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Arboleda A, Prajna NV, Lalitha P, Srinivasan M, Rajaraman R, Krishnan T, Mousa HM, Feghali J, Acharya NR, Lietman TM, Perez VL, Rose-Nussbaumer J. Validation of the C-DU(KE) Calculator as a Predictor of Outcomes in Patients Enrolled in Steroids for Corneal Ulcer and Mycotic Ulcer Treatment Trials. Cornea 2024; 43:166-171. [PMID: 37335849 DOI: 10.1097/ico.0000000000003313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 04/10/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE The aim of this study was to validate the C-DU(KE) calculator as a predictor of treatment outcomes on a data set derived from patients with culture-positive ulcers. METHODS C-DU(KE) criteria were compiled from a data set consisting of 1063 cases of infectious keratitis from the Steroids for Corneal Ulcer Trial (SCUT) and Mycotic Ulcer Treatment Trial (MUTT) studies. These criteria include corticosteroid use after symptoms, visual acuity, ulcer area, fungal etiology, and elapsed time to organism-sensitive therapy. Univariate analysis was performed followed by multivariable logistic regressions on culture-exclusive and culture-inclusive models to assess for associations between the variables and outcome. The predictive probability of treatment failure, defined as the need for surgical intervention, was calculated for each study participant. Discrimination was assessed using the area under the curve for each model. RESULTS Overall, 17.9% of SCUT/MUTT participants required surgical intervention. Univariate analysis showed that decreased visual acuity, larger ulcer area, and fungal etiology had a significant association with failed medical management. The other 2 criteria did not. In the culture-exclusive model, 2 of 3 criteria, decreased vision [odds ratio (OR) = 3.13, P < 0.001] and increased ulcer area (OR = 1.03, P < 0.001), affected outcomes. In the culture-inclusive model, 3 of 5 criteria, decreased vision (OR = 4.9, P < 0.001), ulcer area (OR = 1.02, P < 0.001), and fungal etiology (OR = 9.8, P < 0.001), affected results. The area under the curves were 0.784 for the culture-exclusive model and 0.846 for the culture-inclusive model which were comparable to the original study. CONCLUSIONS The C-DU(KE) calculator is generalizable to a study population from large international studies primarily taking place in India. These results support its use as a risk stratification tool assisting ophthalmologists in patient management.
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Affiliation(s)
- Alejandro Arboleda
- Byers Eye Institute, Department of Ophthalmology, Stanford University, Palo Alto, CA
| | | | - Prajna Lalitha
- Aravind Eye Care System, Aravind Eye Hospital, Tamil Nadu, India
| | | | | | | | - Hazem M Mousa
- Foster Center for Ocular Immunology, Department of Ophthalmology, Duke Eye Center, Duke University, Durham, NC
| | - James Feghali
- Department of Ophthalmology and Francis I. Proctor Foundation, University of California, San Francisco, CA
| | - Nisha R Acharya
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD; and
| | - Thomas M Lietman
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD; and
| | - Victor L Perez
- Foster Center for Ocular Immunology, Department of Ophthalmology, Duke Eye Center, Duke University, Durham, NC
| | - Jennifer Rose-Nussbaumer
- Byers Eye Institute, Department of Ophthalmology, Stanford University, Palo Alto, CA
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD; and
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Prajna NV, Lalitha P, Krishnan T, Rajaraman R, Radnakrishnan N, Srinivasan M, Devi L, Das M, Liu Z, Zegans ME, Acharya NR, Porco TC, Lietman TM, Rose-Nussbaumer J. Patterns of Antifungal Resistance in Adult Patients With Fungal Keratitis in South India: A Post Hoc Analysis of 3 Randomized Clinical Trials. JAMA Ophthalmol 2022; 140:179-184. [PMID: 35024776 PMCID: PMC8759027 DOI: 10.1001/jamaophthalmol.2021.5765] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
IMPORTANCE Antifungal resistance has been shown to impact treatment success, but research analyzing antifungal resistance is scarce. OBJECTIVE To evaluate changes in antifungal resistance over time. DESIGN, SETTING, AND PARTICIPANTS Ad hoc analysis of 3 randomized clinical trials including consecutive patients 18 years and older presenting with smear-positive fungal ulcers to Aravind Eye Hospitals in Madurai, Coimbatore, Pondicherry, and Tirunelveli in South India who participated in 1 of 3 clinical trials: the Mycotic Ulcer Treatment Trials (MUTT) I (2010 to 2011) or II (2010 to 2015) or the Cross-Linking Assisted Infection Reduction (CLAIR) trial (2016 to 2018). This post hoc analysis was designed in March 2021 and data were analyzed in May and November 2021. INTERVENTIONS Minimum inhibitory concentration (MIC) of natamycin and voriconazole was determined from corneal cultures obtained using standardized methods outlined in the Clinical and Laboratory Standards Institute. MAIN OUTCOMES AND MEASURES The primary outcome of this post hoc analysis was MIC of natamycin and voriconazole. RESULTS A total of 890 fungal isolates were obtained from 651 patients (mean [SD] age, 49.6 [13.0]; 191 [43.3%] female) from 2010 to 2018. MICs were available for 522 samples in 446 patients. Fungal isolates overall demonstrated a 1.02-fold increase per year in voriconazole resistance as measured by MICs (95% CI, 1.00-1.04; P = .06). In subgroup analyses, Fusarium species demonstrated a 1.04-fold increase in voriconazole resistance per year (95% CI, 1.00-1.06; P = .01). Fungal isolates showed a 1.06-fold increase in natamycin resistance per year overall (95% CI, 1.03-1.09; P < .001). Fusarium species had a 1.06-fold increase in natamycin resistance (95% CI, 1.05-1.08; P < .001), Aspergillus had a 1.09-fold increase in resistance (95% CI, 1.05-1.15; P < .001), and other filamentous fungi had a 1.07-fold increase in resistance to natamycin per year (95% CI, 1.04-1.10; P < .001). CONCLUSIONS AND RELEVANCE This post hoc analysis suggests that susceptibility to both natamycin and voriconazole may be decreasing over the last decade in South India. While a trend of increasing resistance could impact treatment of mycoses in general and infectious fungal keratitis in particular, further study is needed to confirm these findings and determine their generalizability to other regions of the world. TRIAL REGISTRATION ClinicalTrials.gov Identifiers: NCT00996736 and NCT02570321.
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Affiliation(s)
- N. Venkatesh Prajna
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Prajna Lalitha
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Tiruvengada Krishnan
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Naveen Radnakrishnan
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Muthiah Srinivasan
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Lumbini Devi
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Manoranjan Das
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Zijun Liu
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco
| | | | - Nisha R. Acharya
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco,Department of Ophthalmology, University of California, San Francisco, San Francisco
| | - Travis C. Porco
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco,Department of Ophthalmology, University of California, San Francisco, San Francisco,UCSF Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco,Department of Ophthalmology, University of California, San Francisco, San Francisco,UCSF Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco,Department of Ophthalmology, University of California, San Francisco, San Francisco,Byers Eye Institute, Stanford University, Palo Alto, California
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3
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Pickel J, Narayana S, Krishnan T, Ramakrishnan S, Samantaray PP, Porco TC, Redd T, Lietman TM, Rose-Nussbaumer J. The Prognostic Value of Persistent Culture Positivity in Fungal Keratitis in the Mycotic Antimicrobial Localized Injection Trial. Am J Ophthalmol 2020; 215:1-7. [PMID: 32171765 DOI: 10.1016/j.ajo.2020.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 02/18/2020] [Accepted: 02/24/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE To evaluate the utility of repeat cultures at days 3 and 7 after starting antifungal medications for predicting outcomes in fungal keratitis. DESIGN Prespecified secondary analysis of the randomized clinical Mycotic Antimicrobial Localized Injection trial. METHODS Patients presenting to Aravind Eye Hospital, Pondicherry, India, with fungal keratitis and visual acuity worse than 20/70 received topical natamycin and were randomized to either receive intrastromal injection of voriconazole or topical therapy alone. All subjects received corneal cultures at date of presentation, day 3, and day 7. Outcome measures included 3-week and 3-month visual acuity and scar size, corneal perforation, and/or the need for therapeutic penetrating keratoplasty (TPK). Visual acuity and scar size were analyzed with multiple linear regression controlling for baseline measures. Survival analysis was used to analyze the risk of corneal perforation and/or need for TPK. RESULTS Of the 70 study subjects with fungal keratitis, 25 of 69 (36%) remained culture positive at day 3, and 20 of 62 (32%) were culture positive at day 7. Culture positivity at day 3 conferred a hazard ratio of 2.8 for requiring TPK (P = .03) but was not a statistically significant predictor of perforation, scar size, or final visual acuity. Culture positivity at day 7 had a hazard ratio of 3.5 for requiring TPK (P = .003). Those with positive cultures at day 7 had on average 3 logMAR lines worse visual acuity at 3 months (95% confidence interval 0.9 to 5.2 logMAR lines, P = .006) and 1.1 mm larger scar size at 3 months after controlling for baseline measures (95% confidence interval 0.1 to 2.2 mm; P = .03). CONCLUSIONS While not as predictive as day 7 cultures, culture positivity at day 3 after starting treatment is a significant predictor of the need for TPK in patients with moderate-to-severe filamentous fungal keratitis. This has applications for risk stratification, and may facilitate earlier consideration of TPK in high-risk patients.
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Affiliation(s)
- Julia Pickel
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | | | | | | | | | - Travis C Porco
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA; UCSF Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Travis Redd
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA; UCSF Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA; UCSF Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA; UCSF Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA; UCSF Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA; The Permanente Medical Group, Redwood City, California, USA.
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Narayana S, Krishnan T, Ramakrishnan S, Austin A, Lietman T, Rose-Nussbaumer J. Reply. Ophthalmology 2019; 126:e86-e87. [DOI: 10.1016/j.ophtha.2019.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 06/30/2019] [Accepted: 07/02/2019] [Indexed: 10/25/2022] Open
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Narayana S, Krishnan T, Ramakrishnan S, Samantaray PP, Austin A, Pickel J, Porco T, Lietman T, Rose-Nussbaumer J. Mycotic Antimicrobial Localized Injection: A Randomized Clinical Trial Evaluating Intrastromal Injection of Voriconazole. Ophthalmology 2019; 126:1084-1089. [PMID: 30904540 DOI: 10.1016/j.ophtha.2019.03.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/22/2019] [Accepted: 03/08/2019] [Indexed: 10/27/2022] Open
Abstract
PURPOSE To determine if there is a benefit to adjuvant intrastromal voriconazole (ISV) injections for primary treatment of filamentous fungal keratitis. DESIGN Outcome-masked, randomized controlled clinical trial. PARTICIPANTS Patients with moderate vision loss resulting from a smear-positive fungal ulcer. METHODS Study eyes were randomized to topical natamycin plus ISV injection versus topical natamycin alone. MAIN OUTCOME MEASURES The primary outcome of the trial was microbiological cure on 3-day repeat culture analysis. Secondary outcomes included microbiological cure on 7-day repeat culture analysis; 3-week and 3-month best spectacle-corrected visual acuity; infiltrate or scar size or both; rate of perforation; therapeutic penetrating keratoplasty (TPK); and other adverse events. RESULTS A total of 151 patients with smear-positive ulcers were screened and 70 were enrolled at Aravind Eye Hospital, Pondicherry, India. Baseline cultures grew Fusarium in 19 samples (27%), Aspergillus in 17 samples (24%), and other filamentous fungi in 19 samples (27%) and showed negative results in 13 samples (19%). Those randomized to ISV injection had 1.82 times the odds of 3-day culture positivity after controlling for baseline culture status (95% confidence interval [CI], 0.65-5.23; P = 0.26, bias-corrected logistic regression) and 1.98 times the odds of positive 7-day culture results, after controlling for baseline culture status (95% CI, 0.69-5.91; P = 0.20, bias-corrected logistic regression). Those randomized to ISV injection showed 0.5 logMAR lines (approximately 0.5 Snellen lines) of decreased visual acuity (95% CI, -2.6 to 3.6 lines; P = 0.75) and 0.55 mm worse infiltrate or scar size or both at 3 months after controlling for baseline values (95% CI, -0.13 to 1.25; P = 0.11). Intrastromal voriconazole injections showed a 2.85-fold increased hazard of perforation after controlling for baseline infiltrate depth (95% CI, 0.76-10.75; P = 0.12) but no difference in the rate of TPK (hazard ratio, 0.95; 95% CI, 0.44-2.04; P = 0.90). CONCLUSIONS There seems to be no benefit to adding ISV injections to topical natamycin in the primary treatment of moderate to severe filamentous fungal ulcers. Studies consistently suggest that voriconazole has a limited role in the treatment of filamentous fungal ulcers.
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Affiliation(s)
| | | | | | | | - Ariana Austin
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Julia Pickel
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Travis Porco
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Tom Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, San Francisco, California.
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Ravindran RD, Sundaresan P, Krishnan T, Vashist P, Maraini G, Saravanan V, Chakravarthy U, Smeeth L, Nitsch D, Young IS, Fletcher AE. Genetic variants in a sodium-dependent vitamin C transporter gene and age-related cataract. Br J Ophthalmol 2018; 103:1223-1227. [PMID: 30442817 PMCID: PMC6709767 DOI: 10.1136/bjophthalmol-2018-312257] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 10/01/2018] [Accepted: 10/17/2018] [Indexed: 12/02/2022]
Abstract
Background Cataract is a major health burden in many countries and a significant problem in India. While observational studies show lower cataract risk with increasing dietary or plasma vitamin C, randomised controlled trials of supplements have been negative. Genetic variants in vitamin C transporter proteins (SLC23A1), especially rs33972313, may provide evidence on a causal association of vitamin C with cataract. Methods We used data from a randomly selected population-based study in people aged 60 years and above in north and south India. Of 7518 sampled, 5428 (72%) were interviewed for socioeconomic and lifestyle factors, attended hospital for lens imaging and blood collection and were subsequently genotyped for rs33972313 and rs6596473. Mixed or pure types of cataract were graded by the Lens Opacity Classification System III as nuclear (2404), cortical (494) or posterior subcapsular cataract (PSC) (1026); 1462 had no significant cataract and no history of cataract surgery and 775 had bilateral aphakia/pseudophakia. Results rs33972313 was associated with cortical (OR 2.16; 95% CI 1.34 to 3.49, p=0.002) and PSC (OR 1.68; 95% CI 1.06 to 2.65, p=0.03) but not with nuclear cataract. In analyses of pure cataracts, associations were found only between rs33972313 and pure cortical cataracts (OR 2.29; 95% CI 1.12 to 4.65, p=0.03) and with a standardised cortical opacity score. There was no association with rs6596473 and any cataract outcomes. Conclusions Using an established genetic variant as a proxy for lifetime ascorbate concentrations, our results support a causal association of vitamin C with cataract.
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Affiliation(s)
| | - Periasamy Sundaresan
- Department of Genetics, Dr.G.Venkataswamy Eye Research Institute, Aravind Medical Research Foundation, Madurai, India
| | | | - Praveen Vashist
- Community Ophthalmology Department, Dr.Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Delhi, India
| | - Giovanni Maraini
- Dipartimento di Scienze Otorino-Odonto-Oftalmologiche e Cervico Facciali, Universitá degli Studi di Parma, Parma, Italy
| | - Vijayan Saravanan
- Department of Genetics, Dr.G.Venkataswamy Eye Research Institute, Aravind Medical Research Foundation, Madurai, India
| | | | - Liam Smeeth
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Dorothea Nitsch
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Ian S Young
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Astrid E Fletcher
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
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Cho J, Prajna NV, Lalitha P, Rajaraman R, Krishnan T, Lin YB, Ray KJ, Lietman TM, Rose-Nussbaumer J. Therapeutic Penetrating Keratoplasty Button Cultures in The Mycotic Ulcer Treatment Trial II: A Randomized Trial Comparing Oral Voriconazole Versus Placebo. Am J Ophthalmol 2018; 192:142-145. [PMID: 29758184 DOI: 10.1016/j.ajo.2018.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/03/2018] [Accepted: 05/04/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare oral voriconazole vs placebo in addition to topical antifungals in the treatment of filamentous fungal keratitis. DESIGN Non-prespecified, secondary case-control analysis from a multicenter, double-masked, randomized placebo-controlled clinical trial. METHODS Study Participants: Patients with smear-positive filamentous fungal ulcers and visual acuity of 20/400 or worse who eventuated to therapeutic penetrating keratoplasty (TPK). INTERVENTION Study participants were randomized to oral voriconazole vs oral placebo; all received topical antifungal drops. MAIN OUTCOME MEASURES TPK button culture positivity. RESULTS A total of 95 of 194 (49.5%) study participants enrolled at Madurai, Coimbatore, or Pondicherry, India eventuated to TPK in an average of 20.9 days (standard deviation 15.2 days, range 2-71 days). TPK button cultures were available for 67 of 95 (71%) of the TPKs performed and were positive for filamentous fungus in 45 of 67 (67%) cases. For each 1-day increase in the time to TPK there was 0.94-fold decreased odds of fungal culture positivity (95% confidence interval [CI] 0.90-0.98, P = .005). Those randomized to oral voriconazole had 1.26-fold increased odds of TPK button culture positivity after controlling for time to TPK and baseline organism, but this was not statistically significant (95% CI 0.32-4.87; P = .74). Those who underwent TPK for lack of response to medical therapy were 10.64-fold more likely to be culture positive than if the indication for surgery was perforation and this was statistically significant (95% CI 2.16-51.70; P = .003). CONCLUSIONS There appears to be no benefit to adding oral voriconazole to topical antifungal agents in the treatment of severe filamentous fungal ulcers. Infection rather than inflammation appears to be the reason for the worsening clinical picture in many of these patients.
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Affiliation(s)
- Julie Cho
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | | | | | | | | | - Yijie Brittany Lin
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA; Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA; Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA; Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA; Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.
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Oldenburg CE, Prajna NV, Krishnan T, Rajaraman R, Srinivasan M, Ray KJ, O’Brien KS, Glymour MM, Porco TC, Acharya NR, Rose-Nussbaumer J, Lietman TM. Regression Discontinuity and Randomized Controlled Trial Estimates: An Application to The Mycotic Ulcer Treatment Trials. Ophthalmic Epidemiol 2018; 25:315-322. [PMID: 29718751 PMCID: PMC5980795 DOI: 10.1080/09286586.2018.1469156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 03/20/2018] [Accepted: 04/16/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE We compare results from regression discontinuity (RD) analysis to primary results of a randomized controlled trial (RCT) utilizing data from two contemporaneous RCTs for treatment of fungal corneal ulcers. METHODS Patients were enrolled in the Mycotic Ulcer Treatment Trials I and II (MUTT I & MUTT II) based on baseline visual acuity: patients with acuity ≤ 20/400 (logMAR 1.3) enrolled in MUTT I, and >20/400 in MUTT II. MUTT I investigated the effect of topical natamycin versus voriconazole on best spectacle-corrected visual acuity. MUTT II investigated the effect of topical voriconazole plus placebo versus topical voriconazole plus oral voriconazole. We compared the RD estimate (natamycin arm of MUTT I [N = 162] versus placebo arm of MUTT II [N = 54]) to the RCT estimate from MUTT I (topical natamycin [N = 162] versus topical voriconazole [N = 161]). RESULTS In the RD, patients receiving natamycin had mean improvement of 4-lines of visual acuity at 3 months (logMAR -0.39, 95% CI: -0.61, -0.17) compared to topical voriconazole plus placebo, and 2-lines in the RCT (logMAR -0.18, 95% CI: -0.30, -0.05) compared to topical voriconazole. CONCLUSIONS The RD and RCT estimates were similar, although the RD design overestimated effects compared to the RCT.
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Affiliation(s)
| | | | | | | | | | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Kieran S. O’Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | - M. Maria Glymour
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Travis C. Porco
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
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9
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Ray KJ, Prajna NV, Lalitha P, Rajaraman R, Krishnan T, Patel S, Das M, Shah R, Dhakhwa K, McLeod SD, Zegans ME, Acharya NR, Lietman TM, Rose-Nussbaumer J. The Significance of Repeat Cultures in the Treatment of Severe Fungal Keratitis. Am J Ophthalmol 2018; 189:41-46. [PMID: 29438654 DOI: 10.1016/j.ajo.2018.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 02/02/2018] [Accepted: 02/03/2018] [Indexed: 12/01/2022]
Abstract
PURPOSE To identify fungal keratitis patients who are at risk of a poor outcome and may benefit from closer follow-up or more aggressive treatment. DESIGN Secondary analysis of randomized clinical trial data. METHODS We compared the clinical outcomes of patients who had positive 6-day fungal cultures with those who did not, using backward stepwise regression with covariates for all baseline clinical characteristics. SUBJECTS Patients presenting with a smear-positive filamentous fungal ulcer and visual acuity of 20/400 or worse, and who subsequently had a 6-day fungal culture performed at the Aravind Eye Care system (India), Lumbini Eye Hospital (Nepal), or Bharatpur Eye Hospital (Nepal). MAIN OUTCOME MEASURES The primary outcome is rate of corneal perforation and/or the need for therapeutic penetrating keratoplasty. Secondary outcomes include 3-month best spectacle-corrected visual acuity (BSCVA), 3-month infiltrate and/or scar size, and rate of re-epithelialization. RESULTS Patients who tested positive at their 6-day culture had twice the hazard of experiencing a corneal perforation or the need for therapeutic penetrating keratoplasty (P = .002) than those who tested negative, even after controlling for baseline ulcer characteristics. These patients also had on average 0.26 logMAR lines worse BSCVA at 3 months (P = .001). Culture positivity at day 6 was not a statistically significant predictor of 3-month infiltrate/scar-size (-0.24 mm1; P = .45) or time to re-epithelialization (hazard ratio = .81; P = .31). CONCLUSIONS Here we identify a uniquely valuable clinical tool, day 6 culture results, for the treatment of severe fungal keratitis. Risk stratification based on repeat culture positivity is an objective way to assess response to medical therapy and identify patients who are at high risk of a poor clinical outcome. This establishes a new standard of care for severe fungal keratitis management.
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Affiliation(s)
- Kathryn J Ray
- Francis I. Proctor Foundation, San Francisco, California
| | | | - Prajna Lalitha
- Aravind Eye Care System, Madurai, Pondicherry, and Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System, Madurai, Pondicherry, and Coimbatore, India
| | | | | | - Manoranjan Das
- Aravind Eye Care System, Madurai, Pondicherry, and Coimbatore, India
| | | | | | - Stephen D McLeod
- Francis I. Proctor Foundation, San Francisco, California; UCSF Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | | | - Nisha R Acharya
- Francis I. Proctor Foundation, San Francisco, California; UCSF Department of Ophthalmology, University of California San Francisco, San Francisco, California; UCSF Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Thomas M Lietman
- Francis I. Proctor Foundation, San Francisco, California; UCSF Department of Ophthalmology, University of California San Francisco, San Francisco, California; UCSF Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, San Francisco, California; UCSF Department of Ophthalmology, University of California San Francisco, San Francisco, California.
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10
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Joseph S, Krishnan T, Ravindran RD, Maraini G, Camparini M, Chakravarthy U, Ravilla TD, Hutchings A, Fletcher AE. Prevalence and risk factors for myopia and other refractive errors in an adult population in southern India. Ophthalmic Physiol Opt 2018; 38:346-358. [PMID: 29574882 PMCID: PMC6001660 DOI: 10.1111/opo.12447] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 02/02/2018] [Indexed: 12/17/2022]
Abstract
PURPOSE To investigate prevalence and risk factors for myopia, hyperopia and astigmatism in southern India. METHODS Randomly sampled villages were enumerated to identify people aged ≥40 years. Participants were interviewed for socioeconomic and lifestyle factors and attended a hospital-based ophthalmic examination including visual acuity measurement and objective and subjective measurement of refractive status. Myopia was defined as spherical equivalent (SE) worse than -0.75 dioptres (D), hyperopia as SE ≥+1D and astigmatism as cylinder <-0.5. RESULTS The age-standardised prevalences of myopia, hyperopia and astigmatism were 35.6% (95% CI: 34.7-36.6), 17.0% (95% CI: 16.3-17.8) and 32.6 (29.3-36.1), respectively. Of those with myopia (n = 1490), 70% had advanced cataract. Of these, 79% had presenting visual acuity (VA) less than 6/18 and after best correction, 44% of these improved to 6/12 or better and 27% remained with VA less than 6/18. In multivariable analyses (excluding patients with advanced cataract), increasing nuclear opacity score, current tobacco use, and increasing height were associated with higher odds of myopia. Higher levels of education were associated with increased odds of myopia in younger people and decreased odds in older people. Increasing time outdoors was associated with myopia only in older people. Increasing age and female gender were associated with hyperopia, and nuclear opacity score, increasing time outdoors, rural residence and current tobacco use with lower odds of hyperopia. After controlling for myopia, factors associated with higher odds of astigmatism were age, rural residence, and increasing nuclear opacity score and increasing education with lower odds. CONCLUSIONS In contrast to high-income settings and in agreement with studies from low-income settings, we found a rise in myopia with increasing age reflecting the high prevalence of advanced cataract.
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Affiliation(s)
- Sanil Joseph
- Lions Aravind Institute of Community OphthalmologyAravind Eye Care SystemMaduraiIndia
| | | | | | - Giovanni Maraini
- Sezione di OftalmologiaDipartimento di Scienze Otorino‐Odonto‐Oftalmologiche e Cervico FaccialiUniversità degli Studi di ParmaParmaItaly
| | - Monica Camparini
- Dipartimento di Scienze Biomediche, Biotecnologiche e Traslazionali‐S.Bi.Bi.TUniversità degli Studi di ParmaParmaItaly
| | - Usha Chakravarthy
- Centre for Vision & Vascular ScienceSchool of Medicine, Dentistry and Biomedical SciencesQueen's University BelfastBelfastUK
| | - Thulasiraj D. Ravilla
- Lions Aravind Institute of Community OphthalmologyAravind Eye Care SystemMaduraiIndia
| | - Andrew Hutchings
- Department of Health Services, Research and PolicyLondon School of Hygiene & Tropical MedicineLondonUK
| | - Astrid E. Fletcher
- Faculty of Epidemiology & Population HealthLondon School of Hygiene & Tropical MedicineLondonUK
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11
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Prajna NV, Krishnan T, Rajaraman R, Patel S, Shah R, Srinivasan M, Das M, Ray KJ, Oldenburg CE, McLeod SD, Zegans ME, Acharya NR, Lietman TM, Rose-Nussbaumer J. Predictors of Corneal Perforation or Need for Therapeutic Keratoplasty in Severe Fungal Keratitis: A Secondary Analysis of the Mycotic Ulcer Treatment Trial II. JAMA Ophthalmol 2017; 135:987-991. [PMID: 28817744 DOI: 10.1001/jamaophthalmol.2017.2914] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Identifying patients with infectious keratitis who are at risk of experiencing a poor outcome may be useful to allocate resources toward high-risk patients, particularly in resource-poor settings. Objective To determine baseline patient and ulcer characteristics that predict a high risk of developing corneal perforation and/or the need to undergo therapeutic penetrating keratoplasty (TPK). Design, Setting, and Participants This is a secondary analysis of Mycotic Ulcer Treatment Trial II, a multicenter, double-masked, placebo-controlled randomized clinical trial that enrolled 240 patients with smear-positive filamentous fungal corneal ulcers who enrolled between May 2010 and August 2015. Participants had a baseline visual acuity of 20/400 or worse and were randomized to receive oral voriconazole or a placebo (all participants received topical voriconazole, 1%). After 39 participants (16.3%) were enrolled, topical natamycin, 5%, was also added. Main Outcomes and Measures The primary outcome of this secondary analysis was the rate of corneal perforation or the need to undergo TPK. Results The mean (SD) age at enrollment was 49 (13) years, 104 participants (43.3%) were women, and all were of Southeast Asian descent. The presence of hypopyon at baseline indicated 2.28 times the odds of the patient developing corneal perforation and/or needing TPK (95% CI, 1.18-4.40; P = .01). Study participants whose infiltrate involved the posterior one-third had a 71.4% risk of developing corneal perforation and/or needing TPK. For each 1-mm increase in the geometric mean of the infiltrate, there was 1.37 (95% CI, 1.12-1.67; P = .002) increased odds of developing perforation and/or needing TPK. Other clinical features such as visual acuity, baseline culture positivity, type of filamentous fungal organism and duration of symptoms, and demographic characteristics, such as sex and occupation, were not significant predictors in the multivariable regression analysis. Conclusions and Relevance These results suggest that risk stratification from baseline ulcer characteristics can identify those at highest risk for developing corneal perforation and/or needing TPK. Trial Registration clinicaltrials.gov Identifier: NCT00996736.
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Affiliation(s)
- N Venkatesh Prajna
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli and Coimbatore, India
| | - Tiruvengada Krishnan
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli and Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli and Coimbatore, India
| | | | | | - Muthiah Srinivasan
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli and Coimbatore, India
| | - Manoranjan Das
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli and Coimbatore, India
| | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California-San Francisco, San Francisco
| | - Catherine E Oldenburg
- Francis I. Proctor Foundation, University of California-San Francisco, San Francisco
| | - Stephen D McLeod
- Francis I. Proctor Foundation, University of California-San Francisco, San Francisco.,Department of Ophthalmology, University of California-San Francisco, San Francisco
| | | | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California-San Francisco, San Francisco.,Department of Ophthalmology, University of California-San Francisco, San Francisco.,Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California-San Francisco, San Francisco.,Department of Ophthalmology, University of California-San Francisco, San Francisco.,Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California-San Francisco, San Francisco.,Department of Ophthalmology, University of California-San Francisco, San Francisco
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12
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Prajna NV, Krishnan T, Rajaraman R, Patel S, Shah R, Srinivasan M, Devi L, Das M, Ray KJ, O'Brien KS, Oldenburg CE, McLeod SD, Zegans ME, Acharya NR, Lietman TM, Rose-Nussbaumer J. Adjunctive Oral Voriconazole Treatment of Fusarium Keratitis: A Secondary Analysis From the Mycotic Ulcer Treatment Trial II. JAMA Ophthalmol 2017; 135:520-525. [PMID: 28426856 DOI: 10.1001/jamaophthalmol.2017.0616] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Importance Fusarium keratitis is common and often results in poor outcomes. No new treatments since natamycin have become available. Objective To explore the role of adjuvant oral voriconazole on clinical outcomes in Fusarium keratitis. Design, Setting, and Participants In this prespecified subgroup analysis of a multicenter, double-masked, placebo-controlled randomized clinical trial, 240 patients from the Aravind Eye Care System in India, the Lumbini Eye Hospital and Bharatpur Eye Hospital in Nepal, and the University of California, San Francisco, who had culture-positive fungal ulcer and baseline visual acuity of 20/400 or worse were randomized to receive oral voriconazole vs placebo. Enrollment started May 24, 2010, and the last patient study visit was November 23, 2015. All patients received topical voriconazole, 1%, and after the results of the Mycotic Ulcer Treatment Trial (MUTT) II became available, topical natamycin, 5%, was added for all patients. Data analysis was performed from September 2 to October 28, 2016. Main Outcomes and Measures The primary outcome of the trial was the rate of corneal perforation or the need for therapeutic penetrating keratoplasty. Secondary outcomes included rate of reepithelialization, best spectacle-corrected visual acuity, and infiltrate or scar size at 3 months. Results Of the 240 study participants, 72 (30.4%) were culture positive for Fusarium species (41 [56.9%] male and 31 [43.1%] female; median [interquartile range] age, 50 [45-57] years). Of these, 33 (45.8%) were randomized to oral voriconazole and 39 (54.2%) to placebo. Fusarium ulcers randomized to oral voriconazole had a 0.43-fold decreased hazard of perforation or therapeutic penetrating keratoplasty compared with placebo after controlling for baseline infiltrate depth (95% CI, 0.22-fold to 0.84-fold; P = .01). Multiple linear regression revealed a 1.89-mm decreased infiltrate and/or scar size at 3 weeks (95% CI, -2.69 to -1.09 mm; P < .001) and a 0.83-mm decreased infiltrate and/or scar size at 3 months after correcting for baseline values (95% CI, -1.33 to -0.32 mm; P = .001) in eyes randomized to oral voriconazole vs placebo. Eyes treated with oral voriconazole also had a mean 0.29 decreased logMAR (improved) (Snellen equivalent 20/40) visual acuity at 3 months after controlling for baseline visual acuity, although this finding was not statistically significant (95% CI, -0.57 to 0.002; P = .052). Conclusions and Relevance Although MUTT II could not find a benefit for all corneal ulcers, Fusarium keratitis may benefit from the addition of oral voriconazole to topical natamycin, and physicians should consider prescribing oral voriconazole in these cases. Trial Registration clinicaltrials.gov Identifier: NCT00996736.
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Affiliation(s)
- N Venkatesh Prajna
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Tiruvengada Krishnan
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | | | | | - Muthiah Srinivasan
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Lumbini Devi
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Manoranjan Das
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | | | - Stephen D McLeod
- Francis I. Proctor Foundation, University of California, San Francisco5Department of Ophthalmology, University of California, San Francisco
| | | | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California, San Francisco5Department of Ophthalmology, University of California, San Francisco7Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco5Department of Ophthalmology, University of California, San Francisco7Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco5Department of Ophthalmology, University of California, San Francisco
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13
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Odayappan A, Shivananda N, Ramakrishnan S, Krishnan T, Nachiappan S, Krishnamurthy S. A retrospective study on the incidence of post-cataract surgery Descemet's membrane detachment and outcome of air descemetopexy. Br J Ophthalmol 2017; 102:182-186. [PMID: 28611131 DOI: 10.1136/bjophthalmol-2016-309766] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 05/09/2017] [Accepted: 05/21/2017] [Indexed: 11/04/2022]
Abstract
PURPOSE To study the anatomic and functional outcome of air descemetopexy in postcataract surgery Descemet's membrane detachment (DMD). DESIGN Retrospective study. METHODS Setting: Institutional. STUDY POPULATION Records of 112 patients who underwent air descemetopexy for postcataract surgery sight-threatening DMD at Aravind Eye Hospital, Pondicherry, between January 2013 and December 2015 were studied. MAIN OUTCOME MEASURES Anatomical outcome refers to reattachment of the Descemet's membrane (DM). Functional outcome was given by the best-corrected visual acuity. RESULTS The mean age was 66.47±8.46 (SD) years, the male to female ratio was 45:67. The incidence of DMD was more in extracapsular cataract extraction (0.26%) and manual small incision cataract surgery (0.11%) than phacoemulsification (0.04%) (p=0.005 and p<0.0001). DMD was more common among surgical trainees (0.17%) than consultants (0.07%) (p≤0.0001). After primary air descemetopexy, 78 (71%) out of the 110 patients had DM reattachment. The complications noted after descemetopexy include persistent DMD (21.8%), corneal decompensation (7.3%), appositional angle closure (18%), pupillary block with air (2.7%) and uveitis (2.7%). Age, sex and timing of intervention did not influence the reattachment rate. Fifteen patients underwent repeat air descemetopexy for persistent DMD among whom nine (60%) had successful reattachment. Almost 75% of patients had vision better than 6/18 1 month after anatomically successful descemetopexy. CONCLUSION Air descemetopexy is a safe and efficient modality of treatment of DMD and should be tried even in patients with severe DMD before planning a major surgery like endothelial keratoplasty.
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Affiliation(s)
- Annamalai Odayappan
- Department of General Ophthalmology, Aravind Eye Hospital, Pondicherry, India
| | | | | | | | - Sivagami Nachiappan
- Department of General Ophthalmology, Aravind Eye Hospital, Madurai, Tamil Nadu, India
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14
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Ray KJ, Lalitha P, Prajna NV, Rajaraman R, Krishnan T, Srinivasan M, Ryg P, McLeod S, Acharya NR, Lietman TM, Rose-Nussbaumer J. The Utility of Repeat Culture in Fungal Corneal Ulcer Management: A Secondary Analysis of the MUTT-I Randomized Clinical Trial. Am J Ophthalmol 2017; 178:157-162. [PMID: 28385473 DOI: 10.1016/j.ajo.2017.03.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 03/24/2017] [Accepted: 03/27/2017] [Indexed: 11/18/2022]
Abstract
PURPOSE To determine whether patients who had a positive repeated culture was predictive of worse clinical outcome than those who achieved microbiological cure at 6 days in the Mycotic Ulcer Treatment Trial I (MUTT-I). DESIGN Secondary analysis from a multicenter, double-masked, randomized clinical trial. METHODS setting: Multiple hospital sites of the Aravind Eye Care System, India. STUDY POPULATION Patients with culture-positive filamentous fungal ulcers and visual acuity of 20/40 to 20/400 reexamined 6 days after initiation of treatment. INTERVENTION Corneal scraping and cultures were obtained from study participants at day 6 after enrollment. MAIN OUTCOME MEASURES We assessed 3-month best spectacle-corrected visual acuity (BSCVA), 3-month infiltrate/scar size, corneal perforation, and re-epithelialization rates stratified by culture positivity at day 6. RESULTS Of the 323 patients with smear-positive ulcers enrolled in MUTT-I, 299 (92.6%) were scraped and cultured 6 days after enrollment. Repeat culture positivity was 31% (92/299). Among patients who tested positive at enrollment, those with positive 6-day cultures had significantly worse 3-month BSCVA (0.39 logMAR; 95% confidence interval [CI]: 0.24-0.44; P < .001), had larger 3-month scar size (0.39 mm; 95% CI: 0.06-0.73; P = .02), were more likely to perforate or require therapeutic penetrating keratoplasty (odds ratio: 6.27; 95% CI: 2.73-14.40; P < .001), and were slower to re-epithelialize (hazard ratio: 0.33; 95% CI: 0.21-0.50; P < .001) than those with a negative 6-day culture result. CONCLUSIONS Early microbiological cure on culture is a predictor of clinical response to treatment.
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Affiliation(s)
- Kathryn J Ray
- Francis I. Proctor Foundation, San Francisco, California
| | - Prajna Lalitha
- Aravind Eye Care System, Madurai, Pondicherry, and Coimbatore, India
| | | | - Revathi Rajaraman
- Aravind Eye Care System, Madurai, Pondicherry, and Coimbatore, India
| | | | | | - Peter Ryg
- Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | - Stephen McLeod
- Francis I. Proctor Foundation, San Francisco, California; Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | - Nisha R Acharya
- Francis I. Proctor Foundation, San Francisco, California; Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | - Thomas M Lietman
- Francis I. Proctor Foundation, San Francisco, California; Department of Ophthalmology, University of California San Francisco, San Francisco, California; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, San Francisco, California; Department of Ophthalmology, University of California San Francisco, San Francisco, California.
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15
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Prajna NV, Krishnan T, Rajaraman R, Patel S, Srinivasan M, Das M, Ray KJ, O'Brien KS, Oldenburg CE, McLeod SD, Zegans ME, Porco TC, Acharya NR, Lietman TM, Rose-Nussbaumer J. Effect of Oral Voriconazole on Fungal Keratitis in the Mycotic Ulcer Treatment Trial II (MUTT II): A Randomized Clinical Trial. JAMA Ophthalmol 2017; 134:1365-1372. [PMID: 27787540 DOI: 10.1001/jamaophthalmol.2016.4096] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective To compare oral voriconazole with placebo in addition to topical antifungals in the treatment of filamentous fungal keratitis. Design, Setting, and Participants The Mycotic Ulcer Treatment Trial II (MUTT II), a multicenter, double-masked, placebo-controlled, randomized clinical trial, was conducted in India and Nepal, with 2133 individuals screened for inclusion. Patients with smear-positive filamentous fungal ulcers and visual acuity of 20/400 (logMAR 1.3) or worse were randomized to receive oral voriconazole vs oral placebo; all participants received topical antifungal eyedrops. The study was conducted from May 24, 2010, to November 23, 2015. All trial end points were analyzed on an intent-to-treat basis. Interventions Study participants were randomized to receive oral voriconazole vs oral placebo; a voriconazole loading dose of 400 mg was administered twice daily for 24 hours, followed by a maintenance dose of 200 mg twice daily for 20 days, with dosing altered to weight based during the trial. All participants received topical voriconazole, 1%, and natamycin, 5%. Main Outcomes and Measures The primary outcome of the trial was rate of corneal perforation or the need for therapeutic penetrating keratoplasty (TPK) within 3 months. Secondary outcomes included microbiologic cure at 6 days, rate of re-epithelialization, best-corrected visual acuity and infiltrate and/or scar size at 3 weeks and 3 months, and complication rates associated with voriconazole use. Results A total of 2133 patients in India and Nepal with smear-positive ulcers were screened; of the 787 who were eligible, 240 (30.5%) were enrolled. Of the 119 patients (49.6%) in the oral voriconazole treatment group, 65 were male (54.6%), and the median age was 54 years (interquartile range, 42-62 years). Overall, no difference in the rate of corneal perforation or the need for TPK was determined for oral voriconazole vs placebo (hazard ratio, 0.82; 95% CI, 0.57-1.18; P = .29). In prespecified subgroup analyses comparing treatment effects among organism subgroups, there was some suggestion that Fusarium species might have a decreased rate of perforation or TPK in the oral voriconazole-treated arm; however, this was not a statistically significant finding after Holms-Šidák correction for multiple comparisons (effect coefficient, 0.49; 95% CI, 0.26-0.92; P = .03). Patients receiving oral voriconazole experienced a total of 58 adverse events (48.7%) compared with 28 adverse events (23.1%) in the placebo group (P < .001 after Holms-Šidák correction for multiple comparisons). Conclusions and Relevance There appears to be no benefit to adding oral voriconazole to topical antifungal agents in the treatment of severe filamentous fungal ulcers. All patients in this study were enrolled in India and Nepal; therefore, it is possible that organisms in this region may exhibit characteristics different from those in other regions of the world. Trial Registration clinicaltrials.gov Identifier: NCT00996736.
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Affiliation(s)
- N Venkatesh Prajna
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - Tiruvengada Krishnan
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | | | - Muthiah Srinivasan
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - Manoranjan Das
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | | | - Stephen D McLeod
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco
| | | | - Travis C Porco
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco.,Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco.,Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco
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16
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Prajna NV, Lalitha P, Rajaraman R, Krishnan T, Raghavan A, Srinivasan M, O'Brien KS, Zegans M, McLeod SD, Acharya NR, Keenan JD, Lietman TM, Rose-Nussbaumer J. Changing Azole Resistance: A Secondary Analysis of the MUTT I Randomized Clinical Trial. JAMA Ophthalmol 2017; 134:693-6. [PMID: 27054515 DOI: 10.1001/jamaophthalmol.2016.0530] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The development of multiple triazole resistance in pathogenic filamentous fungi has become an increasing clinical concern and has been shown to increase the risk for treatment failure. OBJECTIVE To determine whether antifungal resistance increased during the Mycotic Ulcer Treatment Trial I (MUTT I), as measured by minimum inhibitory concentrations (MICs) in baseline cultures. DESIGN, SETTING, AND PARTICIPANTS This secondary analysis of a double-masked, multicenter, randomized clinical trial included patients with culture- or smear-positive filamentous fungal corneal ulcer and a baseline visual acuity of 20/40 to 20/400. Culture-positive samples with susceptibility testing were included in this analysis. The patients were treated at multiple locations of the Aravind Eye Care Hospital system in South India. Data were collected from April 3, 2010, to December 31, 2011, and analyzed from July 15 to September 1, 2015. INTERVENTIONS Corneal smears and cultures were obtained from all study participants at baseline. Susceptibility testing was performed for each culture-positive specimen. MAIN OUTCOMES AND MEASURES Minimum inhibitory concentration of voriconazole and natamycin in baseline cultures. RESULTS Of 323 participants with smear-positive specimens (183 men [56.7%]; 140 women [43.3%]; median [interquartile range] age, 47 [38-56] years), fungal-positive cultures were obtained for 256 (79.3%). The MIC data were available for 221 of 323 participants (68.4%), because 35 samples had no growth during susceptibility testing. A 2.14-fold increase per year (95% CI, 1.13-4.56; P = .02) in voriconazole MICs after controlling for the infectious organism was found. This association was not found when looking at natamycin MICs of baseline cultures after controlling for the infectious organism (1.26; 95% CI, 0.13-12.55; P = .85). CONCLUSIONS AND RELEVANCE Susceptibility to voriconazole appeared to decrease during the relatively short enrollment period of the clinical trial. This decrease may be more related to increased resistance of environmental fungi rather than previous treatment with azoles, because presenting with azole treatment was not a risk factor for resistance. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00996736.
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Affiliation(s)
| | - Prajna Lalitha
- Aravind Eye Care System at Madurai, Pondicherry, and Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System at Madurai, Pondicherry, and Coimbatore, India
| | | | - Anita Raghavan
- Aravind Eye Care System at Madurai, Pondicherry, and Coimbatore, India
| | | | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Michael Zegans
- Department of Ophthalmology, Dartmouth Medical School, Hanover, New Hampshire
| | - Stephen D McLeod
- Department of Ophthalmology, University of California, San Francisco
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California, San Francisco4Department of Ophthalmology, University of California, San Francisco5Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California, San Francisco4Department of Ophthalmology, University of California, San Francisco
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco4Department of Ophthalmology, University of California, San Francisco5Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco4Department of Ophthalmology, University of California, San Francisco6Department of Optometry, University of California, Berkeley
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Ravilla TD, Gupta S, Ravindran RD, Vashist P, Krishnan T, Maraini G, Chakravarthy U, Fletcher AE. Use of Cooking Fuels and Cataract in a Population-Based Study: The India Eye Disease Study. Environ Health Perspect 2016; 124:1857-1862. [PMID: 27227523 PMCID: PMC5132636 DOI: 10.1289/ehp193] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 12/15/2015] [Accepted: 04/25/2016] [Indexed: 05/06/2023]
Abstract
BACKGROUND Biomass cooking fuels are commonly used in Indian households, especially by the poorest socioeconomic groups. Cataract is highly prevalent in India and the major cause of vision loss. The evidence on biomass fuels and cataract is limited. OBJECTIVES To examine the association of biomass cooking fuels with cataract and type of cataract. METHODS We conducted a population-based study in north and south India using randomly sampled clusters to identify people ≥ 60 years old. Participants were interviewed and asked about cooking fuel use, socioeconomic and lifestyle factors and attended hospital for digital lens imaging (graded using the Lens Opacity Classification System III), anthropometry, and blood collection. Years of use of biomass fuels were estimated and transformed to a standardized normal distribution. RESULTS Of the 7,518 people sampled, 94% were interviewed and 83% of these attended the hospital. Sex modified the association between years of biomass fuel use and cataract; the adjusted odds ratio (OR) for a 1-SD increase in years of biomass fuel use and nuclear cataract was 1.04 (95% CI: 0.88, 1.23) for men and 1.28 (95% CI: 1.10, 1.48) for women, p interaction = 0.07. Kerosene use was low (10%). Among women, kerosene use was associated with nuclear (OR = 1.76, 95% CI: 1.04, 2.97) and posterior subcapsular cataract (OR = 1.71, 95% CI: 1.10, 2.64). There was no association among men. CONCLUSIONS Our results provide robust evidence for the association of biomass fuels with cataract for women but not for men. Our finding for kerosene and cataract among women is novel and requires confirmation in other studies. Citation: Ravilla TD, Gupta S, Ravindran RD, Vashist P, Krishnan T, Maraini G, Chakravarthy U, Fletcher AE. 2016. Use of cooking fuels and cataract in a population-based study: the India Eye Disease Study. Environ Health Perspect 124:1857-1862; http://dx.doi.org/10.1289/EHP193.
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Affiliation(s)
- Thulasiraj D. Ravilla
- Lions Aravind Institute of Community Ophthalmology, Aravind Eye Care System, Madurai, India
| | - Sanjeev Gupta
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | | | - Praveen Vashist
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | | | - Giovanni Maraini
- Dipartimento di Scienze Otorino-Odonto-Oftalmologiche e Cervico Facciali, Universita` degli Studi di Parma, Parma, Italy
| | - Usha Chakravarthy
- Centre for Vision and Vascular Science, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, United Kingdom
| | - Astrid E. Fletcher
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Krishnan T, Mustakos R, Steinke K. EP 54. Modeling the effects of current steering with directional leads. Clin Neurophysiol 2016. [DOI: 10.1016/j.clinph.2016.05.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Ramakrishnan S, Baskaran P, Fazal R, Sulaiman SM, Krishnan T, Venkatesh R. Spring-action Apparatus for Fixation of Eyeball (SAFE): a novel, cost-effective yet simple device for ophthalmic wet-lab training. Br J Ophthalmol 2016; 100:1317-21. [DOI: 10.1136/bjophthalmol-2015-308330] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 07/06/2016] [Indexed: 11/03/2022]
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Sun CQ, Prajna NV, Krishnan T, Rajaraman R, Srinivasan M, Raghavan A, O'Brien KS, McLeod SD, Acharya NR, Rose-Nussbaumer J. Effect of pretreatment with antifungal agents on clinical outcomes in fungal keratitis. Clin Exp Ophthalmol 2016; 44:763-767. [PMID: 27329780 DOI: 10.1111/ceo.12794] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 06/12/2016] [Accepted: 06/14/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND To determine if pretreatment with antifungal agents is predictive of worse clinical outcome in a fungal keratitis clinical trial. DESIGN Non-pre-specified subgroup analysis of a randomized controlled trial in a tertiary hospital. PARTICIPANTS Three hundred twenty-three fungal ulcer cases with an enrolment visual acuity of 20/40 to 20/400. METHODS The Mycotic Ulcer Treatment Trial I was a randomized, double-masked trial to determine the optimal treatment for filamentous fungal keratitis at the Aravind Eye Care System, India. Enrolled cases were randomized to receive topical natamycin or voriconazole. Prior antifungal medication use, dose and duration were collected at enrolment. A subgroup analysis was performed to determine if patients using natamycin or azoles at presentation have worse clinical outcomes compared with those who were not pretreated. MAIN OUTCOME MEASURES Three-month visual acuity (primary), 3-month infiltrate or scar size, corneal perforation and/or transplant and re-epithelialization time. RESULTS Of the 323 patients enrolled, 44% presented on an antifungal agent. Pretreated patients had larger mean baseline infiltrate size (P < 0.001) and epithelial defect size (P = 0.02). Multivariate regression analysis demonstrated that pretreatment was associated with significantly worse 3-month visual acuity (P = 0.006), larger 3-month scar size (P < 0.001) and increased odds of corneal perforation and/or transplant (P = 0.001). CONCLUSIONS Fungal keratitis that is smear-positive despite being pretreated with appropriate antifungal agents appears to be a risk factor for worse outcomes, likely a result of initial ulcer severity and treatment failure. These patients may benefit from more aggressive multimodal therapy at a tertiary centre.
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Affiliation(s)
- Catherine Q Sun
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - N Venkatesh Prajna
- Aravind Eye Care System at Madurai, Pondicherry and Coimbatore, Madurai, India
| | | | - Revathi Rajaraman
- Aravind Eye Care System at Madurai, Pondicherry and Coimbatore, Madurai, India
| | - Muthiah Srinivasan
- Aravind Eye Care System at Madurai, Pondicherry and Coimbatore, Madurai, India
| | - Anita Raghavan
- Aravind Eye Care System at Madurai, Pondicherry and Coimbatore, Madurai, India
| | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Stephen D McLeod
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.,Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Nisha R Acharya
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.,Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Jennifer Rose-Nussbaumer
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.,Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Department of Optometry, University of California Berkeley, Berkeley, California, USA
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Rose-Nussbaumer J, Prajna NV, Krishnan T, Mascarenhas J, Rajaraman R, Srinivasan M, Raghavan A, Oldenburg CE, O'Brien KS, Ray KJ, Porco TC, McLeod SD, Acharya NR, Keenan JD, Lietman TM. Risk factors for low vision related functioning in the Mycotic Ulcer Treatment Trial: a randomised trial comparing natamycin with voriconazole. Br J Ophthalmol 2015; 100:929-932. [PMID: 26531051 DOI: 10.1136/bjophthalmol-2015-306828] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 09/04/2015] [Accepted: 10/03/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND/AIMS The Mycotic Ulcer Treatment Trial I (MUTT I) was a double-masked, multicentre, randomised controlled trial, which found that topical natamycin is superior to voriconazole for the treatment of filamentous fungal corneal ulcers. In this study, we determine risk factors for low vision-related quality of life in patients with fungal keratitis. METHODS The Indian visual function questionnaire (IND-VFQ) was administered to MUTT I study participants at 3 months. Associations between patient and ulcer characteristics and IND-VFQ subscale score were assessed using generalised estimating equations. RESULTS 323 patients were enrolled in the trial, and 292 (90.4%) completed the IND-VFQ at 3 months. Out of a total possible score of 100, the average VFQ score for all participants was 81.3 (range 0-100, SD 23.6). After correcting for treatment arm, each logMAR line of worse baseline visual acuity in the affected eye resulted in an average 1.2 points decrease on VFQ at 3 months (95% CI -1.8 to 0.6, p<0.001). Those who required therapeutic penetrating keratoplasty had an average of 25.2 points decrease on VFQ after correcting for treatment arm (95% CI -31.8 to -18.5, p<0.001). Study participants who were unemployed had on average 28.5 points decrease on VFQ (95% CI -46.9 to -10.2, p=0.002) after correcting for treatment arm. CONCLUSIONS Monocular vision loss from corneal opacity due to fungal keratitis reduced vision-related quality of life. Given the relatively high worldwide burden of corneal opacity, improving treatment outcomes of corneal infections should be a public health priority. TRIAL REGISTRATION NUMBER Clinicaltrials.gov Identifier: NCT00996736.
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Affiliation(s)
- Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.,Department of Optometry, University of California Berkeley
| | | | | | | | | | | | - Anita Raghavan
- Aravind Eye Care System at Madurai, Pondicherry and Coimbatore
| | - Catherine E Oldenburg
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Travis C Porco
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.,Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Stephen D McLeod
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.,Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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Abstract
AIM To evaluate the outcomes of treating deep recalcitrant fungal keratitis with intrastromal voriconazole injection. METHODS Twenty-five patients with culture proven fungal keratitis, not responding to a combination of topical 5% natamycin and 1% voriconazole were treated with intrastromal voriconazole (50 µg/0.1 mL) injected in five divided doses around the infiltrate to form a depot of the drug around the circumference of the lesion. RESULTS The mean age of the patients was 52.52±12.21 years and mean time to presentation was 17.12±13.75 days from the onset of symptoms. The mean area of the infiltrate was 30.41±17.2 mm(2), hypopyon was present in 88% and all cases had infiltrates that extended beyond the mid-stromal level. Intrastromal voriconazole helped to resolve the infection in 18 (72%) patients and about 15% of these needed more than one injection. Smaller ulcers responded better to treatment. Fusarium spp were responsible for six of the seven cases that failed treatment. CONCLUSIONS Targeted delivery of voriconazole by intrastromal injection (50 µg/0.1 mL) is a safe and effective way to treat deep recalcitrant fungal keratitis, though some may need repeated injections. Fusarium keratitis may show suboptimal response but this needs further study.
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Affiliation(s)
| | - Sivananda Narayana
- Cornea and Refractive Services, Aravind Eye Hospital, Pondicherry, India
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Yap PSX, Krishnan T, Yiap BC, Hu CP, Chan KG, Lim SHE. Membrane disruption and anti-quorum sensing effects of synergistic interaction between Lavandula angustifolia (lavender oil) in combination with antibiotic against plasmid-conferred multi-drug-resistant Escherichia coli. J Appl Microbiol 2014; 116:1119-28. [PMID: 24779580 DOI: 10.1111/jam.12444] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 01/03/2014] [Accepted: 01/07/2014] [Indexed: 12/16/2022]
Abstract
AIM The aim of this study was to investigate the mode of action of the lavender essential oil (LV) on antimicrobial activity against multi-drug-resistant Escherichia coli J53 R1 when used singly and in combination with piperacillin. METHOD AND RESULTS In the time-kill analysis, a complete killing of bacteria was observed based on colony counts within 4 h when LV was combined with piperacillin during exposure at determined FIC concentrations. Analysis of the membrane permeabilizing effects of LV on treated cultures through their stability against sodium dodecyl sulphate revealed that the LV played a role in disrupting the bacterial cell membrane. The finding is further supported by scanning electron microscopy analysis and zeta potential measurement. In addition, reduction in light production expression of E. coli [pSB1075] by the LV showed the presence of potential quorum sensing (QS) inhibitors. CONCLUSIONS These results indicated that the LV has the potential to reverse bacterial resistance to piperacillin in E. coli J53 R1. It may operate via two mechanisms: alteration of outer membrane permeability and inhibition of bacterial QS. SIGNIFICANCE AND IMPACT OF THE STUDY These findings offer a novel approach to develop a new option of phytopharmaceuticals against multi-drug-resistant E. coli.
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Affiliation(s)
- P S X Yap
- School of Postgraduate Studies and Research, International Medical University, Kuala Lumpur, Malaysia
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Prajna NV, Srinivasan M, Lalitha P, Krishnan T, Rajaraman R, Ravindran M, Mascarenhas J, Oldenburg CE, Ray KJ, McLeod SD, Acharya NR, Lietman TM. Differences in clinical outcomes in keratitis due to fungus and bacteria. JAMA Ophthalmol 2013; 131:1088-9. [PMID: 23929517 DOI: 10.1001/jamaophthalmol.2013.1612] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Krishnan T, Winship A, Sonderegger S, Menkhorst E, Horne AW, Brown J, Zhang JG, Nicola NA, Tong S, Dimitriadis E. The role of leukemia inhibitory factor in tubal ectopic pregnancy. Placenta 2013; 34:1014-9. [PMID: 24074901 DOI: 10.1016/j.placenta.2013.09.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 09/04/2013] [Accepted: 09/06/2013] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Ectopic pregnancy is unique to humans and a leading cause of maternal morbidity and mortality. The etiology remains unknown however factors regulating embryo implantation likely contribute. Leukemia inhibitory factor (LIF) has roles in extravillous trophoblast adhesion and invasion and is present in ectopic implantation sites. We hypothesised that LIF facilitates blastocyst adhesion/invasion in the Fallopian tube, contributing to ectopic pregnancy. METHODS We immunolocalised LIF receptor (R) in tubal ectopic pregnancy (N = 5). We used an oviduct cell line (OE-E6/E7) to model Fallopian tube epithelial cells and a trophoblast spheroid co-culture model (HTR-8/SVneo cell line formed spheroids) to model blastocyst attachment to the Fallopian tube. We examined LIF signaling pathways in OE-E6/E7 cells by Western blot. The effect of LIF and LIF inhibition (using a novel LIF inhibitor, PEGLA) on first-trimester placental outgrowth was determined. RESULTS LIFR localised to villous and extravillous trophoblast and Fallopian tube epithelium in ectopic pregnancy. LIF activated STAT3 but not the ERK pathway in OE-E6/E7 cells. LIF stimulated HTR-8/SVneo spheroid adhesion to OE-E6/E7 cells which was significantly reduced after PEGLA treatment. LIF promoted placental explants outgrowth, while co-treatment with PEGLA blocked outgrowth. DISCUSSION Our data suggests LIF facilitates the development of ectopic pregnancy by stimulating blastocyst adhesion and trophoblast outgrowth from placental explants. Ectopic pregnancy is usually diagnosed after 6 weeks of pregnancy, therefore PEGLA may be useful in targeting trophoblast growth/invasion. CONCLUSION LIF may contribute to the development of ectopic pregnancies and that pharmacologically targeting LIF-mediated trophoblast outgrowth may be useful as a treatment for ectopic pregnancy.
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Affiliation(s)
- T Krishnan
- Prince Henry's Institute of Medical Research, P.O. Box 5152, Clayton, Victoria 3168, Australia; Faculty of Medicine, Nursing & Health Sciences, Wellington Road, Monash University, Clayton, Victoria 3800, Australia
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Sun CQ, Prajna NV, Krishnan T, Mascarenhas J, Rajaraman R, Srinivasan M, Raghavan A, O'Brien KS, Ray KJ, McLeod SD, Porco TC, Acharya NR, Lietman TM. Expert prior elicitation and Bayesian analysis of the Mycotic Ulcer Treatment Trial I. Invest Ophthalmol Vis Sci 2013; 54:4167-73. [PMID: 23702779 DOI: 10.1167/iovs.13-11716] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To perform a Bayesian analysis of the Mycotic Ulcer Treatment Trial I (MUTT I) using expert opinion as a prior belief. METHODS MUTT I was a randomized clinical trial comparing topical natamycin or voriconazole for treating filamentous fungal keratitis. A questionnaire elicited expert opinion on the best treatment of fungal keratitis before MUTT I results were available. A Bayesian analysis was performed using the questionnaire data as a prior belief and the MUTT I primary outcome (3-month visual acuity) by frequentist analysis as a likelihood. RESULTS Corneal experts had a 41.1% prior belief that natamycin improved 3-month visual acuity compared with voriconazole. The Bayesian analysis found a 98.4% belief for natamycin treatment compared with voriconazole treatment for filamentous cases as a group (mean improvement 1.1 Snellen lines, 95% credible interval 0.1-2.1). The Bayesian analysis estimated a smaller treatment effect than the MUTT I frequentist analysis result of 1.8-line improvement with natamycin versus voriconazole (95% confidence interval 0.5-3.0, P = 0.006). For Fusarium cases, the posterior demonstrated a 99.7% belief for natamycin treatment, whereas non-Fusarium cases had a 57.3% belief. CONCLUSIONS The Bayesian analysis suggests that natamycin is superior to voriconazole when filamentous cases are analyzed as a group. Subgroup analysis of Fusarium cases found improvement with natamycin compared with voriconazole, whereas there was almost no difference between treatments for non-Fusarium cases. These results were consistent with, though smaller in effect size than, the MUTT I primary outcome by frequentist analysis. The accordance between analyses further validates the trial results. (ClinicalTrials.gov number, NCT00996736.).
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Affiliation(s)
- Catherine Q Sun
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California, USA
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Prajna NV, Krishnan T, Mascarenhas J, Rajaraman R, Prajna L, Srinivasan M, Raghavan A, Oldenburg CE, Ray KJ, Zegans ME, McLeod SD, Porco TC, Acharya NR, Lietman TM. The mycotic ulcer treatment trial: a randomized trial comparing natamycin vs voriconazole. JAMA Ophthalmol 2013; 131:422-429. [PMID: 23710492 PMCID: PMC3769211 DOI: 10.1001/jamaophthalmol.2013.1497] [Citation(s) in RCA: 200] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
OBJECTIVE To compare topical natamycin vs voriconazole in the treatment of filamentous fungal keratitis. METHODS This phase 3, double-masked, multicenter trial was designed to randomize 368 patients to voriconazole (1%) or natamycin (5%), applied topically every hour while awake until reepithelialization, then 4 times daily for at least 3 weeks. Eligibility included smear-positive filamentous fungal ulcer and visual acuity of 20/40 to 20/400. MAIN OUTCOME MEASURES The primary outcome was best spectacle-corrected visual acuity at 3 months; secondary outcomes included corneal perforation and/or therapeutic penetrating keratoplasty. RESULTS A total of 940 patients were screened and 323 were enrolled. Causative organisms included Fusarium (128 patients [40%]), Aspergillus (54 patients [17%]), and other filamentous fungi (141 patients [43%]). Natamycintreated cases had significantly better 3-month best spectacle-corrected visual acuity than voriconazole-treated cases (regression coefficient=0.18 logMAR; 95% CI, 0.30 to 0.05; P=.006). Natamycin-treated cases were less likely to have perforation or require therapeutic penetrating keratoplasty (odds ratio=0.42; 95% CI, 0.22 to 0.80; P=.009). Fusarium cases fared better with natamycin than with voriconazole (regression coefficient=0.41 logMAR; 95% CI,0.61 to 0.20; P<.001; odds ratio for perforation=0.06; 95% CI, 0.01 to 0.28; P<.001), while non-Fusarium cases fared similarly (regression coefficient=0.02 logMAR; 95% CI, 0.17 to 0.13; P=.81; odds ratio for perforation=1.08; 95% CI, 0.48 to 2.43; P=.86). CONCLUSIONS Natamycin treatment was associated with significantly better clinical and microbiological outcomes than voriconazole treatment for smear-positive filamentous fungal keratitis, with much of the difference attributable to improved results in Fusarium cases. APPLICATION TO CLINICAL PRACTICE Voriconazole should not be used as monotherapy in filamentous keratitis. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00996736
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Okamoto M, Palanichamy K, Gordon N, Patel D, Walston S, Krishnan T, Chakravarti A. Radiation-induced HIF-1α Induces Radioresistance and Enhances the Migration Abilities in Glioblastoma Cells Through Pten-src-hif-1α Signaling Axis. Int J Radiat Oncol Biol Phys 2012. [DOI: 10.1016/j.ijrobp.2012.07.1792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Prajna VN, Lalitha PS, Mascarenhas J, Krishnan T, Srinivasan M, Vaitilingam CM, Oldenburg CE, Sy A, Keenan JD, Porco TC, Acharya NR, Lietman TM. Natamycin and voriconazole in Fusarium and Aspergillus keratitis: subgroup analysis of a randomised controlled trial. Br J Ophthalmol 2012; 96:1440-1. [PMID: 22914503 DOI: 10.1136/bjophthalmol-2012-301825] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Krishnan T, Prajna NV, Gronert K, Oldenburg CE, Ray KJ, Keenan JD, Lietman TM, Acharya NR. Gender differences in re-epithelialisation time in fungal corneal ulcers. Br J Ophthalmol 2011; 96:137-8. [PMID: 21979901 DOI: 10.1136/bjophthalmol-2011-300441] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Oldenburg CE, Prajna VN, Prajna L, Krishnan T, Mascarenhas J, Vaitilingam CM, Srinivasan M, See CW, Cevallos V, Zegans ME, Acharya NR, Lietman TM. Clinical signs in dematiaceous and hyaline fungal keratitis. Br J Ophthalmol 2011; 95:750-1. [PMID: 21317213 DOI: 10.1136/bjo.2010.198648] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Nataraju SM, Ganesh B, Das S, Chowdhury S, Nayak MK, Ghosh M, Chatterjee MK, Sarkar U, Mitra U, Bhattacharya MK, Arora R, Kobayashi N, Krishnan T. Emergence of Noroviruses homologous to strains reported from Djibouti (horn of Africa), Brazil, Italy, Japan and USA among children in Kolkata, India. Eur Rev Med Pharmacol Sci 2010; 14:789-794. [PMID: 21061839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
AIM A total of 625 faecal specimens of diarrheic cases (n-313) and non diarrheic controls (n-312), were screened by RT-PCR to detect Noroviruses in children aged below 5 years in Kolkata, India. MATERIALS AND METHODS Out of the 313 fecal specimens (cases) screened using CDC primer set, 10 (3.19%) showed amplification in reverse transcription-polymerase chain reaction (RT-PCR) for Norovirus. These included 5 of 260 (1.92%) from hospitalized and 5 of 53 (9.43%) from out patients departament (OPD) cases. RESULTS Nine (90%) of Norovirus positive cases belonged to genogroup GII and one specimen (10%) was positive for genogroup GI. Among the 312 non diarrheic controls 2 (0.63%) were positive for Norovirus GII. Partial RNA dependent RNA polymerase gene (RdRp) sequences corresponding to the six Norovirus GII positive samples showed homology to the sequences of Djibouti (horn of Africa), Brazil, Italy, Japan and US norovirus strains. CONCLUSION This study shows the detection of newly emerging Norovirus strains among diarrheic and non diarrheic children in Kolkata.
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Affiliation(s)
- S M Nataraju
- Division of Virology, National Institute of Cholera and Enteric Diseases (NICED), Beliaghata, Kolkata, West Bengal, India
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Prajna NV, Mascarenhas J, Krishnan T, Reddy PR, Prajna L, Srinivasan M, Vaitilingam CM, Hong KC, Lee SM, McLeod SD, Zegans ME, Porco TC, Lietman TM, Acharya NR. Comparison of natamycin and voriconazole for the treatment of fungal keratitis. ACTA ACUST UNITED AC 2010; 128:672-8. [PMID: 20547942 DOI: 10.1001/archophthalmol.2010.102] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To conduct a therapeutic exploratory clinical trial comparing clinical outcomes of treatment with topical natamycin vs topical voriconazole for fungal keratitis. METHODS The multicenter, double-masked, clinical trial included 120 patients with fungal keratitis at Aravind Eye Hospital in India who were randomized to receive either topical natamycin or topical voriconazole and either had repeated scraping of the epithelium or not. MAIN OUTCOME MEASURES The primary outcome was best spectacle-corrected visual acuity (BSCVA) at 3 months. Other outcomes included scar size, perforations, and a subanalysis of BSCVA at 3 months in patients with an enrollment visual acuity of 20/40 to 20/400. RESULTS Compared with those who received natamycin, voriconazole-treated patients had an approximately 1-line improvement in BSCVA at 3 months after adjusting for scraping in a multivariate regression model but the difference was not statistically significant (P = .29). Scar size at 3 months was slightly greater with voriconazole after adjusting for scraping (P = .48). Corneal perforations in the voriconazole group (10 of 60 patients) were not significantly different than in the natamycin-treated group (9 of 60 patients) (P >.99). Scraping was associated with worse BSCVA at 3 months after adjusting for drug (P = .06). Patients with baseline BSCVA of 20/40 to 20/400 showed a trend toward a 2-line improvement in visual acuity with voriconazole (P = .07). CONCLUSIONS Overall, there were no significant differences in visual acuity, scar size, and perforations between voriconazole- and natamycin-treated patients. There was a trend toward scraping being associated with worse outcomes. Application to Clinical Practice The benefit seen with voriconazole in the subgroup of patients with baseline visual acuity of 20/40 to 20/400 needs to be validated in a confirmatory clinical trial. Trial Registration clinicaltrials.gov Identifier: NCT00557362.
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Yamamoto D, Kobayashi N, Ghosh S, Nagashima S, Krishnan T, Chawla-Sarkar M, Paul S, Aung T. Full genome sequence analysis of Group B human rotaviruses. Int J Infect Dis 2010. [DOI: 10.1016/j.ijid.2010.02.643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Keane N, Roberts S, Laird R, Chopra A, Krishnan T, Almeida C, Bronke C, Mallal S, James I, John M. P09-15. Selection of higher avidity HLA-restricted T cell responses as a viral adaptation strategy. Retrovirology 2009. [PMCID: PMC2767613 DOI: 10.1186/1742-4690-6-s3-p128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Krishnan T, Ravindran RD, Murthy GVS, Vashist P, Fitzpatrick KE, Thulasiraj RD, John N, Maraini G, Camparini M, Chakravarthy U, Fletcher AE. Prevalence of early and late age-related macular degeneration in India: the INDEYE study. Invest Ophthalmol Vis Sci 2009; 51:701-7. [PMID: 19696177 DOI: 10.1167/iovs.09-4114] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To estimate the prevalence of early and late age-related macular degeneration (AMD) in India. METHODS Of 7518 people aged 60 years and older identified from randomly sampled villages in North and South India, 5853 (78%) attended an eye examination including fundus photography. Fundus images were graded according to the Wisconsin Age-Related Maculopathy Grading System. RESULTS Fundus images were ungradable in 1587 people, mainly because of cataract. People 80 years of age and older were less likely to attend the eye examination and more likely to have ungradable images. For ages 60 to 79 years, the percent prevalence (95% confidence interval [CI]) were late AMD 1.2 (0.8-1.5); and early AMD: grade 1 (soft distinct drusen or pigmentary irregularities), 39.3 (37.2-41.5); grade 2 (soft distinct drusen with pigmentary irregularities or soft indistinct or reticular drusen), 6.7 (5.8-7.6); and grade 3 (soft indistinct or reticular drusen with pigmentary irregularities), 0.2 (0.1-0.4). For ages 80 and older, the respective percent prevalence was: late AMD, 2.5 (0.4-4.7); and early AMD: grade 1, 43.1(35.7-50.6); grade 2, 8.1 (4.3-12.0); and grade 3, 0.5 (0-1.5). CONCLUSIONS The prevalence of early AMD (grades 1 and 2) is similar to that observed in Western populations, but grade 3 appears to be lower. The prevalence of late AMD is comparable to that in Western populations in the age group 60 to 79 years. It is likely that the prevalence in the 80 and older age group is underestimated.
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Nataraju SM, Chattopadhyay UK, Krishnan T. A study on the possibility of zoonotic infection in rotaviral diarrhoea among calves and buffalo calves in and around Kolkata, India. Eur Rev Med Pharmacol Sci 2009; 13:7-11. [PMID: 19364081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Group A and group B rotaviruses are important diarrhea causing agents among calves and buffalo calves. Epidemiological studies in Indian calves revealed the predominance of group A rotavirus strains with G6, G8, and G10 specificity and group B rotaviruses. A total of 95 fecal samples were collected from calves and buffalo calves affected with diarrhea from an unorganized cattle farm and two cattle markets in and around Kolkata, in the state of West Bengal of Eastern India. Rotaviruses were detected in 23.15% (22/95) samples by polyacrylamide gel electrophoresis. Of 22 rotavirus positive cases, 10.52% (10/95) samples showed characteristic group A rotavirus-like long type electropherotype (e-type) pattern and 4.21% (4/95) samples showed the characteristic group B rotavirus long type of electropherotype pattern and in 8.42% (8/95) the electropherotype pattern could not be recorded. Out of 22 positive samples, 7 samples of group A rotaviruses were subjected to reverse transcription-polymerase chain reaction, using VP7 generic and genotype [G type] specific primers and 2 of 7 isolates were identified as G10.
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Affiliation(s)
- S M Nataraju
- All India Institute of Hygiene & Public Health, Government of India, Kolkata, India
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Alam MM, Kobayashi N, Ishino M, Nagashima S, Paul SK, Chawla-Sarkar M, Krishnan T, Naik TN. Identical rearrangement of NSP3 genes found in three independently isolated virus clones derived from mixed infection and multiple passages of Rotaviruses. Arch Virol 2007; 153:555-9. [PMID: 18092125 DOI: 10.1007/s00705-007-0004-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Accepted: 11/07/2007] [Indexed: 10/22/2022]
Abstract
Three rotavirus variants with a rearranged RNA segment derived from the NSP3 gene were isolated in three independent experiments of coinfection and multiple passages of simian rotavirus strain SA11 and single-VP7-gene- or NSP1-gene-substitution reassortants having genetic background of SA11. Sequence analysis indicated that the three rearranged NSP3 genes had almost identical sequences and genomic structures organized by partial duplication of the open reading frame in a head-to-tail orientation following the termination codon. The junction site of the original NSP3 gene (first copy) and the duplicated portion (second copy) was identical among the three rearranged genes, while a direct repeat, i.e., a homologous sequence between the first copy and second template for duplication, typically located at the junction site, was not detected. However, short similar sequences were present at the end of the first copy and beginning of the second copy. These findings suggest that rearrangement of the NSP3 gene may occur at a certain preferential site which is related to sequence similarity between 3'-untranslated region and a region near the 5'-end of ORF.
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Affiliation(s)
- M M Alam
- Faculty of Veterinary Science, Bangladesh Agricultural University, Mymensingh, Bangladesh
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Samajdar S, Varghese V, Barman P, Ghosh S, Mitra U, Dutta P, Bhattacharya SK, Narasimham MV, Panda P, Krishnan T, Kobayashi N, Naik TN. Changing pattern of human group A rotaviruses: Emergence of G12 as an important pathogen among children in eastern India. J Clin Virol 2006; 36:183-8. [PMID: 16679056 DOI: 10.1016/j.jcv.2006.03.006] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2005] [Revised: 03/22/2006] [Accepted: 03/24/2006] [Indexed: 11/20/2022]
Abstract
BACKGROUND Rotavirus genotypes, G1-G4 and G9 are associated with childhood diarrhoea throughout the world. In our previous study, we detected G1, G2, G4 and three G12 strains from Kolkata, India. OBJECTIVES To study the prevalence of G- and P-genotypes of rotaviruses associated with dehydrating diarrhoea in children admitted to two leading hospitals in eastern India. STUDY DESIGN An active surveillance was conducted for elucidation of rotavirus infection in two leading hospitals in Kolkata, West Bengal and Berhampur (GM), Orissa, India, separated by 603km from January 2003 to April 2005. The rotaviruses were detected by RNA electrophoresis in polyacrylamide gels. G- and P-typing of the positive samples were accomplished by amplifying VP7 and VP4 genes by RT-PCR and genotyped by seminested multiplex PCR methods. Sequencing, sequence analysis and phylogenetic analysis of VP7 genes of G12 strains were carried out to understand the variations between the strains isolated from different parts of the world. RESULTS The genotypic distribution varied remarkably from our earlier study period (1998-2001) with G1 (53.8%) being the most predominant strain followed by G2 (22.5%), G12 (17.1%), G9 (2.1%) and not a single G3 or G4 isolate was detected separately. 35.2% samples exhibited mixed P-types followed by P[4] (31.7%), P[8] (21.8%) and P[6] (9.8%). The phylogenetic analysis of G12 strains revealed that the G12 strains detected from different parts of the world clustered into three different lineages. Though VP7 sequences of G12 strains isolated from Kolkata and Berhampur are conserved, their P-types were different. CONCLUSION During this study period we reported emergence of G12 strains as an important pathogen among children in eastern India, thus necessitating its inclusion in future polyvalent vaccine to control rotavirus diarrhoea.
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Affiliation(s)
- S Samajdar
- Division of Virology, National Institute of Cholera and Enteric Diseases, P-33, C. I. T. Road Scheme XM, Beliaghata, Kolkata 700010, West Bengal, India
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Barman P, Ghosh S, Samajdar S, Mitra U, Dutta P, Bhattacharya SK, Krishnan T, Kobayashi N, Naik TN. RT-PCR based diagnosis revealed importance of human group B rotavirus infection in childhood diarrhoea. J Clin Virol 2006; 36:222-7. [PMID: 16765641 DOI: 10.1016/j.jcv.2006.02.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2005] [Revised: 12/27/2005] [Accepted: 02/20/2006] [Indexed: 12/01/2022]
Abstract
BACKGROUND Human group B rotavirus was first identified as causative agent of a large outbreak of severe gastroenteritis affecting more than 1 million people, predominantly adults in China in 1982-1983. In spite of serological evidences for the presence of group B rotavirus in many countries of the world, the virus has been detected only from China, India and Bangladesh, where most of the cases were from adults. OBJECTIVES To ascertain the role of group B rotavirus as an aetiological agent of diarrhoea among children in Kolkata, India. STUDY DESIGN An active surveillance was conducted for rotavirus infection in children in a leading referral paediatric hospital and a few samples were also collected from adults of another hospital in Kolkata, India over a period of 3 years (2002-2004). After primary screening of rotaviruses by RNA electrophoresis in polyacrylamide gel, 200 of 412 samples negative by PAGE were screened by reverse transcription polymerase chain reaction for group B rotaviruses. The group B rotavirus positives samples were also confirmed by dot-blot hybridization. RESULT During the study period, we detected 37 (18.5%) sporadic cases of human group B rotavirus infection in children below 3 years of age of which 15 (7.5%) showed mixed infection with group A rotaviruses by RT-PCR. In dot-blot hybridization studies the RNA of all rotavirus positive samples hybridized with the nonisotopic psoralen-biotin labeled total RNA probe generated from a human group B rotavirus CAL-1 strain confirming the samples as group B rotaviruses. CONCLUSION The shift in age preference of group B rotavirus infection from adult to children and mixed infection of group B and group A rotaviruses reveals the importance of group B rotavirus as an etiological agent of childhood diarrhoea. Therefore, future vaccination strategy should include both group A and B rotaviruses to control rotavirus diarrhoea.
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Affiliation(s)
- P Barman
- Division of Virology, National Institute of Cholera and Enteric Diseases, P-33 CIT Road, Scheme XM, Beliaghata, Kolkata-700010, West Bengal, India
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Barman P, Ghosh S, Das S, Varghese V, Chaudhuri S, Sarkar S, Krishnan T, Bhattacharya SK, Chakrabarti A, Kobayashi N, Naik TN. Sequencing and sequence analysis of VP7 and NSP5 genes reveal emergence of a new genotype of bovine group B rotaviruses in India. J Clin Microbiol 2004; 42:2816-8. [PMID: 15184480 PMCID: PMC427839 DOI: 10.1128/jcm.42.6.2816-2818.2004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Three bovine group B rotavirus strains were detected from diarrheic calves during a surveillance study of rotaviral diarrhea in West Bengal, India. The sequence analysis of VP7 and NSP5 genes of these strains demonstrates a high degree of sequence variation from other group B rotavirus strains, indicating the emergence of a new genotype.
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Affiliation(s)
- P Barman
- Division of Virology, National Institute of Cholera and Enteric Diseases, P-33, CIT Road, Scheme XM, Beliaghata, Calcutta 700010, India
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Varghese V, Das S, Singh NB, Kojima K, Bhattacharya SK, Krishnan T, Kobayashi N, Naik TN. Molecular characterization of a human rotavirus reveals porcine characteristics in most of the genes including VP6 and NSP4. Arch Virol 2003; 149:155-72. [PMID: 14689281 DOI: 10.1007/s00705-003-0199-1] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2003] [Revised: 01/01/2003] [Accepted: 07/01/2003] [Indexed: 11/28/2022]
Abstract
Long electropherotype with Subgroup I specificity is a common feature of animal rotaviruses. In an epidemic of infantile gastroenteritis in Manipur, India, long but SG I strains predominated in the outbreak in the year 1987-88. One such strain isolated from that region, following the outbreak had G9P [19] specificity. As this is a rare combination, the gene sequences encoding VP4, VP6, VP7, NSP1, NSP2, NSP3, NSP4 and NSP5 of this strain were analyzed. All these genes except VP7 were closely related to porcine rotaviruses (95-99% identity at amino acid level) and clustered with the porcine strains in phylogenetic analysis. In addition, it had subgroup I nature and belonged to NSP4 genotype B which is characteristic of animal rotaviruses. This is the first report of a rotavirus with VP6 and NSP4, two crucial proteins thought to be involved in host range restriction and pathogenicity, were of porcine origin and caused diarrhoea in a human host. Among the genes of this strain sequenced so far, only VP7 had highest identity to human strains at amino acid level. This study suggests reassortment may be occurring between human and other animal strains and some of the reassortant viruses may be virulent to humans.
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Affiliation(s)
- V Varghese
- Division of Virology, National Institute of Cholera and Enteric Diseases, Calcutta, India
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Das S, Varghese V, Chaudhury S, Barman P, Mahapatra S, Kojima K, Bhattacharya SK, Krishnan T, Ratho RK, Chhotray GP, Phukan AC, Kobayashi N, Naik TN. Emergence of novel human group A rotavirus G12 strains in India. J Clin Microbiol 2003; 41:2760-2. [PMID: 12791925 PMCID: PMC156500 DOI: 10.1128/jcm.41.6.2760-2762.2003] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Three rare human G12 strains were detected from diarrheic clinical samples of children (<8 months of age) in Calcutta during a routine surveillance study of rotaviral diarrhea in India. The VP7 genes of G12 strains and their products showed maximum homology (97 to 99% at the nucleotide level and 98% at the amino acid level, respectively) with those of two recently reported G12 strains (from the United States and Thailand) but lesser homology with those of prototype G12 strain L26.
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Affiliation(s)
- Soma Das
- Division of Virology, National Institute of Cholera and Enteric Diseases, Calcutta 700010, India
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Das S, Sen A, Uma G, Varghese V, Chaudhuri S, Bhattacharya SK, Krishnan T, Dutta P, Dutta D, Bhattacharya MK, Mitra U, Kobayashi N, Naik TN. Genomic diversity of group A rotavirus strains infecting humans in eastern India. J Clin Microbiol 2002; 40:146-9. [PMID: 11773108 PMCID: PMC120101 DOI: 10.1128/jcm.40.1.146-149.2002] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Between 1998 and 2000, a total of 266 samples were found positive for group A rotaviruses by RNA electrophoresis. Samples were collected from patients admitted to two leading hospitals in Calcutta. Serotyping could be done only with 22% of the positive samples, leaving 78% untypeable. The G (VP7 genotypes) and P (VP4 genotypes) types were determined for 159 samples by reverse transcription and multiplex PCR. The predominant genotype was G1P[8] (20%), followed by G2P[4] (15%) and G4P[8] (6%). A number of uncommon genotypes, G1P[4] (4%), G2P[8] (2.5%), G2P[6] (0.6%), G4P[4] (2.5%), and G4P[6] (1.25%), were also detected during this study period. Twenty two percent of specimens showed mixed infections, 38 (24%) of the total samples remained untypeable for either VP7 or VP4, while only 4 (2.5%) of the samples were untypeable for both genes. Eleven specimens collected from Manipur were also genotyped and revealed a very high degree of genomic reassortment.
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Affiliation(s)
- Soma Das
- Division of Virology, National Institute of Cholera and Enteric Diseases, Kolkata, India
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Kobayashi N, Naik TN, Kusuhara Y, Krishnan T, Sen A, Bhattacharya SK, Taniguchi K, Alam MM, Urasawa T, Urasawa S. Sequence analysis of genes encoding structural and nonstructural proteins of a human group B rotavirus detected in Calcutta, India. J Med Virol 2001; 64:583-8. [PMID: 11468747 DOI: 10.1002/jmv.1089] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Nucleotide sequences of RNA segments encoding structural proteins(VP4, VP6, and VP7) and nonstructural proteins(NSP1 and NSP3) of a human group B rotavirus CAL-1, which was detected in Calcutta, India, were determined and their relatedness with cognate genes of other group B rotaviruses was analyzed. The CAL-1 genes showed generally high sequence identities (more than 90%) to those of human group B rotavirus, adult diarrheal rotavirus (ADRV) in China, while identities with bovine, murine, and ovine viruses were considerably lower (58-73%). Among RNA segments analyzed, sequence identity of the VP6 gene was relatively high compared with other gene segments. In the CAL-1 VP7 sequence, many characteristics were shared by ADRV, but not by other animal group B rotaviruses. In contrast, VP4 and NSP3 of CAL-1 were single amino acid and 23 amino acids longer than those of ADRV strain, respectively, due to differences of a few nucleotides. These findings suggested that human group B rotaviruses CAL-1 and ADRV might have originated from a common ancestral virus distinct from animal group B rotaviruses reported so far, while some notable sequence differences indicated the distinct nature of these viruses.
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Affiliation(s)
- N Kobayashi
- Department of Hygiene, Sapporo Medical University School of Medicine, S-1, W-17, Chuo-ku, Sapporo, Japan.
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Abstract
The largest reported rotavirus epidemic affected well over a million people in China during 1982-83 and was caused by the adult diarrhoea rotavirus (ADRV), a serogroup B rotavirus. However, ADRV has not been reported outside China since the last recorded small outbreak there in 1987. Here we present evidence that offers an explanation for the sudden appearance and disappearance of the epidemic ADRV strain.
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Sen A, Kobayashi N, Das S, Krishnan T, Bhattacharya SK, Urasawa S, Naik TN. Amplification of various genes of human group B rotavirus from stool specimens by RT-PCR. J Clin Virol 2000; 17:177-81. [PMID: 10996114 DOI: 10.1016/s1386-6532(00)00093-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The detection of the human group B rotavirus (HuGBR) CAL strain from India has given us an opportunity to design suitable primers for the detection of HuGBR since CAL is the second HuGBR detected until now, the Chinese Adult Diarrhoea Rotavirus (ADRV) being the first reported human pathogen belonging to this group of viruses. The primers described here may thus be used for the detection of human group B rotaviruses by reverse transcription-PCR (RT-PCR) in a diagnostic laboratory. OBJECTIVE To establish a set of primers suitable for the detection of various genes of human group B rotaviruses using a rapid RT-PCR assay. STUDY DESIGN Until recently, the Chinese ADRV strain was the only HuGBR strain that had been partially sequenced by cloning various viral genes using vector-specific primers. Consequently, there are very few reports in the literature describing primers that may be used for the detection of HuGBR viruses using RT-PCR in a clinical laboratory. The sequences of various genes from the ADRV strain that had been submitted to the nucleotide sequence database GenBank were analyzed in order to design several putative detection primer pairs for an RT-PCR assay. The rationale was to amplify the cognate genes from five isolates of the HuGBR CAL strain (CAL-1 to CAL-5) that have been detected to date from India. Primers that resulted in a specific product of the expected size from the CAL isolates were used to standardize a protocol for amplifying various genes of the CAL isolates under identical reaction conditions. RESULTS Out of several synthetic oligonucleotides designed, 12 were found to be satisfactory for the amplification of gene segments 4, 5, 6, 7, and 9 from the five CAL isolates and are presented here. A set of previously described primers that have been shown to be specific for human group B rotavirus gene segment 8 were also found to amplify the cognate gene from the CAL isolates. All the reactions were carried out using the same thermal cycling conditions. CONCLUSIONS The extreme virulence potential of HuGBR has been documented in several epidemics in China. Until recently, the Chinese ADRV strain was the only known HuGBr strain. As there have not been any reports of HuGBR infections outside China, there are no consensus nucleotide sequences available for HuGBR that may be used to validate primers for the detection of HuGBR. Here we report a set of 12 primer sequences that were designed from ADRV sequences and also found to amplify various genes from the different CAL isolates and hence may represent consensus primers suitable for the detection of HuGBR.
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Affiliation(s)
- A Sen
- Division of Virology, National Institute of Cholera and Enteric Diseases, P-33, C.I.T. Road, Scheme XM, Beliaghata, 700 010, Calcutta, India
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Krishnan T, Naik TN. Electronmicroscopic evidence of torovirus like particles in children with diarrhoea. Indian J Med Res 1997; 105:108-10. [PMID: 9119415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Pleomorphic virus-like particles approximately 90 nm in diameter with short fringe (7-9 nm long) were observed in faecal specimens of two diarrhoeic children in the course of routine screening of samples for viruses by electronmicroscopy. No other viral, bacterial or parasitic pathogens were detected in the same samples. Immune electronmicroscopic examination showed that these virus like particles were agglutinated by immunesera raised against Breda I and Breda II viruses of calves. This observation suggests that torovirus may be a new viral pathogen of humans.
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Affiliation(s)
- T Krishnan
- Division of Virology, National Institute of Cholera & Enteric Diseases, Calcutta
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