Surveillance of drug-resistant tuberculosis in the state of Gujarat, India

BACKGROUND

Limited information about the prevalence of drug-resistant tuberculosis (TB) has been reported from India, the country with the world's highest burden of TB. We conducted a representative state-wide survey in the state of Gujarat (2005 population: 56 million).

METHODS

Mycobacterium tuberculosis isolates from a representative sample of new and previously treated smear-positive pulmonary TB (PTB) cases were subjected to drug susceptibility testing (DST) against first-line drugs at a World Health Organization supranational reference laboratory. Isolates found to have at least both isoniazid (INH) and rifampicin (RMP) resistance (i.e., multidrug-resistant TB [MDR-TB]) were subjected to second-line DST.

RESULTS

Of 1571 isolates from new patients, 1236 (78.7%) were susceptible to all first-line drugs, 173 (11%) had any INH resistance and MDR-TB was found in 37 (2.4%, 95%CI 1.6-3.1). Of 1047 isolates from previously treated patients, 564 (54%) were susceptible to all first-line drugs, 387 (37%) had any INH resistance and MDR-TB was found in 182 (17.4%, 95%CI 15.0-19.7%). Among 216 MDR-TB isolates, 52 (24%) were ofloxacin (OFX) resistant; seven cases of extensively drug-resistant TB (XDR-TB) were found, all of whom were previously treated cases.

CONCLUSION

MDR-TB prevalence remains low among new TB patients in Gujarat, but is more common among previously treated patients. Among MDR-TB isolates, the alarmingly high prevalence of OFX resistance may threaten the success of the expanding efforts to treat and control MDR-TB.

Huge placental myxoid chorangioma presenting with severe antepartum hemorrhage

A 2nd gravida presented at 27 weeks with antepartum hemorrhage. Ultrasound showed a single live fetus (parameters approximately 23 weeks) and a huge placenta with multiple cystic areas extending into the lower uterine segment; some of which showed increased vascularity on colored doppler. A diagnosis of low lying placenta with a possibility of chorangioma or a partial mole was made. The next bout of antepartum hemorrhage was severe necessitating an emergency cesarean. Histopathology of the placenta (weighing 2240 grams) revealed a myxoid chorangioma. All features in this woman are uncommonly reported in literature (large size, myxoid degeneration and severe antepartum hemorrhage necessitating a cesarean).

Detection of Magnaporthe grisea in infested rice seeds using polymerase chain reaction

AIM

To develop a diagnostic assay based on polymerase chain reaction for the detection of Magnaporthe grisea from infested rice seeds.

METHODS AND RESULTS

Primers were designed based on the nucleotide sequence of the mif 23, an infection-specific gene of M. grisea. The primers amplified target DNA from genetically and geographically diverse isolates of the pathogen. The lowest concentration of template DNA that led to amplification was 20 rhog. No PCR product was detected when DNA from other fungi was used, indicating the specificity of the primers. With this PCR based seed assay, M. grisea was detected in rice seedlots with infestation rates as low as 0.2%.

CONCLUSION

The PCR detection of M. grisea is simple, rapid, specific, sensitive and suitable for the routine detection of the pathogen in infested seeds.

SIGNIFICANCE AND IMPACT OF THE STUDY

Introduction of the blast fungus into new areas where it has not been previously recorded could be avoided by the detection of infested seedlots. A PCR-based seed assay could facilitate risk assessment of naturally infested rice seeds; help design management programs and optimize fungicide use.

No association between E- and L-selectin genes and SLE: soluble L-selectin levels do correlate with genotype and a subset in SLE

Altered function of selectin glycoprotein adhesion molecules may modulate severity and organ-specific manifestations of autoimmune and inflammatory disease via changes in leukocyte trafficking. Serum concentrations of selectin molecules have been suggested as useful biomarkers in systemic lupus erythematosus (SLE). We identified increased levels of soluble L-selectin (sL-selectin), but not soluble E-selectin (sE-selectin) in 278 European-Caucasian lupus patients compared to 230 healthy siblings (P=0.002). sL-selectin levels were markedly elevated in patients with IgG antiphospholipid autoantibodies (P=0.002), suggesting that perhaps sL-selectin defines a subgroup of lupus with vasculopathy. sL-selectin level was also influenced by two L-selectin polymorphisms: 665C>T, F206L in the epidermal growth factor-like domain (P=0.015) and rs12938 in the 3'-untranslated region (P=0.06). Having shown increased sL-selectin levels in lupus patients, we used genetics to investigate whether this was a secondary phenomena or the result of an underlying genetic mechanism. The inheritance of nine single-nucleotide polymorphisms (SNP) spanning the selectin locus was tested in 523 UK simplex SLE families. No association with SLE, or related phenotypes, was evident with any single SNP, or haplotype in family-based tests of association. Selectin polymorphisms are, therefore, unlikely to be independent factors in SLE susceptibility.

Fine needle aspiration cytology of thyroid nodules: how accurate is it and what are the causes of discrepant cases?

Fine-needle aspiration cytology (FNAC) is widely accepted as the most accurate, sensitive, specific and cost-effective diagnostic procedure in the assessment of thyroid nodules and helps to select people preoperatively for surgery. The purpose of this study was to evaluate the results of thyroid FNAC in our institution and to determine the reasons for discrepancies between the cytological and histological diagnosis. We evaluated the cytological and histological results of 254 FNACs obtained from 231 patients who underwent subsequent thyroid surgery. All of the material was blindly reviewed for quality control, by one experienced cytopathologist. All FNACs were carried out under ultrasound guidance. The cytological diagnosis was classified as benign, suspicious, malignant or unsatisfactory. The definitive histological study showed benign lesions in 195 of the 231 patients (84%). A benign diagnosis based on FNAC was correct in 105 of the 108 benign cases (97%). FNACs diagnosed as 'suspicious' resulted in a distribution of 49 benign (79%) and 13 malignant (21%) diagnoses. FNAC showed malignancy in 34 cases (13%) and in only one case did the final histology differ from cytology (correlation 97%). The percentage of FNACs that were inadequate for diagnosis was 20%. Review of cytological and histological slides did not lead to any change in the original diagnosis. Our study revealed a cytological-histological discrepancy (2%) in only 4 out of 231 cases over a period of 10 years, due to either a diagnostic or sampling error.

Random amplified polymorphic DNA (RAPD) analysis in Indian mung bean (Vigna radiata (L.) Wilczek) cultivars

Greengram [Vigna radiata (L.) Wilczek], also known as mung bean, widely cultivated in a large number of countries, is an important pulse crop of Asia and is considered one of the ancestral species of the genus Vigna. Since yields of greengram have remained low across subtropical and tropical Asia, it is important to estimate genetic diversity in existing cultivars in order to see if the lack of genetic variability might be a constraining factor. In this study, 32 Indian cultivars of greengram were subjected to random amplified polymorphic DNA (RAPD) analysis using 21 decamer primers. A total of 267 amplification products were formed at an average of 12.71 per primer with an overall polymorphism of 64%. The extent of polymorphism was moderate to low. Jaccard similarity coefficient values ranged from 0.65 to 0.92. The cluster analysis resulted in mainly three clusters revealing greater homology between cultivars released from the same source. The results of principal components analysis also substantiated this conclusion. The close genetic similarity between the cultivars could be explained due to the high degree of commonness in their pedigrees. The narrow genetic base of the greengram cultivars revealed in the present analysis emphasises the need to exploit the large germplasm collections having diverse morphoagronomic traits in cultivar improvement programs.

A neglected foreign body in the oesophagus

Foreign body ingestion is a clinical emergency requiring prompt action to ensure speedy recovery and minimise the complications. We report here a case of a neglected foreign body which remained within the oesophagus of a child for 6 years before the diagnosis was made and appropriate treatment given.

Patterns of dysphoria in a Puerto Rican urban community

This study was undertaken to explore the prevalence of perceived dysphoria in a poor, urban, predominantly Puerto Rican community. A cross-sectional sample of 704 adult respondents were asked a single validated question, with a five-item Likert scale response, about their level of perceived dysphoria. Chi-squared analysis and Spearman's correlation coefficients were used to assess the association of level of dysphoria with social characteristics, barriers to health care, health status, and substance use. Linear regression modeling was used to control for confounding variables. Twenty percent of the respondents were dysphoric. Respondents with no health insurance or no source of health care were least likely to be dysphoric. Persons who perceived distance to the hospital and the doctor, and understanding language of the doctor and office staff as barriers to care were more likely to be dysphoric. Ethnicity was not correlated with level of perceived dysphoria; however, age, gender, and health status were found to be associated with level of dysphoria after controlling for other correlated variables. These results indicate that the psychological needs of communities need to be understood and interventions that are appropriate for the population need to be devised.

Histopathologic features of vulvar vestibulitis

Vulvar vestibulitis, a subset of vulvodynia, is present in 15% of patients in a general gynecologic practice. Only a few studies have focused on pathologic features of vulvar vestibulitis and none have included a control group. Punch biopsies from the vulvar vestibule of 12 patients with an age range of 22 to 51 years (mean 28 years) and 12 age-matched controls were analyzed for histopathologic features and investigated for the role of probable etiologic factors including human papillomavirus (HPV). A chronic inflammatory infiltrate was present in all specimens from patients with vestibulitis, and was composed predominantly of T-lymphocytes with a small number of B cells and an admixture of plasma cells, mast cells, and occasional monocytes. T-helper suppressor ratio was normal. The infiltrate was mild in 5 patients, moderate in 1, and severe in 6. Minor vestibular glands were observed in 8 (66%) patients and were associated with a periglandular inflammatory infiltrate. Squamous metaplasia was observed in 4 (44%) patients. Epithelial hyperplasia was present in 10 (83%) patients with mild dysplasia in 2 (16%). Immunohistochemistry for immunoglobulins IgG, IgA, and IgM showed the presence of IgG-positive plasma cells in 75% of patients, suggesting chronic irritation, but an autoimmune etiology cannot be excluded or confirmed. Biopsies of control cases did not show any inflammatory infiltrate. In situ hybridization for HPV 6, 11, 16, and 18 was negative in the patient group as well as in the control group. We conclude that histopathologic abnormalities in patients with vulvar vestibulitis are the result of a chronic inflammatory reaction of the mucosa of the vulvar vestibule, for which the cause remains unclear.

Auditory brainstem responses in high risk and normal newborns

We studied the auditory brainstem responses of 50 high risk neonates from NICU and compared with those of 25 normal neonates in order to determine the percentage of significant auditory impairment in NICU and correlated it to various risk factors. Infants with the risk factors of low birth weight, hyperbilirubinemia, asphyxia, septicemia and meningitis were included in the study group. All the 150 ears were tested at 4 intensities 30 dB, 46 dB, 60 dB and 75 dB. The study recorded prolongation of latency of wave V and I-V Interwave interval in the study group with a statistically significant difference denoting an impaired condition. Incidence of significant auditory impairment was 18%. On follow up at 6 months incidence of persistent auditory abnormality was 4%. On the basis of this study it is suggested that all high risk neonates should undergo screening for hearing impairment.

Mechanism(S) of interferon inhibitory activity in blood from patients with AIDS and patients with lupus erythematosus with vasculitis

We have earlier reported that patients suffering from acquired immuno-deficiency syndrome (AIDS), systemic lupus erythematosus (SLE) with vasculitis, Wegner granulomatosis and certain types of late stage cancer have interferon inhibitory activity in their serum. The purpose of this study was to identify the factor(s) involved in this interferon inhibitory activity. Twenty patients with advanced AIDS, twenty patients with SLE and vasculitis and twenty normal healthy controls between ages 25-40 years were studied. In contrast to normal, healthy controls, significant interferon inhibitory activity was found in AIDS and SLE patients. This appears to be largely due to: (a) increased soluble circulating interferon alpha/beta receptors, (b) increased prostaglandin E2 levels which inhibits interferon and (c) a interferon inhibitory protein. Further understaging of the nature of interferon inhibitory activity in the patient's sera and development of anti-interferon inhibitory agents would greatly enhance interferons potential as a treatment modality.

Behavioral approach with or without surgical intervention to the vulvar vestibulitis syndrome: a prospective randomized and non-randomized study

This article describes the outcome of a behavioral approach with or without preceding surgical intervention in 48 women with the vulvar vestibulitis syndrome. In the first part of the study, 14 women with the vulvar vestibulitis syndrome were randomly assigned to one of two treatment programs: either a behavioral approach or a behavioral approach preceded by surgery. In the second part of the study, 34 women and their partners were given a choice of treatment. Follow-up data were gathered a mean of 3 and 2 1/2 years after treatment, respectively. In the randomized patient population, the intervention had a positive effect on all of them: the complaints disappeared, diminished or did not change but formed less of a problem. The difference in outcome between the two different treatments, a behavioral approach with or without preceding surgery, was not statistically significant. In the second non-randomized part of the study, 28 out of the 34 women (82%) chose the behavioral approach without preceding surgery. The difference in outcome between the two treatments was not statistically significant. Two out of the 28 women who chose behavioral treatment without preceding surgery had to be referred for psychiatric consultation because of serious psycho-sexual problems. In one woman, psychiatric treatment was successful. Three other women, whose behavioral treatment failed, underwent additional surgery, which clearly helped them to overcome the deadlock in the behavioral approach. The behavioral approach should be the first choice of treatment for the vulvar vestibulitis syndrome. Surgical intervention should be considered as an additional form of treatment in some cases with the vulvar vestibulitis syndrome to facilitate breaking the vicious circle of irritation, pelvic floor muscle hypertonia and sexual maladaptive behavior.

Effect of mechanical removal of the pulp upon the retention of odontoblasts around the pulp chamber of human third molars

The pulp chambers of 11 freshly extracted human third molars were exposed by cutting off the roots apical to the cervical margin and the pulps were either removed with forceps and discarded or left in situ. The teeth were fixed, demineralized, divided longitudinally, embedded in resin and 2-micron sections stained with toluidine blue were examined by light microscopy. In pulp-removed specimens the percentage retention of the odontoblast layer with the predentine varied near the longitudinal division but when sectioned deeper all six specimens displayed 100% retention. The intactness of the retained odontoblast layer was mostly good as judged by the mutual close apposition of the distal ends of the cell bodies and their relation to the predentine. The retention of the odontoblast layer with the predentine may be due to the distribution of fibronectin, which others have shown is present between odontoblasts, and between odontoblasts and predentine, but lacking beneath the odontoblast layer.

Lipid-zinc interaction: its effect on the testes of mice

Lipid-Zn interaction in the testes of mice was studied by feeding them low-fat (30 g maize oil/kg; group LFZD) and high-fat (90 g maize oil/kg; group HFZD) Zn-deficient diets for 6 weeks. The results were compared with those of corresponding Zn-supplemented-diet-fed controls (groups LFZS and HFZS). The integument-related Zn-deficiency symptoms appeared in group HFZD and not in group LFZD mice despite lack of Zn in their ration and an equal level of Zn in their blood serum. The feed intake, gain in body weight and testes weight of the LFZD group were comparable with those of the LFZS and HFZS groups (P > 0.05) but were higher than those of the group HFZD (P < 0.05). The testes of group HFZD displayed necrotic changes marked by the presence of giant cells, lower RNA, DNA and protein concentrations and higher phospholipid and cholesterol levels than those of mice in the LFZD group. The concentrations of these fractions were not significantly different between LFZD and HFZS. The results do not support the hypothesis that Zn is essential either for testicular function or for nucleic acid and protein synthesis in animals fed on a low-fat diet; however, it appears to be essential for animals fed on a high-fat diet. The changes observed in the testes of the HFZD animals suggest the excess intake of fat as their cause in Zn-deficient animals.

Cutaneous metastasis following laparoscopic pelvic lymphadenectomy for prostatic carcinoma

A case of implantation metastasis in the abdominal wall following transabdominal laparoscopic pelvic lymphadenectomy is reported. A cutaneous nodule was palpated at 1 of the laparoscopic ports 6 months after laparoscopic lymphadenectomy in a 66-year-old patient with stage T3pN1M0, grade 2 adenocarcinoma of the prostate. Aspiration cytology confirmed metastatic adenocarcinoma.