Species distribution and anti-fungal susceptibility of Candidaemia at a multi super-specialty center in Southern India

Candidaemia is one of the leading causes of nosocomial bloodstream infections. There is a rise in the incidence of non-albicans candidaemia and emergence of anti-fungal resistance. We performed a retrospective laboratory-based study over a period of 2 years (January 2009 to December 2010) at our quaternary care multi super-specialty hospital in Southern India. There had been 68 Candida isolates detected from the bloodstream of 55 patients during the study period. Overall, 74% of cases were due to non-albicans Candida. C. tropicalis was most commonly isolated (39.7%), followed by C. albicans (26.4%). All Candida isolates remain susceptible to voriconazole, whereas highest degree of resistance was observed for fluconazole.

Skeletal fluorosis due to excessive tea and toothpaste consumption

We describe the case of a 53-year-old woman who presented with a metatarsal fracture and was found to have a bone mineral density (BMD) T-score of +11 in the lumbar spine and +7.6 in the hip. Subsequent investigation revealed very high serum, urine and tissue fluoride levels, associated with excessive tea and toothpaste consumption. The case emphasises the need to exclude fluorosis in individuals with unexpectedly high BMD levels.

First Report of Garlic virus X Infecting Garlic in India

Garlic (Allium sativum) is an important crop in several states of India. Filamentous viruses such as Onion yellow dwarf virus (OYDV), Shallot latent virus (SLV), and Garlic common latent virus (GarCLV) have been reported previously in different garlic cultivars from India (4). These viruses are transmitted from generation to generation through cloves and cause severe reduction in yield and quality. During December 2010, garlic plants were observed with mosaic leaf symptoms and stunting in an experimental field at the Indian Agricultural Research Institute, Delhi. Cloves and leaves from 3-month-old symptomatic plants of five different cultivars (G-282, IC-375416, Ruag, Yamuna Safed, and ACC-40), originally from different regions of India, were collected from the field in Delhi and total RNA was extracted using an RNeasy Plant Mini Kit (Qiagen, Valencia, CA). The presence of OYDV and GarCLV was confirmed by reverse transcription (RT)-PCR in all cultivars, while the presence of SLV was only confirmed in cv. G-282 by RT-PCR. Since Allexiviruses are common in garlic, their detection in cloves was confirmed by RT-PCR using primers ALLEX 1 and ALLEX 2 (2). An ~200-bp amplification product was observed in all five cultivars. To further characterize the Allexivirus in these cultivars, an amplicon of ~900 bp was amplified with Allex-CP (1) and ALLEX 2 (2) primers and cloned and sequenced. BLAST analysis of the nucleotide sequences from five garlic cultivars showed identity with different allexiviruses, Garlic virus A (GarV-A) (74 to 83%), Garlic virus E (GarV-E) (74 to 80%), Garlic virus D (GarV-D) (76 to 79%), and Garlic virus X (GarV-X) (75 to 78%). Since species demarcation in the genus Allexivirus is based on the coat protein (CP) gene (3), another set of primers, 5'-MYT KGA GTG GCT VAC ACA YAT-3' and 5'-ATT RAA GTC GTG RGG ATG CAT-3' was designed. These primers were derived from conserved regions of ORF4 and ORF5 (CP) sequences of allexiviruses available in the NCBI database and used in RT-PCR to obtain the complete CP. An ~1.5-kb amplicon was obtained only in cv. G-282 that originated from the southern part of India. A similar amplicon was obtained from Chenopodium amaranticolor mechanically inoculated with leaf sap from cv. G-282. Sequences (1,422 bp) obtained from three clones each from garlic cv. G-282 and C. amaranticolor were identical and BLAST analysis of the consensus nucleotide sequence showed maximum identity of 75 to 81% with isolates of GarV-X. The 1,422 nucleotide sequence was comprised of 690 bp of ORF4 (partial) and 732 bp of the CP. The coat protein sequence (GenBank Accession No. HQ822272) shared a 79.6 to 81.1% identity in nucleotide and 89.3 to 90.9% in amino acid sequence with different isolates of GarV-X (GenBank Accession Nos. AJ292229, U89243, and GQ475426). To our knowledge, this is the first report of GarV-X in a garlic cultivar from India. The characterization and identification of allexiviruses is important for production of virus-free garlic plants through tissue culture in India. References: (1) J. Chen et al. Arch. Virol. 149:435, 2004. (2) C. I. Dovas et al. J. Phytopathol.149:731, 2001. (3) C. M. Fauquet et al. Virus Taxonomy-VIIIth Report of the ICTV, Academic Press, London, 2005. (4) S. Majumder and V. K. Baranwal. Plant Dis. 93:106, 2009.

Churg-strauss syndrome without respiratory symptoms in a child

Churg-Strauss Syndrome (CSS) is rare in children. It consists of a small- and medium-sized vessel vasculitis, with skin and peripheral nerve involvement. It is characterized by eosinophilia, extravascular necrotizing granuloma, and eosinophilic infiltration of multiple organs particularly the lungs, but may also involve the gastrointestinal tract, the heart, and the kidneys. The condition is usually associated with a preceding history of asthma or allergic sinusitis. It has rarely been reported in children, where most of the cases had pre-existing asthma, allergic rhinitis, or atopic disease. We report a 10-year-old Arab girl proven to have CSS, with no history of asthma or allergic rhinitis, who presented with tender cutaneous nodules of lower extremities, foot drop, and peripheral eosinophilia, without any clinical respiratory symptoms or signs.

Probabilistic Relational Planning with First Order Decision Diagrams

Dynamic programming algorithms have been successfully applied to propositional stochastic planning problems by using compact representations, in particular algebraic decision diagrams, to capture domain dynamics and value functions. Work on symbolic dynamic programming lifted these ideas to first order logic using several representation schemes. Recent work introduced a first order variant of decision diagrams (FODD) and developed a value iteration algorithm for this representation. This paper develops several improvements to the FODD algorithm that make the approach practical. These include, new reduction operators that decrease the size of the representation, several speedup techniques, and techniques for value approximation. Incorporating these, the paper presents a planning system, FODD-Planner, for solving relational stochastic planning problems. The system is evaluated on several domains, including problems from the recent international planning competition, and shows competitive performance with top ranking systems. This is the first demonstration of feasibility of this approach and it shows that abstraction through compact representation is a promising approach to stochastic planning.

Papillary thyroid carcinoma presenting as a lateral neck cyst

BACKGROUND

Solitary lateral cervical cystic mass is an uncommon presentation of papillary thyroid carcinoma.

OBJECTIVES

To report our recent experience in the diagnosis and management of papillary thyroid carcinoma presenting as a lateral neck cyst.

METHODS

Patients who had papillary thyroid carcinoma and presented as a painless lateral neck cyst at the Department of Surgery, Al-Ain Hospital, from April 2005 to June 2009 were retrospectively studied. Their clinical presentation, diagnosis and management were reviewed.

RESULTS

Five patients were studied. No thyroid nodules were clinically palpable in all patients. Fine needle aspiration cytology from the cyst was positive for papillary thyroid carcinoma in three patients (60 percent). Two patients were diagnosed after excisional biopsy. Three patients had total thyroidectomy with modified radical neck dissection and postoperative radioactive iodine ablation. Two patients preferred to travel overseas for treatment. Thyroid histopathological examination has shown papillary thyroid carcinoma in all operated patients with multiple microscopic foci in two of them. This was associated with multiple bilateral cervical lymph node involvement.

CONCLUSIONS

Metastatic papillary thyroid carcinoma presenting as a neck cyst is a diagnostic challenge. Excisional biopsy is indicated if fine needle aspiration cytology was inconclusive so as to rule out malignancy.

Hospital antibiogram: a necessity

The hospital antibiogram is a periodic summary of antimicrobial susceptibilities of local bacterial isolates submitted to the hospital's clinical microbiology laboratory. Antibiograms are often used by clinicians to assess local susceptibility rates, as an aid in selecting empiric antibiotic therapy, and in monitoring resistance trends over time within an institution. Antibiograms can also used to compare susceptibility rates across institutions and track resistance trends. Some hospitals have adequate support from the computer department to be able to extract data from their reporting module. The WHONET software can be freely downloaded and used for analysis. Consensus guidelines have been developed by the Clinical and Laboratory Standards Institute (CLSI) to standardise methods used in constructing antibiograms. These guidelines can be incorporated into the WHONET software for analysis. Only the first isolate from the patient is to be included in the analysis. The analysis should be done on the basis of patient location and specimen type. The percentage susceptibility of the most frequently isolated bacteria should be presented in the antibiogram, preferably in a tabular form. The antibiogram must be printed or put up in the intranet for easy access to all clinicians. Antibiotic policy is one of the mandatory requirements for accreditation, and making an antibiogram is the first step before framing the antibiotic policy. The future of antibiograms would be the incorporation of patient related data to make information more reliable and for predicting outbreaks.

Does the 'P300' speller depend on eye gaze?

Many people affected by debilitating neuromuscular disorders such as amyotrophic lateral sclerosis, brainstem stroke or spinal cord injury are impaired in their ability to, or are even unable to, communicate. A brain-computer interface (BCI) uses brain signals, rather than muscles, to re-establish communication with the outside world. One particular BCI approach is the so-called 'P300 matrix speller' that was first described by Farwell and Donchin (1988 Electroencephalogr. Clin. Neurophysiol. 70 510-23). It has been widely assumed that this method does not depend on the ability to focus on the desired character, because it was thought that it relies primarily on the P300-evoked potential and minimally, if at all, on other EEG features such as the visual-evoked potential (VEP). This issue is highly relevant for the clinical application of this BCI method, because eye movements may be impaired or lost in the relevant user population. This study investigated the extent to which the performance in a 'P300' speller BCI depends on eye gaze. We evaluated the performance of 17 healthy subjects using a 'P300' matrix speller under two conditions. Under one condition ('letter'), the subjects focused their eye gaze on the intended letter, while under the second condition ('center'), the subjects focused their eye gaze on a fixation cross that was located in the center of the matrix. The results show that the performance of the 'P300' matrix speller in normal subjects depends in considerable measure on gaze direction. They thereby disprove a widespread assumption in BCI research, and suggest that this BCI might function more effectively for people who retain some eye-movement control. The applicability of these findings to people with severe neuromuscular disabilities (particularly in eye-movements) remains to be determined.

Primary pleuro-pulmonary synovial sarcoma

Primary pleuro-pulmonary synovial sarcoma (PPSS) is a rare tumour and poses adiagnostic challenge particularly when unusual histological features are present. We report a case of a 30-year-old immunocompromised human immunodeficiency virus (HIV) sero-positive male who was referred to us with complaints of cough, breathlessness and left-sided chestpain for the past two months. The PPSS can be confirmed on tru-cut biopsy.

Correlations between genotyping and antibiograms of clinical isolates of Pseudomonas aeruginosa from three different south Indian hospitals

PURPOSE

To compare the molecular relationships and antibiograms of nosocomial isolates of Pseudomonas aeruginosa obtained from three different genres of hospitals located in Southern India, two located at Hyderabad (one private hospital and an ophthalmic hospital) and one in Puducherry (tertiary care teaching hospital). Each of these hospitals, which follow different infection control strategies and various problems associated with it, were investigated.

MATERIALS AND METHODS

Antibiograms generated by disk diffusion susceptibility testing for clinically relevant antibiotics and genotyping through fluorescent amplified fragment length polymorphism analysis (fAFLP) were the tools used in the study.

RESULTS

Molecular genotyping revealed a heterogeneous group of unrelated molecular clusters of P. aeruginosa strains having higher resistance that are apparently being endemic throughout the tertiary care teaching hospital. In eye care hospital, only a few distinct strains of P. aeruginosa predominating the study period were shown to be responsible for outbreaks. The third private hospital witnessed a group of resistant and persistent strains that might have clonally originated from a diverse collection of strains.

CONCLUSIONS

The divergent kind of strains in our study suggests that there may be a direct link between the infection control practices followed in each hospital and kind of strains isolated in that particular setup. The study also emphasizes the need for maintaining infection control practices in hospitals with superior standards, failure of which might result in thriving of persistent P. aeruginosa clones in the hospitals.

Preventive effect of crocin of Crocus sativus on hemodynamic, biochemical, histopathological and ultrastuctural alterations in isoproterenol-induced cardiotoxicity in rats

We investigated the effects of crocin, a pharmacologically active constituent of Crocus sativus L., in isoproterenol (ISO)-induced cardiotoxicity with reference to hemodynamic, antioxidant, histopathological and ultrastructural parameters. Rats were administered crocin (5, 10 and 20mg/kg/day) or vehicle orally for 21 days along with ISO (85mg/kg, subcutaneously, at 24h interval) on 20th and 21st day. On 22nd day ISO-control rats showed cardiac dysfunction as indicated by lowering of systolic, diastolic and mean arterial blood pressures. In addition, a significant decrease in maximum positive and negative rate of developed left ventricular pressure (+/-LVdp/dt(max)) and an increase in left ventricular end-diastolic pressure (LVEDP) were observed. Furthermore, a marked reduction in the activities of myocardial creatine kinase-MB (CK-MB) isoenzyme, lactate dehydrogenase (LDH), superoxide dismutase (SOD), catalase (CAT), and reduced glutathione (GSH) levels along with an increase in content of malondialdehyde (MDA) were observed. Myocardial necrosis, edema and inflammation were evident from the light microscopic and ultrastructural changes. Crocin at the dose of 20mg/kg/day significantly modulated hemodynamic and antioxidant derangements. The preventive role of crocin on ISO-induced MI was reconfirmed by histopathological and ultrastructural examinations. The effect at the dose of 20mg/kg/day of crocin was more pronounced than that of other two doses (5 and 10mg/kg/day). The results suggest that crocin may have cardioprotective effect in ISO-induced cardiac toxicity through modulation of oxidative stress in such a way that maintains the redox status of the cell.

The Lost Generation: Impact of the 56-hour EWTD on Current Surgical Training

The reform of specialist surgical training – the New Deal (1991), the Calman report (1993) and the implementation of the European Working Time Directive (EWTD, 1998) – has resulted in shorter training periods with reduced working hours. The Calman reform aimed to improve and structure training with regular assessment and supervision whereas the New Deal and the EWTD have concentrated predominantly on a reduction in hours. The adoption of full or partial shift work to provide surgical cover at night compliant to a 56-hour working week, as stipulated by phase one of the EWTD, has resulted in daytime hospital attendance for surgical trainees of an average three days per week despite almost universal acknowledgement of the limited training opportunities available at night.

Biology of the mealybug, Phenacoccus solenopsis on cotton in the laboratory

Phenacoccus solenopsis Tinsley (Hemiptera: Pseudococcidae) has been the current topic of research for insect taxonomists and applied entomologists in India due to its invasiveness, rapid spread, morphological and biological variations and the need for establishing an effective control strategy. The biology of the mealybug P. solenopsis was studied on cotton under laboratory conditions between August and October of 2009 with mean temperature and relative humidity of 23.3–30.2° C and 40.5–92.5% RH, respectively, in central India. Neonate crawlers that emerged from a field population were collected and constituted the study population. The developmental period from immature crawler to adult stage was greater for males (18.7 ± 0.9 days) compared to females (13.2 ± 1.8 days), probably due to the additional molt to the pupal stage in males. Survival of second instars was lower (45.5%) than first and third instars (71.4%). Females showed dynamic patterns of fecundity with the number of crawlers produced per female ranging between 128 and 812, with a mean of 344 ± 82. The reproductive period lasted 30.2 ± 8.2 days. Parthenogenesis with ovoviviparity (96.5%) was dominant over the oviparous (3.5%) mode of reproduction. Adult females lived 42.4 ± 5.7 days. Males accounted for less than 5% of the population, and lived 1.5 ± 0.1 days. The life history parameters of P. solenopsis adult females are discussed relative to the appearance of symptoms on the cotton crop, and the importance of making management interventions during the effective reproductive period of the insect.

Slow intracellular accumulation of GABA(A) receptor delta subunit is modulated by brain-derived neurotrophic factor

GABA(A) receptors composed of the gamma2 and delta subunits have distinct properties, functions and subcellular localization, and pathological conditions differentially modulate their surface expression. Recent studies demonstrate that acute seizure activity accelerated trafficking of the gamma2 and beta2/3 subunits but not that of the delta subunit. The trafficking of the gamma2 and beta2/3 subunits is relatively well understood but that of the delta subunit has not been studied. We compared intracellular accumulation of the delta and gamma2 subunits in cultured hippocampal neurons using an antibody feeding technique. Intracellular accumulation of the delta subunit peaked between 3 and 6 h, whereas, maximum internalization of the gamma2 subunit took 30 min. In the organotypic hippocampal slice cultures internalization of the delta subunit studied using a biotinylation assay revealed highest accumulation between 3 and 5 h and that of the gamma2 subunit between 15 and 45 min. The surface half-life of the delta subunit was 171 min in cultured hippocampal neurons and 102 min in the organotypic hippocampal slice cultures. In the subsequent studies, internalization of the delta subunit was found to be dependent on network activity but independent of ligand-binding. Brain-derived neurotrophic factor (BDNF) reduced buildup of the delta subunit in the cytoplasmic compartments and increased its surface expression, and this BDNF effect was independent of network activity. BDNF effect was mediated by activation of TrkB receptors, PLCgamma and PKC. Increase in the basal PKC activity augmented cell surface stability of the delta subunit. These results suggest that rate of intracellular accumulation of the delta subunit was distinct and modulated by BDNF.

Low-dose and high-dose synacthen tests and the hemodynamic response to hydrocortisone in acute traumatic brain injury

INTRODUCTION

In order to identify whether low-dose (1 microg) tetracosactide (Synacthen) testing may be preferable to high-dose (250 microg) testing in the diagnosis of adrenal insufficiency in traumatic brain injury (TBI), as suggested by studies in other forms of critical illness.

METHODS

We retrospectively reviewed the results of modified tetracosactide tests (involving administration of both low-dose and high-dose tetracosactide) conducted for clinical indications in patients in a neurocritical care unit within 10 days of TBI. Sixty-three modified tests were included and cortisol concentrations before and after administration of tetracosactide were extracted from the hospital records. Data were also extracted regarding hemodynamic response to empirical corticosteroid therapy, based on rapid weaning from vasoactive drugs.

RESULTS

Cortisol increments at 30 and 60 min following tetracosactide correlated well in the low-dose test (r(2) = 0.875, P < 0.0001). The mean cortisol concentration was 581 nmol/l at 30 min and 556 nmol/l at 60 min in the low-dose test. Cortisol increments following low-dose and high-dose testing correlated well overall (r(2) = 0.839, P < 0.0001), but results were discordant in 27 of 63 cases (43%) when the same diagnostic threshold was used. ROC curve analysis showed that both tests performed poorly in identifying hemodynamic steroid responsiveness (AUC 0.553 and 0.502, respectively).

CONCLUSIONS

In the low-dose tetracosactide test, it is sufficient to determine cortisol concentrations at baseline and at 30 min. Low-dose and high-dose tests give discordant results in a significant proportion of cases when using the same diagnostic threshold. Neither test can be used to guide the initiation of corticosteroid therapy in acute TBI.

Socio-economic status and the risk of liver cancer mortality: a prospective study in Korean men

OBJECTIVE

To examine the association between socio-economic status (SES) and liver cancer mortality among Korean men.

STUDY DESIGN

Prospective cohort study

METHODS

Data were acquired from a large, prospective cohort study that included 548,530 civil service workers aged 30-59 years who had undergone health examination in 1998 provided by the Korean National Health Insurance System. Information on lifestyle and demographic characteristics was acquired through self-administered questionnaires. The main outcome event was mortality from liver cancer. Cox proportional hazards model was used to estimate relative risks (RRs) and 95% confidence intervals (95% CIs) after adjusting for age, body mass index, fasting serum glucose, alcohol consumption, smoking and hepatitis B surface antigen (HBsAg) status.

RESULTS

Liver cancer mortality differentials relating to SES were statistically significant and consistent in the fully adjusted model. Compared with the highest SES category, excess risk associated with liver cancer mortality was observed with decreasing SES levels: the RRs in the upper middle, lower middle and low SES categories were 1.35 (95% CI 1.13-1.61), 1.54 (95% CI 1.28-1.86) and 1.72 (95% CI 1.45-2.04), respectively. There was no effect modification by HBsAg status on the association between SES and liver cancer mortality.

CONCLUSIONS

This study demonstrated an inverse association between SES and liver cancer mortality, suggesting that SES is an independent predictor of liver cancer mortality. The policies and interventions regarding prevention of liver cancer need to focus on disadvantaged groups in order to reduce health disparities related to liver cancer.