Diagnosis of Paediatric Extrapulmonary Tuberculosis by the MPT64 Antigen at a Tertiary Care Hospital

Background Tuberculosis (TB) remains a global health concern, with India bearing a substantial burden. Paediatric TB, especially extrapulmonary TB (EPTB), presents unique diagnostic challenges due to its paucibacillary nature and the difficulty in obtaining suitable samples in children. Accurate and timely diagnosis is crucial to initiate appropriate treatment and mitigate disease spread. The MPT64 antigen test has shown promise in diagnosing TB, but its performance in paediatric EPTB remains underexplored. This study aimed to evaluate the diagnostic utility of the MPT64 antigen test in paediatric EPTB cases at a tertiary care hospital in India. Methods We conducted a prospective cross-sectional study at the Indira Gandhi Institute of Medical Sciences (IGIMS), a tertiary care hospital in India. A total of 250 paediatric participants, aged 0-18 years, with clinical suspicion of extrapulmonary tuberculosis (EPTB) were included. Diagnostic samples (e.g., tissue biopsies, pus, cerebrospinal fluid (CSF), and lymph node aspirates) were obtained, and tests including microscopy for acid-fast bacilli (AFB), mycobacterial cultures, GeneXpert MTB/RIF assay, and the TB Antigen MPT64 Rapid ICT Kit were performed. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of the MPT64 antigen test were calculated using culture and GeneXpert as reference standards. Results Among the 250 participants, 34 (13.6%) were confirmed to have EPTB. The MPT64 antigen test demonstrated a sensitivity of 70.6% and specificity of 92.1% in detecting EPTB cases. Mycobacterial cultures had the highest sensitivity (91.2%) and specificity (97.7%). GeneXpert showed a sensitivity of 70.6% and specificity of 93.9%. Overall diagnostic accuracy ranged from 88.7% for acid-fast bacteria (AFB) staining to 96.9% for mycobacterial cultures. The MPT64 antigen test had an area under the curve (AUC) of 0.814, indicating a good diagnostic accuracy. Conclusion The MPT64 antigen test demonstrates promising sensitivity and specificity for diagnosing paediatric EPTB, making it a valuable diagnostic tool, especially in resource-limited settings. However, mycobacterial cultures maintain the highest accuracy. Combining the MPT64 antigen test with other methods may enhance diagnostic capabilities.

Effectiveness of high flow nasal cannula (HFNC) versus bilevel positive airway pressure (BiPAP) in preventing tracheal reintubation in patients with high risk of extubation failure in intensive care unit - A randomised comparative trial

Background and Aims

The incidence of tracheal extubation failure in high-risk patients is higher, and non-invasive ventilation is suggested to avoid tracheal reintubation. This study compares the effectiveness of bilevel positive airway pressure (BiPAP) and high flow nasal cannula (HFNC) to reduce the rate of reintubation in intensive care unit (ICU) patients with increased risk of extubation failure.

Methods

This randomised comparative trial was conducted on 60 high-risk patients on mechanical ventilators admitted to the ICU, ready for weaning after a spontaneous breathing trial. They were randomised to Group H for HFNC and Group B for BiPAP therapy. Designated therapy was administered in these high-risk patients for up to 48 hours after tracheal extubation. Haemodynamic parameters [mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), a saturation of peripheral oxygen (SpO2), electrocardiogram (ECG)], arterial blood gas analysis (ABG) parameter [potential of hydrogen (pH), partial pressure of carbon dioxide (pCO2), partial pressure of oxygen/fraction of inspired oxygen (paO2/FiO2) ratio], the effectiveness of cough, comfort level was recorded and continuous monitoring for signs of respiratory distress and failure was done.

Results

Most of the patients were obese and had more than two risk factors for extubation failure. Several patients in Group B have significantly higher successful extubation than in Group H (P = 0.044). Most of the reintubation took place within 24 hours. The HFNC therapy was more comfortable and acceptable to patients.

Conclusion

BiPAP therapy was more efficient than HFNC in preventing tracheal reintubation among patients with a high risk of extubation failure.

Ayush [Indian System of Medicines] Prophylaxis Against COVID-19: A Living Systematic Review and Meta-Analysis (Second Update)

Background: Ayush (Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy) system of medicine has been extensively used in India for the prevention and management of coronavirus disease 2019 (COVID-19). The present report is the second update of a living systematic review and meta-analysis and has been intended to assess the preventive potential and safety of Ayush drugs against COVID-19. Methods: A search of databases such as PubMed, the Cochrane central register of controlled trials, the World Health Organization (WHO) COVID-19 database, the clinical trial registry-India, the AYUSH research portal, and preprint repositories was performed till March 1, 2023. Randomized controlled trials or analytical observational studies were included. Incidences of COVID-19 infections and mortality were taken as primary outcome measures; and symptomatic severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) infection, incidences of hospital admissions, and adverse events were taken as secondary outcomes. The risk of bias was evaluated by version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB-2) and the Risk of Bias in Non-Randomized Studies-of Interventions (ROBINS-I) tool. Data were synthesized through the RevMan 5.4 tool, and the certainty of the evidence was ranked through the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Results: Out of 2350 articles, 15 studies were included in the review. The pooled estimate of Guduchi [Tinospora cordifolia (Thunb.) Miers], Chyawanprasha, and Ayuraksha kit was obtained. Meta-analysis of the data suggested that Guduchi may reduce the incidences of COVID-19 infections (risk ratio [RR]: 0.67 [95% confidence interval, CI: 0.48-0.95]) and the symptom development among the infected (RR: 0.88 [95% CI: 0.73-1.08]), however, no change was observed in hospital admissions (RR: 0.96 [95% CI: 0.20-4.53]). It is uncertain that Chyawanprasha reduces the incidence of COVID-19 infection (RR: 0.28; [95% CI: 0.07-1.08]). Ayuraksha kit as chemoprophylaxis may reduce the incidences of COVID-19 infections (RR: 0.49; [95% CI: 0.32-0.77]). The certainty of the evidence was low to moderate mainly due to the serious risk of bias. Conclusion: Prophylactic use of Ayush medicines for populations at risk may help to prevent COVID-19 infection by reducing incidence and severity. However, considering the certainty and fewer studies, high-quality studies are still desired to confirm the efficacy and safety of Ayush chemoprophylaxis for COVID-19. Nevertheless, this update will serve as a torchbearer for policymakers, physicians, and other stakeholders for their decision-making through evidence-based medicine.

Case Report: An Atypical Case of Post-Kala-Azar Dermal Leishmaniasis with Ulcers and Verrucous Lesions: Clinical and Therapeutic Implications

About 75% cases of post-kala-azar dermal leishmaniasis (PKDL) occur in India. Although the classic description of PKDL is the progression from initial hypopigmented macular lesions to papules to plaques and nodular lesions, atypical morphologies are also seen and are easily missed or misdiagnosed. We report a case of a 27-year-old man who presented to us with multiple acral ulcers and verrucous lesions for 5 years. A diagnosis of PKDL was made based on slit skin smear, histopathology, and quantitative polymerase chain reaction. The patient was given combination therapy with four doses of liposomal amphotericin B and miltefosine 50 mg twice daily for 45 days. In this report, we discuss unusual morphologies of PKDL, the pathway to the diagnosis, and the therapeutic options available along with their efficacy.

Comparison of Cytokines Profiles and Monocyte Response Among Tuberculosis Patients Versus Patients Coinfected With Intestinal Helminth and Tuberculosis

Background Tuberculosis (TB) and intestinal helminth infections often coexist, posing a significant health challenge. TB, caused by Mycobacterium tuberculosis, and helminths elicit distinct immune responses - Th1 for TB and Th2 for helminths. Co-infection introduces a complex immunological challenge, potentially compromising TB control. This study addresses the research gap by comparing cytokine profiles and monocyte responses in TB patients, helminth-infected individuals, and those with both. Insights gained may enhance diagnosis, treatment, and disease control strategies where TB and helminths prevail. Methods A cross-sectional observational study conducted at Indira Gandhi Institute of Medical Sciences, Patna, Bihar, aimed to compare cytokine profiles and monocyte responses in TB patients and those coinfected with TB and helminths. The study included 150 newly diagnosed active TB individuals aged 18 to 65 years. TB diagnosis was confirmed through clinical assessment, sputum microscopy, and GeneXpert (Cepheid, Sunnyvale, CA, USA) testing. Stool examination employed various methods, including the Kato-Katz technique and formalin-ether concentration. Blood samples were collected for hematological analysis, cytokine profiling, and monocyte isolation. Statistical analysis, using SPSS version 20.0 (IBM Corp., Armonk, NY, USA), included descriptive statistics, and t-test analyses. Results In our study of 150 participants, half (50.0%) showed positive helminth status. The sociodemographic analysis revealed no significant differences in age, gender, education, occupation, marital status, smoking, alcohol, BMI, diabetes, and hypertension between TB patients (n=75) and TB+Helminth patients (n=75), ensuring baseline matching. The prevalence of specific helminth infections in TB+Helminth patients included Ascaris lumbricoides (24.0%), Trichuris trichiura (18.7%), and others. Hematological parameters showed significant differences, with TB+Helminth patients exhibiting higher RBC count, hemoglobin, hematocrit, neutrophil count, and monocyte count; also eosinophil count was more raised in TB+Helminth patients (0.36 x 103/μL) when compared to TB patients (0.25 x 103/μL). Cytokine profiles and monocyte responses varied significantly between the groups, with TB patients having higher IL-4, IL-6, IFN-γ, TNF-α, and IL-1β levels, while TB+Helminth patients had elevated IL-10. Monocyte response time did not differ significantly. Conclusion The observed differences in hematological parameters and cytokine profiles emphasize the need for tailored approaches to diagnosis and treatment in co-infected individuals. These findings suggest that the management of TB patients should consider the potential influence of helminth co-infections.

Comparative Evaluation of Broth Microdilution With Disc Diffusion and VITEK 2 for Susceptibility Testing of Colistin on Multidrug-Resistant Gram-Negative Bacteria

Background The rise of antibiotic resistance, particularly in Gram-negative bacteria, poses a significant global health threat. Colistin, a last-resort antibiotic, has witnessed renewed use. However, accurate susceptibility testing for colistin is challenging, with various methods available, leading to potential discrepancies. Ensuring reliable testing is crucial for effective patient treatment and antimicrobial stewardship. This study addresses the need to compare different colistin susceptibility testing methods, providing insights into their accuracy and relevance in clinical settings. Methods In this one-year prospective observational cross-sectional study conducted at Indira Gandhi Institute of Medical Sciences (IGIMS), Bihar, India, a tertiary care hospital from July 2021 to June 2022, we aimed to evaluate the concordance between two widely used methods, VITEK 2 and Disc Diffusion, for antibiotic susceptibility testing in clinical multidrug-resistant Gram-negative bacterial isolates. These isolates, including species like Klebsiella pneumoniae, Acinetobacter baumannii, Klebsiella oxytoca, Pseudomonas aeruginosa, Citrobacter freundii, and Escherichia coli, were isolated from various clinical specimens. After rigorous species-level identification and quality control measures, antibiotic susceptibility testing was performed using both methods, and their agreement was assessed through Percentage Agreement analysis. Results In our study, we isolated and identified bacterial isolates from 105 patients, with a mean age of 47.30 years, demonstrating a wide age range. Pus samples were the most common type (25.7%), and K. pneumoniae was the most prevalent organism (45.7%). Antibiotic resistance patterns revealed significant challenges in treating infections caused by K. pneumoniae and A. baumannii, with resistance rates exceeding 70% for certain antibiotics. Among the 48 isolates of K. pneumoniae, the agreement was 93.8%, with 89.6% being sensitive and 6.3% being resistant by Disc Diffusion, while VITEK 2 indicated 0% resistance. E. coli isolates (n=21) had an agreement of 90.5%, with 90.5% sensitivity and 9.5% resistance by Disc Diffusion, and no resistance by VITEK 2. Conclusion The comparative analysis of antibiotic susceptibility testing methods reveals the superior performance of the VITEK 2 system, particularly in sensitivity and negative predictive value, emphasizing its potential as a reliable tool for guiding antibiotic therapy decisions.

Comparative efficacy of Micropore™ surgical dressing, Tegaderm™ and Lockit plus® for lumbar epidural catheter fixation in children: a prospective parallel group randomized controlled trial

BACKGROUND

Proper fixation of an epidural catheter is necessary for desired drug effect and to prevent catheter displacement. Different techniques have been used for epidural catheter fixation. The aim of the study was to compare the relative efficacy of Micropore™ surgical dressing, Tegaderm™, and Lockit plus® in preventing lumbar epidural catheter migration in children.

METHODS

We studied 167 patients aged 5-16 years, for up to 48 h. After the elective abdominal or lower limb surgery. Patients were randomly assigned to one of three groups: (1) Micropore™ surgical dressing (group M), (2) Tegaderm™ (group T), or (3) Lockit plus® (group L). Incidence and extent of epidural catheter migration in centimetres (cm); was compared at 24 and 48 h post epidural fixation. Correlation between epidural catheter migration and patient characteristics, and relative incidence of complications in three groups was also analysed.

RESULTS

Incidence of catheter migration was 9.6% at 24 h (group M: 7.1%, group T: 21.1% and group L: 0%) and 45.5% at 48 h (group M: 66.1%, group T: 45.6% and group L: 24.1%). After 48 h, absolute migration (mean migration rounded off to the nearest 0.5 cm) was least in patients in group L: 0.34 cm (1.39) compared to group M 1.22 cm (SD: 1.85) group T: 0.94 cm (1.94) (p = <0.001).

CONCLUSION

Up to 48 h after surgery, the Lockit plus® device demonstrated the less epidural catheter migration when compared to micropore surgical dressing or tegaderm in children undergoing elective abdominal or lower limb surgery.

Covalent organic frameworks (COFs) and metal-organic frameworks (MOFs) as electrochemical sensors for the efficient detection of pharmaceutical residues

Pharmaceutical residues are the undecomposed remains from drugs used in the medical and food industries. Due to their potential adverse effects on human health and natural ecosystems, they are of increasing worldwide concern. The acute detection of pharmaceutical residues can give a rapid examination of their quantity and then prevent them from further contamination. Herein, this study summarizes and discusses the most recent porous covalent-organic frameworks (COFs) and metal-organic frameworks (MOFs) for the electrochemical detection of various pharmaceutical residues. The review first introduces a brief overview of drug toxicity and its effects on living organisms. Subsequently, different porous materials and drug detection techniques are discussed with materials' properties and applications. Then the development of COFs and MOFs has been addressed with their structural properties and sensing applications. Further, the stability, reusability, and sustainability of MOFs/COFs are reviewed and discussed. Besides, COFs and MOFs' detection limits, linear ranges, the role of functionalities, and immobilized nanoparticles are analyzed and discussed. Lastly, this review summarized and discussed the MOF@COF composite as sensors, the fabrication strategies to enhance detection potential, and the current challenges in this area.

Identification of Fungal Isolates in Patients With Pulmonary Tuberculosis Treated at a Tertiary Care Hospital

Introduction Pulmonary tuberculosis (TB) has long been associated with opportunistic fungal infections and could prove lethal if these fungal infections are not detected in the early stages of tuberculosis. TB patients are mostly immunocompromised, and an association with a fungal infection fuels each other, thus decreasing host immunity and making it difficult to treat. Extensive use of antibiotics and steroids has resulted in increasing trends of these fungal infections globally. Material and methods This observational, retrospective hospital-based medical record review study was conducted in the Department of Microbiology at the Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, Bihar, India. A total of 200 medical records of pulmonary tuberculosis patients diagnosed by using sputum as clinical samples were evaluated and analysed for two years, from January 2020 to December 2021. This study was started after approval from the institutional ethical committee. Data were obtained from the mycology test records from the Department of Microbiology and from the data files of the medical records section over a period of two years. Results Our study included the medical records of 200 pulmonary tuberculosis patients who underwent treatment at IGIMS Patna. Out of 200 patient records, 124 (62%) were males and 76 (38%) were females. The male-to-female ratio was 1.6:1. After analysis and evaluation of 200 medical records of pulmonary tuberculosis patients, fungal species were detected in 16 (8%) sputum samples. Among 16 culture-positive sputum samples, 10 (8.06%) and six (7.1%) were diagnosed in male and female patients, respectively. Fisher's exact test showed a non-significant two-sided p-value of 1.000 with a relative risk of 0.9982. The prevalence, or positivity rate, was 8% in two years. The age group of 31-45 years had the most fungal co-infection at 37.5%. Among the fungal isolates, 5/16 (31.25%) were yeasts, and the remaining 11/16 (68.75%) isolates were mycelial fungi. Conclusion According to the findings of the present study, pulmonary fungal infections co-exist in tuberculosis patients, although the prevalence rates of all the coinfections are low and statistically not significant. Being chronic in nature and with confusing clinical and radiological findings, these fungal infections are misdiagnosed as reactivation of tuberculosis. Hence, the increasing rate of morbidity and mortality can decrease if adequate measures are taken for the diagnosis at an early stage and appropriate treatment of these fungal mycoses with antifungal therapy is instituted.

AYUSH (Indian System of Medicines) Therapeutics for COVID-19: A Living Systematic Review and Meta-Analysis (First Update)

Background: In India, alternative and complementary therapies (Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy [AYUSH] medicines) are extensively utilized in COVID-19 management, and some were investigated clinically. This study assessed the effectiveness of AYUSH therapeutic on COVID-19 through a living systematic review and meta-analysis approach. Methods: Databases like PubMed; the Cochrane central register of controlled trials; WHO COVID-19 database; the central trial registry-India; Digital Helpline for Ayurveda Research Articles and AYUSH research portal, and preprint repositories were searched till August 1, 2021. Randomized controlled trials or analytical observational studies were included only. Primary outcomes selected were clinical improvement, WHO ordinal scale, viral clearance, and mortality, whereas secondary outcomes were the use of O₂ therapy or mechanical ventilator, admission to high dependency unit or emergency unit, duration of hospitalization, the time to symptom resolution, and adverse events. The risk of bias was evaluated by Version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB-2) and Risk of Bias in Nonrandomized Studies-of Interventions (ROBINS-I) tools; data were synthesized through RevMan 5.4 tool, and the certainty of the evidence was ranked through the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Results: Of 3609 studies retrieved, 17 were included in the systematic review, and 3 AYUSH therapeutics were meta-analyzed. Meta-analysis suggested that add-on AYUSH-64 likely provides therapeutic benefits by reducing time to symptom resolution (mean difference [MD] 2.35 days lower [95% confidence interval, CI; 4.05 lower to 0.65 lower]) and hastening clinical improvement (365 more per 1000 [95% CI; 4 more to 1000 more]) in mild-to-moderate COVID-19 patients. Kabasura Kudineer adjuvant to standard care is likely to reduce symptom resolution (MD; 1.93 days lower [95% CI; 2.28 lower to 1.58 lower]) and hospital stay (MD; 4.2 days lower [95% CI; 4.97 lower to 3.43 lower]) in mild-to-moderate COVID-19 patients. Co-administration of Guduchi (Tinospora cordifolia [Willd.] Miers.) to standard care may reduce the duration of hospitalization (MD; 3.93 days, lower [95% CI; 8.83 lower to 0.97 higher]) in mild-to-moderate COVID-19 patients. Furthermore, all three agents seemed safe in adjunct usage to standard care. The certainty of evidence for most outcomes was moderate to low, primarily due to the high risk of bias or imprecision owing to the small sample size. Conclusion: Rational use of integrated or standalone AYUSH interventions in mild-to-moderate COVID-19 patients is safe and may provide therapeutic benefits. The effect estimates may be changed with additional evidence in upcoming updates.

Bacterial profile and antibiotic susceptibility pattern of uropathogens causing urinary tract infection in the eastern part of Northern India

Urinary tract infection (UTI) is a common infectious disease that affects men and women. It is a significant health concern due to multidrug-resistant (MDR) organisms. Therefore, it is necessary to have a current understanding of the antibiotic susceptibility (AS) pattern of uropathogens to manage UTI effectively. Since the bacterial pathogen causing UTI and its AS vary with time and place, the prevailing AS pattern of the causative agents are essential for empirical antibiotic therapy. This study aims to determine the prevalence and AS of uropathogens isolated from UTI patients in the eastern part of Northern India. The study was carried out between November 2018 and December 2019. Clean catch midstream urine samples were collected and processed using standard guidelines for microbiological procedures. Positive microbiological cultures were found in 333 of the 427 patients, where 287 were gram-negative bacteria (GNB), and 46 were gram-positive bacteria (GPB). Females had a higher prevalence of UTI (60.7%) than males (39.3%) (p = 0.00024). The most susceptible age group in females was 18–50 years as compared to males, whereas at the age of 51–80 years and >80 years males were more susceptible than females (p = 0.053). The most prevalent pathogen identified were Escherichia coli (55.0%), followed by Proteus sp. (6.9%), Klebsiella pneumoniae (6.6%), Pseudomonas aeruginosa (6.3%), of which 96.0% were MDR bacteria. The susceptibility pattern of our study also revealed that amikacin, gentamycin and imipenem were the most effective drugs against GNB. In contrast, nitrofurantoin, vancomycin, and chloramphenicol were the most effective drugs against GPB. According tothe findings, MDR pathogens are very much prevalent. Since UTI is one of the most frequent bacterial diseases, proper management necessitates extensive investigation and implementation of antibiotic policy based on AS patterns for a particular region.

Impact of AYUSH interventions on COVID-19: a protocol for a living systematic review and meta-analysis

Background: The coronavirus disease 2019 (COVID-19) pandemic has created a great burden on governments and the medical fraternity globally. Many clinical studies from the Indian system of Traditional Medicines [Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homoeopathy (AYUSH)] have been carried out to find appropriate solutions. Through a living systematic review and meta-analysis, this study aims to determine the effectiveness of the Traditional System of Indian Medicine (AYUSH system) in lowering the incidence, duration, and severity of COVID-19.

Methods: We will search the following databases: Pubmed; the Cochrane central register of controlled trials (CENTRAL); the Clinical Trials Registry - India (CTRI); Digital Helpline for Ayurveda Research Articles (DHARA); AYUSH research portal; Google scholar and World Health Organization (WHO) COVID-19 database. Clinical improvement, WHO ordinal scale, viral clearance, incidences of COVID-19 infection, and mortality will be considered as primary outcomes. Secondary outcomes will be use of O2 therapy or mechanical ventilator, admission to high dependency unit or emergency unit, duration of hospitalization, the time to symptom resolution, and adverse events. Data will be synthesized, with RevMan 5.4 tool and the risk of bias will be assessed with RoB 2 (for RCTs) and ROBINS I (for NRSIs). Certainty of evidence will be assessed through the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) tool. The review will be updated bi-monthly with two updates.

Conclusion: This living systematic review will be the first to address AYUSH interventions in COVID-19, synthesizing the full spectrum of Indian Traditional System of Medicine against COVID-19. It will facilitate professionals, guideline developers, and authorities with up to date synthesis on interventions periodically to make health-care decisions on AYUSH therapies in the management of COVID-19.

Downregulation of PTEN Promotes Autophagy via Concurrent Reduction in Apoptosis in Cardiac Hypertrophy in PPAR α−/− Mice

Cardiac hypertrophy is characterized by an increase in the size of the cardiomyocytes which is initially triggered as an adaptive response but ultimately becomes maladaptive with chronic exposure to different hypertrophic stimuli. Prolonged cardiac hypertrophy is often associated with mitochondrial dysfunctions and cardiomyocyte cell death. Peroxisome proliferator activated receptor alpha (PPAR α), which is critical for mitochondrial biogenesis and fatty acid oxidation, is down regulated in hypertrophied cardiomyocytes. Yet, the role of PPAR α in cardiomyocyte death is largely unknown. To assess the role of PPAR α in chronic hypertrophy, isoproterenol, a β-adrenergic receptor agonist was administered in PPAR α knock out (PPAR α−/−) mice for 2 weeks and hypertrophy associated changes in cardiac tissues were observed. Echocardiographic analysis ensured the development of cardiac hypertrophy and compromised hemodynamics in PPAR α−/− mice. Proteomic analysis using high resolution mass spectrometer identified about 1,200 proteins enriched in heart tissue. Proteins were classified according to biological pathway and molecular functions. We observed an unexpected down regulation of apoptotic markers, Annexin V and p53 in hypertrophied heart tissue. Further validation revealed a significant down regulation of apoptosis regulator, PTEN, along with other apoptosis markers like p53, Caspase 9 and c-PARP. The autophagy markers Atg3, Atg5, Atg7, p62, Beclin1 and LC3 A/B were up regulated in PPAR α−/− mice indicating an increase in autophagy. Similar observations were made in a high cholesterol diet fed PPAR α−/−mice. The results were further validated in vitro using NRVMs and H9C2 cell line by blocking PPAR α that resulted in enhanced autophagosome formation upon hypertrophic stimulation. The results demonstrate that in the absence of PPAR α apoptotic pathway is inhibited while autophagy is enhanced. The data suggest that PPAR α signaling might act as a molecular switch between apoptosis and autophagy thereby playing a critical role in adaptive process in cardiac hypertrophy.

Case Report: Rapid Response to Low-Dose Thalidomide in a Case of Severe Steroid Recalcitrant Erythema Nodosum Leprosum

Erythema nodosum leprosum (ENL), or type 2 lepra reaction, presents with crops of evanescent, tender erythematous nodules accompanied by fever, arthralgia, malaise and organ-specific manifestations and is seen in borderline and lepromatous leprosy. The drugs approved for ENL include nonsteroidal anti-inflammatory drugs, systemic steroids, thalidomide and clofazimine. The management of ENL is challenging because long-term steroid use leads to steroid dependence. The present patient had severe steroid recalcitrant ENL with vesicular and pustular lesions mimicking Sweet's syndrome and was treated effectively with a low-dose thalidomide regimen (100 mg/d) as opposed to high dose (400 mg/d) recommended in literature. We discuss the patho-mechanics and clinical utility of a low-dose thalidomide regimen as an effective treatment option for ENL.

Role of Ayurveda treatment in the management of hepatitis B (Ubhayapatha Ashrita Swatantra Kamala)- A case report

Hepatitis B is one of the most common causes of liver disease, and due to unawareness of the safety measures, more prone to spread. As per the World Health Organization, for the South East Asia region, its prevalence is 2%. Yellowish discoloration of the eyes, body, and urine, abdominal discomfort, and vomiting is its cardinal symptoms. In Ayurveda, this set of symptoms is known as Kamala. This case report illustrates the effectiveness of the Ayurveda treatment modality in a patient with a viral load of 3705.71 IU/ml, and the values of AST (aspartate aminotransferase) and alanine transaminase (ALT) were 140 IU/ml and 173 IU/ml, respectively. A 40-year-old female patient with a complaint of yellowish discoloration of urine, eyes, and skin with fatigue and irritability was diagnosed with Ubhayapatha Ashrita Swatantra Kamala. The patient was treated with Ayurveda drugs and Virechana Karma (therapeutic purgation). After the treatment for 13 months, the disease was cured. Improvement was observed based on hepatitis B virus deoxyribonucleic acid (DNA) polymerase chain reaction (PCR) (hepatitis B DNA PCR) (decreased from 3705.71 IU/ml to <50.0 IU/ml) and the values of AST (decreased from 140 IU/ml to 19.0 IU/ml) and ALT (decreased from 173 IU/ml to 28 IU/ml). The patient was stable and asymptomatic during the follow-up period of 4 months.

Antibody conjugated magnetic nanoparticle based colorimetric assay for the detection and quantification of aflatoxin B1 in wheat grains

Aflatoxin B1 (AFB1) is a most potent carcinogenic secondary metabolite produced by Aspergillus flavus. As a food safety concern, development of a rapid, cost effective, sensitive and easy to use method for the detection of aflatoxin is of prime requirement. In this study, AFB1 was conjugated with bovine serum albumin (BSA), and AFB1-BSA conjugate was purified by HPLC. Purification was confirmed by UV-Vis spectroscopy, FTIR and MALDI-TOF mass spectrometry. The polyclonal antibody was raised against AFB1-BSA conjugate in rabbit and purified by protein A sepharose and BSA sepharose affinity columns. Iron oxide nanoparticles (MNPs) were synthesised by co-precipitation method and their surface was functionalised with (3-aminopropyl) triethoxysilane (APTES). Size of APTES conjugated MNPs was determined by electron microscopy, and characterised by several biophysical techniques. The purified anti-AFB1 antibody was conjugated with surface functionalised MNPs and the conjugation was confirmed by determining the sizes of free and antibody conjugated MNPs by field emission scanning electron microscope where increase of particle sizes from 10-20 to 40-50 nm was observed due to antibody conjugation. Anti-AFB1 antibody conjugated MNPs were used for capturing AFB1 from the aflatoxin spiked wheat grains with a recovery percentage of more than 80% and used effectively five times. The captured AFB1 was then quantified by a sensitive colorimetric assay where colourless AFB1 was first converted into coumaric acid by NaOH. Subsequently, coumaric acid reacted with 2,6-dibromoquinone-4-chloroimide (DBQC) to a green-coloured indophenol product which was quantified spectrophotometrically. AFB1 contamination as low as 2 μg/kg in wheat grains was detected by the developed technique suggesting its potential application for both qualitative and quantitative analysis of aflatoxins present in feed and food materials.

Impact of AYUSH interventions on COVID-19: a protocol for a living systematic review and meta-analysis

Background: The coronavirus disease 2019 (COVID-19) pandemic has created a great burden on governments and the medical fraternity globally. Many clinical studies from the Indian system of Traditional Medicines [Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homoeopathy (AYUSH)] have been carried out to find appropriate solutions. Through a living systematic review and meta-analysis, this study aims to determine the effectiveness of the Traditional System of Indian Medicine (AYUSH system) in lowering the incidence, duration, and severity of COVID-19. Methods: We will search the following databases: Pubmed; the Cochrane central register of controlled trials (CENTRAL); the Clinical Trials Registry - India (CTRI); Digital Helpline for Ayurveda Research Articles (DHARA): AYUSH research portal; and World Health Organization (WHO) COVID-19 database. Clinical improvement, WHO ordinal scale, viral clearance, incidences of COVID-19 infection, and mortality will be considered as primary outcomes. Secondary outcomes will be use of O2 therapy or mechanical ventilator, admission to high dependency unit or emergency unit, duration of hospitalization, the time to symptom resolution, and adverse events. Two authors will independently search the articles, extract the data and disagreements will be resolved by the involvement of a third reviewer. Data will be synthesized, and the risk of bias will be assessed with RevMan 5.4 tool. Certainty of evidence will be assessed through the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) tool. The review will be updated bi-monthly with two updates. Conclusion: This living systematic review will be the first to address AYUSH interventions in COVID-19, synthesizing the full spectrum of Indian Traditional System of Medicine against COVID-19. It will facilitate professionals, guideline developers, and authorities with up to date synthesis on interventions periodically to make health-care decisions on AYUSH therapies in the management of COVID-19.

The peripheral immune response in hyperglycemic stroke

OBJECTIVES

Hyperglycemia is common in acute ischemic stroke patients and is associated with poor clinical outcome. However, aggressive reduction of post-stroke hyperglycemia did not improve clinical outcome, suggesting that other mechanisms are playing a detrimental role in hyperglycemic stroke. We hypothesize that the acute post-stroke immune response is altered in the hyperglycemic state leading to higher mortality and morbidity. The objective of this study was to characterize temporal changes in circulating immune cells after stroke and their association with clinical outcomes in hyperglycemic compared to euglycemic patients.

PATIENTS AND METHODS

This retrospective study included 97 (58 % euglycemic, 42 % hyperglycemic) patients presenting within 12 h of symptom onset of stroke. Blood neutrophil, monocyte and lymphocyte concentrations were measured sequentially for 96 h post stroke. Primary clinical outcome was the difference in the NIH stroke scale at admission compared to discharge. Secondary outcome measures included discharge disposition and the modified Rankin Scale (mRS) at 90 days.

RESULTS

Circulating neutrophils were significantly higher in hyperglycemic than in euglycemic patients within the first 48 h post stroke, while lymphocyte counts trended to be lower. Hyperglycemic patients had higher mortality rates, less favorable discharge disposition and worse neurological function at 90 days. In both groups, the neutrophil to lymphocytes ratio ((NLR) remained strongly associated with neurological function at discharge within the first 24 h (p < 0.001), and remained significant in hyperglycemic patients up to 48 h (p < 0.001). Multivariate regression analysis showed no confounding by other factors and a significant correlation with differences in NIHSS score (CI; - 9.287 to -1.46, p = 0.0077**) and NLR (CL; 0.6058-6.901, p = 0.0203*) in hyperglycemic patients.

CONCLUSIONS

Our data suggests that circulating immune cells play an important role in mediating poor clinical outcome in hyperglycemic patients following stroke. The NLR is a strong predictor of neurological outcomes in hyperglycemic patients. Thus, the modulation of immune cells may be a viable therapeutic approach to improve outcomes for this high risk group.

Brown gold of marginal soil: Plant growth promoting bacteria to overcome plant abiotic stress for agriculture, biofuels and carbon sequestration

Marginal land is defined as land with poor soil characteristics and low crop productivity with no potential for profit. Poor soil quality due to the presence of xenobiotics or climate change is of great concern. Sustainable food production with increasing population is a challenge which becomes more difficult due to poor soil quality. Marginal soil can be made productive with the use of Plant Growth Promoting Bacteria (PGPB). This review outlines how PGPB can be used to improve marginal soil quality and its implications on agriculture, rhizoremediation, abiotic stress (drought, salinity and heavy metals) tolerance, carbon sequestration and production of biofuels. The feasibility of the idea is supported by several studies which showed maximal increase in the growth of plants inoculated with PGPB than to uninoculated plants grown in marginal soil when compared to the growth of plants inoculated with PGPB in healthy soil. The combination of PGPB and plants grown in marginal soil will serve as a green technology leading to the next green revolution, reduction in soil pollution and fossil fuel use, neutralizing abiotic stress and climate change effects.

Knowledge and practices about sterilization and disinfection

Aims

The aim of the present study was to evaluate the knowledge and practices employed for infection control in dental laboratories.

Materials and Methods

A preformed questionnaire comprised of 16 questions related to infection control measures was prepared. This questionnaire based survey was then conducted among dental technicians of 60 dental colleges in East India. Data were then recorded and analyzed.

Results

Majority of impressions/prosthesis were carried in plastic bags (93.8%) by laboratory attendants to the laboratory. The responses revealed that majority of impressions were received after wearing gloves (54.6%) from dental attendant. Majority of dental technicians (78.1%) admitted in their responses that they are not aware of infection control measures taken in dental laboratory. Only 32.8% technicians were found to practice disinfection procedure after receiving impression/prosthesis in laboratory from dental operatory. Among protective wears, 70.3%, 95.3%, 32.8%, and 92.2% technicians were found to use gloves, Apron, eye shield, and face mask, respectively. Among all respondents, 59.3% were found to be vaccinated for hepatitis B vaccine.

Conclusion

There is lack of knowledge and motivation among dental technician to practice infection control measures in dental laboratories of dental institutes in North India.

Evaluation of tumor necrosis factor-alpha (TNF-α) and interleukin (IL)-1β levels among subjects vaping e-cigarettes and nonsmokers

AIM

The present study aimed to evaluate peri-implant immunological parameters along with clinical and radiographic parameters amongst subjects vaping e-cigarettes and nonsmokers (NS). Two immunological parameters that were included were measurement of tumor necrosis factor-alpha (TNF-α) and interleukin (IL)-1β.

MATERIALS AND METHODS

A statistically significant number of subjects were included in the study and further divided into two groups: Group-1: Vaping e-cigs (n = 47) Group-2: Nonsmokers (n = 45) A structured questionnaire was used at baseline for data collection related to demographic and peri-implant data of each individual. Baseline parameters included plaque index, bleeding on probing, probing pocket depth, and peri-implant bone loss (PI, BOP, PD, and PIBL, respectively) for those vaping e-cigs and nonsmokers with the aid of standardized digital radiographs. ELISA kit was used to assess immunologic parameters using sulcular fluid collected from peri-implant region (PISF).

RESULTS

Bleeding on probing (BOP) was found significantly high in nonsmokers compared to the vaping group. But probing depth greater than 4 mm and PIBL scores were significantly higher in the vaping group than nonsmokers. Mean concentrations of immunologic parameters were significantly higher in vaping group than in nonsmokers. TNF-α levels and IL-1β levels were found to have a positive correlation with bone loss around implants (PIBL). Besides, TNF-α also had a positive correlation with bleeding on probing in vaping group compared to nonsmokers.

CONCLUSIONS

Owing to the effect of nicotine on the peri-implant tissue, levels of inflammatory mediators as detected by ELISA tests were found to be higher showing a greater amount of localized inflammatory tissue destruction and a compromised peri-implant area in vaping subjects. PISF concentrations were also found relatively higher than nonsmokers.

Association of ITGAM, TNFSF4, TNFAIP3 and STAT4 gene polymorphisms with risk of systemic lupus erythematosus in a North Indian population

Several susceptibility genes have been associated with systemic lupus erythematosus (SLE) across different populations worldwide. However, data on association between genetic polymorphisms and SLE from Indian population is scarce. We aimed to replicate the association of single nucleotide polymorphisms (SNPs) in ITGAM, TNFSF4, TNFAIP3 and STAT4 genes with susceptibility to SLE in a North Indian population. Three hundred and ninety-four SLE patients and 583 unrelated healthy controls of the same ethnic background were enrolled. All samples were genotyped for SNPs in ITGAM (rs1143679), TNFSF4 (rs2205960), TNFAIP3 (rs5029939) and STAT4 (rs7574865) using TaqMan genotyping assay. At allele level, significant association with susceptibility to SLE was detected with polymorphisms in ITGAM (A vs. G, odds ratio (OR) = 1.73, 95% confidence interval (CI) = 1.30–2.30, p < 0.001), TNFSF4 (T vs. G, OR = 1.33, 95% CI = 1.08–1.64, p < 0.01), TNFAIP3 (G vs. C, OR = 1.91, 95% CI = 1.27–2.85, p < 0.01) and STAT4 (T vs. G, OR = 1.38, 95% CI = 1.13–1.69, p < 0.01). All four SNPs were associated with SLE under a dominant model with an OR of 1.47 (95% CI = 1.07–2.04, p < 0.05) for ITGAM, 1.30 (95% CI = 1.01–1.69, p < 0.05) for TNFSF4, 1.90 (95% CI = 1.25–2.90, p < 0.01) for TNFAIP3 and 1.38 (95% CI = 1.06–1.78, p < 0.05) for STAT4. Under a recessive model, significant association was found with ITGAM (OR = 4.87, 95% CI = 2.17–10.91, p < 0.001), TNFSF4 (OR = 1.84, 95% CI = 1.13–3.00, p < 0.05) and STAT4 (OR = 1.82, 95% CI = 1.19–2.77, p < 0.01). In conclusion, single nucleotide polymorphisms in ITGAM, TNFSF4, TNFAIP3 and STAT4 genes are associated with susceptibility to SLE in a North Indian population.

Effectiveness and tolerability of simeprevir and sofosbuvir in nontransplant and post-liver transplant patients with hepatitis C genotype 1

BACKGROUND

Hepatitis C virus genotype 1a (HCV-1a), prior treatment, cirrhosis and post-transplant status are historically associated with poor treatment responses. The new oral direct-acting agents appear to be effective and safe in these patients.

AIMS

To evaluate the effectiveness and tolerability of simeprevir and sofosbuvir in a diverse real-life cohort of patients, including difficult-to-treat patients.

METHODS

We conducted a retrospective cohort study in 198 consecutive patients with hepatitis C genotype 1 (148 nontransplant, 50 post transplant), who were treated with simeprevir and sofosbuvir for 12 weeks between December 2013 and December 2014. Primary outcome was sustained virological response with undetectable HCV RNA 12 weeks after completion of therapy (SVR12). Risk factors evaluated for lack of SVR12 included HCV 1a (vs. 1b), prior treatment (vs. none), and cirrhosis (vs. no cirrhosis).

RESULTS

SVR12 rates were similar in non- and post-transplant settings, 82% and 88%, respectively. There were no significant differences in adverse events in patients regardless of cirrhosis or transplant status. On multivariate analysis also inclusive of gender and liver transplant status, negative predictors of SVR12 were having at least 2 or 3 risk factors (OR 0.30, 95% CI 0.10-0.87, P = 0.027 or 0.29, 95% CI 0.09-0.85, P = 0.025, respectively).

CONCLUSION

Simeprevir and sofosbuvir combination is a safe and effective regimen for the treatment of non- and post-transplant patients with traditional risk factors for poor treatment response, unless more than 2 difficult-to-treat risk factors are present.

Detection of rifampicin resistance in tuberculosis by molecular methods: A report from Eastern Uttar Pradesh, India

Diagnosis of drug resistance tuberculosis (TB) by the gold standard method is labour intensive and time consuming. Hence, there is an urgent need for introduction of rapid diagnostic techniques. Line probe assay (LPA) and cartridge-based nucleic acid amplification test (CBNAAT) have been introduced in India under Revised National Tuberculosis Control Program. Spot and morning sputum samples of previously treated patients by anti-TB drugs were subjected to LPA or CBNAAT. Total 682/1253 (54.4%) were diagnosed as rifampicin-resistant. The patients could be diagnosed early by molecular methods and put on second line treatment.

Homology and enzymatic requirements of microhomology-dependent alternative end joining

Nonhomologous DNA end joining (NHEJ) is one of the major double-strand break (DSB) repair pathways in higher eukaryotes. Recently, it has been shown that alternative NHEJ (A-NHEJ) occurs in the absence of classical NHEJ and is implicated in chromosomal translocations leading to cancer. In the present study, we have developed a novel biochemical assay system utilizing DSBs flanked by varying lengths of microhomology to study microhomology-mediated alternative end joining (MMEJ). We show that MMEJ can operate in normal cells, when microhomology is present, irrespective of occurrence of robust classical NHEJ. Length of the microhomology determines the efficiency of MMEJ, 5 nt being obligatory. Using this biochemical approach, we show that products obtained are due to MMEJ, which is dependent on MRE11, NBS1, LIGASE III, XRCC1, FEN1 and PARP1. Thus, we define the enzymatic machinery and microhomology requirements of alternative NHEJ using a well-defined biochemical system.

Sofosbuvir and simeprevir combination therapy in the setting of liver transplantation and hemodialysis

We report safety, tolerability, and 12-week sustained virologic response with half-standard dose sofosbuvir and standard-dose simeprevir combination therapy in a hepatitis C virus genotype 1a-infected liver transplant recipient on hemodialysis - uncharted territory for sofosbuvir-based therapy. The patient was a non-responder to prior treatment with pegylated interferon plus ribavirin. Sofosbuvir efficacy was maintained despite pill-splitting and administration of half-standard dose, 200 mg per day. No drug-drug interactions were noted with tacrolimus-based immunosuppression. Laboratory tests remained stable or improved during therapy. Our observation, if reproduced in a larger study, may lead to significant improvement in clinical outcomes and cost savings in this patient population.

Renal angioplasty for atherosclerotic renal artery stenosis: Cardiologist's perspective

Atherosclerotic renal artery stenosis (ARAS) is frequently associated with concomitant coronary and peripheral arterial disease with a significant impact on cardiovascular morbidity and mortality. Renal angioplasty of ARAS is more challenging because of increased incidence of technical failures, complications, and restenosis; while there is barely perceptible control of hypertension and only marginal improvement in renal function. This is because most of the patient population in recent randomized trials had unmanifested or clinically silent renovascular disease. Manifestations of RAS should be looked for and incorporated in the management plan particularly before deciding for revascularization. In the absence of clinical manifestation like renovascular hypertension, ischemic nephropathy, left ventricular failure, or unstable coronary syndromes; mere presence of RAS is analogous to presence of concomitant peripheral arterial disease which increases risk of adverse coronary events. Dormant-RAS in the absence of any manifestations can be managed with masterly inactivity. Chronological sequence of events and clinical condition of the patient help in decision making by identifying progressive renovascular disease. Selecting patients for renal artery stenting who actually will benefit from revascularization shall also decrease the unnecessary complications inherent with any interventional procedure. The present review is an attempt to analyze the current view on the diagnostic and management issues more specifically about the need and rationale behind angioplasty.