Artificial intelligence in parasitic disease control: A paradigm shift in health care

Parasitic diseases, including malaria, leishmaniasis, and trypanosomiasis, continue to plague populations worldwide, particularly in resource-limited settings and disproportionately affecting vulnerable populations. It has limited the use of conventional health-care delivery and disease control approaches and necessitated exploring innovative strategies. In this direction, artificial intelligence (AI) has emerged as a transformative tool with immense promise in parasitic disease control, offering the potential for enhanced diagnostics, precision drug discovery, predictive modeling, and personalized treatment. Predictive AI algorithms have assisted in understanding parasite transmission patterns and outbreaks by analyzing vast amounts of epidemiological data, environmental factors, and population demographics. This has strengthened public health interventions, resource allocation, and outbreak preparedness strategies, enabling proactive measures to mitigate disease spread. In diagnostics, AI-enabled accurate and rapid identification of parasites by analyzing microscopic images. This capability is particularly valuable in remote regions with limited access to diagnostic facilities. AI-driven computational methods have also assisted in drug discovery for parasitic diseases by identifying novel drug targets and predicting the efficacy and safety of potential drug candidates. This approach has streamlined drug development, leading to more effective and targeted therapies. This article reviews these current developments and their transformative impacts on the health-care sector. It also assessed the hurdles that require attention before these transformations can be realized in real-life scenarios.

Deep tech innovation for parasite diagnosis: New dimensions and opportunities

By converging advanced science, engineering, and design, deep techs are bringing a great wave of future innovations by mastering challenges and problem complexity across sectors and the field of parasitology is no exception. Remarkable research and advancements can be seen in the field of parasite detection and diagnosis through smartphone applications. Supervised and unsupervised data deep learnings are heavily exploited for the development of automated neural network models for the prediction of parasites, eggs, etc., From microscopic smears and/or sample images with more than 99% accuracy. It is expected that several models will emerge in the future wherein greater attention is being paid to improving the model's accuracy. Invariably, it will increase the chances of adoption across the commercial sectors dealing in health and related applications. However, parasitic life cycle complexity, host range, morphological forms, etc., need to be considered further while developing such models to make the deep tech innovations perfect for bedside and field applications. In this review, the recent development of deep tech innovations focusing on human parasites has been discussed focusing on the present and future dimensions, opportunities, and applications.

Balamuthia mandrillaris: An opportunistic, free-living ameba - An updated review

Balamuthia mandrillaris is an opportunistic, free-living ameba that is pathogenic to humans. It has a worldwide distribution but is mainly detected in warmer regions. Balamuthia infections are rare but have been reported in both immunocompetent and immunocompromised individuals of all ages. B. mandrillaris can enter through wounds on the skin or the nose and cause cutaneous lesions and the usually fatal Balamuthia amebic encephalitis (BAE). Infection usually spreads from the lungs or through nerve fibers, and attacks the central nervous system, forming granulomatous lesions and necrosis in the brain. Balamuthia infection is usually chronic, and patients initially present with nonspecific symptoms, including headache, nausea, myalgia, and low-grade fever. As the disease progresses, the patient becomes paralyzed and comatose, often leading to death. Lack of knowledge of predisposing factors, specific treatment, and standardized detection tools have resulted in a nearly cent percent fatality rate. Although only about 200 cases have been reported worldwide since its characterization in the 1990s, the number of reported cases has increased over the years. BAE is an emerging disease and a major health concern. Few patients have survived Balamuthia infections with antimicrobial treatment that has largely been empirical. Early diagnosis is the key and requires familiarity with the disease and a high degree of suspicion on the part of the diagnostician. There are currently no specific treatment and prevention recommendations. This review highlights our current understanding of B. mandrillaris in terms of its pathogenicity, genomics, and novel diagnostic and therapeutic approaches against BAE infections.

Molecular diagnosis of infectious parasites in the post-COVID-19 era

The endemicity of several parasitic diseases across the globe and recent evidence of distress among COVID-19 patients with preexisting parasitic infections requires strengthening One Health framework and advanced strategies for parasitic detection. Owing to the greater sensitivity and accuracy, molecular technologies such as conventional polymerase chain reaction (PCR), reverse transcription (RT)-PCR, nested PCR, loop-mediated isothermal amplification (LAMP), and xMAP technology have been extensively studied for parasitic diagnosis. Varieties of genes have been targeted for primer development where 18S rRNA, internal transcribed spacer regions, and mitochondrial DNAs coding for cytochrome, and other enzymes have been widely used. More recent, low-cost sequencing and advances in big data management have resulted in a slow but steady rise of next-generation sequencing-based approaches for parasite diagnosis. However, except for few parasites of global concerns such as Plasmodium and Entamoeba, most of the molecular tools and technologies are yet to witness bench to bedside and field translations. This review looks into some of the advancements in the molecular diagnosis of parasites that have potential relevance to clinical purposes and may pave the way toward disease management in an efficient and timely manner.

Pondicherry declaration on the identification and detection of Entamoeba histolytica

Stake holders meet on “Identification and Detection of Entamoeba histolytica” was conducted on July 21, 2019 at Sri Balaji Vidyapeeth Deemed-to-be-University, Pondicherry. This programme was of national importance, since the amoebiasis is being increasingly reported from different parts of India because of poor socioeconomic conditions and sanitation levels. Experts in amoebiasis research across India attended this meeting. This meeting was conducted with an objective to frame the guidelines on the identification and detection of E. histolytica with reference to conventional diagnostic methods and molecular diagnosis targeting appropriate genes of E. histolytica. The recommendations of the panel were released as declaration on the diagnosis of amoebiasis and were circulated to various administrative and scientific bodies in India as reference policy document on the diagnosis of amoebiasis.

Lophomonas blattarum: A new flagellate causing respiratory tract infections

Lophomonas blattarum is a flagellate protozoan parasite which was originally described as a commensal in the gut of cockroaches. From the 1990s, reports started coming out of peoples Republic of China about its possible role in bronchopulmonary infections, and this was followed by reports from some other parts of the world as well. There had been some skepticism regarding the misidentification of bronchial ciliated epithelial cells as L. blattarum, but recent use of molecular diagnosis has come as an aid in clearing the controversy. This review focuses on the various aspects of the parasite including its biology, epidemiology, clinical manifestations, laboratory diagnosis, and the treatment aspects. Molecular diagnosis has recently been employed and more reports concerning its validation is needed. More basic research concerning the genomic and proteomic analysis is necessary to develop reliable molecular and serological tests for this parasite in future.

Detection of heterogeneous vancomycin-intermediate Staphylococcus aureus: A preliminary report from south India

Background & objectives

Although there are reports of heterogeneous vancomycin-intermediate Staphylococcus aureus (hVISA) across the globe, there is a lack of reliable data on hVISA in India. The present study was undertaken to determine the rate of hVISA among the methicillin-resistant Staphylococcus aureus (MRSA) isolates, and to compare the brain heart infusion agar with vancomycin 4 μg/ml (BHIV4) method with population analysis profile-area under the curve (PAP-AUC) method for the detection of hVISA and to study the distribution of mobile genetic element that carries methicillin-resistance gene SCCmec (Staphylococcal cassette chromosome mec) types among these isolates.

Methods

BHIV4 and PAP-AUC methods were employed to detect hVISA among 500 clinical isolates of MRSA. SCCmec typing of these isolates was performed by multiplex polymerase chain reaction. The clinical presentation, treatment with vancomycin and outcome was documented for patients with hVISA.

Results

The rate of hVISA was 12.4 per cent by PAP-AUC method. Sensitivity, specificity, PPV, NPV and kappa agreement of BHIV4 with PAP-AUC was 58.06, 93.15, 54.55, 94.01 per cent and 0.498, respectively. The isolation of hVISA was significantly (P<0.01) higher in patients admitted to intensive care units and wards than in patients attending the outpatient departments. Only 38 per cent of the patients received vancomycin as therapy. Majority of the hVISA isolates carried SCCmec type V or IV.

Interpretation & conclusions

The rate of hVISA isolation in our study was 12.4 per cent. The sensitivity of the BHIV4 screening test was low, and was in moderate agreement with PAP-AUC test. SCCmec type V was the predominant type seen in half of the isolates. More studies need to be done in different parts of the country on a large number of isolates to confirm our findings.

Risk factors for intestinal colonization with vancomycin resistant enterococci' A prospective study in a level III pediatric intensive care unit

PURPOSE:

Vancomycin-resistant enterococci (VRE) emerged as one of the major nosocomial pathogens across the globe. Gut colonization rate with VRE is higher in patients admitted to intensive care units (ICUs) due to the higher antibiotic pressure. VRE colonization increases the risk of developing infection up to 5–10 folds. The aim of this study was to determine the rates of VRE colonization among the patients admitted to pediatric ICU (PICU) and risk factors associated with it.

MATERIALS AND METHODS:

Rectal swabs were collected after 48 h of admission to PICU from 198 patients. The samples were inoculated onto bile esculin sodium azide agar with 6 mg/ml of vancomycin. Growth on this medium was identified by the standard biochemical test, and minimum inhibitory concentration of vancomycin and teicoplanin was detected by agar dilution method. Resistance genes for vancomycin were detected by polymerase chain reaction. Risk factors were assessed by logistic regression analysis.

RESULTS:

The rates of VRE colonization in patients admitted to PICU was 18.6%. The majority of the isolates were Enterococcus faecium (75.6%) followed by Enterococcus faecalis (24.4%). One patient acquired a VRE bloodstream infection (2.6%) among colonized patients, and none of the noncolonized patients acquired the infection. Consumption of vancomycin was found to be the only risk factor significantly associated with VRE colonization.

CONCLUSION:

Routine surveillance and isolation of patients found to be VRE colonized may not be possible in tertiary care hospitals; however, educating health-care workers, promoting handwashing with antiseptic soaps or solutions, and antibiotic Stewardship policy may help in the reduction of vancomycin resistance and VRE colonization.

Molecular characterization & epidemiology of carbapenem-resistant Acinetobacter baumannii collected across India

Background & objectives

Acinetobacter baumannii is an opportunistic pathogen responsible for causing nosocomial infections. A. baumannii develops resistance to various antimicrobial agents including carbapenems, thereby complicating the treatment. This study was performed to characterize the isolates for the presence of various β-lactamases encoding genes and to type the isolates to compare our clones with the existing international clones across five centres in India.

Methods

A total 75 non-repetitive clinical isolates of A. baumannii from five different centres were included in this study. All the isolates were confirmed as A. baumannii by bl a_OXA-51-likePCR. Multiplex PCR was performed to identify the presence of extended spectrum β-lactamases (ESBL) and carbapenemases. Multilocus sequence typing was performed to find the sequence type (ST) of the isolates. e-BURST analysis was done to assign each ST into respective clonal complex.

Results

bla_OXA-51-likewas present in all the 75 isolates. The predominant Class D carbapenemase was bla_OXA-23-likefollowed by Class B carbapenemase, bla_NDM-like. Class A carbapenemase was not observed. bla_PER-likewas the predominant extended spectrum β-lactamase. ST-848, ST-451 and ST-195 were the most common STs. Eight-novel STs were identified. e-BURST analysis showed that the 75 A. baumannii isolates were clustered into seven clonal complexes and four singletons, of which, clonal complex 208 was the largest.

Interpretation & conclusions

Most of the isolates were grouped under clonal complex 208 which belongs to the international clonal lineage 2. High occurrence of ST-848 carrying bla_OXA-23-likegene suggested that ST-848 could be an emerging lineage spreading carbapenem resistance in India.

Molecular characterization of extended-spectrum β-lactamases among clinical isolates of Escherichia coli & Klebsiella pneumoniae: A multi-centric study from tertiary care hospitals in India

Background & objectives:

The increasing prevalence of extended-spectrum β-lactamases (ESBLs) has abated therapeutic options worldwide. This study was undertaken to investigate the molecular profile and resistance patterns of ESBLs among clinical isolates of Escherichia coli and Klebsiella pneumoniae at four tertiary care centres in India.

Methods:

Clinical isolates of E. coli and K. pneumoniae were collected from the All India Institute of Medical Sciences (AIIMS), New Delhi; the Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry; Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh and Christian Medical College (CMC), Vellore, over one and a half year period. Antimicrobial susceptibility was determined by Kirby-Bauer disc diffusion method. ESBLs were confirmed phenotypically, and multiplex PCR was performed to identify genes for β-lactamases (bla_TEM, bla_SHV, bla_OXA-1, bla_CTXM-1, bla_CTXM-2, bla_CTXM-9 and bla_CTXM-15).

Results:

Among 341 E. coli isolates collected during the study period, 171 (50%) harboured bla_TEM, 145 (43%) bla_OXA-1, 70 (21%) bla_CTXM-1, 19 (6%) bla_SHV and four (1%) harboured bla_CTXM-2. Phenotypically, combined disc test detected ESBL production in 98/298 (33%) E. coli. Among 304 K. pneumoniae isolates, 115 (38%), 89 (29%), 83 (27%), 64 (21%) and two (0.6%) harboured bla_TEM, bla_OXA-1, bla_CTXM-1, bla_SHV and bla_CTXM-2, respectively. Combined disc test (CDT) detected ESBL production in 42 per cent K. pneumoniae. Most of the bla_CTXM-1 positive isolates were also bla_CTXM-15 positive. The carbapenem susceptibility ranged from 56 to 88 per cent for E. coli and from 20 to 61 per cent for K. pneumoniae. Antibiotic sensitivity patterns showed that colistin (CST) was the most sensitive drug for both E. coli (271/274, 99%) and K. pneumoniae (229/234, 98%).

Interpretation & conclusions:

The prevalence of ESBL among four study centres varied, and bla_TEM,bla_OXA-1 and bla_CTXM-15 were the most common genotypes in E. coli and K. pneumoniae isolates in India. The growing carbapenem resistance and emerging colistin resistance warrant the judicious use of these antimicrobials.

Applying systems approach for bridging education, research, and patient care in a health sciences university

Systems approach provides a logical and scientific basis for explaining the functioning of a system in a holistic manner. The health sciences university is a system with its three major operations – education, research, and patient care, which can be conceived as inputs, process, and output, respectively. The system is aided by a feedback loop to inform and correct the system. Systems thinking enable us to identify the deficiencies existing in each of the components so that appropriate remedial action can be taken. In this article, we have identified deficiencies in the health sciences system. Further, we have suggested a five-point formula to achieve connection among education, research, and patient care. We need to Form consortia and networks to create a mass movement, Uniform regulations to remove bottlenecks, Reform curricula to make them credit linked and competency based, Inform all through a faculty development initiative, and finally, Transform the system by setting examples and demonstrating success. The initiative taken by the Medical Council of India in introducing a competency-based curriculum for MBBS, and the revised accreditation manual introduced by the National Assessment and Accreditation Council can provide a lot of opportunities to explore the potentiality educational research to answer many questions that can help us in connecting research with education and patient care.

Genetic diversity of Indian Plasmodium vivax isolates based on the analysis of PvMSP3β polymorphic marker

Background

Malaria is one of the major communicable diseases in India and worldwide. PvMSP3β is a highly polymorphic gene due to its large insertions and deletions in the central alanine-rich region, which, in turn, makes it a valuable marker for population genetic analysis. Very few studies are available from India about the genetic diversity of Plasmodium vivax based on PvMSP3β gene, and hence, this study was designed to understand the molecular diversity of the P. vivax malaria parasite. The accumulating epidemiological data provide insights into the circulating genetic variants of P. vivax in India, and ultimately benefits the vaccine development.

Materials and Methods

A total of 268 samples confirmed to be positive by microscopy, rapid diagnostic test, and quantitative buffy coat test were collected from four different regions of India (Puducherry, Mangaluru, Jodhpur, and Cuttack) in the present study. Polymerase chain reaction (PCR)-based diagnosis was carried out to confirm the P. vivax monoinfection, and only the mono-infected samples were subjected to PvMSP3β gene amplification and further restriction fragment length polymorphism (RFLP) to determine suballeles.

Results

Based on the size of the amplified fragment, the PvMSP3β gene was apportioned into two major types, namely Type A genotype (1.6-2 Kb) was predominantly present in 148 isolates and Type B (1-1.5 Kb) was observed in 110 isolates. The percentage of mixed infections by PCR was 3.73%. All the PCR products were subjected to RFLP to categorize into suballeles and we detected 39 suballeles (A1-A39) in Type A, and 23 suballeles (B1-B23) in Type B genotype. A high degree of diversity was observed among the isolates collected from Mangaluru region when compared to isolates collected from other regions.

Conclusion

The present study showed a high degree of genetic diversity of PvMSP3β gene among the isolates collected from various parts of India. High polymorphism in PvMSP3β gene makes it a promising marker for epidemiological and vaccine development studies.

Assessment of global DNA methylation in children with tuberculosis disease

Background

Studying DNA methylation changes in disease condition provides the basis of disease pathogenesis or host immune response to infection. Evidences suggest that pathogen-mediated DNA methylation changes influences the expression pattern of genes contributing to disease condition to avert host immune response. Hence, we attempted to study the association between tubercle bacilli-mediated global DNA methylation changes in children with tuberculosis (TB) disease and healthy controls.

Methods

Forty-three children diagnosed with TB and 33 healthy children were enrolled in this study. ELISA-based global DNA methylation quantification was performed to measure the changes in percentage of global genomic DNA methylation level.

Results

Highly significant difference in global DNA methylation level was found between cases and controls and median global DNA methylation level was 6.25% (interquartile range [IQR] 2.5%-10%) in cases and 25% (IQR, 12.5%-25%) in controls (P < 0.001). Significant difference was found in GeneXpert-positive cases (P < 0.01). Receiver operating curve analysis showed that area under curve 0.81 for the total study population and 0.76 for GeneXpert-positive cases.

Conclusion

The results show the significant difference in global DNA methylation level in children with TB disease that can serve as a potential biomarker in early diagnosis of TB disease. Measuring global DNA methylation level, however, not an accurate or sensitive diagnostic method but evaluating active demethylation at genome-wide level can be used to monitor disease progression and treatment efficacy.

Systems approach in medical education: The thesis, antithesis, and synthesis

Systems approach is a time tested, method of trying to understand the reality holistically, and resolving the issues by problem-solving method. It has resulted in enormous applications in almost every field of knowledge, science, technology, industries, agriculture, and health or education. The main essence of systems thinking lies in minimizing the inputs, optimizing the process to maximize the outputs through continuous feedback, and monitoring. Medical education has been greatly benefitted as the systems approach has influenced all aspects, from delineating the competencies of doctors, designing curriculum that includes comprehensive assessment. However, of late, there has been a debate as to whether the systems approach can really contribute to resolve complex issues such as bringing curricular reforms, or promote policy changes in patient care, education, or research. This involves a paradigm shift from problem-solving approach to “pattern recognition” and adaptive action to correct the system. This review based on critical appreciation, begins with a thesis that systems approach is a great tool. It then exposes its inadequacy to address complex systems. This is antithesis. In the end, a synthesis of both the contradictory views has been proposed as a take home.

In silico modeling of Plasmodium falciparum chloroquine resistance transporter protein and biochemical studies suggest its key contribution to chloroquine resistance

Chloroquine (CQ) has been used for decades as the primary chemotherapeutic drug for the treatment of malaria. The emergence of drug resistance in Plasmodium falciparum has been considered to be because of the excessive use of antimalarial drugs worldwide. Moreover, the intense distribution and prevalence of chloroquine-resistant strains in endemic regions has aided the incidence of more complications to malaria treatment and control. Due to the lack of literature that portrays evident molecular mechanisms of drug resistance, it has been difficult to understand the drug resistance conferred by Plasmodium species. Intensive research on CQ drug resistance has identified the association of P. falciparum chloroquine resistance transporter protein (PfCRT), which belongs to the drug/metabolite transporter and EamA-like superfamily. Additionally, it has shown that K76 T mutation in PfCRT protein has mainly attributed to CQ resistance than other mutations. This study deals with the development of an in silico model of the PfCRT protein and its interaction with the CQ ligand molecule as well as the biochemical and biophysical characterization of the transmembrane domain 1 (TMD 1) peptide of the PfCRT protein. The physiochemical analysis of the PfCRT protein identified basic differences between the wild and mutant forms of the protein, as well as identifying the high hydrophobic nature of the mutant-type protein. The tertiary structure of the PfCRT protein was predicted and interaction with CQ revealed different active pocket binding regions in both the wild and mutant form of PfCRT proteins. The CQ²⁺ molecule interacts with TMD 10 of the wild-type PfCRT protein, whereas it interacts with TMD 1 of the mutant-type protein. Studies on the TMD 1 peptide revealed the insertion of the peptide in the micelles adopting stable alpha-helical structure. Binding studies with the CQ molecule detected high binding affinity toward the mutant-type TMD 1 peptide rather than the wild-type, thus confirming that the TMD 1 peptide is involved in substrate selectivity. Our findings help to characterize the structure of the PfCRT protein and the role played by the TMD 1 region in CQ resistance using in silico and biochemical approaches. Molecular docking and ligand binding studies confirm that TMD 1 is involved in substrate selectivity and aids in CQ efflux, thereby contributing to the parasite's CQ drug resistance mechanism.

Detection of Blastocystis in clinical stool specimens using three different methods and morphological examination in Jones' medium

Background:

Blastocystis was identified almost a century ago, yet its biology and pathogenicity status in humans is obscure. Studies on Blastocystis in India are scanty and are mostly microscopy based. This study compared three detection modalities to determine their efficiency in the identification of Blastocystis in human feces.

Materials and Methods:

A total of 279 stool samples were screened using microscopy, culture (Jones' medium), and polymerase chain reaction (PCR)-based methods. Among the three, PCR is considered the gold standard test for detection of Blastocystis, as it helps to authenticate the sensitivity, specificity, and kappa agreement obtained by the other two tests. The morphological features of Blastocystis were recorded at 24, 48, and 72 h. After positive morphological identification, ten samples were cultured on Löwenstein–Jensen (LJ) medium and Locke's egg slant medium.

Results:

The sensitivity and specificity determined on the basis of microscopy were 36.2% and 99.4%, respectively. On the other hand, Jones' medium showed 67.6% sensitivity and 100% specificity. Further, we documented various morphological and reproductive features of Blastocystis using various staining techniques on cultures positive in Jones' medium. In addition, we also found that LJ medium was not equally efficacious as Jones' medium in assisting the growth of Blastocystis.

Conclusions:

Although molecular diagnosis is a necessary tool for understanding the true epidemiology of Blastocystis, in laboratories devoid of molecular detection facilities, stool microscopy in conjunction with stool culture on Jones' medium could serve as the best alternative tool for the detection of Blastocystis.

Effect of disease-modifying antirheumatic drug therapy on immune response to trivalent influenza vaccine in rheumatoid arthritis

Background & objectives:

Patients with autoimmune rheumatic diseases may be at an increased risk of infection due to disease and use of disease-modifying antirheumatic drug (DMARD) therapy. The present study was done to evaluate the immune response to influenza vaccination in patients with rheumatoid arthritis (RA).

Methods:

Fifty one RA patients on stable methotrexate (MTX) therapy (≥15 mg/wk), 51 newly diagnosed DMARD-naïve RA patients and 45 healthy controls received a single dose of inactivated seasonal trivalent influenza vaccine. Blood samples were collected just prior to and four weeks after vaccination. Pre- and post-vaccination antibody titres against the three virus strains were measured by hemagglutination inhibition assay. The impact of age, gender, DMARD treatment and pre-vaccination seroprotection on response to the vaccine was assessed by binary logistic regression analysis for each of the virus strains.

Results:

Pre-vaccination antibody titres were found to be high in the three study groups for all influenza strains, except for Yamagata strain, the titres for which were low in healthy controls. Trivalent influenza vaccination was found to be safe and stimulated a good antibody response in all study groups. On regression analysis, there was no association of age, gender or MTX therapy with vaccine response, except for Yamagata strain where healthy controls had higher positive immune response (P=0.008; odds ratio – 3.37, 95% confidence interval: 1.36-8.32).

Interpretation & conclusions:

Our results indicated that influenza vaccination was safe in RA patients with no detrimental effect on disease activity. MTX therapy at a dose ≥15 mg/wk did not affect the vaccine response. Presence of high pre-vaccination seroprotective antibody levels in the study population indicates the need for re-examination of recommended annual influenza vaccination in such subgroups of population.

Clinico-microbiological Profile of Septic Diabetic Foot with Special Reference to Anaerobic Infection

Introduction Diabetic foot infections are a major cause of non-traumatic amputations. The role of anaerobes in the prognosis of these infections is particularly unclear. This study was conducted with the aim of correlating microbiological profiles with clinical outcomes in these diabetic foot ulcer patients. Methodology This prospective observational study was done in a tertiary care centre in South India. All patients admitted with diabetic foot ulcers for two years were included in the study. Tissue biopsies were collected from the ulcer for aerobic and anaerobic cultures. The patients were grouped as those with aerobic infection alone (anaerobe negative) and those with mixed aerobic and anaerobic infections (anaerobe positive). Anaerobic culture was performed using the Robertson cooked meat (RCM) medium. The ulcer of the foot was described with respect to site, size, duration, history of previous amputation(s), and history of number and class of antibiotic intake prior to hospitalization. Clinical course and Wagner's grades of the diabetic foot ulcers were compared for aerobic and anaerobic infections. Results A total of 104 patients were included in the study. There were no significant differences between the two groups with regards to duration of diabetes, random blood sugar (RBS) at the time of admission, compliance to drugs, and mode of blood sugar control and prior intake of antibiotics. Patients with anaerobic infections were found to have a higher incidence of fever in this study (38.1% vs. 14.5%; p = 0.0057), as compared to patients with aerobic infections. More than half of the patients in the anaerobic infection group presented with Wagner's grade IV and above, as compared to the aerobic infection group (59.5% vs. 32.2%; p = 0.0059), which was statistically significant. Patients with anaerobic infections also had high numbers of major and minor amputations when compared to patients with aerobic infections. Conclusion Septic diabetic foot patients with fever at the time of admission and a high Wagner's grade have a greater chance of harbouring anaerobic infections. Drugs for anaerobic coverage should be considered for wounds beyond Wagner's grade III. Anaerobic infections resulted in increased risk of morbidity in diabetic foot ulcer patients but did not have any influence on mortality.

Short Term Oral Zinc Supplementation among Babies with Neonatal Sepsis for Reducing Mortality and Improving Outcome - A Double-Blind Randomized Controlled Trial

OBJECTIVE

To evaluate the efficacy of short term zinc supplementation on the mortality rate and neurodevelopment outcome in neonates with sepsis at 12 mo corrected age.

METHODS

The clinical trial was undertaken in the neonatal intensive care unit of JIPMER during the time period from September 2013 through December 2016. Neonates with clinical manifestations of sepsis who exhibited two positive screening tests (microESR, C- reactive protein, band cell count) were included and randomized into no zinc and zinc group. The intervention was zinc sulfate monohydrate given at a dose of 3 mg/kg twice a day orally for 10 d along with standard antibiotics. The no zinc group was on antibiotic treatment. Blood samples from both groups were collected at baseline and after day 10. Babies were carefully discharged from the hospital. The babies were followed up till 12 mo corrected age using DASII (Development Assessment Scale for Indian Infants).

RESULTS

At the time of enrolment, patient characteristics were similar in both the groups. The mortality rate was significantly higher in no zinc compared to zinc group (5 vs. 13; P = 0.04). Although motor development quotient was similar, mental development quotient was significantly better among babies who received zinc supplementation.

CONCLUSIONS

Short term zinc supplementation of newborns with sepsis reduces mortality and improves mental development quotient at 12 mo of age.

Chitinase-gene-based analysis of the genetic variability among the clinical isolates of Entamoeba dispar from Puducherry, India

Introduction:

Amebiasis is known to be caused by the protozoan parasite Entamoeba histolytica. Entamoeba dispar is considered to be a sibling species of E. histolytica, as the two are phylogenetically closest. There are reports that certain strains of E. dispar isolated were capable of causing hepatic lesions in the experimental animal models. The intra-/inter-species genetic variation has been found to have profound implication in the invasiveness of the disease. Thus, studying polymorphism in E. dispar aids to improve our perspective related to the variability in the genome of the parasite.

Materials and Methods:

The highly polymorphic region of the gene encoding the enzyme chitinase was targeted for the strain variation analysis in E. dispar. Isolates from the stool and liver abscess aspirate were subjected to the polymerase chain reaction (PCR) for the amplification of the targeted polymorphic loci. The PCR products were sequenced, and genetic variability analysis was carried out.

Results:

A total of 23 samples in the stool and 1 sample from liver abscess pus were positive for E. dispar by nested multiplex PCR which was confirmed by sequencing. Of these positive samples, 13 amplified for chitinase gene by PCR. We observed seven genotypes in our study isolates, of which four were found to be distinct.

Conclusion:

This study shows that high degree of genetic variation exists among the clinical isolates of E. dispar in our location. The future studies including the analysis of other genetic makers such as serine-rich E. dispar protein or other loci have to be carried out to get an idea about the distribution of the different strains of E. dispar.

Ethics of translational medical research

Translational research is the science of application of basic research knowledge to develop novel methods of improving public health outcome. This review briefly discusses the various phases involved and the hurdles faced in the translational pathway, how translational science originated, and the infrastructures consigned for translational research. Translational research also faces numerous diverse ethical issues similar to those observed in biomedical research. The various types of ethical issues faced whereas conducting translational research are discussed briefly in this review to help researchers identify and prevent unethical practices while conducting or regulating translational research.

Multiple parasitic and viral infections in a patient living with HIV/AIDS on antiretroviral therapy

Patients with human immunodeficiency virus (HIV) infection are more prone for gastrointestinal infections causing diarrhoea, particularly with parasites. Parasitic infections have been regularly reported in such patients. A female patient confirmed positive for HIV 1 on antiretroviral therapy came with complaints of chronic diarrhoea for the past 7 months. Her initial CD4 count was 89 cells/μl of blood, and antibodies to cytomegalovirus and herpes simplex virus 1 and 2 virus were found to be positive in the patient's serum, but there was no HIV-associated retinopathy. Her stool examination showed decorticated fertilised eggs of Ascaris lumbricoides, cysts of Blastocystis sp. and Entamoeba species in the unconcentrated sample and oocysts of Cystoisospora species, egg of Schistosoma haematobium and eggs of Trichuris trichiura in the concentrated. The patient responded well to cotrimoxazole and albendazole, and repeat samples were negative for all these parasites.

A Stratified Analysis of Clinical Manifestations and Different Diagnostic Methods of Neurocysticercosis-Suspected Tamilian Population Residing in and Around Puducherry

INTRODUCTION

Human beings are accidental hosts for Cysticercus cellulosae showing varied clinical manifestations based on the site harbored by the parasitic cyst because of which disease profile remains unexplored at large. Besides this, diagnosis of the disease with a single conventional method is problematic due to lack of specificity and sensitivity.

AIM

To assess the varied clinical manifestations and stratify based on imaging and serological methods for diagnosis of Neurocysticercosis (NCC) in our study population.

MATERIALS AND METHODS

A hospital-based study was carried out at Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER), the tertiary care centre caters patients from Puducherry and surrounding regions of Tamil Nadu. This is a cross-sectional analysis of clinically and radiologically suspected cases of NCC (n=119) for a period of three years (2012 to 2015). The collection of detailed clinical history and imaging findings (MRI or CT) along with the lifestyle parameters was done after obtaining informed consent. Enzyme-Linked Immune-Electro Transfer Blot (EITB) was carried out for the samples collected from study subjects.

RESULTS

Based on dietary and environmental factors non-vegetarians, pork eaters, raw vegetable consumers and open-field defecation showed significant seropositivity. The clinical manifestations like seizures, blurring of vision and chronic headache with nausea followed by neck pain, cognitive deficits and movement disorder have higher seropositivity respectively. Generalized seizures were found to be more than focal seizures. While comparing the imaging and serological tests for NCC diagnosis, the positivity rate was 46.2% considering positive by both methods; but 18.5% of sero-positive cases were imaging negative, and 16% of the sero-negative cases were imaging positive. The study showed a predominance of multiple cysts (62%) in cases with cystic lesions.

CONCLUSION

This study is first of its kind in associating varied and less commonly explored clinical manifestations with two different diagnostic measures in practice and its importance among our study settings. These manifestations must be considered as strong disease entities of NCC, which has to be suggested for differential diagnosis, and cannot be left ignored. Combinatorial diagnostic methods like serology and imaging techniques should be followed in diagnosis and assessing the disease burden.

In-silico prediction and modeling of the Entamoeba histolytica proteins: Serine-rich Entamoeba histolytica protein and 29 kDa Cysteine-rich protease

BACKGROUND

Amoebiasis is the third most common parasitic cause of morbidity and mortality, particularly in countries with poor hygienic settings. There exists an ambiguity in the diagnosis of amoebiasis, and hence there arises a necessity for a better diagnostic approach. Serine-rich Entamoeba histolyticaprotein (SREHP), peroxiredoxin and Gal/GalNAc lectin are pivotal in E. histolyticavirulence and are extensively studied as diagnostic and vaccine targets. For elucidating the cellular function of these proteins, details regarding their respective quaternary structures are essential. However, studies in this aspect are scant. Hence, this study was carried out to predict the structure of these target proteins and characterize them structurally as well as functionally using appropriate in-silicomethods.

METHODS

The amino acid sequences of the proteins were retrieved from National Centre for Biotechnology Information database and aligned using ClustalW. Bioinformatic tools were employed in the secondary structure and tertiary structure prediction. The predicted structure was validated, and final refinement was carried out.

RESULTS

The protein structures predicted by i-TASSER were found to be more accurate than Phyre2 based on the validation using SAVES server. The prediction suggests SREHP to be an extracellular protein, peroxiredoxin a peripheral membrane protein while Gal/GalNAc lectin was found to be a cell-wall protein. Signal peptides were found in the amino-acid sequences of SREHP and Gal/GalNAc lectin, whereas they were not present in the peroxiredoxin sequence. Gal/GalNAc lectin showed better antigenicity than the other two proteins studied. All the three proteins exhibited similarity in their structures and were mostly composed of loops.

DISCUSSION

The structures of SREHP and peroxiredoxin were predicted successfully, while the structure of Gal/GalNAc lectin could not be predicted as it was a complex protein composed of sub-units. Also, this protein showed less similarity with the available structural homologs. The quaternary structures of SREHP and peroxiredoxin predicted from this study would provide better structural and functional insights into these proteins and may aid in development of newer diagnostic assays or enhancement of the available treatment modalities.

Bioethics: A brief review

Medical and life sciences research is a key driver in development, which leads to better quality of life. These pursuits can lead to discrimination, human rights violation, and injustice. The field of bioethics explores the ethical issues arising due to these advances in research and encompasses social, judicial, and environmental aspects affecting human beings. This brief review discusses the origin of bioethics, its principles, various international organizations, and their network involved in the development and propagation of guidelines on conducting biomedical research.

Prevalence and genetic mechanisms of antimicrobial resistance in Staphylococcus species: A multicentre report of the indian council of medical research antimicrobial resistance surveillance network

PURPOSE

Routine surveillance of antimicrobial resistance (AMR) is an essential component of measures aimed to tackle the growing threat of resistant microbes in public health. This study presents a 1-year multicentre report on AMR in Staphylococcus species as part of Indian Council of Medical Research-AMR surveillance network.

MATERIALS AND METHODS

Staphylococcus species was routinely collected in the nodal and regional centres of the network and antimicrobial susceptibility testing was performed against a panel of antimicrobials. Minimum inhibitory concentration (MIC) values of vancomycin (VAN), daptomycin, tigecycline and linezolid (LNZ) against selected methicillin-resistant Staphylococcus aureus(MRSA) isolates were determined by E-test and MIC creep, if any, was determined. Resistant genotypes were determined by polymerase chain reaction for those isolates showing phenotypic resistance.

RESULTS

The prevalence of MRSA was found to be range from moderate (21%) to high (45%) among the centres with an overall prevalence of 37.3%. High prevalence of resistance was observed with commonly used antimicrobials such as ciprofloxacin and erythromycin in all the centres. Resistance to LNZ was not encountered except for a single case. Full-blown resistance to VAN in S. aureus was not observed; however, a few VAN-intermediate S. aureus isolates were documented. The most common species of coagulase negative staphylococci (CoNS) identified was Staphylococcus haemolyticus and Staphylococcus epidermidis. Resistance among CoNS was relatively higher than S. aureus. Most phenotypically resistant organisms possessed the corresponding resistance genes.

CONCLUSION

There were localised differences in the prevalence of resistance between the centres. The efficacy of the anti-MRSA antimicrobials was very high; however, almost all these antimicrobials showed evidence of creeping MIC.

Molecular characterisation of antimicrobial resistance in Pseudomonas aeruginosa and Acinetobacter baumannii during 2014 and 2015 collected across India

BACKGROUND

Surveillance of antimicrobial resistance (AMR) is of great importance. Pseudomonas aeruginosa and Acinetobacter baumannii are important pathogens and emergence of resistance in these have increased the morbidity and mortality rates. This surveillance study was initiated by the Government of India - Indian Council of Medical Research. The aim of this study is to determine the antimicrobial susceptibility profile and to characterise the enzyme mediated antimicrobial resistance such as extended spectrum beta-lactamases (ESBLs) and carbapenemases among multidrug-resistant (MDR) P. aeruginosa and A. baumannii.

MATERIALS AND METHODS

A multi-centric study was conducted from January 2014 to December 2015 with a total number of 240 MDR P. aeruginosa and 312 MDR A. baumannii isolated from blood, cerebrospinal fluid, respiratory, pus, urine and intra-abdominal infections. Kirby-Bauer disc diffusion was done to determine the antimicrobial susceptibility profile. Further, MDR isolates were characterised by multiplex polymerase chain reaction to determine the resistance genes for ESBLs and carbapenemases.

RESULTS

Among the ESBLs, blaVEB (23%), blaTEM (5%) and blaSHV (0.4%) in P. aeruginosa and blaPER (54%), blaTEM (16%) and blaSHV (1%) in A. baumannii were the most prevalent. Likewise, blaVIM (37%), blaNDM (14%), blaGES (8%) and blaIMP (2%) in P. aeruginosa and blaOXA-23like (98%), blaOXA-58like (2%), blaNDM (22%) and blaVIM (3%) in A. baumannii were found to be the most prevalent carbapenemases. blaOXA-51like gene, intrinsic to A. baumannii was present in all the isolates tested.

CONCLUSION

The data shown highlight the wide difference in the molecular mechanisms of AMR profile between P. aeruginosa and A. baumannii. In P. aeruginosa, plasmid-mediated mechanisms are much lesser than the chromosomal mediated mechanisms. In A. baumannii, class D oxacillinases are more common than other mechanisms. Continuous surveillance to monitor the trends in AMR among MDR pathogens is important for implementation of infection control and to guide appropriate empirical antimicrobial therapy.

Decreased baroreflex sensitivity is linked to the atherogenic index, retrograde inflammation, and oxidative stress in subclinical hypothyroidism

Purpose/aim of the study: The present study investigated the link of hyperlipidemia, inflammation and oxidative stress (OS) to cardiovascular (CV) risks in subclinical hypothyroidism (SCH).

MATERIALS AND METHODS

We enrolled 81 subclinical hypothyroid patients and 80 healthy subjects as control. Their CV and autonomic functions were assessed by spectral analysis of heart rate variability (HRV), continuous blood pressure variability (BPV) measurement and conventional autonomic function testing. Thyroid profile, lipid profile, immunological, inflammatory and OS markers were estimated and correlated with the baro-reflex sensitivity (BRS), the marker of sympathovagal imbalance (SVI) & CV risk.

RESULTS

Mean arterial pressure (MAP, P<0.0001), total peripheral resistance (TPR, P<0.0001), ratio of low-frequency to high-frequency power of HRV (LF-HF ratio) (P<0.0001) were significantly higher and BRS (P<0.0001) was significantly lower in SCH group than the control group. BRS significantly correlated with heart rate, MAP, LF-HF ratio, lipid risk factors, anti-thyroperoxidase antibody, thyroid-stimulating hormone, high-sensitive C-reactive protein (hsCRP), malondialdehyde (MDA) and SCH.

CONCLUSIONS

It was concluded that SVI is associated with SCH. Though dyslipidemia, inflammation and OS contributed to decreased BRS, SCH per se contributed maximally to it. Decreased BRS could be a physiological basis of increased CV risks in patients with SCH.

A Study on Gene Expression Profile of Endogenous Antioxidant Enzymes: CAT, MnSOD and GPx in Dengue Patients

Dengue is an arthropod-borne threat among tropical countries. Currently no effective means to treat the virus or to predict which patient will develop the severe form of the disease. Recently the relationship between oxidative/antioxidative response and dengue pathogenesis was suggested. Based on this the present study has analysed the expression of endogenous antioxidant genes: Catalase (CAT), Superoxide dismutase (MnSOD) and Glutathione peroxidase in patients with dengue compared to other febrile illness (OFI) and healthy controls. The study enrolled 88 dengue confirmed patients comprising 56 were patients with non-severe dengue, and 32 were severe dengue cases, 31 were patients with OFI, and 63 healthy controls were also involved. Peripheral blood mononuclear cells isolated from patients and controls during the day of admission and from the available cases on the day of defervescence were used to estimate the transcript levels by quantitative PCR. The expression levels of all the three genes were found to be down-regulated throughout the course of dengue infection (p < 0.05) and OFI cases compared to healthy controls. Within dengue group, no significant difference was observed in any of the parameters between severe and non-severe cases. Interestingly, a significant down-regulation of MnSOD expression was recorded in secondary dengue infection compared to primary during admission (p < 0.05). It was found that all the down-regulated study genes have positively correlated in all dengue cases during the day of admission (p < 0.01). But during defervescence, the same was found only between CAT and MnSOD. Down-regulated endogenous antioxidant enzymes during dengue infection could be the possible rationale of oxidative stress reported in dengue disease earlier. The present study markers could not distinguish dengue from OFI cases and severe from non-severe dengue cases. Mechanism of down-regulation has to be explored further which will pave the way for the therapeutic target in dengue disease.

Ethics of scientific publication

Published scientific research breeds the development of clinical management guidelines and pathways. Currently, scholarly proficiency is assessed using numerous primitive metrics for incentives that can kindle publication of hoax or flawed research content. Such flawed data can lead to wastage of resources, time, and most importantly harm to the society. Authors, editors, and peer reviewers need to be genuine in conducting, analyzing, and publication of scientific research. Institutions need to be aware and utilize advanced metrics to assess the scientific reputation of researchers. This short review discusses in brief the common authorship and editorial ethical issues encountered in scientific publication and the newer metrics available for the assessment of scholarly excellence. Editors and peer reviewers need to be acquainted with the common ethical issues and follow consensus international guidelines on publication ethics to tackle them appropriately.

Screening for Intestinal Colonization with Vancomycin Resistant Enterococci and Associated Risk Factors among Patients Admitted to an Adult Intensive Care Unit of a Large Teaching Hospital

INTRODUCTION

Gut colonization with Vancomycin Resistant Enterococci (VRE) increases the risk of acquiring infection during hospital stay. Patients admitted in the ICU's are the major reservoirs for VRE colonization due to higher antibiotic pressure.

AIM

To determine the rate of VRE colonization among patients admitted in the Medical Intensive Care Unit (MICU) and to assess the various risk factors which are associated with VRE colonization.

MATERIALS AND METHODS

This was a prospective study carried out over a period of 18 months from September 2013 to February 2015 in the Jawaharlal Institute of Post graduate Medical Education and Research (JIPMER), Pondicherry, South India. After 48 hours of ICU admission rectal swabs were collected from a total of 302 patients, admitted in MICU. The samples were inoculated on to Bile Esculin Sodium Azide agar with 6mg/L of vancomycin. Vancomycin resistance was confirmed by determination of Minimum Inhibitory Concentration (MIC) by agar dilution method. Isolates were identified up to species level by standard biochemical tests. Vancomycin resistance genes such as van A, van B and van C, were detected by Polymerase Chain Reaction (PCR). Risk factors were assessed by multivariate logistic regression analysis.

RESULTS

The rates of VRE colonization in patients admitted to MICU was 29%. Majority of the isolates were Enterococcus faecium (77.2 %) followed by Enterococcus faecalis (23.8%). All the VRE isolates were positive for van A gene. Increased duration of hospital stay, younger age, consumption of ceftriaxone and vancomycin were found to be significantly associated with VRE colonization in MICU. Among VRE colonized patients, six (4.5%) acquired VRE infection.

CONCLUSION

The rates of VRE colonization in our ICU were similar to other hospitals worldwide. Educating health care workers on the importance of adherence to hand hygiene is essential to bring down VRE colonization rates.

Indirect Haemagglutination Test in Comparison with ELISA for Detection of Antibodies against Invasive Amoebiasis

INTRODUCTION

Diagnosis of amoebiasis is based on combination of tests like microscopy, imaging, serology and molecular methods. In absence of molecular techniques, serology can be used as an alternative aid. Various serological techniques were reported with different sensitivity and specificity. The diagnostic efficiency of these assays mainly depends on the characteristics of antigen that is being used and various conditions of performance.

AIM

To evaluate the efficiency of recombinant calcium binding domain containing protein by Indirect Haemagglutination Assay (IHA) against a commercial ELISA among amoebic liver abscess cases and control group.

MATERIALS AND METHODS

The study was carried out during the period of 2011-2015 and blood samples were collected from suspected amoebiasis cases who were attending the clinics of Medicine and Paediatrics department, JIPMER. A total of 200 sera samples which included 100 Amoebic Liver Abscess (ALA), 50 cases of other parasitic infections and liver diseases and 50 presumed healthy controls were examined by IHA and commercial ELISA. In brief, chick cells were stabilized by Double Aldehyde Sensitization (DAS) method. Optimum Sensitizing Dose (OSD) of the antigen was determined. The test was performed in a U-bottomed microtiter plate with recombinant amoebic antigen (12.5μg/ml), incubated at Room Temperature (RT) for 2 hours. RIDASCREEN Entamoeba IgG ELISA kit which is commercially available was used to evaluate the samples as per manufacturer's instruction.

RESULTS

The overall sensitivity and specificity of the IHA was 62% and 96%, respectively when compared to ELISA having sensitivity and specificity of 69% and 90%, respectively. The positive predictive value of the IHA was 91% while negative predictive value was 79%. Similarly, the positive predictive value of the ELISA was 87% while negative predictive value was 74%.

CONCLUSION

As serology heavily suffers due to lack of a standardised test system employing the native antigen, there arises need to identify alternative source of recombinant antigen which could effectively improvise the existing lacunae in the current system. Serology acts as an adjunct in clinical decision making if properly interpreted. This is an important consideration in endemic region where health services resources are limited.