Comparison of Clinical Profile and Outcomes of Japanese Encephalitis and Acute Encephalitis Syndrome among Rural Children

The study compared the clinical profile and outcomes of Japanese encephalitis (JE) and acute encephalitis syndrome (AES) in children. Fifty-six consecutive children with symptoms fulfilling the WHO clinical case definition of AES from June 2018 to June 2020 were included in the study. All patients who tested positive for either serum or cerebrospinal fluid (CSF) anti-JE-IgM antibodies were JE patients (n = 24) and compared with non-JE AES cases (n = 32). Fever, seizures, and altered sensorium were the most common presenting symptoms. Low GCS, status epilepticus, meningeal irritation, raised CSF protein, and INR > 1.5 of JE children showed significant association with mortality (p value < 0.05), whereas only low GCS showed significant association in non-JE AES cases. The JE-specific mortality rate was 29%, which was less than the mortality rate of non-JE AES children at 41%. Both JE and non-JE AES children had a similar clinical profile, but only the JE children's poor clinical and laboratory parameters were associated with adverse outcomes.

Infectious Causes of Acute Encephalitis Syndrome in India - Decadal Change and the Way Forward

The diagnosis and management of encephalitis were previously largely based on clinical grounds and minimal laboratory investigations. Japanese encephalitis (JE) gets considered as the probable diagnosis in most encephalitis cases. However, reports of JE in adults and the elderly are increasing after the JE vaccine introduction among children in 2006. The Nipah virus (NiV) emerged in 2002 and continues to afflict humans in new geographic areas. Many other infections cause encephalitis, including Chandipura, chikungunya, dengue, and West Nile. Significant advances in diagnostic testing like multiplex testing panels and metagenomic approaches along with sequencing have helped in the detection of new etiologies. Recent years have witnessed an increase in climate-sensitive zoonotic diseases with encephalitis. This highlights the importance of the One Health approach in studying the impact of climate change-associated infectious diseases on human health. The government of India's efforts to develop health research infrastructure would help future responses to emerging infectious disease epidemics.

Seminal plasma testis expressed sequence (TEX)-101 as a biomarker for the qualitative assessment of male factor infertility: A case-control study

OBJECTIVE

The study was conducted to assess the role of seminal plasma Testis Expressed Sequence (TEX)-101 as a biomarker of male infertility.

STUDY DESIGN

The study was conducted on 180 men (20-50 years) with 90 having abnormal semen reports as cases and 90 with normal reports as controls in a rural tertiary care center in Southern India over two years. After the enrolment of cases and control, semen samples were cryopreserved till the desired sample size was achieved and a biochemical test for TEX-101 was run using Human Testis-expressed Protein 101 ELISA Kit. The results of TEX-101 were compared between cases and controls and correlated with various semen parameters. Statistical analysis was done using SPSS software version 22.0, a p-value < 0.05 was considered statistically significant.

RESULTS

Mean ± SD age of all participants was 29.94 ± 4.91 years. Of 90 cases, 48.9% had asthenospermia, 24.4% oligoasthenospermia, 15.6% oligospermia, 11.1% azoospermia. A statistically significant difference was observed in mean values of seminal plasma TEX-101 between cases (1.45 ± 0.08 ng/mL) and controls (2.26 ± 0.18 ng/mL), p = 0.001. A significant correlation (p = 0.001) was found between seminal TEX-101, semen volume, sperm concentration, progressive motility, and morphology. The area under the Receiver Operating Characteristic curve of TEX-101 between cases and controls was 1.00 (p = 0.001), indicating TEX-101 as a potential biomarker for distinguishing men with abnormal semen parameters from those with normal semen parameters. At a cut-off value of 1.84 ng/mL, seminal plasma TEX-101 had a sensitivity, specificity, and negative and positive predictive values of 100% for male infertility prediction.

CONCLUSION

Seminal TEX-101 is a potential seminal biomarker and can be used in the qualitative assessment of male factor infertility.

Scrub Typhus and Dengue Co-infection in an Adolescent Girl: A Diagnostic Challenge

Scrub typhus and dengue fever are common infectious diseases in tropical regions, and both have overlapping clinico-epidemiological and laboratory features, which often pose a diagnostic challenge. This case report discusses a 15-year-old girl from the Indian subcontinent who presented with acute undifferentiated febrile illness (AUFI) without typical features of any of the common tropical infections. She was diagnosed with co-infection of scrub typhus and dengue fever using laboratory tests with good diagnostic accuracy. The patient was managed on an ambulatory basis, treated with oral doxycycline, and showed symptomatic improvement within 48 hours. Co-infections in endemic areas present a significant diagnostic and therapeutic challenge. This case report highlights the importance of considering co-infections in the differential diagnosis of AUFI, especially during the post-monsoon period, and the use of highly sensitive and specific tests for the diagnosis of co-infections.

Incidence of Japanese Encephalitis and Acute Encephalitis Syndrome Hospitalizations in the Medium-Endemic Region in Central India

BACKGROUND

We estimated the incidence of Japanese encephalitis (JE) and acute encephalitis syndrome (AES) following routine immunization with the live-attenuated SA 14-14-2 JE vaccine.

METHODS

We implemented enhanced surveillance of AES and JE hospitalizations in endemic districts in Maharashtra and Telangana States during 2015-2016 and 2018-2020. We estimated incidence and compared differences in the incidence of JE and AES between two states, and vaccinated and unvaccinated districts during two study periods. We also considered secondary data from public health services to understand long-term trends from 2007 to 2020.

RESULTS

The annual AES incidence rate of 2.25 cases per 100,000 children in Maharashtra during 2018-2020 was significantly lower than 3.36 cases per 100,000 children during 2015-2016. The six JE-vaccinated districts in Maharashtra had significantly lower incidence rates during 2018-2020 (2.03, 95% CI 1.73-2.37) than in 2015-16 (3.26, 2.86-3.70). In addition, the incidence of both JE and AES in two unvaccinated districts was higher than in the vaccinated districts in Maharashtra. Telangana had a lower incidence of both JE and AES than Maharashtra. The AES incidence rate of 0.95 (0.77-1.17) during 2018-2020 in Telangana was significantly lower than 1.67 (1.41-1.97) during 2015-2016.

CONCLUSIONS

The annual incidence rate of Japanese encephalitis was < 1 case per 100,000 children. It indicated accelerated control of Japanese encephalitis after routine immunization. However, the annual incidence of acute encephalitis syndrome was still > 1 case per 100,000 children. It highlights the need for improving surveillance and evaluating the impacts of vaccination.

Effectiveness of Japanese encephalitis vaccination among children in central India

Japanese encephalitis (JE) disease among children continues in central India despite vaccination implemented in the routine immunization program. Therefore, we planned to estimate the JE vaccination effectiveness among children by undertaking a 1:2 individually-matched population-based case-control study from August 2018 to October 2020. The laboratory-confirmed JE cases aged 1-15 years were enrolled along with neighborhood controls without fever and encephalitis matched on the residence area, age and sex. The JE vaccination history was enquired from parents and verified independently from the vaccination cards available at home and records at health facilities. We enrolled 35 JE cases and 70 matched controls. The vaccination effectiveness of 86.7% (95% confidence interval [CI]: 30.8-94.7) was estimated on the per-protocol analysis of 31 case-control sets. The screening method provided an effectiveness of 89.5% (CI: 78.9-94.7) on using the population vaccination coverage of 90% reported earlier in the same area. In conclusion, JE vaccination offered a moderate level of protection among children in JE medium-endemic central India, similar to reports from high-endemic areas in India. The operational aspects of vaccination program implementation need to be evaluated to assess the impact of vaccination on the disease burden of JE in medium-endemic regions of India.

Vaccination coverage and breakthrough infections of COVID-19 during the second wave among staff of selected medical institutions in India

India experienced the second wave of SARS-CoV-2 infection from April 3 to June 10, 2021. During the second wave, Delta variant B.1617.2 emerged as the predominant strain, spiking cases from 12.5 million to 29.3 million (cumulative) by the end of the surge in India. Vaccines against COVID-19 are a potent tool to control and end the pandemic in addition to other control measures. India rolled out its vaccination programme on January 16, 2021, initially with two vaccines that were given emergency authorization-Covaxin (BBV152) and Covishield (ChAdOx1 nCoV- 19). Vaccination was initially started for the elderly (60+) and front-line workers and then gradually opened to different age groups. The second wave hit when vaccination was picking up pace in India. There were instances of vaccinated people (fully and partially) getting infected, and reinfections were also reported. We undertook a survey of staff (front line health care workers and supporting) of 15 medical colleges and research institutes across India to assess the vaccination coverage, incidence of breakthrough infections, and reinfections among them from June 2 to July 10, 2021. A total of 1876 staff participated, and 1484 forms were selected for analysis after removing duplicates and erroneous entries (n = 392). We found that among the respondents at the time of response, 17.6% were unvaccinated, 19.8% were partially vaccinated (received the first dose), and 62.5% were fully vaccinated (received both doses). Incidence of breakthrough infections was 8.7% among the 801 individuals (70/801) tested at least 14 days after the 2nd dose of vaccine. Eight participants reported reinfection in the overall infected group and reinfection incidence rate was 5.1%. Out of (N = 349) infected individuals 243 (69.6%) were unvaccinated and 106 (30.3%) were vaccinated. Our findings reveal the protective effect of vaccination and its role as an essential tool in the struggle against this pandemic.

Coverage of Japanese encephalitis routine vaccination among children in Central India

BACKGROUND

We aimed to estimate the coverage of Japanese encephalitis (JE) vaccination in central India to help explain the continued occurrence of JE disease despite routine vaccination.

METHODS

We implemented a 30-cluster survey for estimating the coverage of JE vaccination in the medium-endemic areas implemented with JE vaccination in central India. The parents were enquired about the uptake of the JE vaccine by their children aged 2 to 6 years, followed by verification of the immunization cards at home along with reasons for non-vaccination. Vaccination coverage was reported as a percentage with 95% confidence intervals.

RESULTS

We estimated high coverage of live-attenuated SA 14-14-2 JE vaccination in Maharashtra (94.8%, 95% CI 92.7-96.3) and Telangana (92.8%, 90.0-94.9). The vaccination card retention was 90.3% in Maharashtra and 70.4% in Telangana state. There were no gender differences in coverage in both states. A similar level of JE vaccination coverage was observed during the year 2013 to 2021 in both states. In Maharashtra, the maximum age-wise coverage was 96.6% in the >60 months age category, whereas in Telangana it was in the <24 months age category (97.2%). The timeliness of JE vaccination was appropriate and similar in both states. We found very good agreement between JE and Measles-Rubella vaccinations administered simultaneously. The reasons for non-vaccination were the shortage of vaccines and the parental migration for work.

CONCLUSIONS

The coverage of Japanese encephalitis vaccination was high in medium-endemic regions in central India. Vaccination effectiveness studies may help further explain the continued incidence of Japanese encephalitis. This article is protected by copyright. All rights reserved.

Scrub typhus in urban areas of Wardha district in central India

Background & objectives

Scrub typhus caused by Orientia tsutsugamushi presents as acute undifferentiated fever and can be confused with other infectious causes of fever. We studied scrub typhus as part of a study on hospital-based surveillance of zoonotic and vector-borne zoonotic diseases at a tertiary care hospital located in the Wardha district, Maharashtra, India. We report here descriptive epidemiology and climatic factors affecting scrub typhus.

Methods

Patients of any age and sex with fever of ≥5 days were enrolled for this study. Data on sociodemographic variables were collected by personal interviews. Blood samples were tested by IgM ELISA to diagnose scrub typhus. Confirmation of scrub typhus was done by indirect immunofluorescence assay for IgM (IgM IFA). The climatic determinants were determined using time-series Poisson regression analysis.

Results

It was found that 15.9 per cent of the study participants were positive for scrub typhus by IgM ELISA and IgM IFA, both. Positivity was maximum (23.0%) in 41-60 yr of age and more females were affected than males (16.6 vs. 15.5%). Farmworkers were affected more (23.6%) than non-farm workers (12.9%). The disease positivity was found to be high in monsoon and post-monsoon seasons (22.9 and 19.4%) than in summer and winter.

Interpretation & conclusions

There were three hot spots of scrub typhus in urban areas of Wardha district. Rainfall and relative humidity in the previous month were the significant determinants of the disease.

MitoQ supplementation augments acute exercise-induced increases in muscle PGC1α mRNA and improves training-induced increases in peak power independent of mitochondrial content and function in untrained middle-aged men

The role of mitochondrial ROS in signalling muscle adaptations to exercise training has not been explored in detail. We investigated the effect of supplementation with the mitochondria-targeted antioxidant MitoQ on a) the skeletal muscle mitochondrial and antioxidant gene transcriptional response to acute high-intensity exercise and b) skeletal muscle mitochondrial content and function following exercise training. In a randomised, double-blind, placebo-controlled, parallel design study, 23 untrained men (age: 44 ± 7 years, VO_2peak: 39.6 ± 7.9 ml/kg/min) were randomised to receive either MitoQ (20 mg/d) or a placebo for 10 days before completing a bout of high-intensity interval exercise (cycle ergometer, 10 × 60 s at VO_2peak workload with 75 s rest). Blood samples and vastus lateralis muscle biopsies were collected before exercise and immediately and 3 h after exercise. Participants then completed high-intensity interval training (HIIT; 3 sessions per week for 3 weeks) and another blood sample and muscle biopsy were collected. There was no effect of acute exercise or MitoQ on systemic (plasma protein carbonyls and reduced glutathione) or skeletal muscle (mtDNA damage and 4-HNE) oxidative stress biomarkers. Acute exercise-induced increases in skeletal muscle peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC1-α) mRNA expression were augmented in the MitoQ group. Despite this, training-induced increases in skeletal muscle mitochondrial content were similar between groups. HIIT-induced increases in VO_2peak and 20 km time trial performance were also similar between groups while training-induced increases in peak power achieved during the VO_2peak test were augmented in the MitoQ group. These data suggest that training-induced increases in peak power are enhanced following MitoQ supplementation, which may be related to the augmentation of skeletal muscle PGC1α expression following acute exercise. However, these effects do not appear to be related to an effect of MitoQ supplementation on exercise-induced oxidative stress or training-induced mitochondrial biogenesis in skeletal muscle.

The Omic Insights on Unfolding Saga of COVID-19

The year 2019 has seen an emergence of the novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing coronavirus disease of 2019 (COVID-19). Since the onset of the pandemic, biological and interdisciplinary research is being carried out across the world at a rapid pace to beat the pandemic. There is an increased need to comprehensively understand various aspects of the virus from detection to treatment options including drugs and vaccines for effective global management of the disease. In this review, we summarize the salient findings pertaining to SARS-CoV-2 biology, including symptoms, hosts, epidemiology, SARS-CoV-2 genome, and its emerging variants, viral diagnostics, host-pathogen interactions, alternative antiviral strategies and application of machine learning heuristics and artificial intelligence for effective management of COVID-19 and future pandemics.

Childhood encephalitis hospitalizations associated with virus agents in medium-endemic states in India

BACKGROUND

Japanese encephalitis (JE) is the leading cause of childhood acute encephalitis syndrome (AES) in India. We enhanced the AES surveillance in sentinel hospitals to determine trends and virus etiologies in central India.

METHODS

The neurological hospitalizations among children ≤15 years were tracked by using the AES case definition implemented by the national program. Acute and convalescent sera along with cerebrospinal fluid (CSF) specimens were collected and tested at the strengthened site hospital laboratories for anti-JE, anti-Dengue and anti-Chikungunya virus by IgM ELISA; along with Chandipura virus RT-PCR. Herpes simplex and enterovirus testing was undertaken at the reference laboratory.

RESULTS

Among 1619 pediatric neurological hospitalizations reported during 2015-16, AES case definition was fulfilled in 332 (20.5%) cases. After excluding 52 non-AES cases, 280 AES cases resident from study districts were considered eligible for study. The treating physicians diagnosed non-viral causes in 90 cases, therefore 190 (67.9%) of 280 AES cases were suspected with viral etiologies. We enrolled 140 (73.7%) of 190 eligible AES cases. Viral etiologies were confirmed in 31 (22.1%) of 140 enrolled AES cases. JE (n = 22) was the leading cause. Additional non-JE viral agents included Chikungunya (5), Dengue (2) and Chandipura (2). However, only 21 (9.4%) of 222 additional AES cases referred from peripheral hospitals were confirmed as JE.

CONCLUSIONS

Japanese encephalitis virus continues to be the leading cause of childhood acute encephalitis syndrome in central India despite vaccination program. Surveillance needs to be intensified for assessing the true disease burden of Japanese encephalitis following vaccination program implementation.

Burden of congenital rubella syndrome (CRS) in India based on data from cross-sectional serosurveys, 2017 and 2019-20

Background

India has set a goal to eliminate measles and rubella/Congenital Rubella Syndrome (CRS) by 2023. Towards this goal, India conducted nationwide supplementary immunization activity (SIA) with measles-rubella containing vaccine (MRCV) targeting children aged between 9 months to <15 years and established a hospital-based sentinel surveillance for CRS. Reliable data about incidence of CRS is necessary to monitor progress towards the elimination goal.

Methods

We conducted serosurveys in 2019–20 among pregnant women attending antenatal clinics of 6 hospitals, which were also sentinel sites for CRS surveillance, to estimate the prevalence of IgG antibodies against rubella. We systematically sampled 1800 women attending antenatal clinics and tested their sera for IgG antibodies against rubella. We used rubella seroprevalence data from the current survey and the survey conducted in 2017 among antenatal women from another 6 CRS surveillance sites to construct a catalytic models to estimate the incidence and burden of CRS.

Result

The seroprevalence of rubella antibodies was 82.3% (95% CI: 80.4–84.0). Rubella seropositivity did not differ by age group and educational status. Based on the constant and age-dependent force of infection models, we estimated that the annual incidence of CRS in India was 225.58 per 100,000 live births (95% CI: 217.49–232.41) and 65.47 per 100,000 live births (95% CI: 41.60–104.16) respectively. This translated to an estimated 14,520 (95% CI: 9,225–23,100) and 50,028 (95% CI: 48,234–51,543) infants with CRS every year based on age-dependent and constant force of infection models respectively.

Conclusions

Our findings indicated that about one fifth of women in the reproductive age group in India were susceptible for rubella. The estimates of CRS incidence will serve as a baseline to monitor the impact of MRCV SIAs, as well progress towards the elimination goal of rubella/CRS.

Rubella infection during the first trimester of pregnancy can affect fetus, resulting in spontaneous abortion, stillbirth or birth of a baby with a combination of birth defects known as congenital rubella syndrome (CRS). Vaccination with rubella containing vaccine (RCV) is recommended as one of the strategies for eliminating rubella/CRS. The Southeast Asia region has set a target to eliminate rubella/CRS by 2023. Towards this goal, India completed nationwide immunization campaigns using measles-rubella vaccine during 2017–19, targeting children aged 9 months to <15 years. A case-based surveillance for CRS was initiated in five sentinel hospitals (Phase-1) in 2016 and later expanded to additional 6 sites (Phase-2) in 2019, to estimate burden of CRS and monitor its trend. As an adjunct to CRS surveillance, periodic serologic surveys were also planned to monitor the rubella seroprevalence among the pregnant women. A serosurvey conducted in 2017 indicated that 83.4% pregnant women attending antenatal clinics of Phase-1 sentinel hospitals had IgG antibodies against rubella. The second serosurvey conducted during 2019–20 in 6 Phase-2 sites indicated a comparable seroprevalence of 82.3%. Using seroprevalence data from these two serosurveys, we estimated that the annual incidence of CRS in India was 225.58 per 100,000 live births with constant force of infection and 65.47 per 100,000 live births with age-dependent force of infection models. This incidence rates translated to an estimated 14,520 to 50,028 infants with CRS every year. The estimates of CRS incidence will serve as a baseline to monitor the progress towards the elimination goal of rubella/CRS in India.

Evaluation of nested PCR and loop mediated isothermal amplification assay (LAMP) targeting 47 ​kDa gene of Orientia tsutsugamushi for diagnosis of scrub typhus

PURPOSE

Diagnostic testing, in particular early detection, is critical for scrub typhus, as most infected individuals have nonspecific symptoms that are easily confused with dengue and malaria. PCR and LAMP offer an alternative DNA amplification method for detection of Orientia tsutsugamushi. Detection of Orientia tsutsugamushi DNA by targeting the 47-kDa gene using nested PCR and LAMP for diagnosis of scrub typhus.

METHODS

A cross-sectional study in a tertiary care hospital in central India. The present study was done on a total of 274 patients with fever of five days or more and negative for other causes of fever viz. malaria, dengue and enteric fever. From each patient 5 ​ml of blood samples was collected in EDTA vial for molecular tests (PCR and LAMP) and in plain vial for serological tests (IgM IFA). The data was entered in Excel sheet and 2 ​× ​2 tables were created to find sensitivity, specificity, positive and negative likelihood ratios, disease prevalence, positive and negative predictive values and accuracy.

RESULTS

PCR showed a sensitivity of 29.73% while the sensitivity of LAMP was 16.22%. The specificity of nested PCR and LAMP was very high, 99.58% and 99.16% respectively. The diagnostic accuracy of nested PCR (90.15%) was found to be marginally better than LAMP (87.96%).

CONCLUSIONS

For the treatment of scrub typhus, a gene-based diagnostic test would enable earlier and more accurate detection of the causative agents of the disease than serology in admission samples of patients with acute febrile illness in endemic areas.

Journey towards National Institute of One Health in India

Background & objectives

Issues such as emerging and re-emerging infectious diseases, antimicrobial resistance, food security, biosafety and biosecurity are associated with changes in land use, population growth, urbanization, global travel and trade and climate change. As a result, a trans-disciplinary approach among human, animal and environmental health disciplines gained support. The Indian Council of Medical Research (ICMR) and Indian Council of Agricultural Research (ICAR) decided to establish a National Institute of One Health at Nagpur, Maharashtra, India. In this context, two collaborative research projects, funded by the ICAR and ICMR were initiated to conduct the epidemiological surveillance of selected zoonotic diseases in Central India.

Methods

Disease surveillance and molecular detection employing standard techniques like enzyme linked immunosorbent assay (ELISA), immuno-fluroscent assay (IFA), standard tube agglutination test (STAT) , Rose Bengal plate test (RBPT) and polymerase chain reaction (PCR) were undertaken based on the disease to be screened.

Results

In animals, the seropositivities for listeriosis (7.66%) and brucellosis (11.69%) were recorded. The occurrence of tuberculosis (3.8%) and leptospirosis (6.33%) was detected by PCR. Through cross-sectional studies from suspected human population with associated risk factors for zoonotic diseases, the seropositivity of brucellosis (1.83-11%), listeriosis (1.01-10.18 %), leptospirosis (8.14-12.67%) and scrub typhus (1.78-20.34%) was recorded. The investigations on scrub typhus indicated bimodal pattern during the months of pre-monsoon and post-monsoon season with a peak in post-monsoon in human cases. Ornithonyssus bacoti mites were identified from the rodents as a vector harbouring Orientia tsutsugamushi. The bovine tuberculosis was detected in 1.43 per cent human cases employing molecular assay.

Interpretation & conclusions

The data indicated the occurrence of important zoonotic diseases adversely affecting the livestock health and human wellbeing. The scientific collaboration between veterinary and medical faculties has set an example for effective implementation of One Health (OH) programme for the establishment of National Institute of OH.

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Funding Acknowledgement

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

Population Genomics of Mycobacterium leprae Reveals a New Genotype in Madagascar and the Comoros

Human settlement of Madagascar traces back to the beginning of the first millennium with the arrival of Austronesians from Southeast Asia, followed by migrations from Africa and the Middle East. Remains of these different cultural, genetic, and linguistic legacies are still present in Madagascar and other islands of the Indian Ocean. The close relationship between human migration and the introduction and spread of infectious diseases, a well-documented phenomenon, is particularly evident for the causative agent of leprosy, Mycobacterium leprae. In this study, we used whole-genome sequencing (WGS) and molecular dating to characterize the genetic background and retrace the origin of the M. leprae strains circulating in Madagascar (n = 30) and the Comoros (n = 3), two islands where leprosy is still considered a public health problem and monitored as part of a drug resistance surveillance program. Most M. leprae strains (97%) from Madagascar and Comoros belonged to a new genotype as part of branch 1, closely related to single nucleotide polymorphism (SNP) type 1D, named 1D-Malagasy. Other strains belonged to the genotype 1A (3%). We sequenced 39 strains from nine other countries, which, together with previously published genomes, amounted to 242 genomes that were used for molecular dating. Specific SNP markers for the new 1D-Malagasy genotype were used to screen samples from 11 countries and revealed this genotype to be restricted to Madagascar, with the sole exception being a strain from Malawi. The overall analysis thus ruled out a possible introduction of leprosy by the Austronesian settlers and suggests a later origin from East Africa, the Middle East, or South Asia.

Diagnosis and management of postlaparotomy wound infection caused by Mycobacterium fortuitum

Mycobacterium fortuitum is ubiquitous in nature and can cause a wide variety of lesions in humans with immunocompromised or antecedent chronic illness. Clinical diagnosis is difficult and relapses are seen. This is due to the fact that they are not critically investigated and are not responded to traditional antitubercular treatment and other antibiotics. Herewith, we report a case of M. fortuitum causing laparotomy port infection-causing repeated multiple abscess on the anterior abdominal wall and treated with amikacin and clarithromycin. The wound healed completely and the patient recovered after administering a combination of amikacin and clarithromycin. We conclude that strict standard operating procedures should be followed to prevent mycobacteria other than tuberculosis (MOTT) infections during and after surgical procedures. Any postoperative, chronic infection which is not responding to conventional antibiotics should be highly suspected for such MOTT infections. Antibiotic susceptibility testing should be performed so as to identify the required antibiotic combination and treated accordingly to prevent further complications and to reduce the cost of treatment.

Human papillomavirus, radiation dose and survival of patients with anal cancer

Purpose: To determine if anal cancer patients with HPV positive disease have different overall survival (OS) compared to those with HPV negative disease, and to elucidate differences in the association between radiation dose and OS.Patients and methods: We utilized the National Cancer Database (NCDB) registry to identify a cohort of non-metastatic anal cancer patients treated with curative intent between 2008 and 2014. Propensity score matching was used to account for potential selection bias between patients with HPV positive and negative disease. Multivariable Cox regression was used to determine the association between HPV status and OS. Kaplan-Meier methods were used to compare actuarial survival estimates.Results: We identified 5927 patients with tumor HPV status for this analysis, 3523 (59.4%) had HPV positive disease and 2404 (40.6%) had HPV negative disease. Propensity-matched analysis demonstrated that patients with HPV positive locally advanced (T3-4 or node positive) anal cancer had better OS (HR = 0.81 (95%CI: 0.68-0.96), p=.018). For patients with early stage disease (T1-2 and node negative) there was no difference in OS (HR = 1.11 (95%CI: 0.86-1.43), p=.43). In the unmatched cohort, we found a significant improvement in OS with increasing radiation dose only for patients with locally advanced, HPV negative disease (p<.001). In those patients, significant improvement in OS compared to the group receiving 30-45 Gy was seen for increasing doses up to 55-60 Gy, but not beyond 60 Gy.Conclusion: We found HPV to be a significant prognostic marker in anal tumors, especially for locally advanced disease. We further found that higher radiation dose up to 55-60 Gy was associated with better OS, but only for patients with locally advanced, HPV negative disease.

Comparing outcomes following total neoadjuvant therapy and following neoadjuvant chemoradiation therapy in patients with locally advanced rectal cancer

BACKGROUND

There is recent interest in treating locally advanced rectal cancer (LARC) patients with total neoadjuvant therapy (TNT). However, whether TNT is associated with improved overall survival (OS) remains unknown. This study compares outcomes following TNT and following neoadjuvant chemoradiation therapy (nCRT) in patients with LARC, clinically defined cT3/4 or node positive disease, using the National Cancer Database.

METHODS

LARC patients diagnosed between 2004-2015 were included. TNT was defined as multi-agent chemotherapy given at least 2 months before RT followed by pre-operative chemoradiation therapy and definitive surgery without adjuvant chemotherapy. nCRT was defined as pre-operative RT and chemotherapy started within 2 weeks from each other followed by definitive surgery with or without adjuvant chemotherapy. Kaplan-Meier curve with logrank test and multivariable Cox proportional hazards regression modelling were used to analyse the primary endpoint of overall survival (OS). Multivariable logistic regression modelling was used for secondary outcomes to determine if TNT is associated with pathological complete response (pCR), defined as ypT0N0, and negative circumferential resection margin (CRM).

FINDINGS

Data from 372 TNT patients and 707 nCRT patients were analysed after a 2:1 propensity matching with replacement. Kaplan-Meier curve showed that OS with TNT was comparable to that with nCRT (p = 0•16). The 5-year OS rates for TNT and nCRT were 73•6% vs. 78•5% (p = 0•20). Multivariable Cox proportional hazards regression modelling confirmed no difference in OS between TNT and nCRT (HR = 1•21, p = 0•25). With TNT, 16•9% patients achieved pCR, whereas 13•1% patients achieved pCR with nCRT (p = 0•12). TNT was not found to be significantly associated with pCR (OR = 1•36, p = 0•13) or negative CRM (OR = 1•77, p = 0•19) in multivariable logistic regression modelling.

INTERPRETATION

With results from current clinical trials pending, our data suggested that TNT and nCRT resulted in similar survival, while TNT led to higher pCR and CRM negative rate, albeit not statistically significant.

Cost and effectiveness of genetic testing in metastatic colorectal cancer (mCRC) at Montefiore Medical Center (MMC)

e15043

Background: Upfront testing for MSI, and mutations in KRAS, NRAS, and BRAF is recommended. The most cost-effective way of obtaining this information remains unclear. We examined cost of broad next generation sequencing (NGS), in comparison to hotspot (HT) and individual target (IT) testing in patients with mCRC with Medicare (MC) and commercial insurance (CI) at MMC. As a surrogate of effectiveness, we hypothesize that patients with NGS are more likely to enroll in clinical trials. Methods: Cost of individual and hotspot tests were derived from known reimbursement rates with insurances affiliated with MMC. Due to ongoing changes in current procedural terminology for NGS, we used known reimbursement amounts from our patients. We applied these costs to a model population of 1,000,000 people. We then evaluated clinical trial enrollment of patients who had either NGS or hotspot/individual testing. Results: MC costs for IT, HT, NGS testing were $1,504, $752, and $4,680 respectively. CI costs were $1,910, $814, $2,366 for IT, HT, and NGS testing respectively. When applied to our model population, NGS cost $914,604 and $1,131,016 more than individual and hot spot testing respectively for MC patients, and $21,432 and $72,924 more for CI patients. Analysis of effectiveness included 136 patients, wherein 8% of those with NGS (n = 5/61) were enrolled in clinical trials as a result of testing compared to 1% of those with HT/IT (n = 1/75). Conclusions: Broad spectrum NGS costs more than individual or hot spot testing in mCRC. However, patients with NGS testing were more likely to be enrolled in clinical trials, suggesting the need for studies to further evaluate ideal testing modality. [Table: see text]

Human papillomavirus, radiation dose and survival of patients with anal cancer

e15071

Background: To determine if anal cancer patients with HPV positive disease have different overall survival (OS) compared to those with HPV negative disease, and to elucidate differences in the association between radiation dose and OS. Methods: We utilized the National Cancer Database (NCDB) registry to identify a cohort of non-metastatic anal cancer patients treated with curative intent between 2008 – 2015. Propensity score matching was used to account for potential selection bias between patients with HPV positive and negative disease. Multivariable Cox regression was used to determine the association between HPV status and OS. Kaplan-Meier methods were used to compare actuarial survival estimates. Results: We identified 5,927 patients with tumor HPV status for this analysis, 3,523 (59.4%) had HPV positive disease and 2,404 (40.6%) had HPV negative disease. Propensity-matched analysis demonstrated that patients with HPV positive locally advanced (T3-4 or node positive) anal cancer had better OS (HR=0.81 (95%CI: 0.68-0.96), p=0.018). For patients with early stage disease (T1-2 and node negative) there was no difference in OS (HR=1.11 (95%CI:0.86-1.43), p=0.43). In the unmatched cohort, there was an increase in 3-year OS for patients with HPV positive tumors or early stage disease up to 45-49.9 Gy (p<0.001), whereas for patients with HPV negative and locally advanced disease there was an increase in survival from 46% at 30-44.9 Gy, to 64% at 45-49.9 Gy (p=0.093) and further to 71% at 50-54.9 Gy (p=0.005). Conclusions: We found HPV to be a significant prognostic marker in anal tumors, especially for locally advanced disease. We further found that higher radiation dose up to 50-55 Gy was associated with better OS, mainly for locally advanced disease in HPV negative patients. Multivariable Cox proportional hazards regression for OS. [Table: see text]

Cost and effectiveness of genetic testing in metastatic colorectal cancer (mCRC) at Montefiore Medical Center (MMC)

643

Background: Upfront testing for MSI, and mutations in KRAS, NRAS, and BRAF is recommended. The most cost-effective way of obtaining this information remains unclear. We examined cost of broad next generation sequencing (NGS), in comparison to hotspot (HT) and individual target (IT) testing in patients with mCRC with Medicare (MC) and commercial insurance (CI) at MMC. As a surrogate of effectiveness, we hypothesize that patients with NGS are more likely to enroll in clinical trials. Methods: Cost of individual and hotspot tests were derived from known reimbursement rates with insurances affiliated with MMC. Due to ongoing changes in current procedural terminology for NGS, we used known reimbursement amounts from our patients. We applied these costs to a model population of 1,000,000 people. We then evaluated clinical trial enrollment of patients who had either NGS or hotspot/individual testing. Results: MC costs for IT, HT, NGS testing were $1,504, $752, and $4,680 respectively. CI costs were $1,910, $814, $2,366 for IT, HT, and NGS testing respectively. When applied to our model population, NGS cost $914,604 and $1,131,016 more than individual and hot spot testing respectively for MC patients, and $21,432 and $72,924 more for CI patients. Analysis of effectiveness included 136 patients, wherein 8% of those with NGS (n = 5/61) were enrolled in clinical trials as a result of testing compared to 1% of those with HT/IT (n = 1/75). Conclusions: Broad spectrum NGS costs more than individual or hot spot testing in mCRC. However, patients with NGS testing were more likely to be enrolled in clinical trials, suggesting the need for studies to further evaluate ideal testing modality. [Table: see text]

Recurrence of tuberculosis among newly diagnosed sputum positive pulmonary tuberculosis patients treated under the Revised National Tuberculosis Control Programme, India: A multi-centric prospective study

Introduction

There is lack of information on the proportion of new smear—positive pulmonary tuberculosis (PTB) patients treated with a 6-month thrice-weekly regimen under Revised National Tuberculosis Control Programme (RNTCP) who develop recurrent TB after successful treatment outcome.

Objective

To estimate TB recurrence among newly diagnosed PTB patients who have successfully completed treatment and to document endogenous reactivation or re-infection. Risk factors for unfavourable outcomes to treatment and TB recurrence were determined.

Methodology

Adult (aged ≥ 18 yrs) new smear positive PTB patients initiated on treatment under RNTCP were enrolled from sites in Tamil Nadu, Karnataka, Delhi, Maharashtra, Madhya Pradesh and Kerala. Those declared “treatment success” at the end of treatment were followed up with 2 sputum examinations each at 3, 6 and 12 months after treatment completion. MIRU-VNTR genotyping was done to identify endogenous re-activation or exogenous re-infection at TB recurrence. TB recurrence was expressed as rate per 100 person-years (with 95% confidence interval [95%CI]). Regression models were used to identify the risk factors for unfavourable response to treatment and TB recurrence.

Results

Of the1577 new smear positive PTB patients enrolled, 1565 were analysed. The overall cure rate was 77% (1207/1565) and treatment success was 77% (1210 /1565). The cure rate varied from 65% to 86%. There were 158 of 1210 patients who had TB recurrence after treatment success. The pooled TB recurrence estimate was 10.9% [95%CI: 0.2–21.6] and TB recurrence rate per 100 person–years was 12.7 [95% CI: 0.4–25]. TB recurrence per 100 person–years varied from 5.4 to 30.5. Endogenous reactivation was observed in 56 (93%) of 60 patients for whom genotyping was done. Male gender was associated with TB recurrence.

Conclusion

A substantial proportion of new smear positive PTB patients successfully treated with 6 –month thrice-weekly regimen have TB recurrence under program settings.

Diagnostic efficacy of microscopy, rapid diagnostic test and polymerase chain reaction for malaria using bayesian latent class analysis

INTRODUCTION

The diagnostic techniques for malaria are undergoing a change depending on the availability of newer diagnostics and annual parasite index of infection in a particular area. At the country level, guidelines are available for selection of diagnostic tests; however, at the local level, this decision is made based on malaria situation in the area. The tests are evaluated against the gold standard, and if that standard has limitations, it becomes difficult to compare other available tests. Bayesian latent class analysis computes its internal standard rather than using the conventional gold standard and helps comparison of various tests including the conventional gold standard.

MATERIALS AND METHODS

In a cross-sectional study conducted in a tertiary care hospital setting, we have evaluated smear microscopy, rapid diagnostic test (RDT), and polymerase chain reaction (PCR) for diagnosis of malaria using Bayesian latent class analysis.

RESULTS

We found the magnitude of malaria to be 17.7% (95% confidence interval: 12.5%-23.9%) among the study subjects. In the present study, the sensitivity of microscopy was 63%, but it had very high specificity (99.4%). Sensitivity and specificity of RDT and PCR were high with RDT having a marginally higher sensitivity (94% vs. 90%) and specificity (99% vs. 95%). On comparison of likelihood ratios (LRs), RDT had the highest LR for positive test result (175) and the lowest LR for negative test result (0.058) among the three tests.

CONCLUSION

In settings like ours conventional smear microscopy may be replaced with RDT and as we move toward elimination and facilities become available PCR may be roped into detect cases with lower parasitaemia.

Clinical and angiographic profiles and six months outcomes of smokers with acute ST segment elevation myocardial infarction undergoing primary percutaneous coronary angioplasty

Background

Outcomes of primary percutaneous coronary intervention (PCI) for acute STEMI (ST-segment elevation myocardial infarction) in smokers are expected to be better than non-smokers as for patients of acute STEMI with or without fibrinolytic therapy.

Objectives

This comparative study was designed to evaluate the outcomes of primary PCI in patients with acute STEMI in smokers and non-smokers. Clinical and angiographic profile of the two groups was also compared.

Methods

Over duration of two year, a total of 150 consecutive patients of acute STEMI eligible for primary PCI were enrolled and constituted the two groups [Smokers (n = 90), Non-smokers (n = 60)] of the study population. There was no difference in procedure in two groups.

Results

In the present study of acute STEMI, current smokers were about a decade younger than non-smokers (p value = 0.0002), majority were male (98.9% vs 56.6%) were male with a higher prevalence of hypertension and diabetes mellitus (61.67% vs 32.28% and 46.67% vs 14.44%, p = 0.001) respectively. Smokers tended to have higher thrombus burden (p = 0.06) but less multi vessel disease (p = 0.028). Thirty day and six month mortality was non-significantly higher in smokers 4.66% vs 1.33% (p = 0.261) and 5.33% vs 2.66% (p = NS) respectively. Rate of quitting smoking among smokers was 80.90% at 6 months.

Conclusion

The study documents that smokers with acute STEMI have similar outcomes as compared to non smokers with higher thrombus burden and lesser non culprit artery involvement. Smokers present at much younger age emphasizing the role of smoking cessation for prevention of myocardial infarction.

Knowledge, attitude and practice about breast cancer and breast self-examination among women seeking out-patient care in a teaching hospital in central India

BACKGROUND

Breast cancer (BC) continues to be a major cause of morbidity and mortality throughout the world. Early detection of BC and early treatment increases the chance of survival. According to Breast Health Global Initiative guidelines for low and middle income countries, diagnosing BCs early by promoting breast self-awareness; clinical breast examination (CBE) and resource adapted mammographic screening will reduce BC mortality. There is a paucity of data on the knowledge and awareness of BC and self-breast examination in India. We designed this hospital based cross sectional descriptive study to evaluate the current status of knowledge, awareness and practices related to BC and breast self-examination in the female rural population attending a teaching hospital.

MATERIALS AND METHODS

We did a random sampling to identify and enroll 360 women and their female relatives. We excluded a participant from the study if she had already undergone a screening mammography or had had a BC. The data was collected by a self-administered questionnaire in vernacular language.

RESULTS

Our study population included 360 women with a mean age of 45.81 (±10.9) years. Only 5 (1.38%) females had a family history of BC. A whopping 81% of women did not have any knowledge about BC. All the women thought that CBE by doctors was the only way for screening BC.

CONCLUSIONS

We concluded that with the results of this study, it is imperative to increase awareness about BC and its detection methods in the community through health education campaigns. We should have major policy changes to increase future screening programs and health education programs which would have an overall positive impact on reducing the disease burden.

Evaluation of Culture Media for Isolation of Mycobacterium Species from Human Clinical Specimens

BACKGROUND

Laboratory diagnosis of tuberculosis has undergone a rapid change during last few years and a number of techniques for culture as well as molecular diagnosis have been used with their respective advantages and disadvantages. Sporadic studies have also reported the isolation of M. tuberculosis on standard blood agar (BA), which at one time was not considered as a suitable medium for mycobacterial culture. The present study was conducted to evaluate the routine use of 5% sheep BA in a mycobacteriology laboratory by comparing isolation rates and time for isolation of mycobacteria from pulmonary and extrapulmonary samples with those on Lowenstein-Jensen (LJ) medium.

MATERIAL AND METHODS

BA with antibiotics was prepared and dispensed as slants in McCartney bottles. LJ was prepared and dispensed following the Revised National Tuberculosis Control Programme (RNTCP) guidelines. A total of 500 suspected tuberculosis samples were inoculated on both media in duplicate, incubated at 37⁰C, and observed daily until the appearance of growth.

RESULTS

Out of 500 inoculated samples, 99 showed growth on BA and 112 showed growth on LJ medium. Mean growth time on BA was less as compared to LJ medium. The contamination rate was found to be more on BA (7.2%) than on LJ (4.8%).

CONCLUSIONS

 Mycobacterial growth time was less on BA as compared to LJ.

Prevalence of pulmonary tuberculosis in Wardha district of Maharashtra, Central India

A house based survey was conducted during 2007–2009 in a representative sample of population in Wardha district implementing Directly Observed Treatment Short Course strategy for tuberculosis (TB) control since 2001. The objective was to estimate prevalence of bacillary pulmonary TB (PTB) in individuals aged 15 years or above, and to estimate trends in prevalence when compared to a previous survey carried out in mid 1980’s. Two sputum samples (one spot, one early morning) collected from individuals having symptoms suggestive of PTB, history of previous anti-TB treatment (ATT) or abnormal pulmonary shadow on Mass Miniature Radiography (MMR) consistent with possibly or probably active tuberculosis were subjected to Ziehl–Neelsen microscopy and culture on Lowenstein–Jensen medium.

Of 55,096 individuals registered into the survey, 50,332 (91.4%) were screened by interview for symptoms and history of ATT and/or by MMR. Of them, 4805 were eligible for sputum collection; both specimens were collected in 4285 (89.2%) and only one specimen in 27 (0.6%).

A total of 86 bacillary cases were detected during the survey. Prevalence of bacillary PTB was estimated at 188.7 (140.3–236.9) per 100,000 populations. There was a decline of 61% in the prevalence of PTB over a period of 22 years.