Medium term results following heart transplantation for end stage heart failure: A single center experience of 257 patients

OBJECTIVE

End stage heart failure is a lethal disease with a dismal 5 year survival. Heart transplantation has proven to be a highly effective modality of treatment in appropriately selected group of such patients. This is a retrospective analysis of medium term outcomes of heart transplantation in the setting of a private health facility in India. The objective of this study was two fold.

METHODS

The outcome of 257 heart transplants done at a single centre from October 2012 to October 2019 was analyzed. Patients with combined Heart and lung transplants and those whose complete medical records were unavailable were excluded from the study. Survival was tracked at 60 days, 90 days, one year and beyond for a maximum of 7 years. Preoperative patient risk profiles were characterized on the basis of INTERMACS category.

RESULTS

There were 176 male and 81 female patients. The age range was from 8 months to 78 years with a mean of 32.9 years. Survival at 2 months was 87%, at 90 days was 83%, at one year was 81%, 2 years was 75%, at 3 years was 72% and at 5 years and beyond was 62% for the whole series. Strong predictors of 90 day mortality included INTERMACS category (odd's ratio 0.289, p = 0.000) and creatinine more than 1.5 mg/dl (odd's ratio 2.48, p = 0.056). Recipient pulmonary vascular resistance and donor organ ischemic times were not found to be statistically significant factors affecting outcome. Medium term survival was influenced by INTERMACS category (Hazard ratio > 3 for INTERMACS category 1 compared to INTERMACS 4 or 5, p < 0.0001) and creatinine > 1.5 mg/dl (Hazard ratio 2.15, p = 0.003). This effect of creatinine was related to the age of the recipient. Hazard ratio 1.4, p = 0.524 if age <30 and Hazard ratio 4.78, p = 0.006, if age was >50.

CONCLUSION

Satisfactory medium term outcome is possible after heart transplantation even in resource constrained environment of a developing country.

Earthquake Probability Assessment for the Indian Subcontinent Using Deep Learning

Earthquake prediction is a popular topic among earth scientists; however, this task is challenging and exhibits uncertainty therefore, probability assessment is indispensable in the current period. During the last decades, the volume of seismic data has increased exponentially, adding scalability issues to probability assessment models. Several machine learning methods, such as deep learning, have been applied to large-scale images, video, and text processing; however, they have been rarely utilized in earthquake probability assessment. Therefore, the present research leveraged advances in deep learning techniques to generate scalable earthquake probability mapping. To achieve this objective, this research used a convolutional neural network (CNN). Nine indicators, namely, proximity to faults, fault density, lithology with an amplification factor value, slope angle, elevation, magnitude density, epicenter density, distance from the epicenter, and peak ground acceleration (PGA) density, served as inputs. Meanwhile, 0 and 1 were used as outputs corresponding to non-earthquake and earthquake parameters, respectively. The proposed classification model was tested at the country level on datasets gathered to update the probability map for the Indian subcontinent using statistical measures, such as overall accuracy (OA), F1 score, recall, and precision. The OA values of the model based on the training and testing datasets were 96% and 92%, respectively. The proposed model also achieved precision, recall, and F1 score values of 0.88, 0.99, and 0.93, respectively, for the positive (earthquake) class based on the testing dataset. The model predicted two classes and observed very-high (712,375 km²) and high probability (591,240.5 km²) areas consisting of 19.8% and 16.43% of the abovementioned zones, respectively. Results indicated that the proposed model is superior to the traditional methods for earthquake probability assessment in terms of accuracy. Aside from facilitating the prediction of the pixel values for probability assessment, the proposed model can also help urban-planners and disaster managers make appropriate decisions regarding future plans and earthquake management.

Canine Toxocariosis: Its prevalence, incidence and occurrence in the Indian subcontinent

Toxocariosis is an important neglected tropical helminth disease of zoonotic significance for which canids are the definitive hosts. Dogs are also considered the sentinel host for the occurrence of T. canis infections in humans. Therefore, understanding its prevalence in canine population is imperative for any effective disease control in humans. A comprehensive review of literature on the prevalence of T. canis in canids was lacking from the Indian subcontinent which necessitated our efforts to compile available data published on this topic. Data on prevalence, incidence and occurrence of this helminths in canids were presented in this review as tabular format for easy comprehension. Moreover, the data were categorized based on the region where the studies were conducted with an aim to understand the spatial distribution of this parasite in the subcontinent. Factors influencing the regional prevalence/occurrence of T. canis such as type of canids (stray or pet), age, sex, breed, season and the choice of analytical methods were also discussed. In addition, data on the prevalence of T. canis in environmental samples and in zoo canids were also compiled and presented. We anticipate such an exhaustive review of literature available mostly in the journals published from the subcontinent would become a point source of information necessary for prioritizing future surveillance efforts in this region and for making informed policy decision to control this zoonotic helminth infection.

Modeling HIV Transmission from Sexually Active Alcohol-Consuming Men in ART Programs to Seronegative Wives

BACKGROUND

The rollout of antiviral therapy in Low and Middle Income Countries (LMICs) has reduced HIV transmission rates at the potential risk of resistant HIV transmission. We sought to predict the risk of wild type and antiviral resistance transmissions in these settings.

METHODS

A predictive model utilizing viral load, ART adherence, genital ulcer disease, condom use, and sexual event histories was developed to predict risks of HIV transmission to wives of 233 HIV+ men in 4 antiretroviral treatment centers in Maharashtra, India.

RESULTS

ARV Therapy predicted a 5.71-fold reduction in transmissions compared to a model of using condoms alone, with 79.9%, of remaining transmissions resulting in primary ART-resistance.

CONCLUSIONS

ART programs reduce transmission of HIV to susceptible partners at a substantial increased risk for transmission of resistant virus. Enhanced vigilance in monitoring adherence, use of barrier protections, and viral load may reduce risks of resistant HIV transmissions in LMIC settings.

Six years of fruit fly surveys in Bangladesh: a new species, 33 new country records and discovery of the highly invasive Bactrocera carambolae (Diptera, Tephritidae)

We engaged in six years of snap-shot surveys for fruit flies in rural environments and ten protected forest areas of Bangladesh, using traps baited with male lures (cue-lure, methyl eugenol, zingerone). Our work has increased the recorded number of species of Tephritidae in the country from seven to 37. We summarize these surveys and report eight new country occurrence records, and a new species (Zeugodacusmadhupuri Leblanc & Doorenweerd, sp. nov.) is described. The highlight among the new records is the discovery, and significant westward range extension, of Bactroceracarambolae Drew & Hancock, a major fruit pest detected in the Chattogram and Sylhet Divisions. We rectify the previously published erroneous record of Bactrocerabogorensis (Hardy), which was based on a misidentification of Zeugodacusdiaphorus (Hendel). We also report the occurrence in Bangladesh of nine other Tephritidae, the rearing of three primary fruit fly parasitoids from Zeugodacus, and records of non-target attraction to fruit fly lures.

Successful nonsurgical treatment of penile Buschke-Löwenstein tumor with 12 weeks of 5% imiquimod alone

Anogenital warts, also known as condylomata acuminata caused by human papillomavirus constitute the most common sexually transmitted infection. Rarely, the disease may evolve into a huge cauliflower-like growth called giant condyloma acuminatum or Buschke–Löwenstein tumor (BLT). In contrast with normal anogenital warts, BLT displays local invasion, lack of spontaneous resolution, posttreatment recurrence, and potential for malignant transformation. Although radical excision with split-thickness skin grafting is considered its first-line treatment, it is not always feasible. While many other treatments have shown variable success and recurrence rates, topical imiquimod 5%, a popular evidence-based therapy for warts has also been reported as an efficacious treatment for BLT. We present a case of penile BLT where the patient refused surgery but recovered completely with no recurrence at five years following 16 weeks’ therapy with topical 5% imiquimod. Excepting a single reported case, this might be another case where BLT resolved with imiquimod as a standalone therapy. We also present a succinct review of past cases of BLT treated with imiquimod.

Novel Victorivirus from a Pakistani Isolate of Alternaria alternata Lacking a Typical Translational Stop/Restart Sequence Signature

The family Totiviridae currently contains five genera Totivirus, Victorivirus, Leishmavirus, Trichomonasvirus, and Giardiavirus. Members in this family generally have a set of two-open reading frame (ORF) elements in their genome with the 5'-proximal ORF (ORF1) encoding a capsid protein (CP) and the 3'-proximal one (ORF2) for RNA-dependent RNA polymerase (RdRp). How the downstream open reading frames (ORFs) are expressed is genus-specific. All victoriviruses characterized thus far appear to use the stop/restart translation mechanism, allowing for the expression of two separate protein products from bicitronic genome-sized viral mRNA, while the totiviruses use a -1 ribosomal frame-shifting that leads to a fusion product of CP and RdRp. We report the biological and molecular characterization of a novel victorivirus termed Alternaria alternata victorivirus 1 (AalVV1) isolated from Alternaria alternata in Pakistan. The phylogenetic and molecular analyses showed AalVV1 to be distinct from previously reported victoriviruses. AalVV1 appears to have a sequence signature required for the -1 frame-shifting at the ORF1/2 junction region, rather than a stop/restart key mediator. By contrast, SDS-polyacrylamide gel electrophoresis and peptide mass fingerprinting analyses of purified virion preparations suggested the expression of two protein products, not a CP-RdRp fusion product. How these proteins are expressed is discussed in this study. Possible effects of infection by this virus were tested in two fungal species: A. alternata and RNA silencing proficient and deficient strains of Cryphonectria parasitica, a model filamentous fungus. AalVV1 showed symptomless infection in all of these fungal strains, even in the RNA silencing deficient C. parasitica strain.

A novel multilocus sequence typing scheme identifying genetic diversity amongst Leishmania donovani isolates from a genetically homogeneous population in the Indian subcontinent

In the Indian subcontinent, infection with Leishmania donovani can cause fatal visceral leishmaniasis. Genetic variation in L. donovani is believed to occur rapidly from environmental changes and through selective drug pressures, thereby allowing continued disease occurrence in this region. All previous molecular markers that are commonly in use multilocus microsatellite typing and multilocus sequence typing, were monomorphic in L. donovani originating from the Indian subcontinent (with only a few exceptions) and hence are not suitable for this region. An multilocus sequence typing scheme consisting of a new set of seven housekeeping genes was developed in this study, based on recent findings from whole genome sequencing data. This new scheme was used to assess the genetic diversity amongst 22 autochthonous L. donovani isolates from Bangladesh. Nineteen additional isolates of the L. donovani complex (including sequences of L. donovani reference strain BPK282A1) from other countries were included for comparison. By using restriction fragment length polymorphism of the internal transcribed spacer 1 region (ITS1-RFLP) and ITS1 sequencing, all Bangladeshi isolates were confirmed to be L. donovani. Population genetic analyses of 41 isolates using the seven new MLST loci clearly separated L. donovani from Leishmania infantum. With this multilocus sequence typing scheme, seven genotypes were identified amongst Bangladeshi L. donovani isolates, and these isolates were found to be phylogenetically different compared with those from India, Nepal, Iraq and Africa. This novel multilocus sequence typing approach can detect intra- and inter-species variations within the L. donovani complex, but most importantly these molecular markers can be applied to resolve the phylogenetically very homogeneous L. donovani strains from the Indian subcontinent. Four of these markers were found suitable to differentiate strains originating from Bangladesh, with marker A2P being the most discriminative one.

Into Africa via docked India: a fossil climbing perch from the Oligocene of Tibet helps solve the anabantid biogeographical puzzle

The northward drift of the Indian Plate and its collision with Eurasia have profoundly impacted the evolutionary history of the terrestrial organisms, especially the ones along the Indian Ocean rim. Climbing perches (Anabantidae) are primary freshwater fishes showing a disjunct south Asian-African distribution, but with an elusive paleobiogeographic history due to the lack of fossil evidence. Here, based on an updated time-calibrated anabantiform phylogeny integrating a number of relevant fossils, the divergence between Asian and African climbing perches is estimated to have occurred in the middle Eocene (ca. 40 Ma, Ma: million years ago), a time when India had already joined with Eurasia. The key fossil lineage is †Eoanabas, the oldest anabantid known so far, from the upper Oligocene of the Tibetan Plateau. Ancestral range reconstructions suggest a Southeast Asian origin in the early Eocene (ca. 48 Ma) and subsequent dispersals to Tibet and then India for this group. Thereby we propose their westbound dispersal to Africa via the biotic bridge between India and Africa. If so, climbing perch precursors had probably followed the paleobiogeographical route of snakehead fishes, which have a slightly older divergence between African and Asian taxa. As such, our study echoes some recent molecular analyses in rejecting the previously held "Gondwana continental drift vicariance" or late Mesozoic dispersal scenarios for the climbing perches, but provides a unique biogeographical model to highlight the role of the pre-uplift Tibet and the docked India in shaping the disjunct distribution of some air-breathing freshwater fishes around the Indian Ocean.

Rabies on the Indian subcontinent

The Indian subcontinent comprises Afghanistan, Bangladesh, Bhutan, India, Nepal, the Maldives, Myanmar, Pakistan and Sri Lanka. In all of these countries, except the Maldives, rabies is endemic. An estimated 59,000 people die from rabies each year; 45% of these deaths occur on the Indian subcontinent and approximately 33% take place in India. The majority of these deaths are attributable to dog bites, and those most affected are children and the poor. Access to post-exposure prophylaxis is limited and costly, the supply of immunoglobulins and vaccines can be irregular and public awareness of rabies is low. Moreover, the vaccination of domestic dogs is not widely implemented. There is a need for increased laboratory capacity and expertise across the continent, as well as better data, improved surveillance and more user-friendly and economical diagnostic tests. An animal birth control programme has met with mixed success in India. However, a greater focus on mass dog vaccination could eliminate the disease at its source, reducing the large burden of mortality for at-risk communities. In this paper, the authors examine the situation in each of the countries on the Indian subcontinent, discuss current needs, obstacles and progress, and examine future strategies, with the objective of eliminating dog-mediated rabies from the subcontinent by 2030.

Latitudinal Pigmentation Variation Contradicts Ultraviolet Radiation Exposure: A Case Study in Tropical Indian Drosophila melanogaster

The effects of ultraviolet radiation (UV) on the animal body have been reported in many studies, and melanin has emerged as a protective mechanism. In smaller insects such as Drosophila, replicated patterns of geographical variation in pigmentation have been observed on multiple continents. Such patterns are particularly pronounced on the Indian subcontinent where several species show a parallel cline in pigmentation traits. However, the potential role of UV exposure in generating the observed patterns of pigmentation variation has not been addressed. Here, we examine the association between UV intensity and body pigmentation in D. melanogaster natural populations collected along the latitudinal gradient of the Indian subcontinent. A strong negative relationship was observed between UV intensity and body pigmentation. This analysis clearly indicates that, in the sampled populations, pigmentation variation is independent of UV exposure and related selection pressures. Patterns of pigmentation in natural populations from the Indian subcontinent are better predicted by latitude itself and temperature-related climatic variables.

Prevalence and determinants of unprotected sex in intimate partnerships of men who inject drugs: findings from a prospective intervention study

Unprotected sex, common among people who inject drugs, puts them and their partners at risk of sexually transmitted infections including human immunodeficiency virus (HIV). This analysis assesses the changes in sexual risk behavior with regular female partners (RFPs), among married men who inject drugs, before and after implementation of a HIV prevention intervention, and identifies correlates of unprotected sex. People who inject drugs (PWID) were assessed at three points: baseline, preintervention follow-up visit (FV)1, and postintervention FV2. Descriptive analysis was used for reporting changes in sexual behavior over time. Generalized estimating equation assessed the population-averaged change in self-reported unprotected sex with an RFP, attributable to intervention uptake. Multivariable logistic regression determined correlates of self-reported unprotected sex with an RFP at FV2. Findings suggest that the proportion of men reporting any unprotected sex remained high (baseline = 46.0%, FV1 = 43.5%, FV2 = 37.0%). A reduction was observed in unprotected sex after the intervention phase, but this could not be attributed to uptake of the intervention. Higher odds of self-reported unprotected sex with an RFP in the past three months at FV2 were associated with self-reported unprotected sex at baseline, living with family, and being HIV-negative. Married male PWID should receive counseling for safe sex with RFPs, especially those who are HIV-negative and live with their families.

Genomic insights into virulence mechanisms of Leishmania donovani: evidence from an atypical strain

Background

Leishmaniasis is a neglected tropical disease with diverse clinical phenotypes, determined by parasite, host and vector interactions. Despite the advances in molecular biology and the availability of more Leishmania genome references in recent years, the association between parasite species and distinct clinical phenotypes remains poorly understood. We present a genomic comparison of an atypical variant of Leishmania donovani from a South Asian focus, where it mostly causes cutaneous form of leishmaniasis.

Results

Clinical isolates from six cutaneous leishmaniasis patients (CL-SL); 2 of whom were poor responders to antimony (CL-PR), and two visceral leishmaniasis patients (VL-SL) were sequenced on an Illumina MiSeq platform. Chromosome aneuploidy was observed in both groups but was more frequent in CL-SL. 248 genes differed by 2 fold or more in copy number among the two groups. Genes involved in amino acid use (LdBPK_271940) and energy metabolism (LdBPK_271950), predominated the VL-SL group with the same distribution pattern reflected in gene tandem arrays. Genes encoding amastins were present in higher copy numbers in VL-SL and CL-PR as well as being among predicted pseudogenes in CL-SL. Both chromosome and SNP profiles showed CL-SL and VL-SL to form two distinct groups. While expected heterozygosity was much higher in VL-SL, SNP allele frequency patterns did not suggest potential recent recombination breakpoints. The SNP/indel profile obtained using the more recently generated PacBio sequence did not vary markedly from that based on the standard LdBPK282A1 reference. Several genes previously associated with resistance to antimonials were observed in higher copy numbers in the analysis of CL-PR. H-locus amplification was seen in one cutaneous isolate which however did not belong to the CL-PR group.

Conclusions

The data presented suggests that intra species variations at chromosome and gene level are more likely to influence differences in tropism as well as response to treatment, and contributes to greater understanding of parasite molecular mechanisms underpinning these differences. These findings should be substantiated with a larger sample number and expression/functional studies.

Electronic supplementary material

The online version of this article (10.1186/s12864-018-5271-z) contains supplementary material, which is available to authorized users.

Late diagnosis of human immunodeficiency virus infections in high-risk groups in Karachi, Pakistan

Human immunodeficiency virus (HIV) infection prevalence in Pakistan has been increasing in high-risk groups, including people who inject drugs (PWID) and transgender hijra sex workers (TG-HSWs) nationwide. Effective control of HIV requires early diagnosis of the infection. We investigated recency of HIV infections in newly-diagnosed cases in PWID and TG-HSWs. This was an observational study with convenience sampling. Overall, 210 HIV-positive subjects comprising an equal number of PWID and TG-HSWs were included. Antibody avidity was tested using the Maxim HIV-1 Limiting Antigen Avidity (LAg) EIA (Maxim Biomedical, Inc. Rockville, Maryland, USA). The mean age of study subjects was 29.5 years: PWID, 28.5 years and TG-HSWs, 30.4 years. Study subjects were married, 27%, or unmarried. Eighteen percent of individuals had recently-acquired HIV infections: 19% of PWID and 17% of TG-HSWs. Eighty-two percent of individuals had long-term HIV infections: 81% of PWID and 83% of TG-HSWs. This is the first study identification of recent HIV-1 infections in Pakistan. We show that most newly-diagnosed HIV patients in the high-risk groups studied had long-term infections. There is an urgent need for intervention in these groups to facilitate early diagnosis and treatment of HIV infection to reduce transmission in Pakistan.

Mutation Spectrum of GNE Myopathy in the Indian Sub-Continent

BACKGROUND

GNE myopathy is an adult onset recessive genetic disorder that affects distal muscles sparing the quadriceps. GNE gene mutations have been identified in GNE myopathy patients all over the world. Homozygosity is a common feature in GNE myopathy patients worldwide.

OBJECTIVES

The major objective of this study was to investigate the mutation spectrum of GNE myopathy in India in relation to the population diversity in the country.

MATERIALS AND METHODS

We have collated GNE mutation data of Indian GNE myopathy patients from published literature and from recently identified patients. We also used data of people of Indian subcontinent from 1000 genomes database, South Asian Genome database and Strand Life Science database to determine frequency of GNE mutations in the general population.

RESULTS

A total of 67 GNE myopathy patients were studied, of whom 21% were homozygous for GNE variants, while the rest were compound heterozygous. Thirty-five different mutations in the GNE gene were recorded, of which 5 have not been reported earlier. The most frequent mutation was p.Val727Met (65%) found mainly in the heterozygous form. Another mutation, p.Ile618Thr was also common (16%) but was found mainly in patients from Rajasthan, while p.Val727Met was more widely distributed. The latter was also seen at a high frequency in general population of Indian subcontinent in all the databases. It was also present in Thailand but was absent in general population elsewhere in the world.

CONCLUSION

p.Val727Met is likely to be a founder mutation of Indian subcontinent.

Foot-and-Mouth Disease in the Middle East Caused by an A/ASIA/G-VII Virus Lineage, 2015-2016

Phylogenetic analyses of foot-and-mouth disease type A viruses in the Middle East during 2015-2016 identified viruses belonging to the A/ASIA/G-VII lineage, which originated in the Indian subcontinent. Changes in a critical antigenic site within capsid viral protein 1 suggest possible evolutionary pressure caused by an intensive vaccination program.

Unsafe injecting practices, sexual risk behaviours and determinants of HIV among men who inject drugs: Results from Integrated Biological and Behavioural Surveillance in India

In India, while an overall reduction in HIV is achieved among most key populations, the continued higher prevalence among people who inject drugs (PWIDs) is an area of concern. This paper analyses unsafe injecting and sexual risk behaviours in male PWIDs according to HIV status and also examines the determinants of HIV infection in this high-risk group. Data from India's Integrated Biological and Behavioural Surveillance, conducted across 29 Indian states and Union Territories among 19,902 male PWIDs, were used. Informed consent was obtained and men aged 15 years or more, who used psychotropic substances or drugs in the past three months for non-medical reasons were recruited for the survey. Results from the multivariable analysis suggest that drug use debut at age 25 years or above (adjusted odds ratio [AOR]: 1.41, confidence interval [CI]: 1.05-1.88), engagement in drug use for a longer duration (AOR: 1.81, CI: 1.32-2.48), injecting three times or more per day (AOR: 1.53, CI: 1.1-2.12), sharing of needle/syringes (AOR: 1.34, CI: 1.02-1.76), self-reported sexually transmitted infections (AOR: 1.55, CI: 1.12-2.14) and higher self-risk perception for exposure to HIV (AOR: 2.08, CI: 1.58-2.75) increase the likelihood of HIV infection. Sustained higher prevalence, unsafe injecting and risky sexual practices are major challenges which may prevent India from reaching the 'end of AIDS' by 2030. This underscores the need for adoption of a tailored, evidence-driven HIV prevention approach that adequately addresses local needs to limit the spread of HIV within this population, and thereby prevents the onward transmission of HIV to the general population.

Leishmaniasis: current challenges and prospects for elimination with special focus on the South Asian region

Leishmania donovani, the most virulent species of Leishmania, is found in the South Asian region that harbours the majority of visceral leishmaniasis (VL) cases in the world. The traditionally accepted relationships between the causative species of Leishmania and the resultant disease phenotype have been challenged during recent years and have underscored the importance of revisiting the previously established taxonomy with revisions to its classification. The weak voice of the afflicted with decades of neglect by scientists and policy makers have led to the miserably inadequate and slow advancements in product development in the fields of diagnostics, chemotherapeutics and vector control that continue to hinder the effective management and control of this infection. Limitations notwithstanding, the regional drive for the elimination of VL initiated over a decade ago that focused on India, Nepal and Bangladesh, the three main afflicted countries in the Indian subcontinent is therefore, commendable, with the subsequent status reviews and restructuring of strategies possibly even more so. However, the renewed efforts would need to be combined with plans to combat new challenges in the South-Asian region that includes the emergence of atypical parasite variants, in order to realistically achieve the set goal of regional elimination of VL.

The Geographic Origins of Ethnic Groups in the Indian Subcontinent: Exploring Ancient Footprints with Y-DNA Haplogroups

Several studies have evaluated the movements of large populations to the Indian subcontinent; however, the ancient geographic origins of smaller ethnic communities are not clear. Although historians have attempted to identify the origins of some ethnic groups, the evidence is typically anecdotal and based upon what others have written before. In this study, recent developments in DNA science were assessed to provide a contemporary perspective by analyzing the Y chromosome haplogroups of some key ethnic groups and tracing their ancient geographical origins from genetic markers on the Y-DNA haplogroup tree. A total of 2,504 Y-DNA haplotypes, representing 50 different ethnic groups in the Indian subcontinent, were analyzed. The results identified 14 different haplogroups with 14 geographic origins for these people. Moreover, every ethnic group had representation in more than one haplogroup, indicating multiple geographic origins for these communities. The results also showed that despite their varied languages and cultural differences, most ethnic groups shared some common ancestors because of admixture in the past. These findings provide new insights into the ancient geographic origins of ethnic groups in the Indian subcontinent. With about 2,000 other ethnic groups and tribes in the region, it is expected that more scientific discoveries will follow, providing insights into how, from where, and when the ancestors of these people arrived in the subcontinent to create so many different communities.

Cryptosporidiosis in children in the Indian subcontinent

Cryptosporidiosis is a leading cause of diarrheal disease among children under two in developing countries. Previous estimates have shown a high burden of cryptosporidial diarrhea in children from Sub-Saharan Africa and South Asia. Asymptomatic cryptosporidial infections which go undetected and untreated have been shown to result in significant malnutrition. In this review, we carried out a literature search of studies published on cryptosporidiosis in children in the Indian subcontinent from 1983 to 2016. Of the 154 publications identified, 54 were included for final analysis with both hospital-based and community-based studies. There were wide variations in reported prevalence rates from hospital studies and highlight the need to be carry out these studies with uniform sampling and molecular tools for detection, especially in countries with a dearth of information. Community-based studies, however, showed similarities in spite of differences in when (the late 1990s up until recently) and where (South India or Bangladesh) they were conducted. When more sensitive detection methods were used, cryptosporidial diarrhea accounted for 7%–9% of all diarrhea episodes and 20%–30% of children in these cohorts experienced at least one cryptosporidial diarrheal episode. High rates of asymptomatic infections with increased detection by serology and multiple infections (symptomatic and asymptomatic) were also documented in all cohorts. This overview brings to light the high burden of disease associated with cryptosporidiosis in children in the subcontinent and the gaps in knowledge to be addressed.

Elimination of visceral leishmaniasis in the Indian subcontinent: a comparison of predictions from three transmission models

We present three transmission models of visceral leishmaniasis (VL) in the Indian subcontinent (ISC) with structural differences regarding the disease stage that provides the main contribution to transmission, including models with a prominent role of asymptomatic infection, and fit them to recent case data from 8 endemic districts in Bihar, India. Following a geographical cross-validation of the models, we compare their predictions for achieving the WHO VL elimination targets with ongoing treatment and vector control strategies. All the transmission models suggest that the WHO elimination target (<1 new VL case per 10,000 capita per year at sub-district level) is likely to be met in Bihar, India, before or close to 2020 in sub-districts with a pre-control incidence of 10 VL cases per 10,000 people per year or less, when current intervention levels (60% coverage of indoor residual spraying (IRS) of insecticide and a delay of 40days from onset of symptoms to treatment (OT)) are maintained, given the accuracy and generalizability of the existing data regarding incidence and IRS coverage. In settings with a pre-control endemicity level of 5/10,000, increasing the effective IRS coverage from 60 to 80% is predicted to lead to elimination of VL 1-3 years earlier (depending on the particular model), and decreasing OT from 40 to 20days to bring elimination forward by approximately 1year. However, in all instances the models suggest that L. donovani transmission will continue after 2020 and thus that surveillance and control measures need to remain in place until the longer-term aim of breaking transmission is achieved.

Highly Pathogenic Reassortant Avian Influenza A(H5N1) Virus Clade 2.3.2.1a in Poultry, Bhutan

Highly pathogenic avian influenza A(H5N1), clade 2.3.2.1a, with an H9-like polymerase basic protein 1 gene, isolated in Bhutan in 2012, replicated faster in vitro than its H5N1 parental genotype and was transmitted more efficiently in a chicken model. These properties likely help limit/eradicate outbreaks, combined with strict control measures.

Insecticide resistance in phlebotomine sandflies in Southeast Asia with emphasis on the Indian subcontinent

BACKGROUND

Visceral leishmaniasis, commonly known as kala-azar in India, is a global public health problem. In Southeast Asia, Bangladesh, Bhutan, India, Nepal, Sri Lanka and Thailand are endemic for visceral leishmaniasis. The role of sandflies as the vector of kala-azar was first confirmed in 1942 in India. Insecticide resistance in Phlebotomus argentipes Annandale and Brunetti, the vector of kala-azar in the Indian subcontinent, was first reported in 1987 in Bihar, India. This article provides a scoping review of the studies undertaken from 1959 to 2015 on insecticide resistance in P. argentipes and P. papatasi (Scopoli), the vectors of visceral and cutaneous leishmaniasis respectively, in Southeast Asia, mainly in Bangladesh, India, Nepal and Sri Lanka.

RESULTS

Studies undertaken in areas of Bihar and West Bengal in India where kala-azar is endemic have reported resistance of P. argentipes to DDT, while in non-endemic areas it has been reported to be susceptible. In areas of Nepal bordering India, there are indications of resistance to DDT; biochemical resistance has been reported in Sri Lanka. No laboratory studies have been undertaken in Bangladesh; however, the sandfly vector is reported to be still susceptible to pyrethroids in all kala-azar endemic areas in the aforementioned countries.

CONCLUSIONS

Studies are needed to determine the resistance of sandfly vectors to all available classes of potential insecticides in kala-azar endemic areas. There is a need to assess the impact of indoor residual spraying with DDT and pyrethroids on the incidence of kala-azar in India where 54 districts remain endemic for the disease, strengthen entomological surveillance capacity, and develop and implement an insecticide management plan. Alpha-cypermethrin indoor residual spraying has been introduced in 33 kala-azar endemic districts in Bihar State of India in a pilot trial; the outcomes should be used to inform decisions on expanding coverage with alpha-cypermethrin in all remaining endemic districts to achieve the revised goal of elimination of visceral leishmaniasis by 2020.

Use of a Macintosh blade in extrahepatic portal vein obstruction with difficult intubation: two case reports

Background

We report the management of two patents from the Indian subcontinent with extrahepatic portal vein obstruction presenting with anticipated difficult airway. A Macintosh blade was used to secure the airway after using various instruments designed for difficult airway. To the best of our knowledge, no case has previously been reported in which a Macintosh blade was used successfully in patients with extrahepatic portal vein obstruction with a difficult airway.

Case presentation

Two women (case 1 and case 2) of South Asian ethnicity with extrahepatic portal vein obstruction presented for an elective splenorenal shunt. They both had micrognathia and restricted mouth openings. They had similar airway profiles with mouth openings of just 2 cm, Mallampati class IV, a thyromental distance <4 cm, a hyomental distance <2.5 cm, and a sternomental distance of 10 cm. Awake intubation was attempted in both patients after standard airway preparation in the form of preoperative 4 % lignocaine nebulization and 2 % viscous lignocaine gargle along with an on-table supralaryngeal nerve block using 2 % lignocaine and transtracheal infiltration with 4 % lignocaine.

The patient in case 1 tolerated the procedure well whereas the patient in case 2 had to be given propofol 60 mg. Endotracheal intubation with a 6.5 mm polyvinyl chloride endotracheal tube was attempted using a Truview EVO2, an Airtraq, and a Miller blade no. 3 but was unsuccessful. Finally, a trial intubation was performed successfully with a Macintosh blade with a stubby handle assisted by a Frova Intubating Introducer in case 1 and a gum elastic bougie in case 2.

Conclusions

Although many instruments have been introduced to manage difficult airways, our experience in these cases suggests that the Macintosh blade can be used first when attempting endotracheal intubation before using other instruments. Patients from the Indian subcontinent with extrahepatic portal vein obstruction are often found to have associated temporomandibular joint ankyloses (hence difficult airways). We hypothesize that a difficult intubation should be anticipated in these patients. Such an association has not been made before.

Nerve abscess in Hansen's disease as part of immune reconstitution inflammatory syndrome: a case report

Immune reconstitution inflammatory syndrome is an inflammatory reaction in HIV-infected patients after initiation of antiretroviral therapy resulting from restored immunity to specific infectious or non-infectious antigens. A 36-year-old male patient on highly active antiretroviral therapy of six months duration, presented with reddish, tender lesions over medial aspect of arm and a single, anaesthetic patch. Tender fluctuant swellings were seen on the medial aspect of left forearm. A few of them had ruptured spontaneously discharging pus. A skin biopsy from the anaesthetic patch showed caseating epitheloid granulomas. A diagnosis of Hansen's disease borderline tuberculoid in type 1 reversal reaction, with formation of nerve abscess due to Immune Reconstitution Inflammatory Syndrome was made. The patient was started on multibacillary multidrug therapy as per WHO guidelines and highly active antiretroviral therapy was continued.