Pharmacogenomics-assisted schizophrenia management: A hybrid type 2 effectiveness-implementation study protocol to compare the clinical utility, cost-effectiveness, and barriers

OBJECTIVES

The response to antipsychotic therapy is highly variable. Pharmacogenomic (PGx) factors play a major role in deciding the effectiveness and safety of antipsychotic drugs. A hybrid type 2 effectiveness-implementation research will be conducted to evaluate the clinical utility (safety and efficacy), cost-effectiveness, and facilitators and barriers in implementing PGx-assisted management compared to standard of care in patients with schizophrenia attending a tertiary care hospital in eastern India.

METHODS

In part 1, a randomized controlled trial will be conducted. Adult patients with schizophrenia will be randomized (2: 1) to receive PGx-assisted treatment (drug and regimen selection depending on the results of single-nucleotide polymorphisms in genes DRD2, HTR1A, HTR2C, ABCB1, CYP2D6, CYP3A5, and CYP1A2) or the standard of care. Serum drug levels will be measured. The patients will be followed up for 12 weeks. The primary endpoint is the difference in the Udvalg for Kliniske Undersøgelser Side-Effect Rating Scale score between the two arms. In part 2, the cost-effectiveness of PGx-assisted treatment will be evaluated. In part 3, the facilitators and barriers to implementing PGx-assisted treatment for schizophrenia will be explored using a qualitative design.

EXPECTED OUTCOME

The study findings will help in understanding whether PGx-assisted management has a clinical utility, whether it is cost-effective, and what are the facilitators and barriers to implementing it in the management of schizophrenia.

TRIAL REGISTRATION

The study has been registered with the Clinical Trials Registry-India (CTRI/2023/08/056210).

Childhood adversities characterize the heterogeneity in the brain pattern of individuals during neurodevelopment

BACKGROUND

Several factors shape the neurodevelopmental trajectory. A key area of focus in neurodevelopmental research is to estimate the factors that have maximal influence on the brain and can tip the balance from typical to atypical development.

METHODS

Utilizing a dissimilarity maximization algorithm on the dynamic mode decomposition (DMD) of the resting state functional MRI data, we classified subjects from the cVEDA neurodevelopmental cohort (n = 987, aged 6-23 years) into homogeneously patterned DMD (representing typical development in 809 subjects) and heterogeneously patterned DMD (indicative of atypical development in 178 subjects).

RESULTS

Significant DMD differences were primarily identified in the default mode network (DMN) regions across these groups (p < 0.05, Bonferroni corrected). While the groups were comparable in cognitive performance, the atypical group had more frequent exposure to adversities and faced higher abuses (p < 0.05, Bonferroni corrected). Upon evaluating brain-behavior correlations, we found that correlation patterns between adversity and DMN dynamic modes exhibited age-dependent variations for atypical subjects, hinting at differential utilization of the DMN due to chronic adversities.

CONCLUSION

Adversities (particularly abuse) maximally influence the DMN during neurodevelopment and lead to the failure in the development of a coherent DMN system. While DMN's integrity is preserved in typical development, the age-dependent variability in atypically developing individuals is contrasting. The flexibility of DMN might be a compensatory mechanism to protect an individual in an abusive environment. However, such adaptability might deprive the neural system of the faculties of normal functioning and may incur long-term effects on the psyche.

Burden of mental health disorders and synthesis of community-based mental health intervention measures among adolescents during COVID-19 pandemic in low middle-income countries: A systematic review and meta-analysis

BACKGROUND

COVID-19 pandemic and the resultant lockdown could have negatively impacted adolescent mental health. The synthesised burden of mental health illness among adolescents during or after the pandemic is unknown in Low Middle-Income Countries (LMICs). The objective was to ascertain the pooled prevalence of mental health disorders among adolescents aged 10 - 19 years and to systematically review & conduct a descriptive synthesis of community-based mental health intervention measures in addressing adolescent mental health disorders during the COVID-19 pandemic in LMICs.

METHODS

The literature was searched in Embase, PubMed, and Scopus and selected the relevant studies. The data was extracted from the selected studies, and its quality was assessed using adapted Newcastle-Ottawa Quality Assessment Scales. Meta-analysis was performed using random effects model to pool the prevalence of mental health disorders. Statistical heterogeneity was evaluated through Cochran's Q test & I2 statistic.

RESULTS

Thirty-five studies were selected out of 7955 identified studies. Most of the studies (n = 7, each) were from India and Iran. The majority of research works were community-based (n = 18), conducted in 2020 (23 articles), and participant interviews were conducted through online mode (n = 21). Varied instruments were used to measure the burden of mental health in different settings. Pooled prevalence (95% confidence intervals) of anxiety, depression and stress was found to be 43.69 (18.58-68.80)%, 47.02 (31.72-62.32)% and 39.97 (30.53-49.40)%, respectively, with high heterogeneity between the studies. No studies reported community-based mental health interventions.

CONCLUSION

There has been a higher prevalence of anxiety, depression, stress, and other mental health illnesses, among adolescents in LMICs during the COVID-19 pandemic. It is important to note that no existing literature directly addresses community-based interventions for these common mental health illnesses. It is imperative to prepare the health system for early identification and management of common mental health illness among the adolescent age group in the event of any future disaster.

Risk clustering and psychopathology from a multi-center cohort of Indian children, adolescents, and young adults

Developmental adversities early in life are associated with later psychopathology. Clustering may be a useful approach to group multiple diverse risks together and study their relation with psychopathology. To generate risk clusters of children, adolescents, and young adults, based on adverse environmental exposure and developmental characteristics, and to examine the association of risk clusters with manifest psychopathology. Participants (n = 8300) between 6 and 23 years were recruited from seven sites in India. We administered questionnaires to elicit history of previous exposure to adverse childhood environments, family history of psychiatric disorders in first-degree relatives, and a range of antenatal and postnatal adversities. We used these variables to generate risk clusters. Mini-International Neuropsychiatric Interview-5 was administered to evaluate manifest psychopathology. Two-step cluster analysis revealed two clusters designated as high-risk cluster (HRC) and low-risk cluster (LRC), comprising 4197 (50.5%) and 4103 (49.5%) participants, respectively. HRC had higher frequencies of family history of mental illness, antenatal and neonatal risk factors, developmental delays, history of migration, and exposure to adverse childhood experiences than LRC. There were significantly higher risks of any psychiatric disorder [Relative Risk (RR) = 2.0, 95% CI 1.8-2.3], externalizing (RR = 4.8, 95% CI 3.6-6.4) and internalizing disorders (RR = 2.6, 95% CI 2.2-2.9), and suicidality (2.3, 95% CI 1.8-2.8) in HRC. Social-environmental and developmental factors could classify Indian children, adolescents and young adults into homogeneous clusters at high or low risk of psychopathology. These biopsychosocial determinants of mental health may have practice, policy and research implications for people in low- and middle-income countries.

Neurocognitive Analysis of Low-level Arsenic Exposure and Executive Function Mediated by Brain Anomalies Among Children, Adolescents, and Young Adults in India

Importance

Arsenic, a contaminant of groundwater and irrigated crops, is a global public health hazard. Exposure to low levels of arsenic through food extends well beyond the areas with high arsenic content in water.

Objective

To identify cognitive impairments following commonly prevalent low-level arsenic exposure and characterize their underlying brain mechanisms.

Design, Setting, and Participants

This multicenter population-based cohort study analyzed cross-sectional data of the Indian Consortium on Vulnerability to Externalizing Disorders and Addictions (cVEDA) cohort, recruited between November 4, 2016, and May 4, 2019. Participants aged 6 to 23 years were characterized using deep phenotyping measures of behavior, neuropsychology, psychopathology, brain neuroimaging, and exposure to developmental adversities and environmental neurotoxins. All analyses were performed between June 1, 2020, and December 31, 2021.

Exposure

Arsenic levels were measured in urine as an index of exposure.

Main Outcomes and Measures

Executive function measured using the cVEDA neuropsychological battery, gray matter volume (GMV) from T1-weighted magnetic resonance imaging, and functional network connectivity measures from resting state functional magnetic resonance imaging.

Results

A total of 1014 participants aged 6 to 23 years (589 male [58.1%]; mean [SD] age, 14.86 [4.79] years) were included from 5 geographic locations. Sparse-partial least squares analysis was used to describe a negative association of arsenic exposure with executive function (r = -0.12 [P = 5.4 × 10-4]), brain structure (r = -0.20 [P = 1.8 × 10-8]), and functional connectivity (within network, r = -0.12 [P = 7.5 × 10-4]; between network, r = -0.23 [P = 1.8 × 10-10]). Alterations in executive function were partially mediated by GMV (b = -0.004 [95% CI, -0.007 to -0.002]) and within-network functional connectivity (b = -0.004 [95% CI, -0.008 to -0.002]). Socioeconomic status and body mass index moderated the association between arsenic and GMV, such that the association was strongest in participants with lower socioeconomic status and body mass index.

Conclusions and Relevance

The findings of this cross-sectional study suggest that low-level arsenic exposure was associated with alterations in executive functioning and underlying brain correlates. These results indicate potential detrimental consequences of arsenic exposure that are below the currently recommended guidelines and may extend beyond endemic risk areas. Precision medicine approaches to study global mental health vulnerabilities highlight widespread but potentially modifiable risk factors and a mechanistic understanding of the impact of low-level arsenic exposure on brain development.

Growth trajectories for executive and social cognitive abilities in an Indian population sample: Impact of demographic and psychosocial determinants

Cognitive abilities are markers of brain development and psychopathology. Abilities, across executive, and social domains need better characterization over development, including factors that influence developmental change. This study is based on the cVEDA [Consortium on Vulnerability to Externalizing Disorders and Addictions] study, an Indian population based developmental cohort. Verbal working memory, visuo-spatial working memory, response inhibition, set-shifting, and social cognition (faux pas recognition and emotion recognition) were cross-sectionally assessed in > 8000 individuals over the ages 6-23 years. There was adequate representation across sex, urban-rural background, psychosocial risk (psychopathology, childhood adversity and wealth index, i.e. socio-economic status). Quantile regression was used to model developmental change. Age-based trajectories were generated, along with examination of the impact of determinants (sex, childhood adversity, and wealth index). Development in both executive and social cognitive abilities continued into adulthood. Maturation and stabilization occurred in increasing order of complexity, from working memory to inhibitory control to cognitive flexibility. Age related change was more pronounced for low quantiles in response inhibition (β∼4 versus  -1 versus -0.25 for lower quantiles). Wealth index had the largest influence on developmental change across cognitive abilities. Sex differences were prominent in response inhibition, set-shifting and emotion recognition. Childhood adversity had a negative influence on cognitive development. These findings add to the limited literature on patterns and determinants of cognitive development. They have implications for understanding developmental vulnerabilities in young persons, and the need for providing conducive socio-economic environments.

Federated Analysis in COINSTAC Reveals Functional Network Connectivity and Spectral Links to Smoking and Alcohol Consumption in Nearly 2,000 Adolescent Brains

With the growth of decentralized/federated analysis approaches in neuroimaging, the opportunities to study brain disorders using data from multiple sites has grown multi-fold. One such initiative is the Neuromark, a fully automated spatially constrained independent component analysis (ICA) that is used to link brain network abnormalities among different datasets, studies, and disorders while leveraging subject-specific networks. In this study, we implement the neuromark pipeline in COINSTAC, an open-source neuroimaging framework for collaborative/decentralized analysis. Decentralized exploratory analysis of nearly 2000 resting-state functional magnetic resonance imaging datasets collected at different sites across two cohorts and co-located in different countries was performed to study the resting brain functional network connectivity changes in adolescents who smoke and consume alcohol. Results showed hypoconnectivity across the majority of networks including sensory, default mode, and subcortical domains, more for alcohol than smoking, and decreased low frequency power. These findings suggest that global reduced synchronization is associated with both tobacco and alcohol use. This proof-of-concept work demonstrates the utility and incentives associated with large-scale decentralized collaborations spanning multiple sites.

Chromium toxicity among leather industry workers in Kolkata-A pilot Study

Introduction: Chromium (Cr) exposure is known to cause various health issues such as cancer, dermatitis, respiratory problems, etc. The recent exposure of Cr can be determined by analysis of Cr either in blood/urine/plasma, Cr (III) ions cannot permeate through cell membranes of red blood cells (RBC) because their ionic radii are bigger as compared to Cr (VI), and hence Cr in RBC is an indicator for exposure to Cr (VI) ions. The purpose of this study was to investigate chromium exposure, hygienic habits and the occurrence of dermatological problems with leather industry workers in Kolkata. Methods: A total of 68 leather industry workers with minimum work exposure of five years and aged between 18-60 years were recruited for this study. The study protocol included a questionnaire and analysis of Cr in blood and urine samples by GF-AAS. Results: All values were under the Biological Exposure Index (BEI) of 25µg /L at the end of the shift of a five-day work week recommended by the American Conference of Governmental Industrial Hygienists (AcGIH).  15.2% of subjects suffered from dermatological problems at least once in the last year during work in the leather industry. Conclusion: It was found that leather industry workers were not using personal protective equipment and it must be promoted to them for occupational health and safety.

Maximising impactful, locally relevant global mental health research conducted in low and middle income country settings: ethical considerations

Background: Achieving ethical and meaningful mental health research in diverse global settings requires approaches to research design, conduct, and dissemination that prioritise a contextualised approach to impact and local relevance. Method: Through three case studies presented at the 2021 Global Forum on Bioethics in Research meeting on the ethical issues arising in research with people with mental health conditions, we consider the nuances to achieving ethical and meaningful mental health research in three diverse settings. The case studies include research with refugees Rwanda and Uganda; a neurodevelopmental cohort study in a low resource setting in India, and research with Syrian refugees displaced across the Middle East. Results: Key considerations highlighted across the case studies include how mental health is understood and experienced in diverse contexts to ensure respectful engagement with communities, and to inform the selection of contextually-appropriate and feasible research methods and tools to achieve meaningful data collection.  Related to this is a need to consider how communities understand and engage with research to avoid therapeutic misconception, exacerbating stigma, or creating undue inducement for research participation, whilst also ensuring meaningful benefit for research participation. Central to achieving these is the meaningful integration of the views and perspectives of local stakeholders to inform research design, conduct, and legacy. The case studies foreground the potential tensions between meeting local community needs through the implementation of an intervention, and attaining standards of scientific rigor in research design and methods; and between adherence to procedural ethical requirements such as ethical review and documenting informed consent, and ethical practice through attention to the needs of the local research team. Conclusions: We conclude that engagement with how to achieve local relevance and social, practice, and academic impact offer productive ways for researchers to promote ethical research that prioritises values of solidarity, inclusion, and mutual respect.

Maximising impactful and locally relevant mental health research: ethical considerations

Background: Achieving ethical and meaningful mental health research in diverse global settings requires approaches to research design, conduct, and dissemination that prioritise a contextualised approach to impact and local relevance. Method: Through three case studies presented at the 2021 Global Forum on Bioethics in Research meeting on the ethical issues arising in research with people with mental health conditions, we consider the nuances to achieving ethical and meaningful mental health research in three diverse settings. The case studies include research with refugees Rwanda and Uganda; a neurodevelopmental cohort study in a low resource setting in India, and research with Syrian refugees displaced across the Middle East. Results: Key considerations highlighted across the case studies include how mental health is understood and experienced in diverse contexts to ensure respectful engagement with communities, and to inform the selection of contextually-appropriate and feasible research methods and tools to achieve meaningful data collection.  Related to this is a need to consider how communities understand and engage with research to avoid therapeutic misconception, exacerbating stigma, or creating undue inducement for research participation, whilst also ensuring meaningful benefit for research participation. Central to achieving these is the meaningful integration of the views and perspectives of local stakeholders to inform research design, conduct, and legacy. The case studies foreground the potential tensions between meeting local community needs through the implementation of an intervention, and attaining standards of scientific rigor in research design and methods; and between adherence to procedural ethical requirements such as ethical review and documenting informed consent, and ethical practice through attention to the needs of the local research team. Conclusions: We conclude that engagement with how to achieve local relevance and social, practice, and academic impact offer productive ways for researchers to promote ethical research that prioritises values of solidarity, inclusion, and mutual respect.

Outcome Analysis of Endoscopic Sinus Surgery in Chronic Sinusitis with Chronic Rhinitis Non-responsive to Medical Therapy

Introduction   Chronic sinusitis with chronic rhinitis affect the patients’ quality of life significantly. Aim of this study is to assess the outcome of Endoscopic Sinus Surgery (ESS) in terms of Quality of Life (QoL) in patient with Chronic Sinusitis with Chronic Rhinitis (CSCR), non-responsive to medical therapy.     Materials and Methods Prospective study was conducted among 75 patients of CSCR non responsive to medical therapy in the age group of 15 to 80 years over a period of 18 months (January 2018 to June 2019). The subjects were randomly grouped into two, namely Group 1- CSCR with Polyp and Group 2- CSCR without Polyp. Subjects were asked to complete SNOT-22 score and Visual analogue scale (VAS) and conventional medical treatment was given for 2 weeks. Those failed to respond as per EPOS guideline were subjected to ESS and followed up at 6 weeks and 12 weeks, re-assessed by SNOT-22 questionnaire and VAS. Data was analyzed by using Paired t- test.   Results Statistically significant (p-value <0.05) improvement in symptom score assessing QoL after Endoscopic sinus surgery.   Conclusion Patients with CRS non- responsive to medical treatment, the decision for surgery should be guided by their pre-operative QoL impairment, as measured by SNOT-22 and VAS.

Adverse childhood experiences and substance misuse in young people in India: results from the multisite cVEDA cohort

BACKGROUND

Adverse childhood experiences (ACEs) increases vulnerability to externalising disorders such as substance misuse. The study aims to determine the prevalence of ACEs and its association with substance misuse.

METHODS

Data from the Consortium on Vulnerability to Externalising Disorders and Addictions (cVEDA) in India was used (n = 9010). ACEs were evaluated using the World Health Organisation (WHO) Adverse Childhood Experiences International Questionnaire whilst substance misuse was assessed using the WHO Alcohol, Smoking and Substance Involvement Screening Test. A random-effects, two-stage individual patient data meta-analysis explained the associations between ACEs and substance misuse with adjustments for confounders such as sex and family structure.

RESULTS

1 in 2 participants reported child maltreatment ACEs and family level ACEs. Except for sexual abuse, males report more of every individual childhood adversity and are more likely to report misusing substances compared with females (87.3% vs. 12.7%). In adolescents, family level ACEs (adj OR 4.2, 95% CI 1.5-11.7) and collective level ACEs (adj OR 6.6, 95% CI 1.4-31.1) show associations with substance misuse whilst in young adults, child level ACEs such as maltreatment show similar strong associations (adj OR 2.0, 95% CI 1.1-3.5).

CONCLUSION

ACEs such as abuse and domestic violence are strongly associated with substance misuse, most commonly tobacco, in adolescent and young adult males in India. The results suggest enhancing current ACE resilience programmes and 'trauma-informed' approaches to tackling longer-term impact of ACEs in India.

FUNDING

Newton Bhabha Grant jointly funded by the Medical Research Council, UK (MR/N000390/1) and the Indian Council of Medical Research (ICMR/MRC-UK/3/M/2015-NCD-I).

SARS-CoV-2 seroprevalence among the general population and healthcare workers in India, December 2020-January 2021

BACKGROUND

Earlier serosurveys in India revealed seroprevalence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) of 0.73% in May-June 2020 and 7.1% in August-September 2020. A third serosurvey was conducted between December 2020 and January 2021 to estimate the seroprevalence of SARS-CoV-2 infection among the general population and healthcare workers (HCWs) in India.

METHODS

The third serosurvey was conducted in the same 70 districts as the first and second serosurveys. For each district, at least 400 individuals aged ≥10 years from the general population and 100 HCWs from subdistrict-level health facilities were enrolled. Serum samples from the general population were tested for the presence of immunoglobulin G (IgG) antibodies against the nucleocapsid (N) and spike (S1-RBD) proteins of SARS-CoV-2, whereas serum samples from HCWs were tested for anti-S1-RBD. Weighted seroprevalence adjusted for assay characteristics was estimated.

RESULTS

Of the 28,598 serum samples from the general population, 4585 (16%) had IgG antibodies against the N protein, 6647 (23.2%) had IgG antibodies against the S1-RBD protein, and 7436 (26%) had IgG antibodies against either the N protein or the S1-RBD protein. Weighted and assay-characteristic-adjusted seroprevalence against either of the antibodies was 24.1% [95% confidence interval (CI) 23.0-25.3%]. Among 7385 HCWs, the seroprevalence of anti-S1-RBD IgG antibodies was 25.6% (95% CI 23.5-27.8%).

CONCLUSIONS

Nearly one in four individuals aged ≥10 years from the general population as well as HCWs in India had been exposed to SARS-CoV-2 by December 2020.

A series of five population-specific Indian brain templates and atlases spanning ages 6-60 years

Anatomical brain templates are commonly used as references in neurological MRI studies, for bringing data into a common space for group‐level statistics and coordinate reporting. Given the inherent variability in brain morphology across age and geography, it is important to have templates that are as representative as possible for both age and population. A representative‐template increases the accuracy of alignment, decreases distortions as well as potential biases in final coordinate reports. In this study, we developed and validated a new set of T1w Indian brain templates (IBT) from a large number of brain scans (total n = 466) acquired across different locations and multiple 3T MRI scanners in India. A new tool in AFNI, make_template_dask.py, was created to efficiently make five age‐specific IBTs (ages 6–60 years) as well as maximum probability map (MPM) atlases for each template; for each age‐group's template–atlas pair, there is both a “population‐average” and a “typical” version. Validation experiments on an independent Indian structural and functional‐MRI dataset show the appropriateness of IBTs for spatial normalization of Indian brains. The results indicate significant structural differences when comparing the IBTs and MNI template, with these differences being maximal along the Anterior–Posterior and Inferior–Superior axes, but minimal Left–Right. For each age‐group, the MPM brain atlases provide reasonably good representation of the native‐space volumes in the IBT space, except in a few regions with high intersubject variability. These findings provide evidence to support the use of age and population‐specific templates in human brain mapping studies.

Outcome of Post-Operative Mastoid Cavity Obliteration with Autologous Adipose Tissue

Introduction Mastoid operations have been in practice for over four centuries for suppurative conditions of the ear. Intact canal wall mastoidectomy has the advantage of better functional results while canal wall down mastoidectomy offers excellent exposure for disease eradication and post operative monitoring but is associated with significant cavity problems. In order to overcome the problems associated with canal wall down procedure while retaining its advantages the concept of mastoid cavity obliteration was introduced. This study analysed the outcomes of mastoid cavity obliteration and to assess the outcomes of mastoid cavity obliteration with autologous adipose tissue. Materials and Methods A prospective, experimental, randomized study was conducted over a period of 18 months among patients presenting with active squamous variety of Chronic Otitis Media. The patients were randomly allocated to two groups, A and B. Both groups underwent canal wall down Mastoidectomy followed by obliteration with autologous adipose tissue in Group B . Results In group A, the mean duration required for complete epithelialization was 10.8 weeks. In group B, the average time taken for complete epithelialization was 5.6 weeks. All cases had their graft intact at the end of 12 weeks. Debris was present in group A for a mean duration of 9.47 weeks. In group B, debris was found for a mean duration of 3.33 weeks. Patients from group A complained of discharge from their ears for a mean duration of 7.47 weeks. In group B the same symptom persisted over 3.33 weeks. Conclusion Cavity problems encountered is considerably less in the group obliterated with adipose tissue.

The Consortium on Vulnerability to Externalizing Disorders and Addictions (c-VEDA): an accelerated longitudinal cohort of children and adolescents in India

The global burden of disease attributable to externalizing disorders such as alcohol misuse calls urgently for effective prevention and intervention. As our current knowledge is mainly derived from high-income countries such in Europe and North-America, it is difficult to address the wider socio-cultural, psychosocial context, and genetic factors in which risk and resilience are embedded in low- and medium-income countries. c-VEDA was established as the first and largest India-based multi-site cohort investigating the vulnerabilities for the development of externalizing disorders, addictions, and other mental health problems. Using a harmonised data collection plan coordinated with multiple cohorts in China, USA, and Europe, baseline data were collected from seven study sites between November 2016 and May 2019. Nine thousand and ten participants between the ages of 6 and 23 were assessed during this time, amongst which 1278 participants underwent more intensive assessments including MRI scans. Both waves of follow-ups have started according to the accelerated cohort structure with planned missingness design. Here, we present descriptive statistics on several key domains of assessments, and the full baseline dataset will be made accessible for researchers outside the consortium in September 2019. More details can be found on our website [cveda.org].

Consortium on Vulnerability to Externalizing Disorders and Addictions (cVEDA): A developmental cohort study protocol

BACKGROUND

Low and middle-income countries like India with a large youth population experience a different environment from that of high-income countries. The Consortium on Vulnerability to Externalizing Disorders and Addictions (cVEDA), based in India, aims to examine environmental influences on genomic variations, neurodevelopmental trajectories and vulnerability to psychopathology, with a focus on externalizing disorders.

METHODS

cVEDA is a longitudinal cohort study, with planned missingness design for yearly follow-up. Participants have been recruited from multi-site tertiary care mental health settings, local communities, schools and colleges. 10,000 individuals between 6 and 23 years of age, of all genders, representing five geographically, ethnically, and socio-culturally distinct regions in India, and exposures to variations in early life adversity (psychosocial, nutritional, toxic exposures, slum-habitats, socio-political conflicts, urban/rural living, mental illness in the family) have been assessed using age-appropriate instruments to capture socio-demographic information, temperament, environmental exposures, parenting, psychiatric morbidity, and neuropsychological functioning. Blood/saliva and urine samples have been collected for genetic, epigenetic and toxicological (heavy metals, volatile organic compounds) studies. Structural (T1, T2, DTI) and functional (resting state fMRI) MRI brain scans have been performed on approximately 15% of the individuals. All data and biological samples are maintained in a databank and biobank, respectively.

DISCUSSION

The cVEDA has established the largest neurodevelopmental database in India, comparable to global datasets, with detailed environmental characterization. This should permit identification of environmental and genetic vulnerabilities to psychopathology within a developmental framework. Neuroimaging and neuropsychological data from this study are already yielding insights on brain growth and maturation patterns.

A multicentre observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India

OBJECTIVES

To describe the epidemiology, management and outcome of individuals with mucormycosis; and to evaluate the risk factors associated with mortality.

METHODS

We conducted a prospective observational study involving consecutive individuals with proven mucormycosis across 12 centres from India. The demographic profile, microbiology, predisposing factors, management and 90-day mortality were recorded; risk factors for mortality were analysed.

RESULTS

We included 465 patients. Rhino-orbital mucormycosis was the most common (315/465, 67.7%) presentation followed by pulmonary (62/465, 13.3%), cutaneous (49/465, 10.5%), and others. The predisposing factors included diabetes mellitus (342/465, 73.5%), malignancy (42/465, 9.0%), transplant (36/465, 7.7%), and others. Rhizopus species (231/290, 79.7%) were the most common followed by Apophysomyces variabilis (23/290, 7.9%), and several rare Mucorales. Surgical treatment was performed in 62.2% (289/465) of the participants. Amphotericin B was the primary therapy in 81.9% (381/465), and posaconazole was used as combination therapy in 53 (11.4%) individuals. Antifungal therapy was inappropriate in 7.6% (30/394) of the individuals. The 90-day mortality rate was 52% (242/465). On multivariate analysis, disseminated and rhino-orbital (with cerebral extension) mucormycosis, shorter duration of symptoms, shorter duration of antifungal therapy, and treatment with amphotericin B deoxycholate (versus liposomal) were independent risk factors of mortality. A combined medical and surgical management was associated with a better survival.

CONCLUSIONS

Diabetes mellitus was the dominant predisposing factor in all forms of mucormycosis. Combined surgical and medical management was associated with better outcomes. Several gaps surfaced in the management of mucormycosis. The rarer Mucorales identified in the study warrant further evaluation.

1410Clinical predictors of NT-proBNP response to early initiation of sacubitril/valsartan after hospitalisation for decompensated heart failure: An analysis of the TRANSITION study

Background

NT-proBNP has diagnostic and prognostic value in patients with heart failure (HF). Compared with enalapril, sacubitril/valsartan (S/V) significantly reduced NT-proBNP within 1 week (wk) of administration and reduced HF re-hospitalisation in patients with acute decompensated HF (ADHF) in PIONEER-HF. Identification of predictors of NT-proBNP reduction with S/V could aid prognostication following hospitalisation.

Methods

TRANSITION (NCT02661217) is an open label study in stabilised ADHF patients with HFrEF that compared S/V initiation pre- versus post-discharge (within 2 wk of discharge). Baseline NT-proBNP was measured at randomisation in both S/V groups (n=950). Clinical predictors of favourable response of NT-proBNP to S/V therapy (defined as reduction to <1000 pg/ml or >30% reduction vs. baseline) were studied at discharge, 4 wk and 10 wk post-randomisation.

Results

Median NT-proBNP at randomisation was similar in patients with S/V started pre- and post-discharge (1919 vs 1659 pg/ml). In patients receiving S/V in-hospital, NT-proBNP was reduced by 28% at discharge, compared to a 3% reduction in patients receiving optimised standard of care (between group p<0.001). A favorable response was reached in 46% vs 18% patients at discharge, 46% vs 42% at 4 weeks and 51% vs 48% at 10 weeks in pre- vs post-discharge groups. (Figure 1). Predictors of favourable NT-proBNP response to S/V at discharge were hypertension and shorter time from admission to first S/V dose. At 4 wk after randomisation, NT-proBNP was reduced similarly in patients started on S/V pre- and post-discharge. When the two S/V initiation groups were combined, predictors of favorable NT-proBNP response at 4 wk were higher initial dose of S/V (≥49/51 mg b.i.d.), higher baseline levels of NT-proBNP, de novo HF hospitalisation, ACEI/ARB naïve, lower baseline creatinine, no atrial fibrillation (AFib), no prior myocardial infarction (MI). A further reduction in NT-proBNP was seen at 10 wk post-randomisation in patients started on S/V pre- and post-discharge (38% vs 34%, between group p=0.250). Predictors of favourable NT-proBNP response to S/V were similar at 4 wk and 10 wk post-randomisation.

Conclusion

In-hospital initiation of sacubitril/valsartan shortly after stabilisation was associated with a prompt improvement of NT-proBNP already at discharge, whereas higher baseline levels of NT-proBNP, higher starting dose, absence of AFib and MI history, de novo HF and ACEI/ARB naïve status were associated with favourable NT-proBNP response in the vulnerable phase after discharge.

Acknowledgement/Funding

The TRANSITION study was funded by Novartis

Mastoid Osteoma

Introduction Osteoma of the mastoid region is an uncommon benign tumor of bone. Osteomas may occur in the external auditory canals but are reported to be very rare in the mastoid region, with about 150 cases reported in literature. Case Report A 20-year-old man presented with painless lump behind the right ear since last 2 years. On examination a 3x3 cm tumour was present in the right post-auricular region. HRCT scan showing hyper-attenuating area close to the right mastoid cortex, measuring approximately 3x3cm, spherical, with cleavage areas between the tumour and the mastoid external cortex. Surgical excision was performed on cosmetic grounds. Postoperative period was uneventful. Discussion Osteoma over the mastoid region is rare and mainly asymptomatic with excellent prognosis after complete removal of the lesion.

Effect of Intratympanic Dexamethasone in Idiopathic Sudden Sensorineural Hearing Loss

Introduction Oral steroids currently represent the standard treatment for idiopathic sudden sensorineural hearing loss The aim of this study is to assess the effectiveness of intratympanic dexamethasone injection for treating ‘Idiopathic sudden sensori-neural hearing loss’ (ISSNHL) not improved with conventional oral steroid. Materials and Methods A prospective study was conducted on 30 patients refractory to oral steroid therapy between June 2017 to May 2018. ‘Intratympanic dexamethasone injection’ (ITDI) was given every week for 3 consecutive weeks. Hearing was assessed by performing pure tone audiogram before every ITDI and also 1 week after the completion of treatment. Results Hearing improvement was found in 19 out of the 30 cases (63.3%).   Conclusions Intratympanic dexamethasone significantly improves the prognosis of ISSNHL and is a safe, inexpensive and effective treatment.

Vitamin D: A Silent Cofactor for Allergic Rhinitis

Introduction   Allergic rhinitis affects around 50% of atopies in India. Vitamin D is related to both humoral and cell mediated immunity and its receptors are found in inflammatory mediators. This study was conducted to assess any possible association between Allergic rhinitis and serum Vitamin D. Materials and Methods A cross sectional study was conducted amongst 41patients with Allergic rhinitis as per ARIA guidelines attending the Otolaryngology outpatient Department of a peripheral tertiary care hospital. Vitamin D levels were assessed in patients with allergic rhinitis in terms of serum Ig-E level and absolute blood eosinophil count (ABEC). Results Among 41 patients, 31 patients (75.6%) had deficiency of vitamin D with mean Vitamin D level of 14.87±1.56ng/ml (normal vitamin D level-30-100ng/ml and low <20ng/ml), mean serum Ig-E level was 1040±303.83Iu/ml (normal-1.90-170 IU/ml by CLIA method) and mean ABEC 1226.77±397.89 (normal-30-350/ml). Conclusion Low serum Vitamin D is common in Allergic rhinitis patients. Low serum Vitamin D seems to be a significant cofactor in aetiopathogenesis of Allergic rhinitis in most of the cases.

Demographic Profile of Hearing Deficiency in a peripheral referral hospital- A Five Year Study

Introduction: This present study is an attempt to study the demographic characteristics of individuals presenting with hearing loss in a peripheral tertiary care hospital using the available database of pure tone audiometry results. Materials and methods: A retrospective, observational, descriptive study was conducted over a period of 5 years in the Department of ENT of a peripheral tertiary care hospital wherein all subjects having a pure tone audiometry were included in the study. The records of PTA done were analyzed followed by systematic analysis. Results: A total of 9790 individuals inclusive of 5566 males and 4224 females were studied. Maximum no of individuals belonged to the age group of 21-30 years. Nearly 63% of total subjects suffered from Bilateral hearing loss. Sensorineural hearing loss was most prevalent type of loss. Mild degree of loss was most prevalent. Adolescents and young adults comprised the bulk of the study population. Sensorineural hearing is the most common type. Bilateral hearing loss is more frequent. Mild degree of loss is most frequent. Conclusion: This study emphasized the ‘Composite parameter distribution’ in addition to the classical single parameter demographic profile of deafness in a remote tertiary care hospital. Adolescents and young adults comprised the bulk of the study population. Sensorineural hearing is the most common type. Bilateral hearing loss is more frequent. Mild degree of loss is most frequent.

Monitoring treatment response in chronic pulmonary aspergillosis: role of clinical, spirometric and immunological markers

OBJECTIVES

The treatment response in chronic pulmonary aspergillosis (CPA) is usually assessed based on the improvement in clinical and imaging findings. Herein, we evaluate serum Aspergillus fumigatus-specific IgG, serum galactomannan, weight change, and lung function for assessing treatment response in subjects with CPA.

METHODS

We categorized treatment response as favourable (improved or stable clinical response with radiologically improved or stable disease) or unfavourable (worsening of symptoms or radiological progression) after 6 months of treatment with antifungal azoles. We measured A. fumigatus-specific IgG, serum galactomannan, weight, and lung function at baseline, 3 months, and 6 months in those with favourable and unfavourable treatment response.

RESULTS

One hundred and twenty-six consecutive treatment-naïve subjects (53.2% (67/126) males; mean ± SD age, 42.3 ± 14.7 years) with CPA were included. One hundred and six and 20 were classified as having favourable and unfavourable response, respectively. After 6 months of treatment, the decline in serum A. fumigatus-specific IgG (n = 119) was similar in those with favourable or unfavourable response (mean ± SD, -26.3 ± 45.5 mgA/L vs. -3.4 ± 65.6 mgA/L; p 0.20). There was no significant change in the serum galactomannan (favourable vs. unfavourable: mean ± SD, -0.11 ± 2.8 vs. -0.62 ± 2; p 0.92) or FEV1 (favourable vs. unfavourable: mean ± SD, 24 ± 250 mL vs. -62 ± 154 mL; p 0.19) after 6 months of treatment. There was significant loss of weight (mean ± SD, -2.5 ± 4.5 kg) in subjects with unfavourable response.

CONCLUSION

Serum A. fumigatus-specific IgG and serum galactomannan inconsistently decrease following treatment and may not be useful indicators for monitoring treatment response in CPA. Similarly, there is little change in pulmonary function following treatment. A gain in body weight is seen in those with favourable response.

Epidemiology and clinical characteristics of invasive mould infections: A multicenter, retrospective analysis in five Asian countries

Formal, large-scale, multicenter studies of invasive mould infection (IMI) in Asia are rare. This 1-year, retrospective study was designed to assess the incidence and clinical determinants of IMI in centers in five countries (Thailand, Taiwan, Singapore, China, India). Patients treated in a single year (2012) were identified through discharge diagnoses, microbiology, and histopathology logs, and entered based on published definitions of IMI. A total of 155 cases were included (median age 54 years; 47.7% male). Of these, 47.7% had proven disease; the remainder had probable IMI. The most frequent host factors were prolonged steroid use (39.4%) and recent neutropenia (38.7%). Common underlying conditions included diabetes mellitus (DM; 30.9%), acute myeloid leukemia (19.4%), and rheumatologic conditions (11.6%). DM was more common in patients with no recent history of neutropenia or prolonged steroid use (P = .006). The lung was the most frequently involved site (78.7%), demonstrating a range of features on computed tomography (CT). Aspergillus was the most common mould cultured (71.6%), primarily A. fumigatus and A. flavus, although proportions varied in different centers. The most often used antifungal for empiric therapy was conventional amphotericin. Ninety-day mortality was 32.9%. This is the first multicenter Asian study of IMI not limited to specific patient groups or diagnostic methods. It suggests that DM and rheumatologic conditions be considered as risk factors for IMI and demonstrates that IMI should not be ruled out in patients whose chest features on CT do not fit the conventional criteria.

Standardization of a two-step real-time polymerase chain reaction based method for species-specific detection of medically important Aspergillus species

PURPOSE

Standardization of Aspergillus polymerase chain reaction (PCR) poses two technical challenges (a) standardization of DNA extraction, (b) optimization of PCR against various medically important Aspergillus species. Many cases of aspergillosis go undiagnosed because of relative insensitivity of conventional diagnostic methods such as microscopy, culture or antigen detection. The present study is an attempt to standardize real-time PCR assay for rapid sensitive and specific detection of Aspergillus DNA in EDTA whole blood.

MATERIALS AND METHODS

Three nucleic acid extraction protocols were compared and a two-step real-time PCR assay was developed and validated following the recommendations of the European Aspergillus PCR Initiative in our setup. In the first PCR step (pan-Aspergillus PCR), the target was 28S rDNA gene, whereas in the second step, species specific PCR the targets were beta-tubulin (for Aspergillus fumigatus, Aspergillus flavus, Aspergillus terreus), gene and calmodulin gene (for Aspergillus niger).

RESULTS

Species specific identification of four medically important Aspergillus species, namely, A. fumigatus, A. flavus, A. niger and A. terreus were achieved by this PCR. Specificity of the PCR was tested against 34 different DNA source including bacteria, virus, yeast, other Aspergillus sp., other fungal species and for human DNA and had no false-positive reactions. The analytical sensitivity of the PCR was found to be 102 CFU/ml.

CONCLUSION

The present protocol of two-step real-time PCR assays for genus- and species-specific identification for commonly isolated species in whole blood for diagnosis of invasive Aspergillus infections offers a rapid, sensitive and specific assay option and requires clinical validation at multiple centers.

Identification of Malassezia species by MALDI-TOF MS after expansion of database

The taxonomy of Malassezia species is evolving with introduction of molecular techniques, and difficulty is faced to identify the species by phenotypic methods. Among 15 known Malassezia species, the present Bruker database could identify only 2 species. The present study was aimed to improve Matrix -assisted laser desorption ionization time-flight mass spectrometry (MALDI-TOF MS) based identification of Malassezia species. A total of 88 isolates (DNA sequencing confirmed) for database preparation and, for the validation of database, 190 isolates confirmed by polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) were used. The main spectrum profile dendrogram showed the sufficient discrimination between all the species by MALDI-TOF MS. The updated Malassezia database could identify 94.7% and 5.3% strains to the species and genus level, respectively. MALDI-TOF MS is a significantly reliable technique, and results were comparable with PCR-RFLP with kappa value 0.9. In conclusion, MALDI-TOF MS could be a possible alternative tool to other molecular methods for rapid and accurate identification of Malassezia species.

Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline

The European Society for Clinical Microbiology and Infectious Diseases, the European Confederation of Medical Mycology and the European Respiratory Society Joint Clinical Guidelines focus on diagnosis and management of aspergillosis. Of the numerous recommendations, a few are summarized here. Chest computed tomography as well as bronchoscopy with bronchoalveolar lavage (BAL) in patients with suspicion of pulmonary invasive aspergillosis (IA) are strongly recommended. For diagnosis, direct microscopy, preferably using optical brighteners, histopathology and culture are strongly recommended. Serum and BAL galactomannan measures are recommended as markers for the diagnosis of IA. PCR should be considered in conjunction with other diagnostic tests. Pathogen identification to species complex level is strongly recommended for all clinically relevant Aspergillus isolates; antifungal susceptibility testing should be performed in patients with invasive disease in regions with resistance found in contemporary surveillance programmes. Isavuconazole and voriconazole are the preferred agents for first-line treatment of pulmonary IA, whereas liposomal amphotericin B is moderately supported. Combinations of antifungals as primary treatment options are not recommended. Therapeutic drug monitoring is strongly recommended for patients receiving posaconazole suspension or any form of voriconazole for IA treatment, and in refractory disease, where a personalized approach considering reversal of predisposing factors, switching drug class and surgical intervention is also strongly recommended. Primary prophylaxis with posaconazole is strongly recommended in patients with acute myelogenous leukaemia or myelodysplastic syndrome receiving induction chemotherapy. Secondary prophylaxis is strongly recommended in high-risk patients. We strongly recommend treatment duration based on clinical improvement, degree of immunosuppression and response on imaging.

Impact of regulatory spin of pioglitazone on prescription of antidiabetic drugs among physicians in India: A multicentre questionnaire-based observational study

Background & objectives:

Pioglitazone was suspended for manufacture and sale by the Indian drug regulator in June 2013 due to its association with urinary bladder carcinoma, which was revoked within a short period (July 2013). The present questionnaire-based nationwide study was conducted to assess its impact on prescribing behaviour of physicians in India.

Methods:

Between December 2013 and March 2014, a validated questionnaire was administered to physicians practicing diabetes across 25 centres in India. Seven hundred and forty questionnaires fulfilling the minimum quality criteria were included in the final analysis.

Results:

Four hundred and sixteen (56.2%) physicians prescribed pioglitazone. Of these, 281 used it in less than the recommended dose of 15 mg/day. Most physicians (94.3%) were aware of recent regulatory events. However, only 333 (44.8%) changed their prescribing pattern. Seventeen of the 416 (4.1%) physicians who prescribed pioglitazone admitted having come across at least one type 2 diabetes mellitus patient (T2DM) who had urinary bladder carcinoma, and of these 13 said that it was in patients who took pioglitazone for a duration of more than two years. Only 7.8 per cent of physicians (n=58) categorically advocated banning pioglitazone, and the rest opined for its continuation or generating more evidence before decision could be taken regarding its use in T2DM.

Interpretation & conclusions:

Majority of the physicians though were aware of the regulatory changes with regard to pioglitazone, but their prescribing patterns were not changed for this drug. However, it was being used at lower than the recommended dose. There is a need for generating more evidence through improved pharmacovigilance activities and large-scale population-based prospective studies regarding the safety issues of pioglitazone, so as to make effectual risk-benefit analysis for its continual use in T2DM.

Friction Stir Processing of Stainless Steel for Ascertaining Its Superlative Performance in Bioimplant Applications

Substrate-cell interactions for a bioimplant are driven by substrate's surface characteristics. In addition, the performance of an implant and resistance to degradation are primarily governed by its surface properties. A bioimplant typically degrades by wear and corrosion in the physiological environment, resulting in metallosis. Surface engineering strategies for limiting degradation of implants and enhancing their performance may reduce or eliminate the need for implant removal surgeries and the associated cost. In the current study, we tailored the surface properties of stainless steel using submerged friction stir processing (FSP), a severe plastic deformation technique. FSP resulted in significant microstructural refinement from 22 μm grain size for the as-received alloy to 0.8 μm grain size for the processed sample with increase in hardness by nearly 1.5 times. The wear and corrosion behavior of the processed alloy was evaluated in simulated body fluid. The processed sample demonstrated remarkable improvement in both wear and corrosion resistance, which is explained by surface strengthening and formation of a highly stable passive layer. The methylthiazol tetrazolium assay demonstrated that the processed sample is better in supporting cell attachment, proliferation with minimal toxicity, and hemolysis. The athrombogenic characteristic of the as-received and processed samples was evaluated by fibrinogen adsorption and platelet adhesion via the enzyme-linked immunosorbent assay and lactate dehydrogenase assay, respectively. The processed sample showed less platelet and fibrinogen adhesion compared with the as-received alloy, signifying its high thromboresistance. The current study suggests friction stir processing to be a versatile toolbox for enhancing the performance and reliability of currently used bioimplant materials.

Controlling a possible outbreak of Candida auris infection: lessons learnt from multiple interventions

BACKGROUND

Multidrug-resistant Candida auris infection has been reported from five continents in recent years. The prevalence of C. auris invasive infection has been estimated at 5.3% for intensive-care-acquired candidaemia in India. The transmission of the organism between the patients and from environment to patients is rapid.

AIM

To understand the intra-hospital dynamics of C. auris transmission and to determine the possible interventions to prevent its spread.

METHODS

Surveillance of intensive care units was carried out to assess patient colonization, environmental contamination and hand carriage of the yeast among healthcare workers. Interventions including chlorhexidine washing of patients and decontamination of environmental surfaces with stabilized hydrogen peroxide disinfectant (Ecoshield) were undertaken. We further evaluated the effectiveness of frequently used disinfectants in the hospital against C. auris on various inanimate surfaces, and its persistence on hospital fabrics.

FINDINGS

Three cases of C. auris bloodstream infection were detected over a period of three months. Many patients admitted at the same time, in the same area, were colonized by C. auris. Surveillance detected C. auris contamination of environmental surfaces and hands of healthcare workers. Interventions such as chlorhexidine washing and appropriate use of disinfectants could eradicate C. auris from patients and hospital environment.

CONCLUSION

The frequently used disinfectants in our hospital and current hand hygiene practices were efficient against C. auris if proper contact time and procedures were followed. Evaluation of possible persistence of C. auris on dry fabrics showed that they can persist for up to seven days.

Kinetic percolation

We demonstrate that kinetic aggregation forms superaggregates that have structures identical to static percolation aggregates, and these superaggregates appear as a separate phase in the size distribution. Diffusion limited cluster-cluster aggregation (DLCA) simulations were performed to yield fractal aggregates with a fractal dimension of 1.8 and superaggregates with a fractal dimension of D=2.5 composed of these DLCA supermonomers. When properly normalized to account for the DLCA fractal nature of their supermonomers, these superaggregates have the exact same monomer packing fraction, scaling law prefactor, and scaling law exponent (the fractal dimension) as percolation aggregates; these are necessary and sufficient conditions for same structure. The size distribution remains monomodal until these superaggregates form to alter the distribution. Thus the static percolation and the kinetic descriptions of gelation are now unified.

A prospective international Aspergillus terreus survey: an EFISG, ISHAM and ECMM joint study

OBJECTIVES

A prospective international multicentre surveillance study was conducted to investigate the prevalence and amphotericin B susceptibility of Aspergillus terreus species complex infections.

METHODS

A total of 370 cases from 21 countries were evaluated.

RESULTS

The overall prevalence of A. terreus species complex among the investigated patients with mould-positive cultures was 5.2% (370/7116). Amphotericin B MICs ranged from 0.125 to 32 mg/L, (median 8 mg/L).

CONCLUSIONS

Aspergillus terreus species complex infections cause a wide spectrum of aspergillosis and the majority of cryptic species display high amphotericin B MICs.

High fungal spore burden with predominance of Aspergillus in hospital air of a tertiary care hospital in Chandigarh

The prevalence of fungal spores in the hospital air is essential to understand the hospital-acquired fungal infections. Air conditioners (ACs) used in hospitals may either reduce spores in air or be colonised by fungi and aid in its dissemination. The present study was conducted to assess the fungal spore burden in AC and non-AC areas. We found a high fungal spore count in air irrespective of whether the area was AC or non-AC. The most predominant species isolated were Aspergillus flavus and Aspergillus fumigatus. Such high concentrations of pathogenic fungi in air may predispose individuals to develop disease.

A Study of Microalbuminuria (MAU) and Advanced Glycation End Products (AGEs) Levels in Diabetic and Hypertensive Subjects

The prevalence of non-communicable diseases like diabetes mellitus (DM) and hypertension (HTN) is growing worldwide. Both lead to nephropathy if not controlled effectively. Microalbuminuria (MAU) is recognized as an early predictor for nephropathy. Additionally, the timely detection of advanced glycation end products (AGEs) is also considered to be an important prognostic factor for diabetic nephropathies. Hence, screening for the early detection of MAU and AGEs would be an useful and relatively inexpensive laboratory test for early clinical diagnosis for the incidence of nephropathy in these diseases. This study was conducted in DM, HTN and pregnancy induced hypertensive (PIH) subjects. MAU and N^ε-Carboxymethyllysine (CML) levels were estimated by in-house RIA kits in the patient groups and controls, while the total AGEs level in serum was determined by ELISA. The levels of MAU, CML and AGE-BSA were observed to be significantly higher in DM, HTN and PIH subjects compared to controls (p < 0.001). Increased serum CML and AGEs levels in DM, HTN and PIH subjects indicated ongoing glycemic damage and their susceptibility to develop renal complications.

Association of acute toxic encephalopathy with litchi consumption in an outbreak in Muzaffarpur, India, 2014: a case-control study

BACKGROUND

Outbreaks of unexplained illness frequently remain under-investigated. In India, outbreaks of an acute neurological illness with high mortality among children occur annually in Muzaffarpur, the country's largest litchi cultivation region. In 2014, we aimed to investigate the cause and risk factors for this illness.

METHODS

In this hospital-based surveillance and nested age-matched case-control study, we did laboratory investigations to assess potential infectious and non-infectious causes of this acute neurological illness. Cases were children aged 15 years or younger who were admitted to two hospitals in Muzaffarpur with new-onset seizures or altered sensorium. Age-matched controls were residents of Muzaffarpur who were admitted to the same two hospitals for a non-neurologic illness within seven days of the date of admission of the case. Clinical specimens (blood, cerebrospinal fluid, and urine) and environmental specimens (litchis) were tested for evidence of infectious pathogens, pesticides, toxic metals, and other non-infectious causes, including presence of hypoglycin A or methylenecyclopropylglycine (MCPG), naturally-occurring fruit-based toxins that cause hypoglycaemia and metabolic derangement. Matched and unmatched (controlling for age) bivariate analyses were done and risk factors for illness were expressed as matched odds ratios and odds ratios (unmatched analyses).

FINDINGS

Between May 26, and July 17, 2014, 390 patients meeting the case definition were admitted to the two referral hospitals in Muzaffarpur, of whom 122 (31%) died. On admission, 204 (62%) of 327 had blood glucose concentration of 70 mg/dL or less. 104 cases were compared with 104 age-matched hospital controls. Litchi consumption (matched odds ratio [mOR] 9·6 [95% CI 3·6 - 24]) and absence of an evening meal (2·2 [1·2-4·3]) in the 24 h preceding illness onset were associated with illness. The absence of an evening meal significantly modified the effect of eating litchis on illness (odds ratio [OR] 7·8 [95% CI 3·3-18·8], without evening meal; OR 3·6 [1·1-11·1] with an evening meal). Tests for infectious agents and pesticides were negative. Metabolites of hypoglycin A, MCPG, or both were detected in 48 [66%] of 73 urine specimens from case-patients and none from 15 controls; 72 (90%) of 80 case-patient specimens had abnormal plasma acylcarnitine profiles, consistent with severe disruption of fatty acid metabolism. In 36 litchi arils tested from Muzaffarpur, hypoglycin A concentrations ranged from 12·4 μg/g to 152·0 μg/g and MCPG ranged from 44·9 μg/g to 220·0 μg/g.

INTERPRETATION

Our investigation suggests an outbreak of acute encephalopathy in Muzaffarpur associated with both hypoglycin A and MCPG toxicity. To prevent illness and reduce mortality in the region, we recommended minimising litchi consumption, ensuring receipt of an evening meal and implementing rapid glucose correction for suspected illness. A comprehensive investigative approach in Muzaffarpur led to timely public health recommendations, underscoring the importance of using systematic methods in other unexplained illness outbreaks.

FUNDING

US Centers for Disease Control and Prevention.

Photochromic histone deacetylase inhibitors based on dithienylethenes and fulgimides

The synthesis, photochromic properties, inhibition of different HDACs and corresponding molecular dockings of photochromic inhibitors are described.