Multiplex MassTag-PCR for respiratory pathogens in pediatric nasopharyngeal washes negative by conventional diagnostic testing shows a high prevalence of viruses belonging to a newly recognized rhinovirus clade

BACKGROUND

Respiratory infections are the most common infectious diseases in humans worldwide and are a leading cause of death in children less than 5 years of age.

OBJECTIVES

Identify candidate pathogens in pediatric patients with unexplained respiratory disease.

STUDY DESIGN

Forty-four nasopharyngeal washes collected during the 2004-2005 winter season from pediatric patients with respiratory illnesses that tested negative for 7 common respiratory pathogens by culture and direct immunofluorescence assays were analyzed by MassTag-PCR. To distinguish human enteroviruses (HEV) and rhinoviruses (HRV), samples positive for picornaviruses were further characterized by sequence analysis.

RESULTS

Candidate pathogens were detected by MassTag PCR in 27 of the 44 (61%) specimens that previously were rated negative. Sixteen of these 27 specimens (59%) contained picornaviruses; of these 9 (57%) contained RNA of a recently discovered clade of rhinoviruses. Bocaviruses were detected in three patients by RT-PCR.

CONCLUSIONS

Our study confirms that multiplex MassTag-PCR enhances the detection of pathogens in clinical specimens, and shows that previously unrecognized rhinoviruses, that potentially form a species HRV-C, may cause a significant amount of pediatric respiratory disease.

Footwear and foot care knowledge as risk factors for foot problems in Indian diabetics

We assessed 300 diabetic and 100 age- and sex-matched controls for correlating foot wear practices and foot care knowledge and the presence of foot complications. A structured questionnaire evaluated the knowledge about foot care, type of footwear used, education level, association of tobacco abuse, and any associated symptoms of foot disease. Clinical evaluation was done by inspection of feet for presence of any external deformities, assessment of sensory function (vibration perception threshold, VPT), vascular status (foot pulses and ankle brachial ratio) and presence of any infection.In the diabetes category, 44.7% patients had not received previous foot care education. 0.6% walked barefoot outdoors and 45% walked barefoot indoors. Fourteen (4.7%) patients gave history of foot ulceration in the past and comprised the high risk group; only 2 out of 14 had received foot care education, 6 gave history of tobacco abuse, 8 had symptoms of claudication, 9 had paresthesias, 2 walked barefoot indoors. Average duration of diabetes in the high-risk and low-risk diabetes group was 10.85 +/- 6.53 and 9.83 +/- 7.99 years, respectively. In the high- and low-risk diabetic groups, VPT was 19.57 +/- 11.26 and 15.20 +/- 10.21V (P < 0.02), ankle brachial ratio was 1.05 +/- 0.19 and 1.14 +/- 0.18 (P < 0.05), and the questionnaire scores was 40.8% and 57%, respectively.In the diabetic and the control group, VPT was 15.62 +/- 10.39 and 8.36 +/- 3.61 V (P < 0.01), ankle brachial ratio was 1.14 +/- 0.18 and 1.15 +/- 0.12, and the questionnaire scores were 57% and 40.3%, respectively.In conclusion, poor knowledge of foot care and poor footwear practices were important risk factors for foot problems in diabetes.

Global distribution of novel rhinovirus genotype

Global surveillance for a novel rhinovirus genotype indicated its association with community outbreaks and pediatric respiratory disease in Africa, Asia, Australia, Europe, and North America. Molecular dating indicates that these viruses have been circulating for at least 250 years.

Staphylococcal scalded skin syndrome in an extremely premature neonate: a case report with a brief review of literature

Staphylococcus aureus can cause a spectrum of exfoliative skin conditions including staphylococcal scalded skin syndrome (SSSS) which can present as a severe and life threatening illness in extremely premature neonates. We describe a case of an extremely premature neonate with SSSS and discuss relevant pathology and issues in clinical management.

A recently identified rhinovirus genotype is associated with severe respiratory-tract infection in children in Germany

Acute respiratory infection is a significant cause of morbidity and mortality in children worldwide. Accurate identification of causative agents is critical to case management and to prioritization in vaccine development. Sensitive multiplex diagnostics provide us with an opportunity to investigate the relative contributions of individual agents and may also facilitate the discovery of new pathogens. Recently, application of MassTag polymerase chain reaction (PCR) to undiagnosed influenza-like illness in New York State led to the discovery of a novel rhinovirus genotype. Here we report the investigation, by MassTag PCR, of pediatric respiratory-tract infections in Germany, studying 97 cases for which no pathogen was identified through routine laboratory evaluation. Respiratory viruses were identified in 49 cases (51%); of the 55 identified viruses, 41 (75%) were rhinoviruses. The novel genotype represented 73% of rhinoviruses and 55% of all identified viruses. Infections with the novel genotype were associated with upper-respiratory-tract symptoms but, more frequently, with bronchitis, bronchiolitis, and pneumonia.

Covert inhibition potentiates online control in a double-step task

A planned action awaiting execution requires withholding a prepared response. We asked whether such a form of inhibition would interact with online decision processes that require changes in planned responses when new goals are unexpectedly specified. To investigate this issue with respect to oculomotor control, subjects performed, in separate sessions, standard visually-guided (SV) saccades, or memory-guided (MG) and delayed visually-guided (DV) saccades, both of which required withholding a planned saccade. To probe control, a second target (target-step) was presented in some trials after a variable delay that instructed subjects to redirect their gaze to the newly specified target. The time taken to cancel or inhibit the saccade directed at the initial target, the target step reaction time, was calculated using a race model that hypothesizes a covert inhibitory process, and was found to be significantly smaller for memory-guided redirect task (MGR; 94 ms) and delayed visually-guided redirect task (DVR; 96 ms) compared to standard visually-guided redirect task (SVR; 117 ms), suggesting facilitation of online inhibition in MGR and DVR. These results suggest that a tonic level of inhibition interacts with online decision processes to potentiate inhibitory control during double-step tasks.

Results of letrozole in postmenopausal women after tamoxifen treatment for advanced breast cancer

AIM

To analyze overall and progression-free survival after letrozole in postmenopausal women with advanced breast cancer who failed after tamoxifen therapy.

MATERIALS AND METHODS

This is a retrospective analysis of 95 patients with breast cancer who were postmenopausal and had failed after tamoxifen therapy. Dose of letrozole was 2.5 mg daily until disease progressed. Patients had estrogen receptor- and/or progesterone receptor-positive tumors or both receptors were unknown. One complete course of (6 cycles) chemotherapy for metastatic disease was allowed. The primary end point was time to progression (TTP). Secondary end points included overall objective response rate (ORR), its duration, time to treatment failure (TTF), overall survival and tolerability.

RESULTS

Median TTP was 10 months. ORR was 21% with complete response rate of 9%. Nine patients died of disease during treatment. Median overall survival was 36 months. Median time to response was three months and median duration of response was 13 months. Time to chemotherapy was 13.5 months and TTF was 9.3 months. Treatment failure was seen in 76% of patients. Disease progression was the main cause for treatment failure. Treatment was well-tolerated by all patients.

CONCLUSION

This retrospective analysis shows that letrozole is quite effective as second line therapy in postmenopausal patients with advanced breast cancer who had failed after tamoxifen therapy.

Natural M-segment reassortment in Potosi and Main Drain viruses: implications for the evolution of orthobunyaviruses

Recently, we identified Batai virus as the M-segment reassortment partner of Ngari virus. Extension of genetic analyses to other orthobunyaviruses related to the Bunyamwera serogroup indicates additional natural genome reassortments. Whereas the relative phylogenetic positions of all three genome segment sequences were similar for Northway and Kairi viruses, the relative positions of Potosi and Main Drain virus M-segment sequences diverged from those of their S- and L-segments. Our findings indicate M-segment reassortment in Potosi and Main Drain viruses and demonstrate natural genome reassortment as a driving force in the evolution of viruses of the Bunyamwera serogroup.

Batai and Ngari viruses: M segment reassortment and association with severe febrile disease outbreaks in East Africa

Ngari virus is an orthobunyavirus recently recognized as a reassortant between Bunyamwera virus and an as yet unidentified M segment donor. Analysis of M segment sequences of Batai and Ilesha viruses revealed 95% deduced amino acid identity between Batai virus and Ngari virus. These findings suggest Batai virus as the donor of Ngari virus M segment sequence. Analysis of Batai virus-related African isolates identified UgMP-6830, isolated from mosquitoes in Uganda, as an isolate of Batai virus. KV-141, isolated during a febrile disease outbreak in Sudan, was identified as another isolate of Ngari virus, emphasizing a role of this reassortant virus in severe human illness throughout East Africa.

Pyrazinamide induced hyperuricaemia presenting as severe bilateral leg cramps

Pyrazinamide is one of the first line drugs used for the treatment of tuberculosis. Hepatotoxicity and hyperuricaemia are important and common untoward effects seen after administration of pyrazinamide. The drug inhibits elimination of urates resulting in hyperuricaemia, the presenting features of which are arthralgia, arthritis or even gout. A-case of bilateral leg cramps due to hyperuricaemia following pyrazinamide therapy is reported here.

Breast Implant Capsules Are Partially Composed of Bone Marrow–Derived Cells

Capsular contracture is the most common complication following breast augmentation or reconstruction with implants. We recently demonstrated that bone marrow-derived cells provide fibroblasts to murine skin during wound healing. To determine if bone marrow-derived cells were the cellular source of periprosthetic capsules, we created chimeric C57BL mice containing bone marrow cells from isogeneic enhanced green fluorescent protein (EGFP) mice and implanted with a textured silicone shell implant. We found that none of the mice developed infection or capsular contracture, but day 30 capsules were composed of 26.4 +/- 6.1% EGFP cells, and day 60 capsules had 21.8 +/- 10.3% EGFP cells. Immunohistochemistry revealed a small population of EGFP cells in the capsules that were myofibroblasts. Thus, breast implant capsules are partially composed of bone marrow-derived cells and, given the potential of these cells to become myofibroblasts, may explain the cellular source of capsular contracture when it develops.

Greene SCPrimer: a rapid comprehensive tool for designing degenerate primers from multiple sequence alignments

Polymerase chain reaction (PCR) is widely applied in clinical and environmental microbiology. Primer design is key to the development of successful assays and is often performed manually by using multiple nucleic acid alignments. Few public software tools exist that allow comprehensive design of degenerate primers for large groups of related targets based on complex multiple sequence alignments. Here we present a method for designing such primers based on tree building followed by application of a set covering algorithm, and demonstrate its utility in compiling Multiplex PCR primer panels for detection and differentiation of viral pathogens.

Rapid molecular strategy for filovirus detection and characterization

Filoviruses have the capacity to cause lethal outbreaks of hemorrhagic fever in primates. Here we present a simple consensus reverse transcription-PCR method for filovirus recognition and characterization and demonstrate its utility with all known filovirus strains. Phylogenetic assignment is achieved by automated web-based sequence analysis of amplification products.

George K, Briese T, Ian Lipkin W. MassTag polymerase-chain-reaction detection of respiratory pathogens, including a new rhinovirus genotype, that caused influenza-like illness in New York State during 2004-2005

In New York State during winter 2004, there was a high incidence of influenza-like illness that tested negative both for influenza virus, by molecular methods, and for other respiratory viruses, by virus culture. Concern that a novel pathogen might be implicated led us to implement a new multiplex diagnostic tool. MassTag polymerase chain reaction resolved 26 of 79 previously negative samples, revealing the presence of rhinoviruses in a large proportion of samples, half of which belonged to a previously uncharacterized genetic clade. In some instances, knowledge of the detected viral and/or bacterial (co)infection could have altered clinical management

MassTag polymerase chain reaction for differential diagnosis of viral hemorrhagic fever

Viral hemorrhagic fevers are associated with high rates of illness and death. Although therapeutic options are limited, early differential diagnosis has implications for containment and may aid in clinical management. We describe a diagnostic system for rapid, multiplex polymerase chain reaction identification of 10 different causes of viral hemorrhagic fevers.

Clinical profile and natural history of children with HIV infection

OBJECTIVE

As the HIV infection spreads in India, increasing number of children are affected. We report the clinical manifestations, the laboratory parameters and follow up of these children.

METHODS

We reviewed case records of all children diagnosed as pediatric HIV infection since 1995 in our department at a tertiary care hospital in north India. Since September 1999, all children with HIV infection registered in our clinic were prospectively followed up. Complete clinical and laboratory evaluation was performed at baseline and thereafter children were followed up. The children were managed according to standard treatment guidelines.

RESULTS

109 children (82 boys, 27 girls) were diagnosed to have HIV infection. The median (range) age at presentation was 48 months (range: 0.75 months-180 months). Eighty one (74.3%) children acquired the infection vertically. Ninety-one (83.5%) children were symptomatic at time of presentation. The common symptoms in the former were failure to thrive (81.3%), recurrent fever (73.6%), diarrhea (50.5%) and recurrent or persistent pneumonia (44%). All children had poor nutritional status at baseline. Of the 67 children who followed up, 36 were receiving antiretroviral drugs (32 received 3 drugs), while families of 31 children did not opt for antiretroviral therapy. Children receiving antiretroviral therapy showed improvement in nutritional parameters.

CONCLUSION

Majority of children with HIV infection presented with various clinical manifestations, poor nutritional status and immunosuppression. Administration of nevirapine based antiretroviral therapy leads to improvement in growth and immune restoration.

Carrier frequency of F508del mutation of cystic fibrosis in Indian population

BACKGROUND

Cystic fibrosis (CF) is considered to be very rare in Indian subcontinent. Based on reports of CF in migrants from Indian subcontinent to United Kingdom and United States of America, the prevalence of CF is estimated to be between 1/10,000 and 1/40,000 in this ethnic group. The present study was done to estimate the carrier frequency of F508del mutation among neonates using cord blood samples to reflect the prevalence of CF in the study population.

METHODS

955 mothers delivering at our hospital between December 1999 and November 2000 were enrolled. Cord blood samples were analyzed for F508del mutation using polymerase chain reaction and gel electrophoresis. The frequency of patients homozygous for F508del mutation in the population was estimated using Hardy-Weinberg principle. The prevalence of CF was estimated by using the proportion of F508del homozygous cases out of all CF patients, as reported in various studies (19-44%) from Indian subcontinent.

RESULTS

Out of 955 cord blood samples, 4 were positive for F508del mutation. The carrier frequency and gene frequency of F508del mutation in the Indian population was calculated to be 1/238 (0.42%) and 1/477 (0.21%), respectively. Frequency of CF patients homozygous for F508del mutation is 1/228,006. The estimated prevalence of CF is 1/43,321 to 1/100,323 in Indian population.

CONCLUSION

CF does occur in Indian subcontinent though the prevalence is lesser than the Caucasian population.

Flexible intramedullary nailing of displaced diaphyseal forearm fractures in children

INTRODUCTION

This study analyses the results of 50 displaced diaphyseal forearm fractures in children treated with flexible intramedullary nailing.

METHODS

Between 1999 and 2002 we treated 50 children aged between 5 and 15 years, with diaphyseal fractures of the forearm using Flexible intramedullary nailing (FIN). Both bones were fractures in 45 patients, radius only in 4 and ulna only in 1. The indications for fixation were instability (26), re-displacement (20), and open fractures (4).

RESULTS

24 patients were reduced closed, followed by nailing, while 26 fractures required open reduction of either one bone(16 cases) or both bones(10 cases) prior to nailing. Bony union of all fractures was achieved by an average of 7 weeks (range 6 weeks to 4 months) with one delayed union. Pronation was restricted by an average of 20 degrees in 9 patients. Two patients developed post operative compartment syndrome requiring fasciotomy. Three patients were lost to follow-up.

INTERPRETATION

FIN led to early bony union with acceptable bony alignment in all 47 patients available at final follow-up. We therefore recommend FIN for the treatment of unstable diaphyseal forearm fractures in children.

Utilisation of redundant time on trauma list for carpal tunnel decompression

This audit reviewed the trauma theatre time utilisation during April 2000 to March 2001. Instead of a scheduled 8 30 am start, first patient was on the table by only 9 40 am because of various reasons. To use this redundant time carpal tunnel release was started under local anaesthesia, as first case. On re-auditing, it was found that the patient for carpal tunnel release was on the table at 8 44 am. The first trauma case was on the table at 9 46 am. This simple idea has helped in the performing of an additional case every day with a delay to the trauma list of only six minutes (p<0.05).