Deciphering Intermediate Nugent scores: Utility of Real-time PCR for Bacterial Vaginosis diagnosis

PURPOSE

To optimize real-time PCR assays for diagnosis of Bacterial Vaginosis (BV) and determine cut-off loads by ROC analysis for Gardnerella vaginalis, Atopobium vaginae and Lactobacillus spp. as compared to Nugent scoring (Gold standard) in clinical samples.

RESULTS

Out of 125 women, 34 were positive, 26 intermediate and 65 negative for BV by Nugent scoring. All three real-time PCR assays were found to be highly sensitive & specific and AUC suggested excellent diagnostic accuracy. An optimal cut-off was >9.45 × 103 copies/ ml, >3.34 × 103 copies/ ml & ≤ 18.63 × 103 copies/ ml for G. vaginalis, A. vaginae and Lactobacillus spp. respectively, in BV positives. Gram staining and qPCR were discordant only in patients with intermediate scores (n = 26) where qPCR identified 15 (57.69%) as positive and 11 (42.3%) as negative.

CONCLUSION

PCR-based molecular BV diagnosis is more accurate and can be used for deciphering intermediate Nugent scores.

Multi-omics analysis identifies potential microbial and metabolite diagnostic biomarkers of bacterial vaginosis

BACKGROUND

Bacterial vaginosis (BV) is a common clinical manifestation of a perturbed vaginal ecology associated with adverse sexual and reproductive health outcomes if left untreated. The existing diagnostic modalities are either cumbersome or require skilled expertise, warranting alternate tests. Application of machine-learning tools to heterogeneous and high-dimensional multi-omics datasets finds promising potential in data integration and may aid biomarker discovery.

OBJECTIVES

The present study aimed to evaluate the potential of the microbiome and metabolome-derived biomarkers in BV diagnosis. Interpretable machine-learning algorithms were used to evaluate the utility of an integrated-omics-derived classification model.

METHODS

Vaginal samples obtained from reproductive-age group women with (n = 40) and without BV (n = 40) were subjected to 16S rRNA amplicon sequencing and LC-MS-based metabolomics. The vaginal microbiome and metabolome were characterized, and machine-learning analysis was performed to build a classification model using biomarkers with the highest diagnostic accuracy.

RESULTS

Microbiome-based diagnostic model exhibited a ROC-AUC (10-fold CV) of 0.84 ± 0.21 and accuracy of 0.79 ± 0.18, and important features were Aerococcus spp., Mycoplasma hominis, Sneathia spp., Lactobacillus spp., Prevotella spp., Gardnerella spp. and Fannyhessea vaginae. The metabolome-derived model displayed superior performance with a ROC-AUC of 0.97 ± 0.07 and an accuracy of 0.92 ± 0.08. Beta-leucine, methylimidazole acetaldehyde, dimethylethanolamine, L-arginine and beta cortol were among key predictive metabolites for BV. A predictive model combining both microbial and metabolite features exhibited a high ROC-AUC of 0.97 ± 0.07 and accuracy of 0.94 ± 0.08 with diagnostic performance only slightly superior to the metabolite-based model.

CONCLUSION

Application of machine-learning tools to multi-omics datasets aid biomarker discovery with high predictive performance. Metabolome-derived classification models were observed to have superior diagnostic performance in predicting BV than microbiome-based biomarkers.

Appendectomy and asthma: a search for an association in older subjects

INTRODUCTION

Several risk factors found to be associated with postoperative complications and cancer surgery, which carry a significant morbidity risk to cancer patients. Therefore, prehabilitation is necessary to improve the functional capability and nutritional status of a patient prior to surgery, so that the patient can withstand any postoperative activity and associated deterioration. Thus, this study aims to assess the effectiveness of prehabilitation interventions on the functional status of patients with gastric and oesophageal cancer who underwent esophagectomy and gastrectomy.

MATERIAL AND METHODS

An interventional study was carried out among oesophageal and gastric cancer patients who had undergone surgery at the National Cancer Institute of Malaysia. The prehabilitation process took a maximum of two weeks, depending on the patient's optimisation before surgery. The prehabilitation is based on functional capacity (ECOG performance status), muscle function (handgrip strength), cardio-respiratory function (peak flow meter) and nutritional status (calorie and protein). Postoperative outcomes are measured based on the length of hospital stay, complications, and Clavien-Dindo Classification.

RESULTS

Thirty-one patients were recruited to undergo a prehabilitation intervention prior to gastrectomy (n=21) and esophagectomy (n=10). Demographically, most of the cancer patients were males (67.7%) with an ideal mean of BMI (23.5±6.0). Physically, the majority of them had physical class (ASA grade) Grade 2 (67.7%), ECOG performance status of 1 (61.3%) and SGA grade B (51.6%). The functional capacity and nutritional status showed a significant improvement after one week of prehabilitation interventions: peak expiratory flow meter (p<0.001), handgrip (p<0.001), ECOG performance (p<0.001), walking distance (p<0.001), incentive spirometry (p<0.001), total body calorie (p<0.001) and total body protein (p=0.004). However, those patients who required two weeks of prehabilitation for optimization showed only significant improvement in peak expiratory flow meter (p<0.001), handgrip (p<0.001), and incentive spirometry (p<0.001). Prehabilitation is significantly associated postoperatively with the length of hospital stay (p=0.028), complications (p=0.011) and Clavien-Dindo Classification (p=0.029).

CONCLUSION

Prehabilitation interventions significantly increase the functional capacity and nutritional status of cancer patients preoperatively; concurrently reducing hospital stays and complications postoperatively. However, certain cancer patients might require over two weeks of prehabilitation to improve the patient's functional capacity and reduce complications postoperatively.

Non-surgical organ preservation in laryngeal and hypopharyngeal cancers: an audit from the clinic

BACKGROUND

There is increasing concern regarding efficacy of organ preservation protocol in laryngeal and hypopharyngeal cancers.

METHOD

This study retrospectively assessed disease-related and functional outcomes of 191 patients with non-metastatic laryngeal or hypopharyngeal squamous cell carcinoma treated with curative intent (radiotherapy with or without chemotherapy).

RESULTS

Seventy-six patients (39.8 per cent) had a primary cancer in the larynx, and 115 patients (60.2 per cent) had a primary cancer in the hypopharynx. The median follow up was 39 months. The 3-year time to progression, overall survival, local control and laryngectomy free survival was 56.2 per cent, 76.3 per cent, 73.2 per cent and 67.2 per cent, respectively. At the time of analysis, 83 patients (43.5 per cent) were alive and disease free at their last follow up and did not require tube feeding or tracheostomy. The laryngo-oesophageal dysfunction-free survival was 61 per cent at 3 years.

CONCLUSION

Organ conservation protocols remain the standard of treatment in appropriately selected patients with laryngeal and hypopharyngeal cancers.

19 A Rare Case of Parapharyngeal Schwannoma Mimicking Peritonsillar Abscess in a Young Female Patient

Introduction

Parapharyngeal Space (PPS) tumours are responsible for 0.5% of head and neck cancers. Presenting features can mimic peritonsillar abscess. A differential diagnosis of PPS tumour should therefore be considered in young, systemically well patients with resistant peritonsillar masses.

Aim

To report a rare case of parapharyngeal schwannoma in a fit and well adult female with a focus on investigations and optimal management.

Method

A 29-year-old, Caucasian female presented with a three-week history of a right sided oropharyngeal mass, odynophagia, and dysphonia. A stagnant clinical picture prompted further investigation with Magnetic Resonance Imaging (MRI). This demonstrated a 7cm right sided PPS mass arising from the deep lobe of the right parotid gland. Mass excision and partial, ipsilateral parotidectomy confirmed Schwannoma (neurilemoma).

Results & Discussion

Schwannomas account for a third of PPS tumours. Arising from neurological Schwann cells, they are often encapsulated, benign tumours which are characterised by slow and asymptomatic growth. Presentation often follows mass effects leading to dysphagia, odynophagia, and dysphonia. MRI and FNAC remain the gold standard in confirmation of diagnosis. Insensitivity to radiotherapy ensures that surgical resection is the mainstay of treatment and may utilise the transcervical, transparotid or transmandibular approach.

Conclusion

There is a significant degree of overlap in the epidemiology and presenting features of peritonsillar abscess and PPS tumours. In cases of treatment resistant, chronic peritonsillar masses a differential diagnosis of PPS tumour must therefore be excluded.

1131 The Integration of Cardiothoracic Practical Skills Workshop in The Undergraduate Medical School Curriculum and Its Impact on Promoting Interest in Cardiothoracic Surgery

Aim

Assess if WETLAB workshop encourages the engagement of medical students in CTS surgery

Method

We hosted a cardiac WETLAB workshop, led by a consultant cardiothoracic surgeon. Attendees were taught how to carry out an end-to-side anastomosis on animal tissue. We used pre-and -post exposure questionnaires composed of 10 items to assess the ability of the workshop to improve undergraduate interest in cardiothoracic surgery. The questionnaire included questions around students’ interest in the speciality, previous exposure to the speciality and whether students want to pursue a career in the speciality.

Results

Out of the 12 attendees, 10 completed both questionnaires. The workshop was well received with the overall satisfaction of 9.64 out of 10. It significantly increased respondents’ interest in CTS(z=-0.06, p = 0.01) but did not show any significant difference in encouraging them to pursue surgery. 100% of respondents agreed that specialised practical workshops should be incorporated within the medical school curriculum and that if the opportunity arises, they will attend another in the future.

Conclusions

Specialised practical workshops have the potential to play a significant role in the medical school curriculum in order to enhance exposure to the field of cardiothoracic surgery. This may lead to a positive impact on the number of doctors wishing to pursue this speciality in the future.

193 Evaluation of the ‘One-Stop Diagnostic Head and Neck Lump Clinic' At A Tertiary Head and Neck Centre

An urgent neck lump service was introduced at the Freeman Hospital (Newcastle-Upon-Tyne) in 2017. All 2-week-wait urgent head and neck referrals were triaged into this service. The clinic involves clinical examination by a head and neck specialist and if appropriate an urgent ultrasound scan (USS) in clinic +/- a fine needle aspiration for cytology (FNAC). This centralised system means patients can be diagnosed earlier and thus receive treatment swiftly.

This audit aimed to primarily identify: The prevalence/pick-up rate of cancer diagnosed through the clinic The utilisation of USS/FNAC The time-to-treatment initiation

Data was collated retrospectively through the electronic record system. The initial evaluation was conducted between June-November 2018 (n = 191). The subsequent re-evaluation was performed between September-November 2019 (n = 159), following increased clinic capacity, implementation of methods to increase awareness and a formal triage process.

In the initial evaluation over 6 months (n = 191), 9.9% underwent an USS in the clinic and 9.95% at a later date. 18% of patients underwent a FNAC. 6.8% patients were diagnosed with cancer. The mean time-to-treatment initiation was 36 days.

In the re-evaluation over 3 months (n = 159), 23.2% had an USS in the clinic and 30.2% at a later date. 13% of patients underwent a FNAC. 9.4% of patients were diagnosed with cancer. The mean time-to-treatment initiation was 44 days.

This affirms the benefits of a swift ‘one-stop clinic’. On average, patients diagnosed with cancer had treatment initiation 40-days post-review. Furthermore, even with a triage process only 1 in 10 patients had cancer.

887 A Quality Improvement Project: Implementation of a New Epistaxis Pathway

Introduction

Epistaxis is one of the most common ENT conditions leading to unplanned hospital admission. This closed loop quality improvement project looked at epistaxis admissions, and whether patients could be safely managed on an ambulatory basis with unilateral intranasal packing, through the implementation of a new epistaxis pathway.

Method

Two prospective cycles at a District General Hospital. First cycle: three-month period (October-December 2018); recorded all patients admitted with epistaxis and the percentage with intranasal packing; criteria for discharge with unilateral intranasal packing created (including normal observations, normal clotting/haemoglobin, only on aspirin, safe home environment). Second cycle (after implementation of new pathway): two months (December 2019 and January 2020); recorded all patients admitted with epistaxis or discharged with unilateral intranasal packing; patient feedback obtained.

Results

First cycle: 31 epistaxis admissions; 12 patients met discharge criteria; average length of stay was 1.4 days. Second cycle: 22 epistaxis admissions; 4 admissions were avoided; 2 admissions were unnecessary according to new pathway; no patient-reported issues with pack at home.

Conclusions

Successful creation and initial implementation of pathway with no adverse outcomes. Approximately £1380 of savings through avoided admissions. Pathway expanded and successfully used during COVID-19 to include patients on anticoagulation as suitable for discharge with intranasal packing.

625 Health Economics and Safety of Frontline Carers in the COVID-19 Era: Time to Abolish Routine Group and Save For Emergency Appendicectomies?

Introduction

Face of healthcare, patient safety and protection of healthcare providers has been completely transformed with global health pandemic. However, emergency surgical procedures must still be performed, with the commonest being appendicectomy.

It is common practice across National Health Service trusts to collect a group and save (G&S) sample pre-operatively which increases healthcare staff exposure to the patient and increased use of personal protective equipment in this pandemic.

Method

Prospective study of adult patients undergoing emergency appendicectomy since the transformation of emergency care with COVID-19 induced restrictions compared with patients undergoing the same operation before the pandemic.

Results

179 adult patients underwent emergency appendicectomy over 6-months in 2019–2020, 60 patients in the 12 weeks period from the start of the transformed emergency services due to the pandemic. Pre-operative G&S samples were taken for 60(33.5%) patients in the pre COVID-19 period, whereas 7(11.6%) were taken for patients undergoing appendicectomy during the pandemic. None of the patients in either group had intra-operative blood loss of more than 500 millilitres and none of them required peri-operative blood transfusion

Conclusions

Our study demonstrates that the routine pre-operative G&S can safely be abandoned as a routine practice for all patients undergoing emergency appendicectomy.

IMPACT OF MOLECULAR METHOD FOR THE DIAGNOSIS OF ACUTE BACTERIAL MENINGITIS IN A TERTIARY HEALTH CARE CENTRE IN NORTH INDIA

Background. Acute bacterial meningitis is one of the significant infectious diseases that add an immense burden to the health system. Proper management of meningitis is an invincible need to overcome the severe consequences. Objectives. The aim of the study is detection of the etiological agents of acute bacterial meningitis by PCR. Methods. Total 267 CSF samples collected from suspected bacterial meningitis cases were processed for the detection of S. pneumoniae, H. influenzae, N. meningitidis, E. coli and Group B streptococci by conventional and molecular diagnosis method. CSF was inoculated on Blood, chocolate and MacConkey agar plates and incubated at 37 °C for 24-48 hrs. Bacteria grown were identified by Matrix assisted laser desorption/ionization time of flight (MALDI-TOF). Multiplex PCR of the enlisted bacteria was performed using DNA extracted from CSF by DNA extraction kit (Qiagen, USA). Results. 5 (1.87%) out of the total 267 CSF samples were culture positive (3 S. pneumoniae and 2 E. coli) and 28 (10.49%) had detectable DNA by conventional PCR. Out of these 28 samples, 20 (71.43%) were S. pneumoniae and 8 (28.57%) were E. coli. 15 (53.57%) out of total S. pneumoniae were present in children below 5 years of age. Similarly, E. coli was predominant in neonates. Sensitivity and specificity of the PCR was 100% and 95-98% respectively. Conclusions. Streptococcus pneumoniae is the commonest cause of community acquired bacterial meningitis in children below five years of age. Hence, for the promising outcome, PCR should be implemented for the diagnosis of acute bacterial meningitis.

Variations in antibiotic use across India: multi-centre study through Global Point Prevalence survey

The aim of the study was to assess antimicrobial prescribing patterns, and variation in practice, in India. A point prevalence survey (PPS) was conducted in October to December 2017 in 16 tertiary care hospitals across India. The survey included all inpatients receiving an antimicrobial on the day of PPS and collected data were analysed using a web-based application of the University of Antwerp. In all, 1750 patients were surveyed, of whom 1005 were receiving a total of 1578 antimicrobials. Among the antimicrobials prescribed, 26.87% were for community-acquired infections; 19.20% for hospital-acquired infections; 17.24% for medical prophylaxis; 28.70% for surgical prophylaxis; and 7.99% for other or undetermined reasons. Antibiotic prescribing quality indicators, such as reason in notes and post-prescription review score, were low. This PPS showed widespread antibiotic usage, underlining the need for antibiotic stewardship to promote evidence-based practice.

Treatment of sialorrhoea with repeated ultrasound-guided injections of botulinum toxin A into the parotid and submandibular glands

Botulinum toxin injections are useful in patients with refractory sialorrhoea although the optimum treatment protocol and its efficacy over a long period of follow up are controversial. The aim of our prospective study was to examine the efficacy and complications of a protocol of repeated ultrasound-guided botulinum toxin injections of fixed doses at a tertiary children's hospital. A total of 79 procedures were done in 34 patients who were followed up for two years. The overall complication rate was 3%. The outcome measures considered included the Drooling Frequency Severity Scale (DFSS), visual analogue scale (VAS), and carers' assessments of the reduction in drooling. Our study highlighted two types on non-responders (primary and secondary) of which 3/34 required definitive surgical management. In summary, this study shows that a protocol of repeated injections of fixed doses of botulinum toxin A, while not beneficial in all cases, is a potentially valuable option for the safe and effective treatment of sialorrhoea in children.

In vitro assessment of gentamicin and azithromycin-based combination therapy against Neisseria gonorrhoeae isolates in India

PURPOSE

The public health burden of infections caused by Neisseria gonorrhoeae is magnified due to high rates of resistance to traditional antimicrobials. The aim of this study was to evaluate the in vitro efficacy of an alternative dual therapy comprising gentamicin and azithromycin.

METHODOLOGY

The E-test method was used to determine the minimum inhibitory concentrations (MICs) of gentamicin and azithromycin individually prior to testing in combination using the cross or 90^o angle formation method. A total of 70 clinical isolates of N.gonorrhoeae displaying varying ceftriaxone MICs along with 2 reference strains (WHO K and P) and 1 ceftriaxone-resistant QA isolate were examined. The fractional inhibitory concentration index (FICI) was calculated and the results were interpreted using the following criteria: synergy, FICI ≤0.5; indifference or additive, FICI >0.5 to ≤4.0; and antagonism, FICI >4.0.

RESULTS

A total of 54 (77.1 %) isolates displayed indifference, while 16 (22.9 %) demonstrated synergy. When azithromycin was tested alone, the MICs ranged from 0.016 to 2 µg ml^-1 . However, in combination with gentamicin, the mean MIC value of all isolates decreased from 0.275 µg ml^-1 to 0.090 µg ml^-1 (P=0.05).When gentamicin was tested alone, the MICs ranged from 0.25 to 8 µg ml^-1, with a mean MIC of 4.342 µg ml^-1, whereas in combination with azithromycin it decreased significantly to 2.042 µg ml^-1 (P=0.04).

CONCLUSION

No antagonism was observed in this combination, suggesting that it could be a future treatment option as we prepare for a post-cephalosporin era. However, comprehensive in vivo evaluations are warranted and recommendations should be made based on clinical trials.

Early viral-specific T-cell testing predicts late cytomegalovirus reactivation following liver transplantation

INTRODUCTION

Although antiviral prophylaxis is effective in preventing early cytomegalovirus (CMV) reactivation following liver transplantation (OLT), it predisposes patients to late CMV after prophylaxis has ceased. QuantiFERON-CMV (QFN-CMV, Qiagen, The Netherlands) measures an individual's viral-specific immune response.

METHODS

Fifty-nine OLT recipients were prospectively monitored post-OLT in an observational cohort study. QFN-CMV was performed at regular time-points. An absolute QFN-CMV <0.1 IU/mL was considered non-reactive.

RESULTS

50/59 (84.7%) had a reactive QFN-CMV by M6. 38/59 (64.4%) had antiviral prophylaxis or treatment before M6, with 31/38 (81.6%) developing a reactive QFN-CMV by 6 months. Over 90% already had a reactive result as early as 3 months post transplant, 3 patients (5.08%) developed late CMV between 6-12 months (median 251 days)-all had a non-reactive M6 QFN-CMV. And 2/3 experienced CMV disease. Non-reactive M6 QFN-CMV was significantly associated with late CMV (OR = 54.4, PPV = 0.33, NPV = 1.00, P = .003).

CONCLUSION

Although only 5% of recipients developed late CMV, 2/3 suffered CMV disease. M6 QFN-CMV has an excellent NPV for late CMV, suggesting patients who exhibit a robust ex vivo immune response at M6 can safely cease CMV monitoring. Furthermore, >90% already express viral-specific immunity as early as 3 months. Conceivably, antiviral prophylaxis could be discontinued early in these patients.

Impact of viral hepatitis aetiology on survival outcomes in hepatocellular carcinoma: A large multicentre cohort study

While HBV and HCV are risk factors for HCC, uncertainty exists as to whether these viral infections have prognostic significance in HCC. Thus, we compared the overall survival of patients with HBV, HCV and nonviral HCC, and evaluated whether the presence of HBV and HCV predicts patient outcomes. We conducted a multicentre study of HCC cases diagnosed at six Melbourne tertiary hospitals between Jan 2000-Dec 2014. Patient demographics, liver disease and tumour characteristics and patient outcomes were obtained from hospital databases, computer records and the Victorian Death Registry. Survival outcomes were compared between HBV, HCV and nonviral hepatitis cases and predictors of survival determined using Cox proportional hazards regression. There were 1436 new HCC cases identified including 776 due to viral hepatitis (HBV 235, HCV 511, HBV-HCV 30) and 660 from nonviral causes. The median survival of HBV, HCV and nonviral HCC patients was 59.1, 28.4 and 20.9 months, respectively (P<.0001). On multivariate analysis, independent risk factors for survival included HCC aetiology, gender, BCLC stage, serum AFP, total number and size of lesions, and serum creatinine and albumin. After adjusting for these and method of detection, HBV remained an independent predictor of improved overall survival when compared to both nonviral (HR 0.60%, 95% CI 0.35-0.98; P=.03) and HCV-related HCC (HR 0.51%, 95% CI 0.30-0.85; P=.01). In this large multicentre study, HBV is independently associated with improved overall survival compared with HCV and nonviral-related HCC. Further studies are needed to determine the underlying factor(s) responsible.

Controlled release of antibiotic amoxicillin drug using carboxymethyl cellulose-cl-poly(lactic acid-co-itaconic acid) hydrogel

In this paper, microwave assisted preparation of carboxymethyl cellulose-cl-poly(lactic acid-co-itaconic acid) (CMC-cl-P(LA-co-IA)) hydrogel was reported via facile graft copolymerization using N,N¹-methylene-bis-acrylamide (MBA) and potassium persulphate as cross linker and initiator. Different reaction parameters were optimized to achieve good yield. The formation of hydrogel was confirmed by characterization techniques such as Fourier transform infrared spectroscopy, field emission scanning electron microscopy, X-ray diffraction, thermo gravimetric analysis, transmission electron microscopy etc. The antimicrobial activities of the hydrogel were studied against Staphylococcus aureus and Escherichia coli. About 95% killing of bacteria was recorded after 24h. The controlled release of amoxicillin drug from hydrogel was evaluated as a function of pH and time. Maximum drug release of 98% was recorded at 2.2 pH after 7h. The kinetic studies showed non-Fickian diffusion of the drug.

Assessing the impact of a program for late surgical intervention in early-blind children

OBJECTIVE

Many blind children in the developing world are unable to obtain timely treatment due to lack of financial and medical resources. Can public health programs that identify and treat such children several years after the onset of blindness enhance their quality of life? The notion that visual development is subject to an early 'critical period' argues against this possibility. However, there are inadequate empirical data from humans on this issue. To address this need, we examined the quality of life of children living in India and who were treated for early-onset blindness (before one year of age), due to cataracts or corneal opacities.

STUDY DESIGN

Survey study.

METHODS

As part of an ongoing scientific effort named Project Prakash, we screened over 40,000 children in rural northern India to identify those suffering from early-onset blindness. They were provided eye surgeries in a tertiary care ophthalmic center in New Delhi. We subsequently surveyed 64 Prakash children, ranging in age from 5 to 22 years and obtained their responses on a multi-dimensional quality of life questionnaire.

RESULTS

Nearly all of the subjects indicated that their quality of life had improved after treatment. Children reported marked enhancement in their mobility, independence, and safety, and also in social integration. Surprisingly, we found no significant correlations between quality of life metrics and factors such as age at treatment, gender, time since treatment, and pre-surgery and post-surgery acuity.

CONCLUSIONS

A key question for public health policy makers is whether a program of surgical intervention for older blind children is likely to be beneficial, or if the resources are better spent on rehabilitation via vocational training and assistive devices. The marked improvements in quality of life we find in our data strongly argue for the provision of surgical care regardless of a child's age.

Gonorrhoea diagnostics: An update

Diagnosis of gonorrhoea is an ongoing challenge. The organism is fastidious requiring meticulous collection and transport for successful cultivation. Asymptomatic infections are common which go undetected by conventional methods thereby leading to continued transmission and the risk of complications. The nucleic acid amplification tests, now increasingly used in developed countries, offer improved sensitivity compared to bacterial culture. However, these continue to suffer sequence related problems leading to false positive and false negative results. Further, these cannot be used for generation of data on antibiotic susceptibility because genetic markers of antibiotic resistance to recommended therapies have not been fully characterised. They are unaffordable in a setting like ours where reliance is placed on syndromic approach for sexually transmitted infection (STI) management. The use of syndromic approach has resulted in a considerable decline in the number of Neisseria gonorrhoeae isolates that have been cultured for diagnostic purposes. Many laboratories formerly doing so are no longer performing culture for gonococci, and the basic skills have been lost. There is a need to not only revive this skill but also adopt newer technologies that can aid in accurate diagnosis in a cost-effective manner. There is room for innovation that can facilitate the development of a point-of-care test for this bacterial STI.

Progeria Syndrome with Characteristic Deformation of Proximal Radius Observed on Ct

The progeria syndrome (Hutchinson-Gilford) is an uncommon disease. A peculiar shape of the proximal radial metaphyseal region caused by an infolding of the cortex was observed on CT in 2 brothers suffering from this disorder, a feature not previously reported. A brief review of the radiologic literature was undertaken. This new observation needs to be further evaluated as it may provide a clinching diagnostic feature of this disease.

Natural history of asymptomatic gallstones: differential behaviour in male and female subjects

OBJECTIVE

The natural history of asymptomatic (silent) gallstones has been inadequately studied. Existing information derives from studies based on oral cholecystography or relatively small sample sizes. We planned a retrospective cohort study in subjects with gallstones to determine conversion rates from asymptomatic to symptomatic.

METHODS

We extracted data from computerised databases of one government hospital and two private clinics in Malaysia. Files were scrutinised to ensure that criteria for asymptomatic gallstones were fulfilled. Patients were called on telephone, further questioned to confirm that the gallstones at detection were truly asymptomatic, and asked about symptoms that were consistent with previously defined criteria for biliary colic. Appropriate ethical clearances were taken.

RESULTS

213 (112 males) patients fulfilled the criteria for asymptomatic gallstones and could be contacted. 23 (10.8%) developed pain after an average follow up interval of 4.02 years (range 0.1-11 years). Conversion rates from asymptomatic to symptomatic gallstones were high in the first two years of follow up, averaging 4.03±0.965 per year. Over time the conversion rates slowed, and by year 10 the annual conversion rate averaged only 1.38±0.29. Conversion rates were much higher for females compared to males (F:M hazard ratio 3.23, SE 1.54, p>z 0.014). The lifetime risks for conversion approached 6.15% for males, and 22.1% for females.

CONCLUSION

In conclusion, asymptomatic gallstones are much more likely to convert to symptomatic in females than in males. Males in whom asymptomatic stones are discovered should be advised conservative treatment. Surgery may be preferable to conservative management if the subject is a young female.

Declining trends of Syphilis seroprevalance among antenatal clinic cases and STD clinic cases in a tertiary care centre: from January 2002 to December 2012

Syphilis affects nearly 1.36 million pregnant women, majority of these cases being concentrated in the developing countries. We aimed at analysing the 11 years' trends in syphilis seroprevalence in antenatal clinics (ANC) and STD clinic cases. Laboratory data of syphilis cases from 2002-2012 were retrospectively analysed. Out of the total 73,642 cases, 393 (0.53%) tested positive for Syphilis. A statistically significant decline in syphilis prevalence was found in both ANC and STD clinic cases. The efforts of various interventional programs should continue to make the screening and treatment facilities readily accessible to continue the decline in syphilis seropositivity.

Study of the role of efflux pump in ciprofloxacin resistance in Salmonella enterica serotype Typhi

PURPOSE

There are increasing reports on failure of clinical response to ciprofloxacin in typhoid fever despite the strain being sensitive to drug in in-vitro using standard guidelines and showing mutations in DNA gyrase. But this increased MIC and clinical failures with ciprofloxacin are not always co-related with mutations presently identified in gyrA and parC genes. This shows that there may be other mechanisms such as an active drug efflux pump responsible as has been shown in other Enterobacteriaceae. This study was carried out to determine the role of efflux pump in Salmonella Typhi isolates.

MATERIALS AND METHODS

Total 25 already characterized nalidixic acid sensitive and nalidixic acid resistant S. Typhi strains with different range of ciprofloxacin MIC were included to study the role of efflux pump in the presence of CCCP (efflux pump inhibitor). For genotypic characterization, the entire acrR gene was sequenced to confirm the presence of any mutation in the gene.

RESULTS

The MIC of ciprofloxacin remained same in the presence and absence of CCCP in the studied strains and no significant mutations were found in the acrR gene in any of the isolates studied.

CONCLUSIONS

No role of efflux pump in ciprofloxacin resistance was found in strains studied. There is a need to explore further mechanism of ciprofloxacin resistance in Salmonella Typhi.

In vitro antimicrobial activity of crude ethanol extracts and fractions of Terminalia catappa and Vitex doniana

BACKGROUND

The spread of microorganisms resistant to some antimicrobial agents necessitates the need to search for novel and effective antimicrobial agents. In this study, the antimicrobial activity of Terminalid catappa Linn. (Combretaceae) and Vitex doniana Sweet. (Verbenaceae), two Nigerian medicinal plants used in folk medicines for the management of various ailments related to microbial infections were evaluated.

OBJECTIVES

To evaluate the antimicrobial activity of the crude ethanol extracts and fractions of the leaves and stem bark of T. catappa and V. doniana.

METHODOLOGY

Four crude ethanol extracts and 16 (n-hexane, ethylacetate, n-butanol and aqueous) fractions of leaves and stem bark of T. catappa and V doniana were evaluated for in vitro antimicrobial activity against fifteen (15) strains of bacteria and fungi. The antimicrobial activity was determined in a 96-well plate using a resazurin based broth microdilution method. Two standard antimicrobial drugs ampicillin and nystatin were included as positive control.

RESULTS

The butanoL fraction of stem bark of T. catappa and ethanol crude extract of leaf of V don iana displayed the highest antibacterial activity with similar minimum inhibitory concentration (MIC) value of 93.75 microg/mL against S. aureus and B. subtilis. Furthermore, the ethyl acetate fraction of stem bark of T. catappa showed the highest antifungal activity with MIC of 187.5 microg/mL against A. sydowi. Amp icillin had MIC of 15.6 and 31.3 microg/mL against S. aureus and B. subtili, respectively while nystatin produced MIC of 3.9 microg/mL against A. sydowi.

CONCLUSION

Termninalia catappa and Vitex doniana may serve as useful sources of plant derived antimicrobial agents.

Using facebook for medical education: will students respond?

There is little information about the willingness of medical students to participate in Facebook for education. I analyzed my interactions with students for the past 14 months to estimate the quantity of student interaction. A Facebook Group was created. Students friend requests were accepted, but "friending" was never solicited. Questions were created around a clinical situation and posted. Forty questions were posted. 5/40 questions were about physics/chemistry. 24 questions focused on basic medical sciences. 11 questions were primarily about clinical medicine. In fourteen months, 533/810 (66%) college students joined the Group. In all, 163/533 students (30%) responded at least once. Half of all responses were comments; the rest were clicks on the "like" button. The average number of responses was 9.5 unique students/question. If participation is voluntary, and targeted students are large in number, one can expect about 66% of students to become members of a site, and about 30% of these to interact. For any given question posted on the site, about 2% of members will respond, regardless of the nature of question: clinically oriented or basic.

Cerebral phaeohyphomycosis by Exophiala dermatitidis

Cerebral phaeohyphomycosis is a rare and frequently fatal disease. We report a case of cerebral phaeohyphomycosis caused by Exophiala dermatitidis in a young immuno competent male presenting to a tertiary care hospital in Jaipur.