographic cardiac left ventricular and left atrial dimensions, left ventricular function and valve lesions were statistically similar for both groups, except PASP was higher amongst tricuspid repair (Group 1: 38.60 + 12.75mHg, Group 2: 61.52 + 19.76mmHg; p= <0.05). At three month’s review after surgery, four patients were in NYHA II amongst those without tricuspid repair (Group II), whilst the rest were in NYHA I. Left ventricular dimensions, Left Ventricular function and valve prosthetic valve function were similar between groups. Eleven (47.8%) patients in Group I and only five (25%) of Group II had trace or less TR at the follow-up (p < 0.05). There were 7 (16.2%) patients who had persistent moderate TR. Higher PASP and larger LV dimensions at three months were predictive of persistent moderate TR. Conclusion Mitral valve replacement does decrease the severity of tricuspid regurgitation amongst those with secondary moderate tricuspid regurgitation by at least one grade, but DeVega’s annuloplasty confers a better repair result. http://dx.doi.org/10.3126/kumj.v9i1.6266 Kathmandu Univ Med J 2011;9(1):64-8

Exploration and innovation in addressing maternal, infant and neonatal mortality

The Government of Nepal has been remarkably progressive in introducing innovative community-based maternal newborn and child health interventions in an effort to address the major causes of maternal and child mortality in the country. This article describes the introduction of innovative interventions, including a review of the landmark research that precipitated the discussion and provided evidence of practical feasibility, the acceptance of the intervention concept and validity, the approval process and the introduction and results from the pilot interventions. These interventions, which include the use of misoprostol to prevent post partum haemorrhage during homebirths, Morang Innovative Neonatal Intervention, gentamicin in Uniject and for the management of neonatal sepsis and newborn vitamin A supplementation, are in various stages and demonstrate the responsiveness of the Government to new approaches that address the major causes of maternal and child mortality.

Ovarian strumal carcinoid presenting as severe progressive constipation

Strumal carcinoid develops in a germ cell tumor characterized by an intimate mixture of thyroid and carcinoid. Unlike other carcinoid tumors, most patients with strumal carcinoid have no symptoms of carcinoid syndrome; few are reported to cause severe constipation.

We report a case of a 60-year-old female patient presenting with severe progressive constipation and painful defecation for last few years. A right ovarian tumor was discovered during clinical examination. CT scan revealed a large lobulated solid cystic right adenexal mass suggestive of monomorphic teratoma, which was successfully removed surgically. The histopathology confirmed the diagnosis of strumal carcinoid tumor. Her constipation completely disappeared post surgery. These tumors are known to produce a biologically active substance like peptide YY, which has a pharmacologic inhibitory action on intestinal motility. This was presumably the cause of the constipation in this patient rather than a mechanical effect of the tumor.

Comparison and suitability of gel matrix for entrapping higher content of enzymes for commercial applications

To check the suitability of enzyme entrapped beads for use in pharmaceutical industry, amylase enzyme was entrapped in agar/agarose, polyacrylamide gels and calcium alginate beads. Sodium alginate of 1% concentration was found to be best with respect to immobilization efficiency and calcium alginate beads so obtained were not much susceptible to breakage. When sodium alginate- amylase mixture was added from a height of about 20-30 cm. into CaCl(2) solution, size of beads was large at higher alginate concentration due to the increase in the size of droplet formation before entering into CaCl(2) solution. Enzyme entrapped polyacrylamide and agar/agarose gels were fragile and could not withstand repeated use whereas enzyme entrapped in large calcium alginate beads was used successfully for 50 cycles for the conversion of starch into product without much damage to the beads under stirring conditions. Amylase preparation was also mixed with urease, lysozyme and coimmobilized in large sized calcium alginate beads. These beads were used for 10 repeated cycles to check the conversion of substrates into their products by their respective enzymes and we concluded that an enzyme or mixture of two or three enzymes can be immobilized in the same large sized calcium alginate beads. This will save the additional cost of bioreactor, manpower, maintenance conditions required for the conversion of one drug into another using enzyme/s entrapped in large sized beads.

Tooth cleaning frequency in relation to socio-demographic variables and personal hygiene measures among school children of Udaipur district, India

OBJECTIVE

The aim of the study was to determine if frequency of tooth cleaning varies with social group, family size, bedtime and other personal hygiene habits among school children.

METHODS

Target population comprised schoolchildren aged 8-16 years of Udaipur district attending public schools. A two stage cluster random sampling procedure was executed to collect the representative sample, consequently final sample size accounted to 852 children. Data were collected by means of structured questionnaires which consisted of questions related to oral hygiene habits including a few general hygiene habits, bed time, family size, family income and dental visiting habits.

RESULTS

The results show that 30.5% of the total sample cleaned their teeth twice or more daily and there was no significant difference between the genders for tooth cleaning frequency. Logistic regression analysis revealed that older children and those having less than two siblings were more likely to clean their teeth twice a day than the younger ones and children with more than two siblings. Furthermore, frequency of tooth cleaning was significantly lower among children of parents with low level of education and less annual income as compared with those of high education and more annual income. In addition, tooth cleaning habits were more regular in children using tooth paste and regularly visiting to the dentist.

CONCLUSIONS

This study observed that tooth cleaning is not an isolated behaviour, but is a part of multifarious pattern of various social and behavioural factors.

Electronic Excitations Preceding Shock Initiation in Explosives

Electronic excitations which precede and can facilitate chemical reactivity of explosive molecules during shock passage will be discussed. The structurally similar family of explosives, TATB, DATB, Picramide and TNB were the focus of this work. It has been found that the energy of shake-up transitions observed in x-ray photoelectron spectra of these molecules shows a linear relation with the explosive sensitivity. To the contrary, optical absorption maxima, dependant upon dipole selection rules display a trend opposite that intuitively expected in relation to ease of initiation. The shake-up transitions are governed by monopole selection rules, so that the transitions between initial and final states of the same symmetry are allowed. The forbiddeness of the excited state may favor proton transfer, bond breakage and free radical formation relative to de-excitation by returning to the ground state. Electronic excitations of this type are believed to be important to multiphonon up pumping. The Is core hole resulting from photoionization creates a central coulomb force that shrinks the orbitals, simulating conditions similar to those of high pressure or shock passage. These factors may be at the heart of the correlation between the shake-up promotion energy and explosive sensitivity.

Fetal demise secondary to massive rhabdomyoma in the early second trimester of pregnancy

Rhabdomyoma is the most common cardiac tumor in fetuses, often associated with tuberous sclerosis complex and usually diagnosed in the third trimester of pregnancy, with a benign course in the majority of cases. The hemodynamic impact of cardiac tumor depends on the location and size of the mass and the presence of dysrhythmia (4). Fetal cardiac rhabdomyoma accounts for less than 10% of fetal demise cases (1). This report presents a case of massive cardiac rhabdomyoma filling the entire right heart with pericardial extension, leading to hydrops and subsequent fetal death in the early second trimester of pregnancy.

Comparison of isoelectric focusing and polymerase chain reaction for the detection of β-lactamases

Extended spectrum β-lactamases (ESBLs) have been observed in virtually all the species of family Enterobacteriaceae. Threat posed by antibiotic resistance because of ESBLs is more serious as a number of technical problems are associated with the detection of these enzymes. Although a number of detection methods have been designed for ESBLs, every method has its own benefits and shortcomings as well. In earlier days, isoelectric focusing (IEF) was used as the gold standard for ESBL detection. This study was undertaken to compare IEF with polymerase chain reaction, a method which has been extensively used for ESBL detection these days.

Nephrogenic fibrosing dermatopathy, cardiac calcification and pulmonary hypertension in an adolescent on chronic hemodialysis

Nephrogenic fibrosing dermatopathy (NFD) is a systemic disorder of unknown etiology. Recent reports have associated the development of NFD with the use of gadolinium-enhanced magnetic resonance imaging (MRI). Here, we present the case of an adolescent with end-stage renal disease who died of biopsy-proven NFD and also developed cardiac calcification and clinical manifestations of pulmonary fibrosis with pulmonary hypertension. Only five cases of NFD have been reported in children, all of which were prior to the information regarding the consequences of using gadolinium. Here, we report a patient with NFD who received gadolinium while on chronic hemodialysis, 16 months prior to the onset of symptoms. Because he succumbed to this disease, we stress on the importance of eliminating the use of gadolinium-enhanced MRI examinations in children with impaired kidney function until the etiology of NFD is clarified