Low yield but high levels of multidrug resistance in urinary tract infections in a tertiary hospital, Nepal

SETTING

There are concerns about the occurrence of multidrug resistance (MDR) in patients with urine tract infections (UTI) in Nepal.

OBJECTIVE

To determine culture positivity, trends in MDR among Escherichia coli and Klebsiella pneumoniae infections and seasonal changes in culture-positive UTI specimens isolated from 2014 to 2018 at the B P Koirala Institute of Health Sciences, Dharan, Eastern Nepal.

DESIGN

This was a cross-sectional study using secondary laboratory data.

RESULTS

Among 116,417 urine samples tested, 19,671 (16.9%) were culture-positive, with an increasing trend in the number of samples tested and culture positivity. E. coli was the most common bacteria (54.3%), followed by K. pneumoniae (8.8%). Among E. coli and K. pneumoniae isolates, MDR was found in respectively 42.5% and 36.0%. MDR was higher in males and people aged >55 years, but showed a decreasing trend over the years. The numbers of isolates increased over the years, with a peak always observed from July to August.

CONCLUSION

Low culture positivity is worrying and requires further work into improving diagnostic protocols. Decreasing trends in MDR are a welcome sign. Information on seasonal changes that peak in July-August can help laboratories better prepare for this time with adequate buffer stocks to ensure culture and antibiotic susceptibility testing.

Guided and unguided de-escalation from potent P2Y12 inhibitors among patients with ACS: a meta-analysis

Background

Dual antiplatelet therapy (DAPT) with a potent P2Y12 inhibitor is recommended in patients with acute coronary syndrome (ACS) and should be tailored according to ischemic and bleeding risks, which are highest in the acute phase, and gradually attenuate overtime. De-escalation strategies of DAPT aim to optimize this balance of risks.

Purpose

We compared guided or unguided DAPT de-escalation strategies from potent P2Y12 inhibitors to either clopidogrel or lower doses of potent P2Y12 inhibitors versus standard DAPT with potent P2Y12 inhibitors among patients with ACS.

Methods

PubMed, Google Scholar and Cochrane Central Register of Controlled Trials were searched from inception till March 10th 2021. 1633 records were screened on DAPT de-escalation strategies after ACS for inclusion. Aspirin monotherapy and non-randomized trials were excluded.

The primary endpoint was BARC ≥2 bleeding. Other endpoints included MACE (defined according to the definitions reported in the original study protocols), all-cause death, cardiovascular death, myocardial infarction, stent thrombosis, and stroke. Hazard ratios (HRs) and 95% CIs were used as metric of choice for treatment effects with random-effects models. Heterogeneity was assessed with the I2 index. We assessed the interaction between de-escalation strategy (guided vs. unguided) and treatment with a random-effects meta-regression analysis with the empirical Bayes method. This study has been submitted to PROSPERO for registration.

Preliminary findings

Four randomised trials and a total of 8,082 patients randomly allocated to a de-escalation strategy (genetic guided to clopidogrel, n=1,242; platelet function guided to clopidogrel, n=1,304; unguided to clopidogrel (n=323); unguided to lower dose, n=1,170) or standard DAPT (n=4,043) were included in our analysis. De-escalation strategy had a reduction in BARC ≥2 bleeding (HR 0.57, 95% CI 0.37–0.89; I2=81%). MACE (HR 0.79, 95% CI 0.62–1.02; I2=0%), all-cause death (HR 0.89, 95% CI 0.58–1.36), cardiovascular death (HR 0.63, 95% CI 0.36–1.10; I2=0%), myocardial infarction (HR 0.81, 95% CI 0.56–1.17; I2=0%), stent thrombosis (HR 0.57, 95% CI 0.19–1.74; I2=0%) and stroke (HR 0.73, 95% CI 0.39–1.35; I2=0%) did not differ between patients with a de-escalation strategy and those without. Meta-regression analysis did not show any significant interaction between de-escalation method (guided vs. unguided) and treatment effects, except for BARC ≥2 bleeding (P interaction = 0.070), suggesting a greater reduction with unguided de-escalation.

Conclusion

A de-escalation strategy of DAPT after ACS was associated with a lower number of clinically relevant bleeding events, mostly in patients who underwent unguided de-escalation, while no association with increased ischemic events was found. However, the observed broad confidence intervals limit the certainty of our findings.

Funding Acknowledgement

Type of funding sources: None. BARC ≥2 bleedingMACE

Ticagrelor monotherapy after percutaneous coronary intervention in patients with concomitant diabetes mellitus and chronic kidney disease: a TWILIGHT substudy

Background

Diabetes mellitus (DM) and chronic kidney disease (CKD) are established risk factors for cardiovascular events, with patients presenting both conditions being at extremely high risk. P2Y12 inhibitor monotherapy with ticagrelor after a short course of dual antiplatelet therapy has emerged as a bleeding avoidance strategy for high-risk patients undergoing percutaneous coronary intervention (PCI).

Purpose

To investigate ischemic and bleeding outcomes associated with ticagrelor monotherapy versus ticagrelor plus aspirin according to the presence or absence of CKD and DM.

Methods

The TWILIGHT trial enrolled patients undergoing PCI with a drug-eluting stent who fulfilled at least one clinical and one angiographic high-risk criterion. Both DM and CKD (estimated glomerular filtration rate <60 mL/min/1.73m2) were clinical study entry criteria. Following 3 months of ticagrelor plus aspirin, patients who had been adherent to treatment and free from major adverse events were randomly assigned to either aspirin or placebo in addition to ticagrelor for 1 year. The primary endpoint was Bleeding Academic Research Consortium (BARC) type 2, 3 or 5 bleeding. The key secondary endpoint was the composite of all-cause death, myocardial infarction, or stroke. Net adverse clinical events (NACE) were defined as BARC type 3 or 5 bleeding, all-cause death, myocardial infarction, or stroke.

Results

Of the 6273 patients included in the analysis, 8.0% had both CKD and DM (DM+/CKD+), 8.9% had CKD only (DM-/CKD+), 29.0% had DM only (DM+/CKD-), and 52.1% had neither CKD nor DM (DM-/CKD-). At 1-year follow-up, there was a progressive increase in the rates of bleeding and ischemic events according to DM and CKD status (Figure 1). Ticagrelor plus placebo reduced the primary bleeding endpoint as compared with ticagrelor plus aspirin across all study groups, including DM+/CKD+ patients (4.7% vs. 8.7%; HR 0.52, 95% CI 0.25–1.07), with no evidence of heterogeneity (p-interaction=0.68). Similar treatment effects of ticagrelor monotherapy were observed for major BARC type 3 or 5 bleeding (p-interaction=0.17), with DM+/CKD+ patients showing the greatest absolute risk reduction (0.9% vs. 5.1%; HR 0.16, 95% CI 0.04–0.72). The key secondary endpoint was not significantly different between treatment arms across study groups, with the exception of a reduced risk in DM+/CKD- patients receiving ticagrelor monotherapy (p-interaction=0.033). A similar pattern in the DM+/CKD- group was observed for NACE (p-interaction=0.030) (Figure 2).

Conclusions

Among high-risk patients undergoing PCI, ticagrelor monotherapy reduced the risk of clinically relevant and major bleeding without a significant increase in ischemic events as compared with ticagrelor plus aspirin, irrespective of the presence of DM and CKD. Furthermore, ticagrelor monotherapy seemed to be associated with a more favourable net benefit in patients with DM without CKD.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Investigator-initiated grant from AstraZeneca Figure 1. Event rates according to DM/CKD statusFigure 2. Effects of ticagrelor monotherapy

Energy and carbon budgeting of traditional land use change with groundnut based cropping system for environmental quality, resilient soil health and farmers income in eastern Indian Himalayas

Energy intensive traditional cereals based monoculture often lead to high greenhouse gas emissions and degradation of land and environmental quality. Present study aimed at evaluating the energy and carbon budget of diversified groundnut (Arachis hypogea L) based cropping system with over existing traditional practice towards the development of a sustainable production technology through restoration of soil and environmental quality and enhancement of farming resiliency by stabilizing farmers' income. The trials comprised of three introduced groundnut based systems viz. groundnut- pea (Pisum sativum), groundnut-lentil (Lens esculenta) and groundnut-toria (Brasssica campestris var. Toria) replacing three existing systems viz. maize (Zea mays L) - fallow, maize - toria, and rice (Oryza sativa L)-fallow systems. Four years study revealed that adoption of groundnut based systems reduced non-renewable energy input use (fertilizers, chemical, machinery and fossil fuels) by 25.5%, consequently that reduced the cost of production. Repeated analysis of variance measurement also affirmed that groundnut based systems (groundnut-pea>groundnut-lentil> groundnut-toria) increased the energy use efficiency, energy productivity, carbon use efficiency, net returns and decreased the specific energy and energy intensiveness. Groundnut based systems increased the mean system productivity and water productivity in terms of groundnut equivalent yield by 3.7 and 3.1 folds over existing practice. The savings of fossil fuel reduced greenhouse gas emissions owing to reduced use of farm machinery and synthetic fertilizers. Groundnut based systems significantly (p < 0.05) enhanced the soil carbon concentration (8.7-18.1%) and enzymatic activities (27.1-51.8%) over existing practice. Consequently, estimated soil quality index values were 35.9-77.3% higher under groundnut based systems than existing practice. Thus, the study indicated the resilient nature of groundnut based systems as an environmentally safe and sustainable production technology for enhancing resource use efficiency, reduce carbon emission, energy intensiveness and cost of production in the Eastern Himalaya region of India and similar ecosystems.

Non-tuberculous mycobacteria: a disease beyond TB and preparedness in India

BACKGROUND AND METHODS

Fifty-six Indian studies on NTM diseases were selected between 1981 and 2020 from various electronic databases (PubMed, EMBASE, Medline, BIOSIS preview, and Scopus) for systematic review.

RESULTS

NTM isolation rates increased from 0.9% between 2001 and 2010 to 1.6% between 2011 and 2020. Prevalence of NTM-pulmonary disease (NTM-PD) among presumptive-TB patients in India was 1.1% (395/34,829). M. avium complex (MAC) (19%) was most commonly isolated from pulmonary specimens followed by M. chelonae (10%), M. fortuitum (9.8%), and M. abscessus (8.8%). M. fortuitum (35.5%), M. chelonae (23.6%) and M. abscessus (15%) were frequently reported from extra-pulmonary specimens. Patients with NTM-PD were mostly treated with a macrolide-based three-drug regimen. Clarithromycin-based-drug regimen in combination with amikacin, ciprofloxacin and several other drugs (rifampicin, imipenem, ofloxacin, linezolid, azithromycin) was used for treatment of EP-NTM. Median duration of the treatment in NTM-PD was 12 months, (6-18 months) whereas it was 6 months (3.1-8.7 months) in EP-NTM. Treatment was successful in 45% (19/42) of NTM-PD patients and 75% (93/124) of EP-NTM patients.

CONCLUSION

It is concluded from this review that most Indian studies have published laboratory data on NTM isolation and speciation and lacked information on clinical, microbiological and radiological correlation and treatment outcome details. Future studies should address these issues while publishing on NTM diseases.

Extrapulmonary tuberculosis

Introduction: Tuberculosis (TB) is a major cause of morbidity and mortality globally. Extrapulmonary TB (EPTB) constitutes about 15%-20% of all TB patients, but accounts for 50% among HIV-coinfected. Confirmation of microbial diagnosis of EPTB is usually challenging.Areas covered: Availability of newer imaging modalities like ¹⁸FDG-PET-CT and PET-MRI has facilitated precise anatomical localization of the lesions and mapping the extent of EPTB. The use of image- and endoscopy-guided invasive diagnostic methods has made procurement of tissue/body fluids for diagnostic testing possible. With the advent of universal drug-susceptibility testing, a rapid diagnosis of drug-resistance is now possible in EPTB. Drug-susceptible EPTB usually responds well to first-line anti-TB treatment; TB meningitis, bone and joint TB and lymph node TB requires longer durations of treatment.Expert opinion: Adjunctive use of corticosteroids in the initial period is recommended in the central nervous system and pericardial TB. Surgical intervention is helpful to obtain tissue samples for diagnosis. Adjunctive surgical treatment along with medical treatment is useful in treating complications like hydrocephalus, Pott's spine. Follow-up of EPTB patients is crucial as treatment period is usually prolonged, requires recognition of development of immune reconstitution and inflammatory syndrome (IRIS), monitoring of adverse events, serious adverse events like anti-TB drug-induced hepatotoxicity, organ-related complications, and treatment adherence.

Morpho-molecular and mating-type locus diversity of Ustilaginoidea virens: an incitant of false smut of rice from Southern parts of India

AIMS

To characterize the geo-distinct isolates of Ustilaginoidea virens for morpho-molecular and mating-type locus diversity.

METHODS AND RESULTS

Sixty-one isolates of U. virens collected from Southern India exhibited significant diversity in mycelial width (3·45-5·50 µm), colony colour (yellow, pale yellow, and white), and growth pattern (thick leather mat, raised-fluffy, flat-fluffy, and raised). Field-borne chlamydospores of each isolate were significantly smaller in size (3·34-5·26 µm² ) compared to those formed on culture media (18·6-100·89 µm² ). The phylogenetic study based on internal transcribed sequences revealed two clusters; however, most isolates (n = 54) were grouped in cluster-I, indicating common ancestral origin. We also identified 42 haplotypes; among them, Hap_3 has the highest number of isolates (n = 19). Mating-type locus (MAT1) analysis revealed all sixty-one isolates as heterothallic, wherein 37 and 24 isolates belonging to MAT1-1-1 and MAT1-2-1 heterothallic mating types, respectively. The microsynteny analysis of MAT1 loci of one of the Indian strain (Uv-Gvt) along with Uv-8b (China) strain revealed synteny conservation at MAT1 locus, which is flanked by conserved genes SLA2 and a hypothetical protein in the upstream and APN2, COX12 and APC5 in the downstream of the locus.

CONCLUSIONS

Morpho-molecular study revealed the significant diversity among geo-distinct isolates, and MAT1 loci analysis indicated the distribution of heterothallic mating types in south Indian paddy fields. And also, complete synteny conservation between Indian and Chinese strain was observed at the MAT1 locus.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is the first report describing the sexuality of Indian strains of the U. virens, which would help better understand the genetic diversity of the U. virens prevailing in Southern India and aid in developing resistant rice cultivars against this pathogen population.

Role of free volumes and segmental dynamics on ion conductivity of PEO/LiTFSI solid polymer electrolytes filled with SiO2 nanoparticles: a positron annihilation and broadband dielectric spectroscopy study

The limited ionic conductivity of polymer electrolytes is a major issue for their industrial application. Enhancement of ionic conductivity in the poly(ethylene oxide), PEO, based electrolyte has been achieved by loading passive nanofillers such as SiO₂ nanoparticles (NPs). To investigate the role of modifications in free volume characteristics and the polymer chain dynamics induced by the loading of passive fillers on the ionic conductivity of the PEO based ternary electrolyte, a systematic investigation has been carried out using positron annihilation and broadband dielectric spectroscopy. As a result of interfacial interactions, the loading of SiO₂ NPs alters the semi-crystalline morphology of PEO resulting in a higher crystallinity at lower loadings due to the surface confinement of PEO chains, and the formation of smaller PEO crystallites at higher loadings due to interparticle nanoconfinement. These modifications are accompanied by a decrease in free volume fraction at the lowest loading (0.5 wt%) followed by an increase at higher loadings (≥2.0 wt%). The Almond-West formalism considering two different universalities in different temperature and frequency ranges has been used to explain the ion-conduction process at different NP loadings. The Li ion conductivity is observed to be maximum for a 5.0 wt% loading of SiO₂ NPs. The enhancement in ionic conductivity is observed to be directly correlated with the free volume characteristics and segmental dynamics of the PEO matrix, confirming their role in ion transport in polymer electrolytes.

Computational exploration and anti-mycobacterial activity of potential inhibitors of Mycobacterium tuberculosis acetyl coenzyme A carboxylase as anti-tubercular agents

Acetyl Coenzyme A Carboxylase (AccD6) is a homodimeric protein which is involved in the carboxylation of acetyl coenzyme A to produce malonyl coenzyme A, which plays an important role in the biosynthesis of fatty acid chain. However, studies suggest that AccD6 in combination with AccA3 produces malonyl co-A. Certain herbicides are known to inhibit plant ACC. Among these herbicides, haloxyfop was found to inhibit AccD6 at IC50 of 21.1 ± 1 µM. In this study, we have performed molecular docking of the Maybridge database consisting of ~55,000 compounds in the active site of the protein with haloxyfop as a reference molecule, followed by molecular dynamics study and biological activity determination of prioritized compounds. Out of the nine compounds selected for biological evaluation, three compounds - CD07230, HTS08529 and KM08871 - were found to exhibit anti-mycobacterial activity.

Coronin-1 levels in patients with tuberculosis

Background & objectives:

Despite advances in diagnostics and therapeutics, tuberculosis (TB) is widely prevalent and contributes to a significant burden of illness in both developing and developed nations. The present study was aimed to assess the role of coronin in TB patients and healthy controls. Coronin is a leucocyte-specific protein that is actively recruited in mycobacterial phagolysosomes, where it inhibits lysosomal delivery of Mycobacterium by activating a calcium-dependent phosphatase-calcineurin.

Methods:

In the study, 100 newly diagnosed cases of TB (pulmonary and extra-pulmonary) and healthy controls were prospectively enrolled over one year and the levels of coronin-1a in these patients and controls were measured by quantitative PCR (qPCR).

Results:

A total of 100 TB patients and 100 healthy individuals as controls were assessed. There were 59 patients with extra-pulmonary TB (EPTB) and 41 of pulmonary TB (PTB). In 47 per cent of patients, corroborative histopathological evidence of TB was also available. Significantly higher values of coronin-1a were observed in TB patients (19.94±2.61) than in healthy controls (16.09±1.91) (P<0.001).

Interpretation & conclusions:

Coronin 1a appears to play an important role in the TB disease pathophysiology and agents developed against coronin may have a role in the treatment of TB. Further studies are required to assess if coronin-1a levels are elevated in non-tubercular infective a etiologies and whether these can be a potential drug target in patients with TB.

Optimizing the treatment of newly diagnosed type 2 diabetes mellitus with combination of dipeptidyl peptidase-4 inhibitors and metformin: An expert opinion

The expanding burden of Type 2 Diabetes Mellitus (T2DM) in today's world, with respect to incidence, prevalence, and cost incurred, is an existential risk to society. Various guidelines recommend individualization of treatment. This expert opinion aims to review the recent evidences and reach a consensus on the preferable combination therapy for use in newly diagnosed Indian T2DM patients with HbA_1C >7.5%. The core committee included seventeen diabetes specialists. Three statements were developed, discussed, and rated by specialists and recommendations were noted. Specialists were requested to rate the statements using a 9-point Likert's scale with score of 1 being “Strongly Disagree” and 9 being “Strongly Agree”. Statement-specific scores of all the specialists were added and mean score of ≥7.00 was considered to have achieved a consensus. Statements used to meet the consensus were: Statement 1. Majority of newly-diagnosed Indian diabetics have HbA_1C >7.5%; Statement 2. Patients with HbA_1C >7.5% may be initiated with dual therapy of dipeptidyl peptidase-4 inhibitors (DPP4Is) + Metformin; and Statement 3. In Indian patients with HbA_1C >7.5% at diagnosis, DPP4Is + Metformin may be considered as a first-line therapy. Literature review revealed that HbA_1C level at the time of diagnosis in majority of Indian T2DM patients is >7.5%. Consensus was reached that dual anti-diabetic therapy should be initiated in patients with HbA_1C >7.5%. DPP4Is + Metformin is the preferred cost-effective option and may be considered as a first-line therapy in Indian T2DM patients with HbA_1C >7.5% at diagnosis.

A deep neural network for estimating the bladder boundary using electrical impedance tomography

OBJECTIVE

Accurate bladder size estimation is an important clinical parameter that assists physicians, enabling them to provide better treatment for patients who are suffering from urinary incontinence. Electrical impedance tomography (EIT) is a non-invasive medical imaging method that estimates organ boundaries assuming that the electrical conductivity values of the background, bladder, and adjacent tissues inside the pelvic domain are known a priori. However, the performance of a traditional EIT inverse algorithm such as the modified Newton-Raphson (mNR) for shape estimation exhibits severe convergence problems as it heavily depends on the initial guess and often fails to estimate complex boundaries that require greater numbers of Fourier coefficients to approximate the boundary shape. Therefore, in this study a deep neural network (DNN) is introduced to estimate the urinary bladder boundary inside the pelvic domain.

APPROACH

We designed a five-layer DNN which was trained with a dataset of 15 subjects that had different pelvic boundaries, bladder shapes, and conductivity. The boundary voltage measurements of the pelvic domain are defined as input and the corresponding Fourier coefficients that describe the bladder boundary as output data. To evaluate the DNN, we tested with three different sizes of urinary bladder.

MAIN RESULTS

Numerical simulations and phantom experiments were performed to validate the performance of the proposed DNN model. The proposed DNN algorithm is compared with the radial basis function (RBF) and mNR method for bladder shape estimation. The results show that the DNN has a low root mean square error for estimated boundary coefficients and better estimation of bladder size when compared to the mNR and RBF.

SIGNIFICANCE

We apply the first DNN algorithm to estimate the complex boundaries such as the urinary bladder using EIT. Our work provides a novel efficient EIT inverse solver to estimate the bladder boundary and size accurately. The proposed DNN algorithm has advantages in that it is simple to implement, and has better accuracy and fast estimation.

222Rn Exhalation Flux Rate and 226Ra in the Soils of a Copper-Mineralised Area

Uranium-series radionuclides exist in trace quantities in all soils and rocks on earth in variable concentrations. Among these, 222Rn gas exhaled by the soil of a geological location is the main contributor to the environmental radioactivity. A 222Rn exhalation flux study was carried out in the heavily mineralised area of the Singhbhum Copper Belt of Jharkhand, India. A significant seasonal variation in the soil gas exhalation was observed, which is attributable to the seasonal atmospheric parameters of the study area. The average 222Rn exhalation flux from the soil was estimated to be in the range of 4.5-$20.1\ \mathrm{Bq}\ {\mathrm{m}}^{-2}\ {\mathrm{s}}^{-1}$ with a mean of $10.1\pm 3.9\ \mathrm{mBq}\ {\mathrm{m}}^{-2}\ {\mathrm{s}}^{-1}$ and geometric mean (GM) of $9.5\ \mathrm{mBq}\ {\mathrm{m}}^{-2}\ {\mathrm{s}}^{-1}$. Also, 20 soil samples collected from the study area were analysed by the emanometric method, which estimated the 226Ra specific activity in the soils in the range of 9-$63\ \mathrm{Bq}\ \mathrm{k}{\mathrm{g}}^{-1}$ and a mean value of $39\pm 16\ \mathrm{Bq}\ \mathrm{k}{\mathrm{g}}^{-1}$.

Evaluation of Gene Xpert as compared to conventional methods in diagnosis of Female Genital Tuberculosis

To evaluate Gene Xpert for diagnosis of Female Genital Tuberculosis (FGTB) as compared to conventional methods.

STUDY DESIGN

It was a prospective study conducted over 167 cases of infertile female genital tuberculosis (FGTB) diagnosed on composite reference standard (CRS) (smear for AFB, histopathological evidence of epithelioid granuloma or definite or possible findings of tuberculosis on laparoscopy). All women underwent endometrial biopsy for AFB microscopy, culture, gene Xpert, PCR and histopathology) and laparoscopy and hysteroscopy for diagnosis and prognostication of disease. The results of Gene Xpert were compared with conventional methods in detection of FGTB. All patients were treated with 6 months course of rifampicin (R), isoniazid (H), pyrazinamide (Z) and ethambutol (E) (RHZE for 2 months, RHE for 4 months) using directly observed treatment short course strategy.

RESULTS

Mean age, parity, body mass index and history of contact was 28.3 years, 0.28, 22.9 Kg/m² and 38.92% respectively. Primary infertility was seen in 87.42% cases with mean duration of 2.42 years. Menstrual dysfunctions, abdominal or pelvic pain and lump were seen in 38.92%, 14.37% and 10.77% cases. Abnormal vaginal discharge and adnexal mass were seen in 28.14% and 13.17 % cases. On diagnostic laparoscopy, definite findings of tuberculosis (beaded tubes, tuebrcles and caseous nodules) were seen in 96 (57.48%) women while probable findings of tuberculosis (pelvic or abdominal adhesions, hydrosaplinx, tubo-ovarian mass, pyosalpinx) were seen in 81 (48.50%) women. On laboratory investigations, positive AFB on microscopy or culture was seen in 2.99% casess, PCR was positive in 47.90% gene Xpert was positive in 18.56% cases while epitheloid granuloma was seen on histopathology in 16 (9.58%) cases. Gene Xpert had sensitivity of 35.63%, specificity of 100%, positive predictive value of 100% and negative predictive value of 58.82% and diagnostic accuracy of 66.47% in the present study.

CONCLUSION

Gene Xpert is a very useful test to rule in tuberculosis whereas when it is negative it is not a good test to rule out tuberculosis.

Epidemiology, diagnosis & treatment of non-tuberculous mycobacterial diseases

Non-tuberculous mycobacteria (NTM) are ubiquitously present in the environment, but NTM diseases occur infrequently. NTM are generally considered to be less virulent than Mycobacterium tuberculosis, however, these organisms can cause diseases in both immunocompromised and immunocompetent hosts. As compared to tuberculosis, person-to-person transmission does not occur except with M. abscessus NTM species among cystic fibrosis patients. Lung is the most commonly involved organ, and the NTM-pulmonary disease (NTM-PD) occurs frequently in patients with pre-existing lung disease. NTM may also present as localized disease involving extrapulmonary sites such as lymph nodes, skin and soft tissues and rarely bones. Disseminated NTM disease is rare and occurs in individuals with congenital or acquired immune defects such as HIV/AIDS. Rapid molecular tests are now available for confirmation of NTM diagnosis at species and subspecies level. Drug susceptibility testing (DST) is not routinely done except in non-responsive disease due to slowly growing mycobacteria ( M. avium complex, M. kansasii) or infection due to rapidly growing mycobacteria, especially M. abscessus. While the decision to treat the patients with NTM-PD is made carefully, the treatment is given for 12 months after sputum culture conversion. Additional measures include pulmonary rehabilitation and correction of malnutrition. Treatment response in NTM-PD is variable and depends on isolated NTM species and severity of the underlying PD. Surgery is reserved for patients with localized disease with good pulmonary functions. Future research should focus on the development and validation of non-culture-based rapid diagnostic tests for early diagnosis and discovery of newer drugs with greater efficacy and lesser toxicity than the available ones.

Seasonal characteristics of aerosols (PM2.5 and PM10) and their source apportionment using PMF: A four year study over Delhi, India

The present study attempts to explore and compare the seasonal variability in chemical composition and contributions of different sources of fine and coarse fractions of aerosols (PM_2.5 and PM₁₀) in Delhi, India from January 2013 to December 2016. The annual average concentrations of PM_2.5 and PM₁₀ were 131 ± 79 μg m^-3 (range: 17-417 μg m^-3) and 238 ± 106 μg m^-3 (range: 34-537 μg m^-3), respectively. PM_2.5 and PM₁₀ samples were chemically characterized to assess their chemical components [i.e. organic carbon (OC), elemental carbon (EC), water soluble inorganic ionic components (WSICs) and heavy and trace elements] and then used for estimation of enrichment factors (EFs) and applied positive matrix factorization (PMF5) model to evaluate their prominent sources on seasonal basis in Delhi. PMF identified eight major sources i.e. Secondary nitrate (SN), secondary sulphate (SS), vehicular emissions (VE), biomass burning (BB), soil dust (SD), fossil fuel combustion (FFC), sodium and magnesium salts (SMS) and industrial emissions (IE). Total carbon contributes ∼28% to the total PM_2.5 concentration and 24% to the total PM₁₀ concentration and followed the similar seasonality pattern. SN and SS followed opposite seasonal pattern, where SN was higher during colder seasons while SS was greater during warm seasons. The seasonal differences in VE contributions were not very striking as it prevails evidently most of year. Emissions from BB is one of the major sources in Delhi with larger contribution during winter and post monsoon seasons due to stable meteorological conditions and aggrandized biomass burning (agriculture residue burning in and around the regions; mainly Punjab and Haryana) and domestic heating during the season. Conditional Bivariate Probability Function (CBPF) plots revealed that the maximum concentrations of PM_2.5 and PM₁₀ were carried by north westerly winds (north-western Indo Gangetic Plains of India).

Prevalence of dengue vectors, larval breeding habitats, Stegomyia indices and their correlation with dengue cases in urban and rural areas of Punjab, India

BACKGROUND & OBJECTIVES

The state of Punjab, India is highly endemic for dengue fever as high number of confirmed dengue cases have been reported since 2013. A better understanding of vectors distribution and their seasonal variation is necessary to control the disease. Therefore, the present study was conducted in both rural and urban areas of 11 out of 22 districts of Punjab to highlight seasonal prevalence of Aedes vector mosquitoes.

METHODS

Entomological surveys were carried out in different seasons and all kinds of indoor and outdoor breeding habitats were examined and Aedes immatures were collected. The Stegomyia indices were calculated and compared from urban and rural areas in different seasons.

RESULTS

Both vectors of dengue, i.e. Aedes aegypti and Ae. albopictus were recorded to be prevalent. Ae. aegypti mosquitoes were observed in all districts surveyed while Ae. albopictus were found only in seven districts of Punjab. The Stegomyia indices were significantly high during monsoon as compared to pre- and post- monsoon periods. Occurrence of dengue cases were found to be correlated with the Stegomyia indices.

INTERPRETATION & CONCLUSION

This is the first detailed study of prevalence of dengue mosquito vectors in Punjab showing the presence of Ae. aegypti and Ae. albopictus in both urban and rural areas of the state, thereby demonstrating wide distribution of this vector. Different breeding habitats identified in the study should be subjected to targeted intervention such as source reduction in order to achieve effective control of dengue cases.

Low Vitamin D Levels in Rheumatoid Arthritis Patient is Associated with Poor Disability Index and Increased Patient Global Disease Assessment Score

BACKGROUND

Rheumatoid arthritis (RA) is a chronic inflammatory connective tissue disorder with wide spectrum of presentation from polyarthritis to multisystem involvement. Apart from bones, muscles and other soft tissues, Vitamin D receptors have been found on many immune cells and tissues. The most vital function of Vitamin D is calcium and phosphorus absorption but it can also act as an immune-modulator hormone, which can affects both innate and adaptive immune responses leading to autoimmune diseases.

OBJECTIVES

To study the relationship of vitamin D insufficiency with disease activity and functional disability in patients of Rheumatoid Arthritis.

MATERIAL AND METHODS

The present study was an observational, cross sectional study done in a tertiary care hospital in New Delhi, India. The inclusion criteria comprised of patients attending the inpatient (IPD) and outpatient department (OPD), age above 18 years and fulfilling 1987 American college of Rheumatology (ACR) criteria for RA. The exclusion criteria was patients suffering from any other connective tissue disorder (CTD) and patients who were taking vitamin D supplements for past 6 months. Thirty patients were enrolled in the study after satisfying inclusion and exclusion criteria and appropriate clinical data and blood sample were collected after informed consent. Joint examination were performed and swollen joint count (SJC), tender joint count (TJC), patient global assessment (PGA) and evaluator global assessment (EGA) scores were recorded. Disease activity using DAS28ESR, DAS28CRP and CDAI were calculated and disability index was assessed using Short Fries Health Assessment Questionnaire.

RESULTS

In our study mean vitamin D level was 18.93 ng/ml (S.D. 6.64 ng/ml). Mean DAS28 ESR was 4.57±1.48. Mean Disability Index was 0.52±0.89. All the study population had low Vitamin D level (100%), while 50% patients had vitamin D level in deficiency range (<20ng/ml). On analysis by student t-test, statistically higher PGA (p value 0.024) and Disability Index (p value < 0.001) in vitamin D deficient patients, compared to vitamin D insufficient patient group was observed, however there was no significant difference in disease activity between the groups.

CONCLUSION

Low Vitamin D levels are common in Indian rheumatoid arthritis patients. Mean PGA significantly increased, and disability index significantly increased in Vitamin D deficient group compared to insufficient group suggesting vitamin D deficient patients poor wellbeing and more disability.

Influence of Vehicular Emissions (NO, NO2, CO and NMHCs) on the Mixing Ratio of Atmospheric Ammonia (NH3) in Delhi, India

Mixing ratios of atmospheric ammonia (NH₃), nitric oxide (NO), carbon monoxide (CO), nonmethane hydrocarbons (NMHCs), and methane (CH₄) were measured to investigate the vehicular emissions, which are a dominant source of atmospheric NH₃ in urban sites of Delhi, India from January 2013 to December 2014. The annual average mixing ratios of NH₃, NO, CO, NMHCs, and CH₄ were 21.2 ± 2.1 ppb, 21.2 ± 6.1 ppb, 1.89 ± 0.18 ppm, 0.67 ± 0.21 ppm and 3.11 ± 0.53 ppm, respectively. Considering NO as a tracer of vehicular plume, ambient NH₃ was correlated with NO during peak traffic hour in the morning (7:00-10:00 h) and evening (17:00-19:00 h) and observed significant positive correlation between them. Result reveals that the mixing ratio of atmospheric NH₃ significantly positive correlated with traffic related pollutants (NO, CO, and NHHCs) during all the seasons (winter, summer, and monsoon). During winter, the average mixing ratio of atmospheric NH₃ was increased by 1.2-3.5 ppb in the morning peak hour, whereas increased by 0.3-1.6 ppb in the evening peak hour. Similarly, an increase in NH₃ mixing ratio was observed during summer (morning: 1.2-2.7 ppb and evening: 1.5-1.6 ppb) and monsoon (morning: 0.4-3.6 ppb and evening: 0.9-1.4 ppb) seasons. The results emphasized that the traffic could be one of the dominant source of ambient NH₃ at the urban site of Delhi, as illustrated by positive relationships of NH₃ with traffic related co-pollutants (NO, CO and NMHCs).

The burden of submicroscopic and asymptomatic malaria in India revealed from epidemiology studies at three varied transmission sites in India

Malaria in India, while decreasing, remains a serious public health problem, and the contribution of submicroscopic and asymptomatic infections to its persistence is poorly understood. We conducted community surveys and clinic studies at three sites in India differing in their eco-epidemiologies: Chennai (Tamil Nadu), Nadiad (Gujarat), and Rourkela (Odisha), during 2012-2015. A total of 6,645 subject blood samples were collected for Plasmodium diagnosis by microscopy and PCR, and an extensive clinical questionnaire completed. Malaria prevalence ranged from 3-8% by PCR in community surveys (24 infections in Chennai, 56 in Nadiad, 101 in Rourkela), with Plasmodium vivax dominating in Chennai (70.8%) and Nadiad (67.9%), and Plasmodium falciparum in Rourkela (77.3%). A proportional high burden of asymptomatic and submicroscopic infections was detected in community surveys in Chennai (71% and 71%, respectively, 17 infections for both) and Rourkela (64% and 31%, 65 and 31 infections, respectively). In clinic studies, a proportional high burden of infections was identified as submicroscopic in Rourkela (45%, 42 infections) and Chennai (19%, 42 infections). In the community surveys, anemia and fever were significantly more common among microscopic than submicroscopic infections. Exploratory spatial analysis identified a number of potential malaria hotspots at all three sites. There is a considerable burden of submicroscopic and asymptomatic malaria in malarious regions in India, which may act as a reservoir with implications for malaria elimination strategies.

Status of vitamin D and the associated host factors in pulmonary tuberculosis patients and their household contacts: A cross sectional study

Innate immunity plays an important role in pathophysiology of tuberculosis which is influenced by various host factors. One such factor is vitamin D which, along with its associated molecule, can alter the host defense against Mycobacterium Tuberculosis (M.Tb.) via altered production of cathelicidin and nitric oxide, both having bactericidal effect. Therefore, assessment of vitamin D and its associated molecules in tuberculosis patients and household contacts as compared to healthy controls were done and the implication of these findings in susceptibility to tuberculosis (TB) was studied. 80 active TB patients, 75 household contacts and 70 healthy controls were included. Vitamin D receptor (VDR), vitamin D binding protein (VDBP) and inducible nitric oxide synthase (iNOS) mRNA levels were studied using quantitative PCR. Serum VDR, cathelicidin, and iNOS levels were measured using ELISA. Vitamin D and NO levels were measured in serum using chemiluminescence based immunoassay and greiss reaction based colorimetry kit respectively. Decreased serum levels of vitamin D were observed in active TB patients as compared to healthy controls (p < 0.001). VDR and iNOS mRNA levels were found to be significantly lower in active TB patients compared to household contacts and healthy controls (p < 0.0001 and 0.005 respectively). VDBP mRNA expression was found to be lower in active TB group as compared to household contacts and healthy controls however the difference was not found to be significant (p > 0.21). Although, mRNA expression of VDR, VDR protein and iNOS along with vitamin D levels were significantly (p < 0.05) higher in household contacts compared to active TB group. However, levels of iNOS, NO and cathelicidin were found to be higher in TB patients as compared to household contacts and healthy controls (p < 0.01, 0.05 and 0.01 respectively). Higher levels of Vitamin D along with VDR and iNOS expression in household contacts as compared to active TB patients suggest vitamin D might have a protective role against TB plausibly decreasing disease susceptibility. Low vitamin D levels in active TB patients warrants further studies to determine the role of vitamin D supplementation in prevention and treatment of TB.