Triazole resistance in Aspergillus fumigatus isolated from a tomato production environment exposed to propiconazole

The emergence of azole-resistant Aspergillus fumigatus (ARAf) across the world is an important public health concern. We sought to determine if propiconazole, a demethylase inhibitor (DMI) fungicide, exerted a selective pressure for ARAf in a tomato production environment following multiple exposures to the fungicide. A tomato field trial was established in 2019 and propiconazole was applied weekly until harvest. Soil, leaf, and fruit (when present) samples were collected at baseline and after each propiconazole application. A. fumigatus isolates (n, 178) were recovered and 173 were tested for susceptibility to itraconazole, posaconazole, voriconazole, and propiconazole in accordance with CLSI M38 guidelines. All the isolates were susceptible to medical triazoles and the propiconazole MIC ranged from 0.25 to 8 mg/L. A linear regression model was fitted that showed no longitudinal increment in the log2-fold azole MIC of the isolates collected after each propiconazole exposure compared to the baseline isolates. AsperGenius real-time multiplex assay ruled out TR34/L98H and TR46/Y121F/T289A cyp51A resistance markers in these isolates. Sequencing of a subset of isolates (n, 46) demonstrated widespread presence of F46Y/M172V/E427K and F46Y/M172V/N248T/D255E/E427K cyp51A mutations previously associated with reduced susceptibility to triazoles.

IMPORTANCE

The agricultural use of azole fungicides to control plant diseases has been implicated as a major contributor to ARAf infections in humans. Our study did not reveal imposition of selection pressure for ARAf in a vegetable production system. However, more surveillance studies for ARAf in food crop production and other environments are warranted in understanding this public and One Health issue.

Health disparities associated with access to disability evaluations for toddlers in Early Head Start

BACKGROUND

The aim of this investigation was to examine developmental, sociodemographic and familial factors associated with parent reported access to an evaluation in an Early Head Start sample. Children with developmental disabilities often require evaluations to access early interventions, which can improve their long-term outcomes.

METHODS

This study (n = 191) examined how developmental, sociodemographic and parent factors at age 2 were associated with parent reporting the child being evaluated by age 3. Two logistic regression analyses were conducted. The first model included children at age 2 with scores at least in the monitoring zone of developmental risk, and the second model included children with high developmental risk.

RESULTS

The first model found that children in the monitoring zone of developmental risk were more likely to be evaluated per parent report if they were born preterm, male, with increased behaviour problems, higher economic risk, increased maternal education, increased parental depressive symptoms and in urban areas and less likely if they were of Black or Hispanic/Latino ethnicity, had no health insurance or more home disorganisation. The second model found that children with high developmental risk were less likely to be evaluated per parent report if they were female, of Hispanic/Latino ethnicity, had better language skills and increased home disorganisation and more likely if their parents reported increased depressive symptoms or less economic risk.

CONCLUSIONS

This study highlights barriers associated with access to developmental and disability evaluations for children in at-risk families. Health disparities are negatively associated with children's access to evaluations, even when supported by systems like Early Head Start.

P294 A descriptive study of Trichosporon fungemia cases from tertiary care center from north India

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

 

Objective

Incidence of fungaemia with Trichosporon spp is increasing especially in immunocompromised patients. High mortality of 60% is associated with T. fungemia. Trichosporon species are intrinsically resistant to echinocandins, exhibit high MICs to amphotericin B, and have a propensity to form biofilm necessitating accurate and timely diagnosis. Cases of Trichosporon fungemia are often misdiagnosed and under-reported owing to the difficulties in diagnosis. Here, we report the clinical presentation and outcome of Trichosporon fungemia cases at the tertiary care center from north India.

Methods

This is a descriptive study conducted at the Department of Medical Microbiology, PGIMER, Chandigarh, India. A total of 8 patients who had fungemia due to Trichosporon spp. were included in the study. Trichosporon spp. was identified by matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) with an updated database. Antifungal susceptibility was done using microbroth dilution method recommended by the Clinical and Laboratory Standards Institute (CLSI). Beta-D-glucan (BDG) assay was performed as per the manufacturer's recommendation. Demographic and clinical data along with treatment outcomes of all the patients were noted from medical records.

Results

The average age of presentation of patients diagnosed with Trichosporon fungemia was 44 years and the male to female ratio was 5:3. The underlying conditions included necrotizing pancreatitis (n = 2), infective endocarditis (n = 2) and renal transplant (n = 1) The other risk factors included the use of broad-spectrum antibiotics (n = 7), a central venous catheter (n = 4), and prior surgical procedures (n = 3) BDG was tested in 5 patients and 4 patients had a positive value of >80 pg/ml. A total of 5/8 patients received antifungal treatment. Six patients clinically improved and were discharged while two patients died of refractory shock despite treatment with amphotericin B. Minimum inhibitory concentration of Trichosporon isolates was (range): amphotericin B 0.5-16 μg/ml, fluconazole 0.12-32 μg/ml, voriconazole 0.03-1 μg/ml, itraconazole 0.03-1 μg/ml, and posaconazole 0.03-0.5 μg/ml.

Conclusion

Trichosporon spp. is an opportunistic pathogen causing fungemia in immunocompromised patients. Most of the patients in our study were immunocompetent except for one post-transplant patient. BDG helps in the diagnosis of this infection. This study highlights the need to accurately diagnose Trichosporon infections and perform antifungal susceptibility testing for guiding appropriate management and reducing mortality.

P019 A 5-year study on prevalence and molecular determinants of fluconazole -resistance in C. parapsilosis spp. complex

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM

 

Objectives

Candida parapsilosis species complex is among the leading agents of invasive candidiasis, notably in neonates and transplant recipients. It exhibits intrinsically reduced susceptibility to echinocandins with increasing reports of acquired resistance to fluconazole from many centers. We evaluated antifungal susceptibility and molecular mechanisms of azole resistance in C. parapsilosis species complex, isolated in the last 5 years.

Methods

The isolates of C. parapsilosis species complex causing infections over a 5-year period (2017-2021) were included in the present study. Species identification of the isolates was performed using MALDI-TOF MS and sequencing of Internal Transcribed Spacer, ITS1. Antifungal susceptibility testing was performed by CLSI broth microdilution in accordance with standard operating procedure described in M27-A3 document. For amphotericin B, itraconazole, and posaconazole, the interpretation of the susceptibility data was done using epidemiological cut-off values provided in CLSI M59 document. The entire coding sequence of ERG11 gene in fluconazole-resistant isolates was PCR-amplified in four overlapping fragments. The sequencing of each fragment was performed by Sanger's bidirectional sequencing method using BigDye termination ready-reaction kit, 3.1. The sequences were assembled and proofread using Seqman software (Laser DNA, Applied Biosystems). The nucleotide sequences were translated into ERG11 protein using nucleotide translation tool, https://web.expasy.org/translate. Multiple sequence alignment with C. parapsilosis reference sequence was performed using BioEdit Sequence Alignment editor.

Results

A total of 580 C. parapsilosis complex clinical isolates were evaluated for antifungal susceptibility. C. parapsilosis sensu stricto, C. orthopsilosis, and C. metapsilosis accounted for 457 (78.8%), 86 (14.8%), and 37 (6.3%), respectively. The isolation distribution revealed an increasing temporal trend over the years. A total of 40 (6.9%) isolates of the species complex exhibited reduced susceptibility to fluconazole, of which 23 were resistant (MIC ≥8 μg/ml) while 17 isolates exhibited susceptible dose-dependent phenotype (MIC, 4 μg/ml). Only two of the fluconazole-resistant isolates were cross-resistant to voriconazole. The resistant isolates were predominantly from adult patients [Median age, IQR; 47 (16-70) years.] The crude mortality rate in resistant cases was 56.5% (13/23). Interestingly, all the fluconazole-resistant isolates were C. parapsilosis sensu stricto, while C. orthopsilosis and C. metapsilosis isolates were susceptible. The fluconazole-resistance rate in the species complex and within the C. parapsilosis sensu stricto was 3.9% (23/599), 4.9% (23/466), respectively. For amphotericin B, the proportion of non-wildtype isolates was 17% (70/411), 25% (9/36), and 0% in C. parapsilosis sensu stricto, C. metapsilosis, and C. orthopsilosis, respectively. For itraconazole, the non-wildtype percentage was 1.7% (7/407), 1.35% (1/74), and 0% in C. parapsilosis sensu stricto, C. orthopsilosis, and C. metapsilosis, respectively. For posaconazole, the non-wildtype percentage was 3.8% (16/413), 2.7% (2/74), and 0% in parapsilosis sensu stricto, C. orthopsilosis and C. metapsilosis, respectively. Sequencing analysis of ERG11 gene revealed two homozygous mutations, Y132F mutation, and R398I in fluconazole-resistant isolates.

Conclusions

C. parapsilosis species complex infections are on the rise. The increasing azole resistance in C. parapsilosis with higher mortality is a great concern in clinical settings.

P010 Evaluation of antifungal efficacy of two novel cyclic lipopeptides of the class Bacillomycin from Bacillus subtilis RLID 12.1 in a murine model of invasive candidiasis

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM

 

Objective

To evaluate the in vivo efficacy of HPLC–purified antifungal lipopeptides (AF4 and AF5) in a murine model of disseminated candidiasis.

Methods

C. albicans AMR16294 isolate was used for all the in vivo experiments. A total of 6-week-old pathogen-free, female BALB/c mice, weighing 20-25 g were used for all animal experiments. For Kaplan-Mier analysis, mice were rendered neutropenic by a loading dose of 200 mg/kg cyclophosphamide three days prior (D-3) to infection and 150 mg/kg (D + 1) maintenance dose on day 1 post-infection (D + 1). A total of 60 mice were randomized into 8 different groups with 5 or 6 animals in each group. Animals were infected with 100μL of ∼ 1 × 10⁵ blastospores (corresponding to LD90) via the lateral tail vein. AF4 and AF5 were formulated in sterile PBS and administered intraperitoneally at doses of 5 mg/kg and 10 mg/kg body weight and compared with a clinically-relevant human equivalent dose of caspofungin. AF4, AF5, caspofungin, or vehicle were administered at 1 h and 24 h post-infection. The survival of the mice was monitored for 14 days post-infection. For organ fungal-burden assessment, mice from each group were euthanized by CO₂ inhalation, and the organs were aseptically removed, homogenized, and cultured on SDA.

Results

Both the doses of AF4 significantly reduced the mortality of mice compared to vehicle-treated mice. The survival over 2 weeks in 5 mg/kg, 10 mg/kg, and caspofungin arms were similar and no death was reported in the three groups (P <.01). In contrast, the mortality in-vehicle- administered group was 80% with a median survival of 8 days. A similar survival benefit was observed in AF5-treated mice. While the median survival in the vehicle-treated arm was 5 days, the 2-week survival in 5 mg/kg and 10 mg/kg arms was 80%-100%, comparable to that in the caspofungin arm (P <.01) (Fig. 1).

The median CFU/g kidney tissue in 5 mg/kg arm of AF4 was 1.3 × 10⁴ equivalent to a 4-log reduction compared to the vehicle arm (3.8 × 10⁸ CFU/g kidney, P <.0001). The in vivo efficacy was higher at a higher dose with the kidney homogenates of 10 mg/kg arm yielding sterile cultures comparable to that of CAS arm (Fig. 2). Similar organ fungal-burden reduction was noted in heart and splenic tissues with a median cfu/g tissue of 1.3 × 10⁴ in 10 mg/kg, while CAS arms yielded sterile cultures.

In AF5 treated groups, the median cfu/g kidney tissue in 5 mg/kg arm was 1.3 × 10⁴, however, the heart and splenic tissue homogenates yielded less fungal burden with median (q2) cfu/g as 0, while q3 of 6.7 × 10³and 1.3 × 10⁴, respectively (Fig. 2).

Conclusion

Both the antifungal compounds demonstrated a remarkable in vivo efficacy against C. albicans with a significant improvement in survival and a reduction in the organ-fungal burden.

P017 Echinocandin resistance mechanism in Candida tropicalis and Candida glabrata

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM

 

Objective

Candida tropicalis and Candida glabrata account for 41.6% and 7.08% of total Candidaemia cases in India. Echinocandins are the first-line treatment option for these infections. Resistance to Echinocandins is rare with Candida sp. However, in recent years, has been noted across many centers. We determined the mechanism of echinocandin resistance in C. tropicalis and C. glabrata.

Methods

C. tropicalis and C. glabrata isolated from Candidaemia patients over a period of 3 years (August 2016-July 2019), identified by MALDI-TOF-MS were used in this study. Antifungal susceptibility testing was done following CLSI broth microdilution reference method (M 27A). FKS1 gene was sequenced using species-specific primers for the presence of any mutation. To determine any changes in the cell wall chitin and glucan contents, expression fold changes of chitin synthase (CHS1, CHS2, and CHS3), and glucan synthase genes upon caspofungin treatment were determined using real-time qPCR. These findings were correlated with cell wall chitin and glucan content determined by flowcytometry.

Results

A total of 3558 Candida species were isolated from patients of all age groups at our hospital. C. tropicalis was the predominant agent (34%), while the prevalence of C. glabrata was 6%. A total of 17 (8.5%) C. glabrata and 3 (0.25%) C. tropicalis exhibited reduced susceptibility to echinocandins. All these isolates carried a wild-type FKS genes.

In C. tropicalis, inducible expression of Chs1, Chs2 and Chs3 genes were comparable among susceptible and resistant isolates1.8 (0.4-2.8) vs. 2.5 (0.9-6.6), P = .247); [0.7 (0.3-1.8) vs. 0.7 (0.2-1.6), P = .793]; [1.3 (0.14-4.8) vs. 1.1(0.48-1.7), P = .522], respectively. In concordance with gene expression, there was no significant difference in cell wall chitin contents among resistant and susceptible [14.37 (6.5-24.8) vs 16.28 (6.0-24.7), P = .114] C. tropicalis isolates. In contrast in resistant isolates of C. glabrata, caspofungin treatment resulted in significantly higher induction of chitin synthase genes compared to susceptible isolates; Chs1 [2.34 (0.24-9.71) vs. 1.56 (0.55-4.5) (P = .007)], CHS2 [1.59 (0.33-8.0) vs. (2.3 (0.69-6.15), P = .0006], and CHS3 gene [3.8 (0.13-12.73) vs. 1.9 (0.56-7.16), P <.0001]. Flowcytometric data in terms of chitin content, correlated well with expression changes as staining index was significantly higher in resistant compared to susceptible isolates [320 (198-535) vs. 164 (5.34-254.10) P = .0001]. Glucan synthase expression was comparable in susceptible and resistant isolates of C. tropicalis [3.47 (1.57-7.63) vs. 4.41 (0.41-17.51), (P = .518)]. However, glucan synthase gene expression was found significantly increased in resistant C. glabrata isolates compared to susceptible isolates; 3.10 (1.02-16.45) vs. 1.61 (0.13-7.67), P <.001.

Conclusion

We evaluated the role of cell wall components in echinocandin resistance in isolates with reduced susceptibility to echinocandins but lacking an FKS1 mutation. While chitin was induced at higher levels in C. glabrata, a similar finding was not observed in C. tropicalis. This warrants further studies to elucidate the role of fungal cell wall polymers in resistance.

P373 Does biofilm forming capacity of Candida tropicalis vary with echinocandin susceptibility?

Poster session 3, September 23, 2022, 12:30 PM - 1:30 PM

 

Objectives

Candida tropicalis is a common cause of nosocomial candidemia and candiduria. The role of biofilm formation in virulence and antimicrobial resistance in C. tropicalis remains under-investigated. We aimed to evaluate the biofilm-forming capacity of C. tropicalis isolates exhibiting resistance, borderline resistance, and sensitivity to echinocandins.

Methods

The echinocandin resistant, borderline resistant, and susceptible isolates of C. tropicalis were collected based on their minimum inhibitory concentration (MIC) values according to Clinical and Laboratory Standard Institute (CLSI) broth microdilution guidelines. The isolates were subjected to FKS1 gene sequencing. To estimate biofilm production, echinocandin resistant (n = 2), borderline resistant (n = 5), and susceptible isolates (n = 3) were seeded at the cell concentration of 1 × 10⁶ cells/mL in RPMI-1640 with 0.165 M MOPS in polystyrene 96-well microtiter plates and incubated for 24 and 48 h at 37°C. The biofilm was quantified by crystal violet/safranin-based spectrophotometric method and XTT (2,3-Bis-(2-Methoxy-4-Nitro-5-Sulfophenyl)-2H-Tetrazolium-5-Carboxanilide) reduction assay. Statistical analysis was performed using one-way ANOVA with Bonferroni's post-hoc test for multiple comparisons among the groups.

Results

FKS1 sequencing analysis revealed S654P mutation in HS1 in both resistant isolates while isolates exhibiting borderline MIC to echinocandins carried wild-type FKS1 gene. Biofilm formation in borderline echinocandin-resistant C. tropicalis isolates was significantly (P <.005) higher compared with resistant and susceptible isolates. However, no significant difference in biofilm formation was noted among resistant and susceptible isolates.

Conclusion

This study suggests differential biofilm-formation capacity among C. tropicalis isolates with reduced susceptibility to echinocandins. However, this warrants further studies before any definitive inference can be made.

Is there an association between zinc and COVID-19-associated mucormycosis? Results of an experimental and clinical study

BACKGROUND

The enormous increase in COVID-19-associated mucormycosis (CAM) in India lacks an explanation. Zinc supplementation during COVID-19 management is speculated as a contributor to mucormycosis. We conducted an experimental and clinical study to explore the association of zinc and mucormycosis.

METHODS

We inoculated pure isolates of Rhizopus arrhizus obtained from subjects with CAM on dichloran rose Bengal chloramphenicol (DRBC) agar enriched with (three different concentrations) and without zinc. At 24 h, we counted the viable colonies and measured the dry weight of colonies at 24, 48 and 72 h. We also compared the clinical features and serum zinc levels in 29 CAM cases and 28 COVID-19 subjects without mucormycosis (controls).

RESULTS

We tested eight isolates of R arrhizus and noted a visible increase in growth in zinc-enriched media. A viable count percentage showed a significantly increased growth in four of the eight isolates in zinc-augmented DRBC agar. A time- and concentration-dependent increase in the mean fungal biomass with zinc was observed in all three isolates tested. We enrolled 29 cases of CAM and 28 controls. The mean serum zinc concentration was below the reference range in all the subjects and was not significantly different between the cases and controls.

CONCLUSIONS

Half of the R arrhizus isolates grew better with zinc enrichment in vitro. However, our study does not conclusively support the hypothesis that zinc supplementation contributed to the pathogenesis of mucormycosis. More data, both in vitro and in vivo, may resolve the role of zinc in the pathogenesis of CAM.

Invasive Aspergillosis by Aspergillus flavus: Epidemiology, Diagnosis, Antifungal Resistance, and Management

Aspergillus flavus is the second most common etiological agent of invasive aspergillosis (IA) after A. fumigatus. However, most literature describes IA in relation to A. fumigatus or together with other Aspergillus species. Certain differences exist in IA caused by A. flavus and A. fumigatus and studies on A. flavus infections are increasing. Hence, we performed a comprehensive updated review on IA due to A. flavus. A. flavus is the cause of a broad spectrum of human diseases predominantly in Asia, the Middle East, and Africa possibly due to its ability to survive better in hot and arid climatic conditions compared to other Aspergillus spp. Worldwide, ~10% of cases of bronchopulmonary aspergillosis are caused by A. flavus. Outbreaks have usually been associated with construction activities as invasive pulmonary aspergillosis in immunocompromised patients and cutaneous, subcutaneous, and mucosal forms in immunocompetent individuals. Multilocus microsatellite typing is well standardized to differentiate A. flavus isolates into different clades. A. flavus is intrinsically resistant to polyenes. In contrast to A. fumigatus, triazole resistance infrequently occurs in A. flavus and is associated with mutations in the cyp51C gene. Overexpression of efflux pumps in non-wildtype strains lacking mutations in the cyp51 gene can also lead to high voriconazole minimum inhibitory concentrations. Voriconazole remains the drug of choice for treatment, and amphotericin B should be avoided. Primary therapy with echinocandins is not the first choice but the combination with voriconazole or as monotherapy may be used when the azoles and amphotericin B are contraindicated.

Magnitude of Voriconazole Resistance in Clinical and Environmental Isolates of Aspergillus flavus and Investigation into the Role of Multidrug Efflux Pumps

The magnitude of azole resistance in Aspergillus flavus and its underlying mechanism is obscure. We evaluated the frequency of azole resistance in a collection of clinical (n = 121) and environmental isolates (n = 68) of A. flavus by the broth microdilution method. Six (5%) clinical isolates displayed voriconazole MIC greater than the epidemiological cutoff value. Two of these isolates with non-wild-type MIC were isolated from same patient and were genetically distinct, which was confirmed by amplified fragment length polymorphism analysis. Mutations associated with azole resistance were not present in the lanosterol 14-α demethylase coding genes (cyp51A, cyp51B, and cyp51C). Basal and voriconazole-induced expression of cyp51A homologs and various efflux pump genes was analyzed in three each of non-wild-type and wild-type isolates. All of the efflux pump genes screened showed low basal expression irrespective of the azole susceptibility of the isolate. However, the non-wild-type isolates demonstrated heterogeneous overexpression of many efflux pumps and the target enzyme coding genes in response to induction with voriconazole (1 μg/ml). The most distinctive observation was approximately 8- to 9-fold voriconazole-induced overexpression of an ortholog of the Candida albicans ATP binding cassette (ABC) multidrug efflux transporter, Cdr1, in two non-wild-type isolates compared to those in the reference strain A. flavus ATCC 204304 and other wild-type strains. Although the dominant marker of azole resistance in A. flavus is still elusive, the current study proposes the possible role of multidrug efflux pumps, especially that of Cdr1B overexpression, in contributing azole resistance in A. flavus.

Mutation in the Squalene Epoxidase Gene of Trichophyton interdigitale and Trichophyton rubrum Associated with Allylamine Resistance

Dermatophytosis, the commonest superficial fungal infection, has gained recent attention due to its change of epidemiology and treatment failures. Despite the availability of several agents effective against dermatophytes, the incidences of chronic infection, reinfection, and treatment failures are on the rise. Trichophyton rubrum and Trichophyton interdigitale are the two species most frequently identified among clinical isolates in India. Consecutive patients (n = 195) with suspected dermatophytosis during the second half of 2014 were included in this study. Patients were categorized into relapse and new cases according to standard definitions. Antifungal susceptibility testing of the isolated Trichophyton species (n = 127) was carried out with 12 antifungal agents: fluconazole, voriconazole, itraconazole, ketoconazole, sertaconazole, clotrimazole, terbinafine, naftifine, amorolfine, ciclopirox olamine, griseofulvin, and luliconazole. The squalene epoxidase gene was evaluated for mutation (if any) in 15 T. interdigitale and 5 T. rubrum isolates exhibiting high MICs for terbinafine. A T1189C mutation was observed in four T. interdigitale and two T. rubrum isolates. This transition leads to the change of phenylalanine to leucine in the 397th position of the squalene epoxidase enzyme. In homology modeling the mutant residue was smaller than the wild type and positioned in the dominant site of squalene epoxidase during drug interaction, which may lead to a failure to block the ergosterol biosynthesis pathway by the antifungal drug.

Candida auris candidaemia in Indian ICUs: analysis of risk factors

Objectives

To identify the risk factors associated with Candida auris candidaemia, as this fungus now poses a global threat.

Methods

We performed a subgroup analysis of a previously reported study of 27 Indian ICUs. The clinical data of candidaemia cases due to C. auris and other Candida species were compared to determine significant risk factors associated with C. auris infection.

Results

Of the 1400 candidaemia cases reported earlier, 74 (5.3%) from 19 of 27 ICUs were due to C. auris . The duration of ICU stay prior to candidaemia diagnosis was significantly longer in patients with C. auris candidaemia (median 25, IQR 12-45 days) compared with the non- auris group (median 15, IQR 9-28, P  <   0.001). Based on logistic regression modelling, admission to north Indian ICUs [OR 2.1 (1.2-3.8); P  =   0.012], public-sector hospital [OR 2.2 (1.2-3.9); P  =   0.006], underlying respiratory illness [OR 2.1 (1.3-3.6); P  =   0.002], vascular surgery [OR 2.3 (1.00-5.36); P  =   0.048], prior antifungal exposure [OR 2.8 (1.6-4.8); P  <   0.001] and low APACHE II score [OR 0.8 (0.8-0.9); P  =   0.007] were significantly associated with C. auris candidaemia. The majority (45/51, 88.2%) of the isolates were clonal. A considerable number of isolates were resistant to fluconazole ( n  =   43, 58.1%), amphotericin B ( n  =   10, 13.5%) and caspofungin ( n  =   7, 9.5%).

Conclusions

Although C. auris infection has been observed across India, the number of cases is higher in public-sector hospitals in the north of the country. Longer stay in ICU, underlying respiratory illness, vascular surgery, medical intervention and antifungal exposure are the major risk factors for acquiring C. auris infection even among patients showing lower levels of morbidity.

Cracked and broken teeth--definitions, differential diagnosis and treatment

Cracked and broken teeth present a diagnostic dilemma to the dentist and the sooner a correct diagnosis is made the greater are the chances to save the tooth. As the location, direction and size of the crack or fracture dictates the choice of treatment, it is important to first define the types of cracks and fractures in the coronal and radicular tooth structure. Cracks and fractures can be classified as follows: 1. craze lines 2. fractured cusps 3. cracked teeth 4. split teeth 5. vertical root fractures. The vertical root fracture has been described recently in two articles in this publication, and therefore will not be discussed here. Diagnosis of a cracked tooth is not always initially obvious. The patient's response to clinical testing is the primary diagnostic tool along with the dental history provided by the patient. Radiographs are secondary in making a diagnosis. Clinical aids for reproducing the patient's symptoms such as occlusal bite devices, observing occlusal wear facets and the application of cold water to one tooth at a time may isolate the offending tooth. In situations where an irreversible pulpitis is diagnosed, endodontic treatment is indicated. In the case of a questionable diagnosis, or one in which a potential reversible pulpitis is made, a provisional restoration can be placed for an unspecified time as a diagnostic aid. If endodontic therapy were indicated, consultation with the patient as to the compromised prognosis and the alternatives to endodontic treatment is essential.

Ovarian remnant excision necessitating resection of the anterior hypogastric system

Ovarian remnant syndrome is an unfortunate complication after bilateral oophorectomy. A case of an ovarian remnant involving the hypogastric vasculature is presented. Successful surgical management required resection of the involved hypogastric artery.

Does combination therapy with a calcium channel blocker and an ACE inhibitor have additive effects on blood pressure reduction?

Reports in the medical literature have suggested that the effects on blood pressure (BP) of calcium channel blockers (CCBs) and angiotensin-converting enzyme (ACE) inhibitors are additive. Most reports have provided neither a definition of 'additive' nor the necessary information to determine whether the effects are additive. In this review of the medical literature, the effects of combination therapy were defined as additive if the sum of the mean reductions in BP following monotherapy with a CCB and an ACE inhibitor was not significantly different from the mean reduction in BP of combination therapy. The review generally showed that combination therapy is more effective than treatment with either monotherapy alone, based on mean decreases in either diastolic or systolic BP. The studies provided no clear evidence that the effects of combination therapy were either additive or less than additive.

A molecular anatomical analysis of mosaic trisomy 16

A one-month-old child presenting with an aortic coarctation was found to have a left single transverse palmar crease and proportionate growth delay on physical examination, prompting a peripheral blood chromosome analysis. This showed a mosaic trisomy of chromosome 16, subsequently observed to decrease with the passage of time. As her phenotype was relatively benign, further analysis was performed to define more precisely the extent of her mosaicism given the supposedly lethal nature of the aneuploid cell line. Fluorescence in situ hybridisation and CA repeat polymorphism studies demonstrated the aneuploidy in multiple tissues, including the structurally affected aorta. Molecular analysis showed both maternal chromosomes 16 to be present in the trisomic cells, but maternal heterodisomy was not present in the diploid cells. Given the increasing number of individuals described with aneuploid mosaicism, we suggest that the study of multiple tissues is a necessary approach, the eventual goal being the appreciation of the relationship between the characteristics of a somatic mosaicism and the phenotype it imparts.

Randomized controlled trial of clemastine fumarate for treatment of experimental rhinovirus colds

We used a rhinovirus challenge model to test the therapeutic efficacy of clemastine fumarate for reducing sneezing and nasal secretion in a double-blind, randomized clinical trial. Clemastine fumarate (1.34 mg) or placebo was administered at 8 A.M. and 8 P.M. for 4 days, beginning 24 hours, 36 hours, 48 hours, and 60 hours after viral challenge. Infected evaluable subjects who received clemastine (n = 75) had reduced sneeze-severity scores compared with those who received placebo (n = 75) on illness days 2 (0.3 vs. 0.5; P = .003), 3 (0.4 vs. 0.8; P = .0003), 4 (0.3 vs. 0.5; P = .025), and 5 (0.1 vs. 0.3; P = .03); sneeze counts for infected evaluable subjects (vs. counts for those who received placebo) were reduced on illness days 2 (1.5 vs. 3.1; P = .01), 3 (1.7 vs. 5.6; P = .0001), and 5 (0.7 vs. 1.9; P = .03). Infected evaluable subjects who received treatment had reduced rhinorrhea scores (compared with those who received placebo) on illness days 2 (0.7 vs. 1.0; P = .04) and 3 (0.6 vs. 0.9; P = .04) and had reduced nasal secretion weights on day 3 (3.6 g vs. 6.3 g; P = .03). Over 4 days of treatment, mean sneeze scores for infected evaluable subjects (vs. scores for those who received placebo) were reduced by 50%, mean sneeze counts by 57%, mean rhinorrhea scores by 27%, and mean nasal secretion weights by 35%. Other cold symptoms were unaffected by treatment. Treatment with clemastine was associated with an excess incidence of dry mouth (6%), dry nose (19%), and dry throat (17%).

Freud, Sellin and the death of Moses

An examination of the actual arguments put forth by the Biblical scholar Ernst Sellin regarding the hypothesis of the murder of Moses, upon which Freud is supposed to have based his own analysis in 'Moses and Monotheism', reveals that Sellin's theory, which differs widely from Freud's, contains many features which ought perhaps to have appealed to Freud, most notably, the depiction of the deed as a graphic scene of oedipal violence and primal scene imagery. In exploring why Freud might have chosen not to use Sellin's reconstruction of the death of Moses, the author proposes that his version allowed, as Sellin's did not, for an analogy between Israelite history and the typical course of an obsessive-compulsive neurosis; and that the value of the latter lay in its providing grounds for hope that psychoanalysis itself might survive a period of 'latency' in the wake of Freud's impending death. In addition to speculating about Freud's motives, the author seeks to give a good exposition of Sellin's ideas, which despite their importance to Freud's thought remain relatively unknown or misunderstood in psychoanalytic circles.

Sudden death as sole symptom of coronary arteritis

A 33-year old man suddenly dropped dead during a military march. He had complained of non-specific thoracoabdominal symptoms, pain and fatigue for a year before his death. Autopsy showed coronary polyarteritis nodosa of the left main coronary artery. This patient seems to be only the second case with isolated polyarteritis nodosa leading to sudden death reported in the literature.

Neuro-osteoarthropathy (Charcot's joint) in diabetes mellitus following revascularization surgery. Three case reports and a review of the literature

The initial primary defect in the development of neuro-osteoarthropathy is neuropathy. Our case reports and a review of the literature strongly implicate a neurally initiated vascular reflex leading to increased blood flow. This may play a pivotal role in the development of Charcot's joint in the neuropathic limb. Mechanical trauma in an insensitive foot is contributory, but it is probably a secondary mechanism.