Molecular characterization of decreased susceptibility to ceftriaxone and genotyping of Neisseria gonorrheae isolates in New Delhi, India

Data on genetic characteristics of Neisseria gonorrhoeae isolates exhibiting decreased susceptibility to extended-spectrum cephalosporins in India is deficient. In this study, we have sequenced penA, porB, mtrR and ponA and bla_TEM genes in 70 clinical isolates of NG with varying ceftriaxone MICs. Amongst these, 22 (31.4%) were PPNG. Additionally, N. gonorrheae Multiantigen Sequence Typing was performed. Fisher exact and χ² were used to evaluate significance of mutations with MICs. A total of six non-mosaic penA (Penicillin binding protein 2 [PBP2]) amino acid patterns were seen (II, IV, IX, XII, XIX, XXII) of which, pattern IX was significantly associated with decreased susceptibility to ceftriaxone. Other significant associations were noted in porB & mtrR genes. There were no mutations in bla_TEM gene. ST6069 was significantly associated with decreased susceptibility to ceftriaxone. To conclude, development of decreased susceptibility to ceftriaxone in gonococci involves cumulation of different mutations in the four chromosomal genes investigated.

Response to single oral dose vitamin D in obese vs non-obese vitamin D-deficient children

Obese individuals are prone to vitamin D deficiency because of sequestration of vitamin D in their body fat. We planned to evaluate the rise in serum 25(OH)D levels in vitamin D-deficient obese vs normal body mass index(BMI) children, after administration of identical single dose of vitamin D. Twenty-two obese and 22 normal BMI children with serum 25 (OH)D < 20 ng/mL were given single oral dose 150,000 IU vitamin D, and 25 (OH)D levels were measured at 1 week and 1 month post-intervention. Results show that rise in 25(OH)D level from baseline was about 2.2 times lesser in obese compared with children with normal BMI, both at 1 week and at 1 month. The rise in 25(OH)D from baseline to 1 month was inversely correlated to BMI (r = - 0.56, p = < 0.001), waist circumference (r = - 0.48, p = 0.001), total fat mass (r = - 0.58, p < 0.001), and fat mass index (r = - 0.59, p < 0.001).Conclusion: The obese children have a 2.2 times lower rise in serum vitamin D levels as compared with the normal BMI children for the same dose of vitamin D supplementation. What is Known: • The obese individuals are prone to vitamin D deficiency and may be given higher doses of vitamin D supplementation. What is New: • Our study demonstrates that obese children have 2.2 times lesser rise in serum 25(OH)D concentrations as compared with normal BMI children when administered similar oral dose vitamin D.

Liver involvement in patients with coeliac disease: proof of causality using IgA/anti-TG2 colocalisation techniques

AIMS

Despite clinical evidence of liver involvement in patients with coeliac disease (CeD), there is a lack of a method to prove this association.

METHODS

Of 146 treatment-naive patients with CeD, 26 had liver dysfunction. Liver biopsies and corresponding small intestinal biopsies were obtained from these 26 patients. Multicolour immunohistochemical and immunofluorescence confocal microscopic studies were performed on paraffin-embedded tissue to detect the IgA/anti-TG2 deposits. Follow-up liver biopsies were taken after a gluten-free diet.

RESULTS

Twenty-six out of the 146 patients (17.8%) with suspected coeliac-associated liver disease on histological examination revealed irregular sinusoidal dilatation in 15 (57.6%), steatohepatitis in 4 (15.3%), non-specific chronic hepatitis in 3 (11.5%), autoimmune hepatitis in 2 (7.6%) biopsies, including cirrhosis in one of them, irregular perisinusoidal fibrosis and changes of non-cirrhotic portal fibrosis in one biopsy each (3.8%). IgA/anti-tTG deposits were observed in 22 (84.6%) liver biopsies by dual immunohistochemistry technique, and in 24 (92.3%) by confocal immunofluorescence technique and in all corresponding duodenal biopsies (100%). Overall, IgA/anti-tTG deposits showed 100% sensitivity, 77% specificity and 85% positive predictive value for establishing an association of extraintestinal pathology and CeD using archived tissues. Follow-up liver biopsies could be obtained in five patients; four of them showed not only resolution of the histological lesions but disappearance of IgA/anti-tTG co-localisation.

CONCLUSIONS

Data of the present study adds to the body of evidence that liver lesions in patients with CeD are disease related and may have been caused by a similar pathogenic mechanism that causes intestinal changes.

Changes in extracellular cytokines in predicting disease severity and final clinical outcome of patients with blunt chest trauma

BACKGROUND

Chest trauma causes substantial morbidity and mortality and its severity is assessed using clinical diagnosis or scoring systems like Injury severity score (ISS) and thoracic trauma severity score (TTSS). Association of inflammatory cytokines with severity of disease and final clinical outcome is not clearly defined in patients with chest trauma. In this study, we thought to evaluate the inflammatory response in serum and bronchoalveolar lavage fluid (BALF) in chest trauma patients and correlate the level of extracellular cytokines with diseases severity and final outcome.

METHODS

A total of 65 patients with blunt chest trauma and 30 healthy controls were enrolled in this prospective observational study. Assessment of inflammatory cytokines such as Interleukin (s) - IL-5, IL-13, IL-2, IL-6, IL-9, IL-1β, IFN-γ, TNF-α, IL-17A, IL-17F,IL-4, IL-21 and IL-22 was performed in both serum and bronchoalveolar lavage fluid using 13-plex multiplex kit using fluorescence-encoded bead based immunoassays.

RESULTS

A significantly higher level of IL-13, IL-2, IL-6, IL-9, IL-1β, IFN-γ, TNF-α, IL-17A, IL-17F, IL-21 and IL-22 cytokines were observed in patients with blunt chest trauma compared to healthy controls. Level of IL-2, IL-6, IL-1β and IL-17A was significantly raised in the patients with blunt chest trauma who had a fatal outcome during the hospital stay. An elevated cytokine response of IL-13, IL-4, and IL-21 was noted in the group of patients with high (>5) thoracic trauma severity score.

CONCLUSION

Routine monitoring of the inflammatory cytokine level in patients with chest trauma may be used routinely. Longer prospective studies should be encouraged to determine the role of cytokines in patients with chest trauma in predicting the patient final clinical outcome.

Impact of a Psychodermatological Education Package on the Subjective Distress, Family Burden, and Quality of Life among the Primary Caregivers of Children Affected with Epidermolysis Bullosa

Background

Epidermolysis bullosa (EB) has profound effect on the subjective distress, family burden, and quality of life (QOL) of the primary caregivers (PCG). Knowledgeable PCG can efficiently manage children with these skin diseases and also improve their QOL.

Objectives

To assess the subjective distress, family burden, and QOL, to develop and assess the short-term effectiveness of a psycho-dermatological education package (PDEP) for the PCG of children with EB.

Methods

In this interventional study, 30 PCG of EB were assessed for subjective distress, family burden, and QOL. PDEP, a structured educational tool explaining the disease and its care and stress management, was developed by the authors for the PCG and administered to them after one month of enrolment. They were reassessed after three months and compared with the baseline assessment scores. For comparison, 37 PCG of CI were also studied.

Results

The mean age (years) of the subjects was 28.7 ± 6.7 for EB and 30.5 ± 4.6 for CI. The mean or median (range) baseline scores for subjective distress, family burden and QOL of PCG (n = 20) of EB were 8.4 ± 7.9, 6.5 (0-30); 28.5 ± 17.5, 24 (7-77) and 12.6 ± 6.7, 11.5 (4-28) and for PCG (n = 14) of CI were 12 ± 4.3, 38.9 ± 16.2 and 17.7 ± 3.6 respectively. The PDEP improved the QOL (p = 0.01), knowledge (p < 0.01) and practices (p < 0.001) for PCG of EB and it improved subjective distress (p < 0.001), QOL (p < 0.01) and knowledge (p < 0.01) for PCG of CI.

Conclusions

PDEP is an effective educational tool in improving the QOL and knowledge of PCG, which in turn provides efficient management and psychological support to children affected with EB and CI. It should, therefore, be routinely used for educating the PCG of children with EB and CI.

Prognostic and Therapeutic Potentials of OncomiRs Modulating mTOR Pathways in Virus-Associated Hepatocellular Carcinoma

Background

Dysregulated oncomiRs are attributed to hepatocellular carcinoma (HCC) through targeting mTOR signaling pathway responsible for cell growth and proliferation. The potential of these oncomiRs as biomarker for tumor response or as target for therapy needs to be evaluated.

AIM

Tumor response assessment by OncomiR changes following locoregional therapy (LRT) and targeting of these oncomiRs modulating pathway

Methods

All consecutive viral-HCC patients of BCLC stage-A/B undergoing LRT were included. OncomiRs (miR-21, -221, and -16) change in circulation and AFP-ratio at 1-month post-LRT to baseline was estimated to differentiate various categories of response as per mRECIST criteria. OncomiR modulating mTOR pathway was studied by generating miR-21 and miR-221 overexpressing Huh7 stable cell lines.

Results

Post-LRT tumor response was assessed in 90 viral-HCC patients (CR, 40%; PR, 31%, and PD, 29%). Significant increase of miRNA-21 and -221 expression was observed in PD (p = 0.040, 0.047) and PR patients (miR-21, p = 0.045). Fold changes of miR-21 can differentiate response in group (CR from PR+PD) at AUROC 0.718 (95% CI, 0.572–0.799) and CR from PD at AUROC 0.734 (95% CI, 0.595–0.873). Overexpression of miR-21 in hepatoma cell line had shown increased phosphorylation p70S6K, the downstream regulator of cell proliferation in mTOR pathway. Upregulation of AKT, mTOR, and RPS6KB1 genes were found significant (P < 0.005) and anti-miR-21 specifically reduced mTOR gene (P = 0.02) expression.

Conclusions

The miR-21 fold change correlates well with imaging in predicting tumor response. Overexpression of miR-21 has a role in HCC through mTOR pathway activation and can be targeted.

Quality of life in paediatric solid tumours: a randomised study of metronomic chemotherapy versus placebo

OBJECTIVE

Health-related quality of life (HRQoL) is an important outcome for paediatric cancer studies. We compared the HRQoL between patients of progressive paediatric solid tumours randomised to metronomic chemotherapy versus placebo.

METHODS

In this double-blinded, placebo-controlled randomised study of 108 children with progressive malignancies, HRQoL was evaluated using the PedsQOL Cancer module V.3 at baseline (A1), A2 (9 weeks or earlier if progressed) or A3 (18 weeks or earlier if progressed).

RESULTS

There was no statistically significant difference in the change in quality of life produced by each arm from A1 to A2 in either mean total scores or individual domain scores, reported by children or their parents. On analysing the response according to the minimal clinically important difference, defined as an improvement by 4.5 points, we found no significant differences, be it among bone-sarcomas, other tumours, responders (those who received ≥9 weeks of treatment) or non-responders.

CONCLUSIONS

The present study concludes that there was no significant difference in HRQoL, between the patients in the two arms at second and later assessments. This is consistent with the other survival endpoints in the study.

TRIAL REGISTRATION NUMBER

Clinical trial registration: clinicaltrials.gov Identifier: NCT01858571.

Prevalence, pattern & correlates of hypertension among tribal population of Kashmir, India: A cross-sectional study

Background & objectives:

The prevalence of hypertension is increasing among all ethnic groups across the globe with only a handful of studies from India addressing the prevalence of hypertension among tribal population. In view of paucity of data, this study was aimed at estimating the prevalence of hypertension and associated risk factors among tribal population of Kashmir, India.

Methods:

This cross-sectional survey included 6808 tribals aged >20 yr (5695 Gujjars and 1113 Bakarwals) from five randomly selected districts of Kashmir. Modified WHO-STEPS surveillance questionnaire was used to collect relevant data. Hypertension was defined by Joint National Committee on Prevention, Detection, Evaluation and Treatment of Hypertension (JNC 8) criteria.

Results:

The mean age of our study participants was 43.12 ± 15.69 years. Overall prevalence of hypertension [95% confidence interval (CI)] was 41.4% (39.9-42.9%) [men=46.7% (44.1-49.1%); women=37.9% (35.9-39.9%)]. The prevalence of prehypertension (95% CI) in our study was 35 per cent (33.7-36.6%). Higher age [adjusted odds ratio (OR) (95% CI): >70 yr-2.2 (1.9-2.4)], passive smoking [OR-1.3 (1.1-1.5)], family history of hypertension [OR-1.6 (1.4-1.7)] and obesity [OR-1.3 (1.1-1.6)] were significantly associated with hypertension. A weak positive correlation was observed between BP (systolic/diastolic) with haemoglobin, red blood cell count and haematocrit (P<0.05).

Interpretation & conclusions:

Gujjar and Bakarwal tribes of Jammu and Kashmir showed high prevalence of hypertension. Hence, urgent policies and reforms are needed to tackle this silent epidemic and further studies focusing on community-based interventions are required.

Histological analyses of trucut liver biopsies from patients with noncirrhotic portal fibrosis and extra-hepatic portal vein obstruction

Background

Both noncirrhotic portal fibrosis (NCPF) and extrahepatic portal venous obstruction (EHPVO) are important causes of noncirrhotic portal hypertension (PH) in the Asian region. In this study, we analyzed the histopathological changes of liver needle-core biopsies from patients with NCPF and EHPVO.

Patients and Methods

The patients were diagnosed as per the Asia Pacific Association for the Study of Liver (APASL) criteria. Minimum adequacy criteria for liver core biopsies were defined, and finally, 69 liver biopsies from patients with NCPF and 100 liver biopsies from patients with EHPVO were analyzed. All histological parameters were predefined, and three experienced pathologists analyzed the biopsies after reaching consensus. Institute ethics committee clearance was taken.

Results

Although some histological features were overlapping, phlebosclerosis of intra-hepatic branches of the portal vein (PV), periportal aberrant vascular channels, remnant portal tracts, and hepatic fibrosis beyond the portal tracts without the formation of complete hepatic nodules (P < 0.001 for all) were common histological characteristics of NCPF on core-needle liver biopsies; while maintained lobular architecture, nonspecific dilatation of PV branches, absence of intra-hepatic PV phlebosclerosis, aberrant vascular channels, and significant fibrosis were characteristics of EHPVO.

Conclusions

Despite the considerable histological overlap between NCPF and EHPVO, careful histological evaluation, supplemented by clinical features, radiological and biochemical findings can help in making a conclusive diagnosis. Patients with NCPF and EHPVO with clinical jaundice show transaminitis, high serum alkaline phosphatase level, more variceal bleed, and histological evidences of nodular regenerative hyperplasia.

Burden of influenza-associated respiratory and circulatory mortality in India, 2010-2013

Background

Influenza causes substantial morbidity and mortality worldwide, however, reliable burden estimates from developing countries are limited, including India. We aimed to quantify influenza-associated mortality for India utilizing 2010-2013 nationally representative data sources for influenza virus circulation and deaths.

Methods

Virological data were obtained from the influenza surveillance network of 10 laboratories led by National Institute of Virology, Pune covering eight states from 2010-2013. Death data were obtained from the nationally representative Sample Registration System for the same time period. Generalized linear regression with negative binomial distribution was used to model weekly respiratory and circulatory deaths by age group and proportion of specimens positive for influenza by subtype; excess deaths above the seasonal baseline were taken as an estimate of influenza-associated mortality counts and rates. Annual excess death rates and the 2011 India Census data were used to estimate national influenza-associated deaths.

Results

Estimated annual influenza-associated respiratory mortality rates were highest for those ≥65 years (51.1, 95% confidence interval (CI) = 9.2-93.0 deaths/100 000 population) followed by those <5 years (9.8, 95% CI = 0-21.8/100 000). Influenza-associated circulatory death rates were also higher among those ≥65 years (71.8, 95% CI = 7.9-135.8/100 000) as compared to those aged <65 years (1.9, 95% CI = 0-4.6/100 000). Across all age groups, a mean of 127 092 (95% CI = 64 046-190,139) annual influenza-associated respiratory and circulatory deaths may occur in India.

Conclusions

Estimated influenza-associated mortality in India was high among children <5 years and adults ≥65 years. These estimates may inform strategies for influenza prevention and control in India, such as possible vaccine introduction.

IMPACT OF MOLECULAR METHOD FOR THE DIAGNOSIS OF ACUTE BACTERIAL MENINGITIS IN A TERTIARY HEALTH CARE CENTRE IN NORTH INDIA

Background. Acute bacterial meningitis is one of the significant infectious diseases that add an immense burden to the health system. Proper management of meningitis is an invincible need to overcome the severe consequences. Objectives. The aim of the study is detection of the etiological agents of acute bacterial meningitis by PCR. Methods. Total 267 CSF samples collected from suspected bacterial meningitis cases were processed for the detection of S. pneumoniae, H. influenzae, N. meningitidis, E. coli and Group B streptococci by conventional and molecular diagnosis method. CSF was inoculated on Blood, chocolate and MacConkey agar plates and incubated at 37 °C for 24-48 hrs. Bacteria grown were identified by Matrix assisted laser desorption/ionization time of flight (MALDI-TOF). Multiplex PCR of the enlisted bacteria was performed using DNA extracted from CSF by DNA extraction kit (Qiagen, USA). Results. 5 (1.87%) out of the total 267 CSF samples were culture positive (3 S. pneumoniae and 2 E. coli) and 28 (10.49%) had detectable DNA by conventional PCR. Out of these 28 samples, 20 (71.43%) were S. pneumoniae and 8 (28.57%) were E. coli. 15 (53.57%) out of total S. pneumoniae were present in children below 5 years of age. Similarly, E. coli was predominant in neonates. Sensitivity and specificity of the PCR was 100% and 95-98% respectively. Conclusions. Streptococcus pneumoniae is the commonest cause of community acquired bacterial meningitis in children below five years of age. Hence, for the promising outcome, PCR should be implemented for the diagnosis of acute bacterial meningitis.

Circulating miR-133b and miR-21: potential non-invasive diagnostic biomarkers of coronary artery disease

Background

While coronary artery disease (CAD) has become a major threat worldwide, the timely biomarker-based early diagnosis of CAD remains a major unmet clinical challenge.

Purpose

We aimed towards assessing the level of circulatory microRNAs as candidates of novel biomarkers in early diagnosis of CAD.

Methods

A total of 147 subjects were recruited from Delhi and surrounding regions which includes 78 subjects with angiographically proven CAD, 15 pre-atherosclerotic normal coronary artery (NCA) subjects and 54 healthy individuals. Quantitative real-time PCR assays were performed using total RNA isolated from plasma of CAD patients and healthy individuals in order to measure the relative expression profiles of circulating miR-133b and miR-21. The severity level of the disease in each individual was assessed on the basis of number of diseased vessels involved and extent of stenosis.

Results

MiR-133b was found to be significantly downregulated (p&lt;0.05) by 4.6 fold whereas miR-21 was significantly upregulated (p&lt;0.05) by ∼2 fold in plasma samples of CAD patients as compared to healthy individuals. Importantly, both the miRNAs showed an association with disease severity as miR-133b was downregulated by 8.45 fold in acute coronary syndrome (ACS), 3.38 fold in Stable angina (SA) and 2.08 fold in NCA. MiR-21 was upregulated by 2.46 fold in ACS, 1.90 fold in SA and 1.12 fold in NCA. Moreover, miR-133b could significantly differentiate subjects with ST-elevation myocardial infarction (STEMI) from Non-STEMI. Both the miRNAs exhibited a noteworthy diagnostic potential as translated through an upstanding sensitivity and specificity. MiR-133b showed an area under the curve (AUC): 0.80 with 75.6% sensitivity and 76% specificity at recommended optimal cut-off point of 14.0 whereas, miR-21 showed and AUC value of 0.79 with 72.2% sensitivity and 69.4% specificity at optimal cut-off point of 5.59 as assessed by receiver operating characteristics (ROC) curve analysis.

Conclusions

The reduced expression of miR-133b and elevated expression level of miR-21 in plasma suggest their significant role in the pathophysiology as well as their implication towards the individual's susceptibility in developing CAD. Thus, we conclude that these two circulating miRNAs could be possible candidates of non-invasive biomarkers in the early prediction and diagnosis of CAD.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Department of Science and Technology, New Delhi, India; University Grant Commission (JRF/SRF Fellowship: Ref no. 22/12/2013(ii)EU-V

Is Endoscopic Third Ventriculostomy a Feasible Option or Ventriculoperitoneal Shunt a Safer Bet for the Treatment of Posttraumatic Hydrocephalus? A Gap Time Model-based Algorithm

Background

Posttraumatic hydrocephalus (PTH) adds to the morbidity and mortality of traumatic brain injury (TBI) and there are insufficient clinical data to suggest usefulness of ventriculoperitoneal shunt (VPS) over endoscopic third ventriculostomy (ETV) in PTH or vice versa.

Objective

To evaluate the usefulness of VPS and ETV in the treatment of PTH and to establish the indications for their usage.

Materials and Methods

This was an ambispective study of 141 patients who developed PTH out of 2500 cases of TBI treated during the study duration (2012-2016). These patients were segregated into two groups depending on the primary procedure for PTH-ETV group and VPS group. The two groups were compared to analyze the differences in radiological and clinical outcome.

Results

141 patients were included in the study and 175 procedures were performed in these patients. ETV group had 30 procedures and VPS had 145 procedures. In the ETV group, 37% of cases showed improvement v/s 73% cases in the VPS group. A statistically significant number of patients had improvement in presenting symptoms in the VPS group, as compared with the ETV group (P = 0.001). There was no significant difference in Glasgow coma scale (GCS) at discharge (P = 0.15) and Glasgow outcome score at 6 months of follow-up (P = 0.22) between the two groups. Poor GCS, previous cerebrospinal fluid infection, and postoperative meningitis were found to have significant effect on the failure-free period of the procedure. On comparing the probabilities of failure-free period of ETV v/s VPS, the chances of VPS failure are 61% lesser than ETV.

Conclusions

VPS is an effective modality for the management of PTH and has a much lower failure rate as compared to ETV. However, ETV can be considered as a salvage procedure in difficult situations of recurrent shunt malfunction or infection.

A split face randomized controlled trial comparing 1,064 nm Q-switched Nd-YAG laser and modified Kligman's formulation in patients with melasma in darker skin

BACKGROUND

No randomized studies compared the efficacy and safety of modified Kligman's triple combination (TC) with 1,064 nm Q-switched Nd-YAG laser (QSNYL) in melasma in darker skin.

OBJECTIVES

To compare the efficacy and safety of QSNYL and TC in the treatment of melasma in Fitzpatrick skin types IV and V.

METHODS

In this split face randomized controlled trial, participants' cheeks were randomized to receive either weekly QSNYL (group A) or daily TC (group B) for 12 weeks, followed by 12 weeks of follow-up.

RESULTS

Twenty-eight patients completed the intervention, and 21 of them completed follow-up. We found a significant but modest reduction in mean melanin index, modified Melasma Area Severity Index (MASI), and photographic and patient's assessment in both modalities (P < 0.01). No significant differences were detected between the groups. All patients had reappearance of pigmentation by the end of follow-up. Adverse reactions were significantly more in group B (P < 0.001).

LIMITATION

The desired sample size could not be achieved.

CONCLUSION AND RELEVENCE

No statistically significant differences were observed between QSNYL and TC as monotherapy in melasma. Reappearance of melasma is inevitable after stopping treatment.

Evaluation of a Chip-Based, Point-of-Care, Portable, Real-Time Micro PCR Analyzer for the Detection of High-Risk Human Papillomavirus in Uterine Cervix in India

PURPOSE

Currently available human papillomavirus (HPV) detection devices are expensive, requiring a continuous power supply, high-priced reagents, skilled laboratory personnel, and infrastructure. These make it difficult to implement primary HPV screening in high-risk (HR) populations, particularly in low-income settings such as in India. The objective of our study was to evaluate the diagnostic performance of a point-of-care, portable, battery-operated device called Truenat, which detects 4 HR HPV genotypes (16, 18, 31, and 45), as a potentially cost-effective alternative to conventional HPV diagnostic tests.

PATIENTS AND METHODS

This was a single-site, blinded, cross-sectional study that evaluated the performance of the Trunat HPV-HR using cervical samples collected from nonpregnant women > 30 years old via consecutive sampling. The comparison was conducted against the Hybrid Capture 2 (HC2) method. All the positive samples were validated by 14 Real-TM Quant Kit.

RESULTS

Of 615 cervical samples, the HR-HPV DNA test was positive in 78 women (12.7%) by HC2 and in 49 (8%) by Truenat. With the consideration of limited genotype inclusivity, the sensitivity and specificity of Truenat HPV-HR were 97.7% and 98.9%, respectively.

CONCLUSION

The performance of Truenat HPV-HR test was comparable to that of HC2 in the 4 HPV genotypes and would be appropriate to consider for use in primary HR cervical cancer screening and particularly in low-income settings.

Validation of the diagnostic criteria for segmental vitiligo

Background

Segmental vitiligo has a different clinical course and prognosis as compared to nonsegmental vitiligo, which necessitates its correct diagnosis. It may be difficult to distinguish segmental vitiligo from the limited or focal types of nonsegmental vitiligo.

Objective

To validate the previously proposed diagnostic criteria for segmental vitiligo.

Methods

This was a cross-sectional validation study involving patients with limited vitiligo. The diagnostic criteria were used to classify vitiligo lesions as segmental or nonsegmental, and was compared with the experts' diagnosis, which was considered as the "gold standard".

Results

The study included 200 patients with 225 vitiligo lesions. As per the diagnostic criteria, 146 vitiligo lesions were classified as segmental and 79 as nonsegmental. The experts classified 147 vitiligo lesions as segmental and 39 as nonsegmental, while the diagnosis either was labeled "unsure" or could not be agreed upon for 39 lesions. As compared with the experts' opinions ("for sure" cases, n = 186), the sensitivity and specificity of the diagnostic criteria was 91.8% (95% confidence interval [CI]: 86.2%-95.7%) and 100% (95% CI: 91%-100%), respectively. The positive predictive value was 100% (95% CI: 97.3-100%), while the negative predictive value was 76.5% (95% CI: 62.5%-87.2%). There was a 93.5% agreement between the clinical criteria and experts' opinions (k = 0.83, P < 0.001).

Limitation

The diagnostic criteria were compared with the experts' opinion in the absence of an established diagnostic "gold standard".

Conclusions

The proposed diagnostic criteria for segmental vitiligo performed well, and can be used in clinical practice, as well as in research settings.

Detection of mycobacterial CFP-10 (Rv3874) protein in tuberculosis patients by gold nanoparticle-based real-time immuno-PCR

Aim: Timely and reliable diagnostic test for tuberculosis (TB) is immediately required. Attempts were made to improve the technology and diagnostic potential of real-time immuno-PCR (RT-I-PCR). Methods: We designed gold nanoparticle (GNP)-based RT-I-PCR (GNP-RT-I-PCR) assay for the detection of Mycobacterium tuberculosis CFP-10 (Rv3874) protein in clinical samples of TB patients. Results: A wide quantitative detection range of CFP-10 was found to be 0.5-5 × 10⁴ pg/ml in bodily fluids of TB patients, which can evaluate the progression of disease. Moreover, sensitivities of 83.7 and 76.2% were observed in pulmonary (n = 49) and extrapulmonary TB (n = 42) patients, respectively, with specificities of 93.5-93.8% (n = 63). Conclusion: Conjugation of detection antibodies and oligonucleotides to functionalized GNPs of GNP-RT-I-PCR is relatively easier, compared with streptavidin-biotin/succinimidyl-4-(N-maleimidomethyl) cyclohexane-1-carboxylate system employed in RT-I-PCR. Our assay also showed better diagnostic performance than RT-I-PCR, which may provide a viable platform for the development of an efficient TB diagnostic test.

Comparison of statistical methods for recurrent event analysis using pediatrics asthma data

When the same type of event is experienced by a subject more than once it is called recurrent event, which possess two important characteristics, namely "within-subject correlation" and "time-varying covariate." As a result, the traditional statistical methods do not work well on recurrent event data. Over the past few decades, many alternatives methods have been proposed for the analysis of recurrent event data. In this article, the six most prominent methods for recurrent event analysis have been compared on pediatric asthma data. Three variance corrected models (viz "Anderson and Gill [AG] model," "Prentice, William, and Peterson-Counting Process [PWP-CP] model," and "Prentice, William, and Peterson-Gap Time [PWP-GT] model") and three corresponding frailty variants (AG-frailty, PWP-CP-frailty, and PWP-GT-frailty) were compared using three mathematical criterion (AIC, BIC, and log-likelihood) and one graphical criteria (Cox-Snell goodness of fit, visual test). All model comparison indices showed the PWP-GT model as the most appropriate model on asthma data over other models. By using PWP-GT model, seven predictors of asthma exacerbation (viz "abdominal pain at previous visit," "Z5 (%) at previous visit," "diagnosis of asthma at previous visit," "calendar month of exacerbation," "history of maternal asthma," "monthly per capita income," and "emotional stress") were identified. The PWP-GT model was identified as the most appropriate model over other models on pediatrics asthma data.

Subnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000-17

BACKGROUND

India has made substantial progress in improving child survival over the past few decades, but a comprehensive understanding of child mortality trends at disaggregated geographical levels is not available. We present a detailed analysis of subnational trends of child mortality to inform efforts aimed at meeting the India National Health Policy (NHP) and Sustainable Development Goal (SDG) targets for child mortality.

METHODS

We assessed the under-5 mortality rate (U5MR) and neonatal mortality rate (NMR) from 2000 to 2017 in 5 × 5 km grids across India, and for the districts and states of India, using all accessible data from various sources including surveys with subnational geographical information. The 31 states and groups of union territories were categorised into three groups using their Socio-demographic Index (SDI) level, calculated as part of the Global Burden of Diseases, Injuries, and Risk Factors Study on the basis of per-capita income, mean education, and total fertility rate in women younger than 25 years. Inequality between districts within the states was assessed using the coefficient of variation. We projected U5MR and NMR for the states and districts up to 2025 and 2030 on the basis of the trends from 2000 to 2017 and compared these projections with the NHP 2025 and SDG 2030 targets for U5MR (23 deaths and 25 deaths per 1000 livebirths, respectively) and NMR (16 deaths and 12 deaths per 1000 livebirths, respectively). We assessed the causes of child death and the contribution of risk factors to child deaths at the state level.

FINDINGS

U5MR in India decreased from 83·1 (95% uncertainty interval [UI] 76·7-90·1) in 2000 to 42·4 (36·5-50·0) per 1000 livebirths in 2017, and NMR from 38·0 (34·2-41·6) to 23·5 (20·1-27·8) per 1000 livebirths. U5MR varied 5·7 times between the states of India and 10·5 times between the 723 districts of India in 2017, whereas NMR varied 4·5 times and 8·0 times, respectively. In the low SDI states, 275 (88%) districts had a U5MR of 40 or more per 1000 livebirths and 291 (93%) districts had an NMR of 20 or more per 1000 livebirths in 2017. The annual rate of change from 2010 to 2017 varied among the districts from a 9·02% (95% UI 6·30-11·63) reduction to no significant change for U5MR and from an 8·05% (95% UI 5·34-10·74) reduction to no significant change for NMR. Inequality between districts within the states increased from 2000 to 2017 in 23 of the 31 states for U5MR and in 24 states for NMR, with the largest increases in Odisha and Assam among the low SDI states. If the trends observed up to 2017 were to continue, India would meet the SDG 2030 U5MR target but not the SDG 2030 NMR target or either of the NHP 2025 targets. To reach the SDG 2030 targets individually, 246 (34%) districts for U5MR and 430 (59%) districts for NMR would need a higher rate of improvement than they had up to 2017. For all major causes of under-5 death in India, the death rate decreased between 2000 and 2017, with the highest decline for infectious diseases, intermediate decline for neonatal disorders, and the smallest decline for congenital birth defects, although the magnitude of decline varied widely between the states. Child and maternal malnutrition was the predominant risk factor, to which 68·2% (65·8-70·7) of under-5 deaths and 83·0% (80·6-85·0) of neonatal deaths in India could be attributed in 2017; 10·8% (9·1-12·4) of under-5 deaths could be attributed to unsafe water and sanitation and 8·8% (7·0-10·3) to air pollution.

INTERPRETATION

India has made gains in child survival, but there are substantial variations between the states in the magnitude and rate of decline in mortality, and even higher variations between the districts of India. Inequality between districts within states has increased for the majority of the states. The district-level trends presented here can provide crucial guidance for targeted efforts needed in India to reduce child mortality to meet the Indian and global child survival targets. District-level mortality trends along with state-level trends in causes of under-5 and neonatal death and the risk factors in this Article provide a comprehensive reference for further planning of child mortality reduction in India.

FUNDING

Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Mapping of variations in child stunting, wasting and underweight within the states of India: the Global Burden of Disease Study 2000-2017

BACKGROUND

To inform actions at the district level under the National Nutrition Mission (NNM), we assessed the prevalence trends of child growth failure (CGF) indicators for all districts in India and inequality between districts within the states.

METHODS

We assessed the trends of CGF indicators (stunting, wasting and underweight) from 2000 to 2017 across the districts of India, aggregated from 5 × 5 km grid estimates, using all accessible data from various surveys with subnational geographical information. The states were categorised into three groups using their Socio-demographic Index (SDI) levels calculated as part of the Global Burden of Disease Study based on per capita income, mean education and fertility rate in women younger than 25 years. Inequality between districts within the states was assessed using coefficient of variation (CV). We projected the prevalence of CGF indicators for the districts up to 2030 based on the trends from 2000 to 2017 to compare with the NNM 2022 targets for stunting and underweight, and the WHO/UNICEF 2030 targets for stunting and wasting. We assessed Pearson correlation coefficient between two major national surveys for district-level estimates of CGF indicators in the states.

FINDINGS

The prevalence of stunting ranged 3.8-fold from 16.4% (95% UI 15.2-17.8) to 62.8% (95% UI 61.5-64.0) among the 723 districts of India in 2017, wasting ranged 5.4-fold from 5.5% (95% UI 5.1-6.1) to 30.0% (95% UI 28.2-31.8), and underweight ranged 4.6-fold from 11.0% (95% UI 10.5-11.9) to 51.0% (95% UI 49.9-52.1). 36.1% of the districts in India had stunting prevalence 40% or more, with 67.0% districts in the low SDI states group and only 1.1% districts in the high SDI states with this level of stunting. The prevalence of stunting declined significantly from 2010 to 2017 in 98.5% of the districts with a maximum decline of 41.2% (95% UI 40.3-42.5), wasting in 61.3% with a maximum decline of 44.0% (95% UI 42.3-46.7), and underweight in 95.0% with a maximum decline of 53.9% (95% UI 52.8-55.4). The CV varied 7.4-fold for stunting, 12.2-fold for wasting, and 8.6-fold for underweight between the states in 2017; the CV increased for stunting in 28 out of 31 states, for wasting in 16 states, and for underweight in 20 states from 2000 to 2017. In order to reach the NNM 2022 targets for stunting and underweight individually, 82.6% and 98.5% of the districts in India would need a rate of improvement higher than they had up to 2017, respectively. To achieve the WHO/UNICEF 2030 target for wasting, all districts in India would need a rate of improvement higher than they had up to 2017. The correlation between the two national surveys for district-level estimates was poor, with Pearson correlation coefficient of 0.7 only in Odisha and four small north-eastern states out of the 27 states covered by these surveys.

INTERPRETATION

CGF indicators have improved in India, but there are substantial variations between the districts in their magnitude and rate of decline, and the inequality between districts has increased in a large proportion of the states. The poor correlation between the national surveys for CGF estimates highlights the need to standardise collection of anthropometric data in India. The district-level trends in this report provide a useful reference for targeting the efforts under NNM to reduce CGF across India and meet the Indian and global targets.

Detection of Mycobacterium tuberculosis lipoarabinomannan and CFP-10 (Rv3874) from urinary extracellular vesicles of tuberculosis patients by immuno-PCR

Extracellular vesicles (EVs), the small circulating vesicles released from urine samples of tuberculosis (TB) patients, contain a pool of biomarkers. We recently detected Mycobacterium tuberculosis lipoarabinomannan (LAM) and CFP-10 (Rv3874) biomarkers from the urinary EVs of pulmonary TB (PTB) and extrapulmonary TB (EPTB) patients by immuno-polymerase chain reaction (I-PCR) assay and the results were compared with the analogous enzyme-linked immunosorbent assay (ELISA). The detection limits of both purified LAM and CFP-10 were determined to be 1 fg/mL with I-PCR, which was 106 times lower than ELISA. Detection of LAM and CFP-10 biomarkers in urinary EVs of TB patients by I-PCR showed superiority over ELISA. Notably, LAM I-PCR revealed sensitivities of 74.3 and 67.9% in PTB (n = 74) and EPTB (n = 53) patients, respectively, with specificities of 91.5-92.8% (n = 116). Moreover, the sensitivities attained with LAM I-PCR were significantly higher (P < 0.01) than with CFP-10 I-PCR. After further improving the sensitivity and specificity of the assay, our I-PCR based on LAM detection in urinary EVs may be used as an adjunct test for rapid diagnosis of TB.