Lack of detection of SARS-CoV-2 in wildlife from Kerala, India in 2020-21

Spillover of SARS-CoV-2 into a variety of wild and domestic animals has been an ongoing feature of the human pandemic. The establishment of a new reservoir in white-tailed deer in North America and increasing divergence of the viruses circulating in them from those circulating in the human population has highlighted the ongoing risk this poses for global health. Some parts of the world have seen more intensive monitoring of wildlife species for SARS-CoV-2 and related coronaviruses but there are still very large gaps in geographical and species-specific information. This paper reports negative results for SARS-CoV-2 PCR based testing using a pan coronavirus end point RDRP PCR and a Sarbecovirus specific E gene qPCR on lung and or gut tissue from wildlife from the Indian State of Kerala. These animals included: 121 Rhinolophus rouxii (Rufous Horsehoe Bat), six Rhinolophus bedommei (Lesser Woolly Horseshoe Bat), 15 Rossettus leschenaultii (Fulvous Fruit Bat), 47 Macaca radiata (Bonnet macaques), 35 Paradoxurus hermaphroditus (Common Palm Civet), five Viverricula indica (Small Indian Civet), four Herpestes edwardsii (Common Mongoose), ten Panthera tigris (Bengal Tiger), eight Panthera pardus fusca (Indian Leopard), four Prionailurus bengalensis (Leopard cats), two Felis chaus (Jungle cats), two Cuon alpinus (Wild dogs) and one Melursus ursinus (sloth bear).

Near-chromosomal de novo assembly of Bengal tiger genome reveals genetic hallmarks of apex predation

The tiger, a poster child for conservation, remains an endangered apex predator. Continued survival and recovery will require a comprehensive understanding of genetic diversity and the use of such information for population management. A high-quality tiger genome assembly will be an important tool for conservation genetics, especially for the Indian tiger, the most abundant subspecies in the wild. Here, we present high-quality near-chromosomal genome assemblies of a female and a male wild Indian tiger (Panthera tigris tigris). Our assemblies had a scaffold N50 of >140 Mb, with 19  scaffolds corresponding to the 19 numbered chromosomes, containing 95% of the genome. Our assemblies also enabled detection of longer stretches of runs of homozygosity compared to previous assemblies, which will help improve estimates of genomic inbreeding. Comprehensive genome annotation identified 26,068 protein-coding genes, including several gene families involved in key morphological features such as the teeth, claws, vision, olfaction, taste, and body stripes. We also identified 301 microRNAs, 365 small nucleolar RNAs, 632 transfer RNAs, and other noncoding RNA elements, several of which are predicted to regulate key biological pathways that likely contribute to the tiger's apex predatory traits. We identify signatures of positive selection in the tiger genome that are consistent with the Panthera lineage. Our high-quality genome will enable use of noninvasive samples for comprehensive assessment of genetic diversity, thus supporting effective conservation and management of wild tiger populations.

Genomic evidence for inbreeding depression and purging of deleterious genetic variation in Indian tigers

Increasing habitat fragmentation leads to wild populations becoming small, isolated, and threatened by inbreeding depression. However, small populations may be able to purge recessive deleterious alleles as they become expressed in homozygotes, thus reducing inbreeding depression and increasing population viability. We used whole-genome sequences from 57 tigers to estimate individual inbreeding and mutation load in a small-isolated and two large-connected populations in India. As expected, the small-isolated population had substantially higher average genomic inbreeding (FROH = 0.57) than the large-connected (FROH = 0.35 and FROH = 0.46) populations. The small-isolated population had the lowest loss-of-function mutation load, likely due to purging of highly deleterious recessive mutations. The large populations had lower missense mutation loads than the small-isolated population, but were not identical, possibly due to different demographic histories. While the number of the loss-of-function alleles in the small-isolated population was lower, these alleles were at higher frequencies and homozygosity than in the large populations. Together, our data and analyses provide evidence of 1) high mutation load, 2) purging, and 3) the highest predicted inbreeding depression, despite purging, in the small-isolated population. Frequency distributions of damaging and neutral alleles uncover genomic evidence that purifying selection has removed part of the mutation load across Indian tiger populations. These results provide genomic evidence for purifying selection in both small and large populations, but also suggest that the remaining deleterious alleles may have inbreeding-associated fitness costs. We suggest that genetic rescue from sources selected based on genome-wide differentiation could offset any possible impacts of inbreeding depression.

Gastrointestinal parasites of captive Asian elephants in Kerala

Gastrointestinal parasitic infections invariably affect the health status of elephants and can cause disease and death in elephants. This study was conducted to assess the incidence of gastrointestinal (GI)parasitesof elephants in Kerala and to relate it to the deworming status. A total of 31 Asian elephants presented to the Teaching Veterinary Clinical Complex, Mannuthy, those under private ownership (Thrissur) and forest department formed the basis of the study.It was observed that 32.2 per cent of elephants in the study were affected with GI parasites. High percentage of strongyle ova was observed followed by the mixed infection of strongyle and Strongyloides ova. Statistical analysis of haematological parameters were done by using student t test in SPSS version 24.0. The haematological studies of elephants infected with GI parasites revealed anaemia and eosinophilia.

Recent Evolutionary History of Tigers Highlights Contrasting Roles of Genetic Drift and Selection

Species conservation can be improved by knowledge of evolutionary and genetic history. Tigers are among the most charismatic of endangered species and garner significant conservation attention. However, their evolutionary history and genomic variation remain poorly known, especially for Indian tigers. With 70% of the world’s wild tigers living in India, such knowledge is critical. We re-sequenced 65 individual tiger genomes representing most extant subspecies with a specific focus on tigers from India. As suggested by earlier studies, we found strong genetic differentiation between the putative tiger subspecies. Despite high total genomic diversity in India, individual tigers host longer runs of homozygosity, potentially suggesting recent inbreeding or founding events, possibly due to small and fragmented protected areas. We suggest the impacts of ongoing connectivity loss on inbreeding and persistence of Indian tigers be closely monitored. Surprisingly, demographic models suggest recent divergence (within the last 20,000 years) between subspecies and strong population bottlenecks. Amur tiger genomes revealed the strongest signals of selection related to metabolic adaptation to cold, whereas Sumatran tigers show evidence of weak selection for genes involved in body size regulation. We recommend detailed investigation of local adaptation in Amur and Sumatran tigers prior to initiating genetic rescue.

Elephant Endotheliotropic Herpesvirus Hemorrhagic Disease in Asian Elephant Calves in Logging Camps, Myanmar

In recent years, an alarming number of cases of lethal acute hemorrhagic disease have occurred in Asian elephant calves raised in logging camps in Myanmar. To determine whether these deaths were associated with infection by elephant endotheliotropic herpesvirus (EEHV), we conducted diagnostic PCR subtype DNA sequencing analysis on necropsy tissue samples collected from 3 locations. We found that EEHV DNA from 7 PCR loci was present at high levels in all 3 calves and was the same EEHV1A virus type that has been described in North America, Europe, and other parts of Asia. However, when analyzed over 5,610 bp, the strains showed major differences from each other and from all previously characterized EEHV1A strains. We conclude that these 3 elephant calves in Myanmar died from the same herpesvirus disease that has afflicted young Asian elephants in other countries over the past 20 years.

FoodKG: A Tool to Enrich Knowledge Graphs Using Machine Learning Techniques

While there exist a plethora of datasets on the Internet related to Food, Energy, and Water (FEW), there is a real lack of reliable methods and tools that can consume these resources. This hinders the development of novel decision-making applications utilizing knowledge graphs. In this paper, we introduce a novel software tool, called FoodKG, that enriches FEW knowledge graphs using advanced machine learning techniques. Our overarching goal is to improve decision-making and knowledge discovery as well as to provide improved search results for data scientists in the FEW domains. Given an input knowledge graph (constructed on raw FEW datasets), FoodKG enriches it with semantically related triples, relations, and images based on the original dataset terms and classes. FoodKG employs an existing graph embedding technique trained on a controlled vocabulary called AGROVOC, which is published by the Food and Agriculture Organization of the United Nations. AGROVOC includes terms and classes in the agriculture and food domains. As a result, FoodKG can enhance knowledge graphs with semantic similarity scores and relations between different classes, classify the existing entities, and allow FEW experts and researchers to use scientific terms for describing FEW concepts. The resulting model obtained after training on AGROVOC was evaluated against the state-of-the-art word embedding and knowledge graph embedding models that were trained on the same dataset. We observed that this model outperformed its competitors based on the Spearman Correlation Coefficient score.

The Indian cobra reference genome and transcriptome enables comprehensive identification of venom toxins

Snakebite envenoming is a serious and neglected tropical disease that kills ~100,000 people annually. High-quality, genome-enabled comprehensive characterization of toxin genes will facilitate development of effective humanized recombinant antivenom. We report a de novo near-chromosomal genome assembly of Naja naja, the Indian cobra, a highly venomous, medically important snake. Our assembly has a scaffold N50 of 223.35 Mb, with 19 scaffolds containing 95% of the genome. Of the 23,248 predicted protein-coding genes, 12,346 venom-gland-expressed genes constitute the ‘venom-ome’ and this included 139 genes from 33 toxin families. Among the 139 toxin genes were 19 ‘venom-ome-specific toxins’ (VSTs) that showed venom-gland-specific expression, and these probably encode the minimal core venom effector proteins. Synthetic venom reconstituted through recombinant VST expression will aid in the rapid development of safe and effective synthetic antivenom. Additionally, our genome could serve as a reference for snake genomes, support evolutionary studies and enable venom-driven drug discovery.

Analysis of a near-chromosomal genome assembly and transcriptome profiling of the Indian cobra identifies genes expressed in the venom glands. These data should help develop a new antivenom.

Next-generation sequencing analysis reveals high bacterial diversity in wild venomous and non-venomous snakes from India

Background

The oral cavities of snakes are replete with various types of bacterial flora. Culture-dependent studies suggest that some of the bacterial species are responsible for secondary bacterial infection associated with snakebite. A complete profile of the ophidian oral bacterial community has been unreported until now. Therefore, in the present study, we determined the complete bacterial compositions in the oral cavity of some snakes from India.

Methods

Total DNA was isolated from oral swabs collected from three wild snake species (Indian Cobra, King Cobra and Indian Python). Next, the DNA was subjected to PCR amplification of microbial 16S rRNA gene using V3-region-specific primers. The amplicons were used for preparation of DNA libraries that were sequenced on an Illumina MiSeq platform.

Results

The cluster-based taxonomy analysis revealed that Proteobacteria and Actinobacteria were the most predominant phyla present in the oral cavities of snakes. This result indicates that snakes show more similarities to birds than mammals as to their oral bacterial communities. Furthermore, our study reports all the unique and common bacterial species (total: 147) found among the oral microbes of snakes studied, while the majority of commonly abundant species were pathogens or opportunistic pathogens to humans. A wide difference in ophidian oral bacterial flora suggests variation by individual, species and geographical region.

Conclusion

The present study would provide a foundation for further research on snakes to recognize the potential drugs/antibiotics for the different infectious diseases.

Electronic supplementary material

The online version of this article (10.1186/s40409-018-0181-8) contains supplementary material, which is available to authorized users.

Reinvestigating the status of malaria parasite (Plasmodium sp.) in Indian non-human primates

Many human parasites and pathogens have closely related counterparts among non-human primates. For example, non-human primates harbour several species of malaria causing parasites of the genus Plasmodium. Studies suggest that for a better understanding of the origin and evolution of human malaria parasites it is important to know the diversity and evolutionary relationships of these parasites in non-human primates. Much work has been undertaken on malaria parasites in wild great Apes of Africa as well as wild monkeys of Southeast Asia however studies are lacking from South Asia, particularly India. India is one of the major malaria prone regions in the world and exhibits high primate diversity which in turn provides ideal setting for both zoonoses and anthropozoonoses. In this study we report the molecular data for malaria parasites from wild populations of Indian non-human primates. We surveyed 349 fecal samples from five different Indian non-human primates, while 94 blood and tissue samples from one of the Indian non-human primate species (Macaca radiata) and one blood sample from M. mulatta. Our results confirm the presence of P. fragile, P. inui and P. cynomolgi in Macaca radiata. Additionally, we report for the first time the presence of human malarial parasite, P. falciparum, in M. mulatta and M. radiata. Additionally, our results indicate that M. radiata does not exhibit population structure probably due to human mediated translocation of problem monkeys. Human mediated transport of macaques adds an additional level of complexity to tacking malaria in human. This issue has implications for both the spread of primate as well as human specific malarias.

Extended genotypic evaluation and comparison of twenty-two cases of lethal EEHV1 hemorrhagic disease in wild and captive Asian elephants in India

Thirteen new lethal cases of acute hemorrhagic disease (HD) with typical histopathogical features were identified in young Asian elephants (Elephas maximus indicus) in India between 2013 and 2017. Eight occurred amongst free-ranging wild herds, with three more in camp-raised orphans and two in captive-born calves. All were confirmed to have high levels of Elephant Endotheliotropic Herpesvirus type 1A (EEHV1A) DNA detected within gross pathological lesions from necropsy tissue by multi-locus PCR DNA sequencing. The strains involved were all significantly different from one another and from nine previously described cases from Southern India (which included one example of EEHV1B). Overall, eight selected dispersed PCR loci totaling up to 6.1-kb in size were analyzed for most of the 22 cases, with extensive subtype clustering data being obtained at four hypervariable gene loci. In addition to the previously identified U48(gH-TK) and U51(vGPCR1) gene loci, these included two newly identified E5(vGPCR5) and E54(vOX2-1) loci mapping far outside of the classic EEHV1A versus EEHV1B subtype chimeric domains and towards the novel end segments of the genome that had not been evaluated previously. The high levels of genetic divergence and mosaic scrambling observed between adjacent loci match closely to the overall range of divergence found within 45 analyzed North American and European cases, but include some common relatively unique polymorphic features and preferred subtypes that appear to distinguish most but not all Indian strains from both those in Thailand and those outside range countries. Furthermore, more than half of the Indian cases studied here involved calves living within wild herds, whereas nearly all other cases identified in Asia so far represent rescued camp orphans or captive-born calves.

Complete mitogenome reveals genetic divergence and phylogenetic relationships among Indian cattle (Bos indicus) breeds

Indigenous cattle of India belong to the species, Bos indicus and they possess various adaptability and production traits. However, little is known about the genetic diversity and origin of these breeds. To investigate the status, we sequenced and analyzed the whole mitochondrial DNA (mtDNA) of seven Indian cattle breeds. In total, 49 single-nucleotide variants (SNVs) were identified among the seven breeds analyzed. We observed a common synonymous SNV in the COII gene (m.7583G > A) of all the breeds studied. The phylogenetic analysis and genetic distance estimation showed the close genetic relationship among the Indian cattle breeds, whereas distinct genetic differences were observed between Bos indicus and Bos taurus cattle. Our results indicate a common ancestor for European Zwergzebu breed and South Indian cattle. The estimated divergence time demonstrated that the Bos indicus and Bos taurus cattle lineages diverged 0.92 million years ago. Our study also demonstrates that ancestors of present zebu breeds originated in South and North India separately ∼30,000 to 20,000 years ago. In conclusion, the identified genetic variants and results of the phylogenetic analysis may provide baseline information to develop appropriate strategies for management and conservation of Indian cattle breeds.

The complete mitochondrial genome of Indian cattle (Bos indicus)

India has 40 distinct zebuine cattle breeds with different adaptability and production traits. In the present study, we report the complete mitochondrial genome sequence of Indian cattle for the first time. The mitogenome contains 13 protein-coding genes, 22 transfer RNA genes, two ribosomal RNA genes and a control region (D-loop region). The phylogenetic analysis showed close genetic relationship among the Indian cattle breeds studied, where as, distinct genetic differences were observed between Bos indicus and Bos taurus cattle. Our results will expand genomic information for further studies on evolution, domestication and conservation of indigenous cattle breeds in India.

Mycobacterium tuberculosis in Wild Asian Elephants, Southern India

We tested 3 ild Asian elephants (Elephas maximus) in southern India and confirmed infection in 3 animals with Mycobacterium tuberculosis, an obligate human pathogen, by PCR and genetic sequencing. Our results indicate that tuberculosis may be spilling over from humans (reverse zoonosis) and emerging in wild elephants.

Conservation priorities for endangered Indian tigers through a genomic lens

Tigers have lost 93% of their historical range worldwide. India plays a vital role in the conservation of tigers since nearly 60% of all wild tigers are currently found here. However, as protected areas are small (<300 km² on average), with only a few individuals in each, many of them may not be independently viable. It is thus important to identify and conserve genetically connected populations, as well as to maintain connectivity within them. We collected samples from wild tigers (Panthera tigris tigris) across India and used genome-wide SNPs to infer genetic connectivity. We genotyped 10,184 SNPs from 38 individuals across 17 protected areas and identified three genetically distinct clusters (corresponding to northwest, southern and central India). The northwest cluster was isolated with low variation and high relatedness. The geographically large central cluster included tigers from central, northeastern and northern India, and had the highest variation. Most genetic diversity (62%) was shared among clusters, while unique variation was highest in the central cluster (8.5%) and lowest in the northwestern one (2%). We did not detect signatures of differential selection or local adaptation. We highlight that the northwest population requires conservation attention to ensure persistence of these tigers.

A novel third species of the Western Ghats endemic genus Ghatixalus (Anura: Rhacophoridae), with description of its tadpole

The Western Ghats biodiversity hotspot is a recognized center of rhacophorid diversity as demonstrated by several recent studies. The endemic genus Ghatixalus is represented by two species from two separate high-elevation regions within the Ghats. Here, we describe a third species that can be distinguished by morphological and larval characters, as well as by its phylogenetic placement.

Two novel genera and one new species of treefrog (Anura: Rhacophoridae) highlight cryptic diversity in the Western Ghats of India

Amphibian diversity in the Western Ghats-Sri Lanka biodiversity hotspot is extremely high, especially for such a geographically restricted area. Frogs in particular dominate these assemblages, and the family Rhacophoridae is chief among these, with hundreds of endemic species. These taxa continue to be described at a rapid pace, and several groups have recently been found to represent unique evolutionary clades at the genus level. Here, we report DNA sequences, larval and breeding data for two species of rhacophorid treefrog (Polypedates bijui and a new, hitherto undescribed species). Remarkably, they represent unique, independent clades which form successive sister groups to the Pseudophilautus (Sri Lanka) + Raorchestes (India, China & Indochina) clades. We place these species into two new genera (Beddomixalus gen. nov. and Mercurana gen. nov.). Both of these genera exhibit a distinct reproductive mode among Rhacophoridae of peninsular India and Sri Lanka, with explosive breeding and semiterrestrial, unprotected, non-pigmented eggs oviposited in seasonal swamp pools, which hatch into exotrophic, free-living aquatic tadpoles. Relationships and representation of reproductive modes in sister taxa within the larger clade into which these novel genera are placed, is also discussed. These results suggest that more undescribed taxa may remain to be discovered in South Asia, and the crucial importance of conserving remaining viable habitats.

A networking approach to reduce academic and social isolation for junior doctors working in rural hospitals in India

INTRODUCTION

Graduates from Christian Medical College (CMC) Vellore face many challenges while doing their service obligation in smaller hospitals, including academic and social isolation. To overcome these challenges, CMC aspired through its Fellowship in Secondary Hospital Medicine (FSHM), a 1-year blended on-site and distance-learning program, to provide academic and social support through networking for junior doctors working in rural areas. The purpose of this paper is to report the evaluation of the networking components of the FSHM program, with a focus on whether it succeeded in providing academic and social support for these junior doctors.

METHODS

A mixed method evaluation was done using written surveys for students and faculty and telephone interviews for students. Evidence for validity was gathered for the written survey. Criteria for validity were also applied for the qualitative data analysis.

RESULTS

The major strengths of networking with faculty and peers identified were that it provided social support,, academic support through discussion about patient management problems and a variety of cases seen in the hospital, guidance on projects and reminders about deadlines. Recommendations for improvement included use of videoconferencing and Yahoo Groups.

CONCLUSION

It is useful to incorporate networking into distance-learning educational programs for providing support to junior doctors working in rural hospitals.

Mitochondrial ATP synthase inhibition and nitric oxide are involved in muscle weakness that occurs in acute exposure of rats to monocrotophos

Organophosphate poisoning in the context of self-harm is a common medical emergency in Asia. Prolonged muscle weakness is an important but poorly understood cause of morbidity and mortality of the poisoning. This study examined mitochondrial function and its modulation by nitric oxide in muscle weakness of rats exposed to an acute, oral (0.8LD(50)) dose of monocrotophos. Muscle mitochondrial ATP synthase activity was inhibited in the rat in acute exposure to monocrotophos while respiration per se was not affected. This was accompanied by decreased mitochondrial uptake of calcium and increased levels of nitric oxide. Reactive cysteine groups of ATP synthase subunits were reduced in number, which may contribute to decreased enzyme activity. The decrease in ATP synthase activity and reactive cysteine groups of ATP synthase subunits was prevented by treatment of animals with the nitric oxide synthase inhibitor, L-N(G) Nitroarginine methyl ester, at 12 mg/kg body weight for 9 days in drinking water, prior to monocrotophos exposure. This indicated a role for nitric oxide in the process. The alterations in mitochondrial calcium uptake may influence cytosolic calcium levels and contribute to muscle weakness of acute organophosphate exposure.

Effect of the UK postcode lottery on survival of patients with metastatic renal cancer: an audit of outcomes in patients with metastatic renal cancer suitable for treatment with tyrosine kinase inhibitors

AIMS

To determine whether primary care trusts' agreement or refusal to fund sorafenib or sunitinib affects outcomes for patients with metastatic renal cell carcinoma.

MATERIALS AND METHODS

This retrospective audit was conducted in a tertiary referral centre for urological cancer. Requests to prescribe drugs not approved by the National Institute for Health and Clinical Excellence are recorded on a trust database. We obtained details of all requests made for sunitinib and sorafenib for patients with renal cell carcinoma since licence in 2006. Outcome measures analysed were overall survival measured from the date of request for funding and hospital resource use as measured from Payment by Results data. Known prognostic factors and the patient's Index of Multiple Deprivation score were assessed at baseline as potential confounders of survival difference.

RESULTS

Seventy-nine patients were identified. The groups were similar with respect to prognostic factors and Index of Multiple Deprivation scores. Thirty-seven and eight patients had funding approved for sunitinib and sorafenib, respectively; 21 and 13 were turned down. Seven patients who were denied funding received one or other of these drugs by self-funding treatment. Survival was longer for patients who received treatment with a drug for which they had applied for funding than for those who did not (hazards ratio 0.46; 95% confidence interval 0.21-1.01; chi(2)=3.80; 1 d.f.; P=0.05); the advantage was similar for patients receiving sunitinib (hazards ratio=0.49; 95% confidence interval 0.18-1.36; chi(2)=1.86; 1 d.f.; P=0.17) and sorafenib (hazard ratio=0.44; 95% confidence interval 0.11-1.69; chi(2)=1.58; 1 d.f.; P=0.21). Overall National Health Service resource use apart from funding for the renal cancer drugs was similar for both groups.

CONCLUSIONS

Compared with patients receiving treatment, patients denied access to sunitinib and sorafenib had substantially worse survival outcomes, despite receiving treatment from the same clinical team. Access to the new drugs did not have an effect on overall use of National Health Service resources by funded patients. Modern treatments for advanced renal cancer should be available to all National Health Service patients with the disease.

Carboplatin, ifosfamide, and mesna (CIM) for the treatment of gynecological carcinosarcoma

e16539

Background: A GOG trial comparing cisplatin/ifosfamide/mesna chemotherapy versus whole abdominal irradiation for FIGO stages I-IV carcinosarcoma (CS) showed an estimated median survival (MS) of 50 months for chemotherapy but high toxicity. This study investigates the efficacy and tolerability of a novel regimen using carboplatin AUC 5, ifosfamide 3 g/m2 and mesna 1 g/m2 (CIM) in both the adjuvant and metastatic setting. Methods: Retrospective analysis of women with CS treated from May 1997-May 2007 with CIM (group 1) versus other chemotherapy regimens (group 2). Toxicity was graded according to the Common Toxicity Criteria and MS estimated using the Kaplan-Meier method. Results: Of 51 eligible women (median age 71 years) 35 (69%) had stage 3 or 4 disease. 35/51 (69%) received chemotherapy; 2 with stage 1c disease received pelvic radiotherapy (pRT) alone whilst the remaining 14 were unfit for any treatment. Median follow-up for the treated patients is 45 months. 11/35 patients (31%) received CIM as first-line chemotherapy. Other regimens included: carboplatin (n = 14); carboplatin/paclitaxel (n = 3); carboplatin/epirubicin (n = 3); carboplatin/doxorubicin (n = 2); doxorubicin/ifosfamide (n = 1); cisplatin/ifosfamide (n = 1). 20/35 (57%) received adjuvant chemotherapy (AC) of which 8 received CIM; 11/20 patients also received adjuvant pRT. MS in the CIM AC group is 54.7 months compared to 37.4 months for other regimens. 3/8 patients (37.5%) in the CIM arm developed recurrent disease compared to 9/12 (75%) for other regimens. 4/16 patients received CIM as first- or second-line palliative chemotherapy. All patients responded of whom 2 achieved clinical and radiological complete response (CR). One woman subsequently relapsed and achieved a second CR with CIM. MS for all chemotherapy-treated patients is 54.7 months (group 1) versus 20.6 months (group 2) (p = 0.07). No patients in group 1 experienced any grade 3/4 toxicity and all patients completed the prescribed treatment. There were 2 unexpected treatment-related deaths in group 2, one of whom received carboplatin/paclitaxel and the other carboplatin/epirubicin. Conclusions: CIM appears to be efficacious and well tolerated in the treatment of CS and merits further investigation in clinical trials.

No significant financial relationships to disclose.

Progression of Type I to Type II paralysis in acute organophosphorous poisoning: Is oxidative stress significant?

Organophosphorous poisoning is a common method of deliberate self-harm in countries where the pesticides are readily available and can result in type I, II and/or III paralysis. The in-hospital morbidity and mortality of the poisoning are mostly associated with type II paralysis (intermediate syndrome). The aim of this study was to determine the role of oxidative stress in relation to the severity of poisoning and development of type II paralysis in patients suffering from acute organophosphate poisoning. This prospective study was carried out at the Christian Medical College Hospital. Thirty-two patients with acute organophosphorous poisoning, admitted in one medical unit over 17 months, were included in the study. They were clinically assessed for severity of poisoning and paralysis during the first 10 days of their hospitalisation. Temporal profiles of butyrylcholinesterase (BuChE) and oxidative stress parameters, for 4, 7 and 10 days of hospitalisation, were established in 25 of these patients. Type I and II paralysis were associated with severe poisoning. The majority of patients with type II paralysis had prior evidence of type I paralysis. The pattern of muscles that were paralysed in type I paralysis occurring alone and in type I paralysis proceeding to type II paralysis were similar. BuChE was significantly inhibited in all patients. Oxidative stress occurred in acute organophosphate poisoned patients and was greater in severe poisoning. The results suggest that type I paralysis may progress to type II paralysis in severely poisoned patients. They demonstrate early occurrence of oxidative stress in severe acute organophosphate poisoning. However, the development of type II paralysis is not associated with the level of oxidative stress. They suggest that mechanisms other than acetylcholine induced oxidative stress may be involved in the progression of type I to type II paralysis.

Disseminated histoplasmosis

OBJECTIVE

To study the clinical features and natural history of disseminated histoplasmosis(DH) in India.

METHODS

We retrospectively analyzed the data obtained from the in-patient medical records of adults (age > 13 years) diagnosed to have DH during the period from January 1989 to December 1999. DH was diagnosed when histologically compatible intracellular organisms were present or Histoplasma capsulatum was obtained in culture from the extrapulmonary sites.

RESULTS

Nineteen patients (18 male and 1 female) were diagnosed to have DH. Diabetes mellitus and HIV infection were the most common co-morbid conditions. Weight loss, fever and oropharyngeal ulcers were the commonest symptoms. Physical signs included hepatosplenomegaly, oropharyngeal ulcers and lymphadenopathy. The diagnosis was confirmed by histopathology and/or culture from the following sites: bone marrow, adrenal gland, lymph node, oropharyngeal ulcers, rectal mucosa and skin. Two patients were treated with Amphotericin B, 6 with various azoles and 3 had Amphotericin B followed by various azoles. Among the eleven treated, 7 were cured, 2 improved, 1 had a relapse and 1 patient died.

CONCLUSION

DH is not uncommon in India and should be considered in the diagnosis of patients with prolonged fever, weight loss, oropharyngeal ulcers, hepatosplenomegaly, lymphadenopathy and adrenal enlargement. Correct diagnosis and treatment leads to a favourable outcome.

Oxidative damage in intermediate syndrome of acute organophosphorous poisoning

BACKGROUND & OBJECTIVES

The main cause of morbidity due to organophosphate poisoning is intermediate syndrome (Type II paralysis) that can occur 48-72 h after poisoning. Mechanisms that underlie the intermediate syndrome are not known. This study investigates the role of oxidative damage to muscles as a possible mechanism underlying the development of the intermediate syndrome.

METHODS

Nineteen patients with acute organophosphate poisoning were evaluated from admission to discharge from intensive care for the severity of poisoning and the development and duration of the intermediate syndrome. Blood cholinesterases and parameters of oxidative stress were studied daily and their temporal profiles analysed according to the severity of poisoning and the development and duration of the intermediate syndrome.

RESULTS

Fifteen patients had severe poisoning and 16 developed intermediate syndrome. There was a positive association between the severity of poisoning and the occurrence of intermediate syndrome. There was no association between the organophosphate ingested and the development of intermediate syndrome. Erythrocyte membrane acetylcholinesterase and serum butyrylcholinesterase levels at admission and over the course of poisoning were significantly (P < 0.001) reduced in patients compared to controls. There were significantly (P < 0.05) higher levels of lipid peroxidation, conjugated dienes and protein thiols in erythrocyte membranes of patients who developed the intermediate syndrome compared to healthy controls, in patients who developed intermediate syndrome compared to those who did not and in patients with long compared to short duration intermediate syndrome.

INTERPRETATION & CONCLUSION

In acute organophosphate poisoning, severe and prolonged acetylcholinesterase inhibition is associated with oxidative stress, detected in erythrocyte membranes, that occurs early in the course of poisoning and may contribute to the development and severity of intermediate syndrome.

Muscle injury in organophosphorous poisoning and its role in the development of intermediate syndrome

Muscle injury and its role in the development of Type II paralysis was studied in 25 patients with acute organophosphate poisoning. All patients were assessed for severity of poisoning at admission and through the course of poisoning for the development and duration of intermediate syndrome (IS) (Type II paralysis). Blood levels of acetylcholinesterase, creatine kinase, creatine kinase MM, LDH and LDH5 were estimated through the course of the poisoning. Of the 25 patients, 22 were severely poisoned and 3 had mild to moderate poisoning. Severely poisoned patients had a significantly greater rate of developing intermediate syndrome (17/22) (P = 0.026). Type I paralysis and fasciculations occurred in 76 and 70.5% of patients who developed intermediate syndrome, in comparison to 38 and 50%, respectively, of those who did not develop intermediate syndrome. Weakness developed in the same groups of muscles in both Types I and II paralysis but was of longer duration in patients who developed Type II paralysis. Acetylcholinesterase was inhibited > 90% throughout the course of poisoning with greater inhibition in patients with longer duration intermediate syndrome. Muscle injury was seen in all patients beginning at admission, peaking over the first 5 days and then declining over the next 5 days. Temporal profiles of blood muscle isoenzymes showed significantly greater muscle injury in those patients with greater severity of poisoning at admission, those who developed intermediate syndrome and in patients with longer duration intermediate syndrome. The findings of this study suggest that Types I and II paralysis in organophosphate poisoning are not separate syndromes but a clinical continuum determined by the severity of poisoning. The magnitude of organophosphate exposure and of muscle injury during the cholinergic crises appears to determine the occurrence and severity of intermediate syndrome.

CD4 counts of normal and HIV-infected south Indian adults: do we need a new staging system?

BACKGROUND

The normal range of CD4 lymphocyte count varies among different ethnic groups. In populations with CD4 counts inherently lower than in the West, the Centers for Disease Control and Prevention (CDC) classification system of HIV-infected individuals may not be appropriate. No such criterion is currently available for ethnic south Indian HIV-infected individuals. We undertook this study to assess the applicability of the western case definition to south Indian HIV patients.

METHODS

The CD4 counts of 104 normal and 79 HIV-infected south Indian adults were estimated by flowcytometry. The mean CD4 counts were estimated and compared between CDC groups A, B and C and controls. Receiver operator characteristics curves were generated to determine the cut-off that correlated best with clinical staging for this population.

RESULTS

The mean CD4 and CD8 cell counts/microl and the CD4/CD8 ratio of the control group were 799.0, 919.6 and 0.94, respectively. For CDC groups A, B and C, the mean CD4 counts/microl were 454.4, 254.4 and 168; mean CD8 counts/microl were 1156, 1070.9 and 1191.3; and mean CD4/CD8 ratios were 0.44, 0.25 and 0.15, respectively.

CONCLUSION

The mean CD4 count among normal south Indians is significantly lower than that in the western population and parallels that of the Chinese. When categorized based on the CDC classification system, the mean CD4 count of HIV-infected individuals was lower. Categories of CD4 counts > 300, 81-300 and < or =80 cells/microl and CD4% > 14, 7-14 and < or = 6 correlate better with disease progression among HIV-infected individuals. A longitudinal study is required before guidelines for the Indian population can be devised.

Correlation of CD4(+) T-Cell counts estimated by an immunocapture technique (Capcellia) with viral loads in human immunodeficiency virus-seropositive individuals

As antiretroviral therapy becomes more affordable, valid, reliable, and inexpensive laboratory tests are also needed to monitor the progression of disease in people with human immunodeficiency virus (HIV) infection. The CD4(+) T-cell counts estimated by Capcellia, an immunocapture method, and flow cytometry were compared and were correlated with HIV type 1 (HIV-1) load. There was a significant negative correlation between the HIV-1 load and CD4(+) T-cell counts estimated by flow cytometry (r = -0.63, P = <0.001) as well as between the HIV-1 load and CD4(+) T-cell counts estimated by Capcellia (r = -0.61, P = <0.001). Capcellia is a cost-effective, user-friendly assay that correlated well with HIV-1 load determinations for individuals both with and without treatment.

Neuroparalysis and oxime efficacy in organophosphate poisoning: a study of butyrylcholinesterase

The temporal profile of butyrylcholinesterase (BuChE) and in vitro pralidoxime-reactivated BuChE was studied in a cohort of 25 organophosphate-poisoned patients to examine their relationship to the development of intermediate syndrome and to understand reasons for lack of efficacy of oxime treatment. The clinical severity of poisoning (assessed by the Namba Scale) correlated significantly with the severity of intermediate syndrome. BuChE activity increased significantly over time and showed significant relationship to muscle power. The temporal profile of the enzyme was correlated to the clinical severity of poisoning. Reactivation potentials of BuChE (the difference between oxime-reactivated and -unreactivated enzyme activity) declined significantly with time after organophosphate ingestion. The reactivation potential of the enzyme at admission decreased significantly with increasing severity of poisoning and was lower in patients who developed intermediate syndrome. Patients who received oxime prior to hospitalization had a higher rate of intermediate syndrome and lower levels of BuChE at admission than those who had not. The study suggests that (i) BuChE reflects the clinical course of poisoning, confirming earlier studies; (ii) intermediate syndrome may be associated with a persistent inhibition of BuChE; and (iii) the lack of oxime efficacy in our patients maybe due to their severity of poisoning and the timing of oxime treatment.

Increase in plasma IL-10 levels and rapid loss of CD4+ T cells among HIV-infected individuals in south India

Increased levels of immune activation among HIV patients from developing countries are believed to accelerate and/or enhance the shift to a Th2 cytokine environment, which in turn may result in a more rapid progression to AIDS. In support of this hypothesis, we present data from a cohort of 35 HIV+ individuals in southern India. Among asymptomatic individuals in this cohort, a dramatic increase in plasma interleukin (IL)-10 coincided with rapid decrease in CD4 counts and progression to AIDS. Serum IL-10 levels were significantly higher after 6 months of follow up (P=0.01), while CD4 counts declined at a rate of 280 cells/ul per year, roughly 3 times the rate of decline reported for HIV+ asymptomatic subjects in developed countries. Changes in serum IL-10 levels and CD4 counts fell short of statistically significant correlation (P=0.1). Among AIDS patients in this cohort, the mean period from diagnosis of AIDS to death was <5 months and is in agreement with an earlier report of rapid progression in India.

Enteric pathogens in southern Indian HIV-infected patients with & without diarrhoea

This study was undertaken to determine the carriage rate of various enteric pathogens in southern Indian patients with HIV infection, both with and without diarrhoea. Stool from 111 consecutive HIV-positive patients (50 without and 61 with diarrhoea) was examined by microscopy and culture. Jejunal biopsy and fluid examination were carried out if diarrhoea persisted, with negative stool examination. Enteric pathogens were detected from stool in 57.4 per cent of diarrhoeal patients compared to 40 per cent of those without diarrhoea (P > 0.05). Jejunal biopsy and fluid examination provided 11 additional diagnoses. Protozoa accounted for 71.8 per cent of all pathogens isolated. Isospora was significantly more common in patients with (11/61) than in those without (2/50) diarrhoea (P < 0.05). Bacterial pathogens were isolated more commonly from patients with diarrhoea (12/61 compared to 2/50, P < 0.05). Isolation rate of pathogens was higher from patients with diarrhoea for more than 2 wk, compared to those with less than 2 wk duration. Remission of diarrhoea either spontaneously or with symptomatic therapy was observed in 22 patients with acute diarrhoea. A high enteric carriage of a number of pathogens was noted in HIV patients without diarrhoea, but I. belli and bacterial enteropathogens were more likely to be associated with diarrhoea.

Epidemiological features of acquired immunodeficiency syndrome in southern India

AIDS was diagnosed in 187 men and 24 women (M:F = 8:1) from April 1987 till December 1994 at the Christian Medical College Hospital, Vellore. The doubling time of the occurrence of AIDS cases was 14 months; during 1987-90 there were an average of 5.7 cases per year; in 1991-93 there were 28 per year; in 1994 there were 104 cases. The mean age of patients was 33 yr for men and 31 for women. Among men, the primary mode of infection was heterosexual contact with female commercial sex workers. Among women, the most common source of infection was their husbands. There were 4 bisexuals and one homosexual subject who might have acquired infection by having sex with other men. There were 135 subjects from urban and 76 from rural communities. Most subjects belonged to the lower socio-economic classes. These data show that HIV infection had been very widespread in this region, both urban and rural.

Molecular forms of adenosine deaminase do not aid the diagnosis of tuberculosis

To investigate the diagnostic utility of adenosine deaminase as a test for tuberculosis, molecular forms of the enzyme indicative of cell-mediated immunity were studied in tuberculosis pleural effusion, peritonitis and meningitis. Twenty-six pleural, 21 peritoneal, and 24 cerebrospinal tuberculous and non-tuberculous fluids were examined for adenosine deaminase and the large and small forms of the enzyme were differentiated on immunoblots. Adenosine deaminase levels ranged from zero to 81 units/L, zero to 31 units/L and zero to 31 units/L in the pleural, peritoneal and cerebrospinal fluids, respectively. The large form of adenosine deaminase (280 kDa) was detected in one of 14 proved tuberculous cases, a peritoneal fluid. The small form of the enzyme (35-39 kDa) was seen in both tuberculous and non-tuberculous conditions in 6 pleural, 7 peritoneal and 8 cerebrospinal fluids. Molecular forms of adenosine deaminase did not appear to help in the diagnosis of tuberculosis in this patient population and may not be suited for analysis in fluids with low enzyme activity.

Epithelioid granulomas in Hodgkin's disease--prognostic significance

Prognostic significance of non-caseating epithelioid granulomas in association with Hodgkin's disease has been studied. Such granulomas were found in 15 of the total of 104 cases of Hodgkin's disease encountered between Jan. 1981 and June 1990. These 15 patients were compared with 30 concurrent patients of Hodgkin's disease who did not have associated granulomas. All the patients were initially staged, treated and followed up for a period of two years. There was no significant difference in overall survival rate between the granuloma group and the control group. However, in relapse free survival rate in advanced stages of the disease (III & IV), although the difference between granuloma group and the control group was not statistically significant (p = 0.11), yet the relapse free survival curves revealed a tendency towards better survival with lesser number of relapses and longer remissions in granuloma group.

Rational drug use--evaluation of a training programme for interns

A workshop covering various aspects of rational drug use was conducted for interns of Christian Medical College, Ludhiana. Evaluation of the workshop revealed that it was able to bring about an attitudinal change regarding rational drug use. The methodology and evaluation procedures have been described. It is suggested that similar attempts should be made at all medical colleges so that every graduate enters medical practice with a positive attitude towards rational drug use.

Hodgkin's disease: a clinicopathologic study

One hundred and four cases of Hodgkin's disease diagnosed between July 1981 and June 1991 have been analysed. There was a definite male preponderance. Majority of the patients (82.7%) were below the age of 50 years. Mixed cellularity was the most common type (57.7%). It was followed by both nodular sclerosis and lymphocyte predominant types (16.3% each). Lymphocyte depletion Hodgkin's disease, the most aggressive variant, was the least common (9.7%). The detailed observations, as compared to the previous studies in this region as well as in other parts of the world have been presented and discussed.

Bone marrow involvement in Hodgkin's disease -- clinicopathological study of seven cases

Bone marrow involvement was observed in 7 cases amongst a total of 75 cases of Hodgkin's disease encountered between January 1981 and June 1990; thus representing an incidence of 9.3 percent. Analysis of these 7 cases showed male preponderance. The age ranged from 26 to 74 years. All patients presented within seven months of onset of symptoms; and all had symptoms at presentation. Lymphadenopathy was found in all the cases, splenomegaly was present in six; and hepatomegaly in 4 cases. Mixed cellularity and lymphocytic depletion subtypes showed the highest frequency of marrow involvement (6 cases; 85.7 percent). Alkaline phosphatase was raised in 6 cases (85.7%). All cases received standard combination chemotherapy with or without local radiation therapy. Two years follow-up revealed an overall survival of 42.9%. Replace free survival at the end of two years was zero, as all the cases relapsed within seven months of initiation of treatment.

Inherited degenerative chondropathy--an autosomal dominant new clinical entity: report two cases and follow-up of four cases

Four cases of the rare disorder, inherited degenerative chondropathy have been previously reported (Kurien et al., 1989). A five-year follow-up of these patients and two additional cases are presented in this report. The progress of this disease appears to be arrested after regular dapsone therapy and there was no other organ involvement noted during the follow-up period.

N-acetyl-beta-D-glucosaminidase in the localisation of urinary tract infection in patients with spinal cord injury

This study evaluates the pattern of urinary N-acetyl-beta-D-glucosaminidase (NAG) isoenzyme excretion in patients with spinal cord injury (SCI) and its use as a diagnostic tool in localising the site of urinary tract infection (UTI). NAG-B excretion in 27 control SCI patients (mean 207.78 units) was significantly higher than in 10 normal controls (mean 12.6 units) p less than 0.001). The relative isoenzyme distribution as represented by NAG-B/Total NAG percentage is however similar in both groups, 24.27 and 20.38% respectively. NAG-B excretion in 6 SCI patients with upper UTI was not significantly higher than in 12 SCI patients with lower UTI. NAG-B/Total NAG percentage was significantly different between these two groups (35.3% and 24.98% respectively, p less than 0.05). There was no significant difference in NAG-B excretion or NAG-B/Total NAG percentage between control SCI patients and those with lower UTI. The results indicate that there is a non-selective increase in urinary NAG excretion in control SCI patients and those with lower UTI. In SCI patients with upper urinary UTI there is a selective increase in NAG-B excretion. The overlap in enzyme values between the different groups suggests that the test may not be clinically useful in localising the site of UTI.