Adaptation of a malaria surveillance system for use in a visceral leishmaniasis elimination programme.

Background: Successful public practice relies on generation and use of high-quality data. A data surveillance system (the Disease Data Management System [DDMS]) in use for malaria was adapted for use in the Indian visceral leishmaniasis elimination programme. Methods: A situational analysis identified the data flows in current use. Taxonomic trees for the vector of visceral leishmaniasis in India, Phlebotomus argentipes, were incorporated into the DDMS to allow entry of quality assurance and insecticide susceptibility data. A new quality assurance module was created to collate the concentration of DDT that was applied to walls during the indoor residual spraying (IRS) vector control programme. Results: The DDMS was implemented in Bihar State and used to collate and manage data from sentinel sites in eight districts. Quality assurance data showed that DDT was under-applied to walls during IRS; this, combined with insecticide susceptibility data showing widespread vector resistance to DDT prompted a national policy change to using compression pumps and alpha-cypermethrin insecticide for IRS. Conclusions: The adapted DDMS centralises programmatic data and enhances evidence-based decision making and active policy change. Moving forward, further modules of the system will be implemented, allowing extended data capture and streamlined transmission of key information to decision makers.

Pharmacovigilance of Miltefosine in Treatment of Visceral Leishmaniasis in Endemic Areas of Bihar, India.

Miltefosine, the only oral drug for visceral leishmaniasis (VL), is being used as the first-line drug under the VL elimination program in the Indian subcontinent. Miltefosine is an oral drug which was used as a topical application for skin metastasis of breast cancer. It was found to be effective against Leishmania donovani The main adverse events (AE) reported previously with miltefosine use includes diarrhea, vomiting, and dehydration. Other AEs include, raised serum alanine transaminase/aspartate aminotransferase and renal parameters such as creatinine. In this study, we report AEs in a large patient cohort of VL treated with miltefosine. The purpose of this pharmacovigilance study was to assess adverse drug reactions (ADRs)/AE of miltefosine treatment under unrestricted condition in the field setup. Patients were followed up to 6 months for therapeutic effectiveness. Outcomes of a larger data set of patients treated with this regimen from April 2012 to March 2015 were recorded. In the present study, 646 patients of VL were given miltefosine. Majority of the study subjects (58%) were male. Relapse occurred in 7% during follow-up period. Main causes of death were VL-pulmonary tuberculosis coinfection, extreme diarrhea, and acute pancreatitis which were reported in 1.7% subjects. Of 553 (85.6%) patients completing full course of treatment, 463 (83.7%) showed ADR with miltefosine during the study period. About 2.3% were suffering severe ADR, 51% from moderate, and the rest had mild ADR. The initial and final cure rate was 97.4% and 85.6%, respectively.

Community perceptions on malaria and care-seeking practices in endemic Indian settings: policy implications for the malaria control programme.

BACKGROUND: The focus of India's National Malaria Programme witnessed a paradigm shift recently from health facility to community-based approaches. The current thrust is on diagnosing and treating malaria by community health workers and prevention through free provision of long-lasting insecticidal nets. However, appropriate community awareness and practice are inevitable for the effectiveness of such efforts. In this context, the study assessed community perceptions and practice on malaria and similar febrile illnesses. This evidence base is intended to direct the roll-out of the new strategies and improve community acceptance and utilization of services. METHODS: A qualitative study involving 26 focus group discussions and 40 key informant interviews was conducted in two districts of Odisha State in India. The key points of discussion were centred on community perceptions and practice regarding malaria prevention and treatment. Thematic analysis of data was performed. RESULTS: The 272 respondents consisted of 50% females, three-quarter scheduled tribe community and 30% students. A half of them were literates. Malaria was reported to be the most common disease in their settings with multiple modes of transmission by the FGD participants. Adoption of prevention methods was seasonal with perceived mosquito density. The reported use of bed nets was low and the utilization was determined by seasonality, affordability, intoxication and alternate uses of nets. Although respondents were aware of malaria-related symptoms, care-seeking from traditional healers and unqualified providers was prevalent. The respondents expressed lack of trust in the community health workers due to frequent drug stock-outs. The major determinants of health care seeking were socio-cultural beliefs, age, gender, faith in the service provider, proximity, poverty, and perceived effectiveness of available services. CONCLUSION: Apart from the socio-cultural and behavioural factors, the availability of acceptable care can modulate the community perceptions and practices on malaria management. The current community awareness on symptoms of malaria and prevention is fair, yet the prevention and treatment practices are not optimal. Promoting active community involvement and ownership in malaria control and management through strengthening community based organizations would be relevant. Further, timely availability of drugs and commodities at the community level can improve their confidence in the public health system.

Effect of two herbicides on Xenylla welchi (Hexapoda:Collembola) under laboratory conditions.

Xenylla welchi was used to evaluate toxicity of two herbicide formulations, pretilachlor (50 EC) and pendimethalin (30 EC) under laboratory conditions. Twenty four hours LC50 value of pretilachlor and pendimethalin formulations on Xenylla welchi were 72.7 and 190.0 g a.i/ha respectively which were less than their corresponding recommended agricultural doses. Again pretilachlor attained fastest LT50 (110 min) followed by pendimethalin (140 min). Significant reductions in hatching success were noted with the application of both the herbicide formulations at all doses excepting ¹/8 and ¹/10th of LC50 (9.1, 7.3 and 23.8, 19.0 g a.i/ha for pretilachlor and pendimethalin, respectively). Hatching success of the test specimens recorded 44.1 and 63.3% reduction from control for the highest applied dose (½ of LC50) of pretilachlor and pendimethalin, respectively. Juveniles of Xenylla welchi exposed to ¹/6, ¹/8 and ¹/10th LC50 for pretilachlor (12.1, 9.1, 7.3 g a.i/ha) and ¹/8 and ¹/10th LC50 for pendimethalin (23.8, 19.0 g ai/ha) survived and exhibited increased moulting frequency (7 moultings in 28 days in both the herbicide treatments) in comparison to control (8 moulting in 42 days). Test specimens required 26.0 ± 1.2 and 28.1 ± 2.1 days to attain sexual maturity exposed to pretilachlor and pendamethalin respectively which was significantly less than control (42 ± 2.6 days).

Studies on relative toxicities of six insecticides on epigeic earthworm, Perionyx excavatus.

The 96 h LC(50) values of six insecticides were determined on a non-target epigeic earthworm Perionyx excavatus under laboratory conditions. Cypermethrin was found most toxic to P. excavatus (LC(50)-0.008 mg/kg), followed by endosulfan (LC(50)-0.03 mg/kg), carbaryl (LC(50)-6.07 mg/kg), chlorpyrifos (LC(50)-7.3 mg/kg), aldicarb (LC(50)-10.63 mg/kg) and monocrotophos (LC(50)-13.04 mg/kg). When these LC(50) values were compared with their respective recommended agricultural doses, aldicarb and carbaryl appeared more dangerous than other pesticides because of their lower LC(50) values than their respective recommended agricultural dose. Mean lethal time to cause 50% mortality at recommended agricultural dose (LT(50)) also indicated that aldicarb achieved the fastest LT(50) (26 h) followed by endosulfan (38 h) and carbaryl (44 h) indicating the danger of these pesticides to P. excavatus.

New perspectives of malaria control in India under World Bank Project.

The World Bank has been assisting Government of India (GoI) for a number of years with development of effective health services for the control of vector borne diseases (VBDs). An Enhanced Malaria Control Project (EMCP) under financial assistance from Bank was implemented in selected tribal states and districts from 1997 to 2005. While most of the project districts did report a decline in malaria incidence, the Implementation Completion Report (ICR) highlighted the need for major reform. Plasmodium falciparum (Pf) malaria, which accounts for almost all malaria related mortality, has been increasing in India and there is widespread resistance to chloroquine. The needed reform would require, first and foremost, updating of policy on malaria case management in public and private sectors. Also needed are innovative approaches for promoting the use of insecticide treated nets (ITNs) and strengthening institutions at the district and state levels for effective implementation of new policies. Several important changes in the policy on diagnosis and treatment of malaria are being implemented in this new project. The most important of these are: Use of artesunate combination therapy (ACT) as the first line treatment for all confirmed Pf malaria cases, introduction of rapid diagnostic kits for quick diagnosis of Pf cases, promotion of long lasting insecticide treated bed nets (LLINs) in vulnerable population. Supervision and monitoring will be strengthened by deployment of Malarial/Kala azar Technical Supervisors (MTS/KTS) and VBD consultants at district level. The project has also envisaged two important components like Environment Management Plan (EMP) for safe use of insecticides and materials and Vulnerable Community Plan (VCP) for the benefit of underprivileged population.

Traumatic brain injury.

PURPOSE: Traumatic brain injury (TBI) leading to severe disability is fortunately rare, but when it occurs, the effect on patients and their families can be devastating. ISSUE: In the UK at the current time, there are insufficient specialist rehabilitation services to cater for the case-load and many patients receive their care in general wards. CONCLUSION: This educational article outlines the principles of management of severe TBI from a practical clinical viewpoint, reviews briefly the evidence for effectiveness of rehabilitation and offers an approach to consistent outcome measurement.

Biochemical changes after trauma and skeletal surgery of the lower extremity: quantification of the operative burden.

OBJECTIVE: To quantify changes in variables of inflammation, coagulation, and fibrinolysis in blunt trauma patients with lower extremity fractures who underwent different types of surgical procedures. DESIGN: Prospective, cohort study. SETTING: Level I university trauma center. PATIENTS: We allocated 83 blunt trauma patients in stable condition and 22 patients eligible for elective hip replacement to four treatment groups. INTERVENTIONS: In 34 multiply traumatized patients with femoral fracture (group PTFF) and in 28 patients with an isolated femoral fracture (group IFF), primary unreamed intramedullary nailing for stabilization of the femoral shaft fracture was performed. In 22 patients, an elective uncemented total hip arthroplasty (group THA) was inserted for osteoarthritis, and in 21 control patients, an isolated ankle fracture (group AF) was acutely stabilized. MEASUREMENTS AND MAIN RESULTS: From serially sampled central venous blood, the perioperative concentrations of interleukin (IL)-6, of tumor necrosis factor-alpha, of prothrombin fragments 1 + 2, and of D-dimer cross-linked fibrin degradation products were evaluated. Intramedullary instrumentation for an isolated femur fracture caused a significant perioperative increase in the concentrations of IL-6 (preoperative IL-6, 52 +/- 12 pg/mL; IL-6 30 mins postinsertion, 78 +/- 14 pg/mL; p = .02). This increase was comparable with group THA (preoperative IL-6, 46 +/- 16 pg/mL; IL-6 30 mins postinsertion, 67 +/- 11 pg/mL; p = .03). A positive correlation occurred between both groups (r = .83, p < .0004). Multiple trauma patients demonstrated significantly (p = .0002) higher IL-6 concentrations than all other groups throughout the study period and showed a significant increase after femoral nailing (preoperative IL-6, 570 +/- 21 pg/mL; IL-6 30 mins postinsertion, 690 +/- 24 pg/mL; p = .003), whereas no perioperative change was seen in group AF. The highest IL-6 increases were associated with a longer ventilation time (group PTFF) and a longer period of positive fluid balances (groups PTFF, IFF, THA). The coagulatory variables demonstrated similar perioperative increases in groups IFF and THA, but not in groups PTFF and AF. The IL-6 concentrations and the prothrombin fragments 1 + 2 concentrations correlated between groups THA and IFF at 30 mins and at 1 hr after surgery (r2 = .64, p < .02). In all patients the clinical variables were stable perioperatively. CONCLUSIONS: Major surgery of the lower extremity causes changes to the inflammatory, fibrinolytic, and coagulatory cascades in patients with stable cardiopulmonary function. The inflammatory response induced by femoral nailing is biochemically comparable to that induced by uncemented total hip arthroplasty. In multiple trauma patients, increases, which occurred in addition to those induced by the initial trauma, were measured. Definitive primary femoral stabilization by intramedullary nailing imposes an additional burden to the patient with blunt trauma. A careful preoperative investigation is required to evaluate whether primary definitive stabilization can be performed safely.

In the human malaria parasite Plasmodium falciparum, polyamines are synthesized by a bifunctional ornithine decarboxylase, S-adenosylmethionine decarboxylase.

The polyamines putrescine, spermidine, and spermine are crucial for cell differentiation and proliferation. Interference with polyamine biosynthesis by inhibition of the rate-limiting enzymes ornithine decarboxylase (ODC) and S-adenosylmethionine decarboxylase (AdoMetDC) has been discussed as a potential chemotherapy of cancer and parasitic infections. Usually both enzymes are individually transcribed and highly regulated as monofunctional proteins. We have isolated a cDNA from the malaria parasite Plasmodium falciparum that encodes both proteins on a single open reading frame, with the AdoMetDC domain in the N-terminal region connected to a C-terminal ODC domain by a hinge region. The predicted molecular mass of the entire transcript is 166 kDa. The ODC/AdoMetDC coding region was subcloned into the expression vector pASK IBA3 and transformed into the AdoMetDC- and ODC-deficient Escherichia coli cell line EWH331. The resulting recombinant protein exhibited both AdoMetDC and ODC activity and co-eluted after gel filtration on Superdex S-200 at approximately 333 kDa, which is in good agreement with the molecular mass of approximately 326 kDa determined for the native protein from isolated P. falciparum. SDS-polyacrylamide gel electrophoresis analysis of the recombinant ODC/AdoMetDC revealed a heterotetrameric structure of the active enzyme indicating processing of the AdoMetDC domain. The data presented describe the occurrence of a unique bifunctional ODC/AdoMetDC in P. falciparum, an organization which is possibly exploitable for the design of new antimalarial drugs.

Japanese Encephalitis epidemic in Anantapur district, Andhra Pradesh (October-November, 1999).

Epidemic of Japanese Encephalitis has occurred in Andhra Pradesh during October-November, 1999 affecting 15 out of 23 districts. In total, 873 cases with 178 deaths have been recorded up to the day 29.11.99. The epidemiological investigation has been done in Anantapur district in western Andhra Pradesh, where the outbreak has started in the third week of October. In the district 47 PHC have been affected. On an average 4.5 per cent of 3175 villages have been affected. Average number of cases per affected village have been 1.5. Rural population has been primarily affected. Age groups 1-14 years including infants have been affected but nearly 86.8% of cases have been among 1-9 year age group. The overall case fatality rate has been 18.4 per cent. Clinical features have been high fever, headache, altered sensorium, convulsions and coma. A marked seasonal onset of a few cases per village and 93.75 per cent of human serum samples collected from hospitalised cases showed the evidence of J.E. virus infection indicating that the present outbreak was due to JE virus. High density of Culex vishnui complex mosquitoes has been observed in the area. All the environmental and ecological conditions, temperature, rainfall and relative humidity have been in favour of JE transmission. Analysis of the data for the last 10 years showed that the human JE cases occurred in Anantapur in September-October months, which shifted to October-November, 99. Prolonged draught conditions were observed till October. Possibly the delayed monsoon and congenial atmospheric conditions after monsoon were favourable to the vector species for extra-human cycle of transmission in 1999. Low level transmission leading to small number of cases continued during the succeeding years every September-October till the present epidemic. In all 24 PHCs and urban towns were identified with 212 cases and 39 deaths till 29.11.99.

Aluminium related changes in brain histology: protection by calcium and nifedipine.

Aluminium (Al; 50 mg AlCl3/kg body wt/day) treatment caused a marked change in histological picture of normal brain as indicated by an increased number of vacuolated spaces. These changes returned to normal partially by simultaneous treatment with nifedipine (0.7 mg/kg body wt/day) and completely by similar treatment with 50 ppm calcium (CaCl2; 12.5 mg/kg body wt./day). Neither nifedipine nor calcium treatment alone altered the normal histological condition. The histological changes could not be correlated with the decrease in calcineurin activities in brain as nifedipine decreases calcineurin activity without any histological changes. Hence the histological changes may be considered as specific for Al and not due to a general decrease in calcineurin activity.

Novel dominant mutations in Saccharomyces cerevisiae MSH6.

Inherited mutations in the mismatch repair (MMR) genes MSH2 and MLH1 are found in most hereditary nonpolyposis colon cancer (HNPCC) patients studied. Eukaryotic MMR uses two partially redundant mispair-recognition complexes, Msh2p-Msh6p and Msh2p-Msh3p (ref.2) Inactivation of MSH2 causes high rates of accumulation of both base-substitution and frameshift mutations. Mutations in MSH6 or MSH3 cause partial defects in MMR, with inactivation of MSH6 resulting in high rates of base-substitution mutations and low rates of frameshift mutations; inactivation of MSH3 results in low rates of frameshift mutations. These different mutator phenotypes provide an explanation for the observation that MSH2 mutations are common in HNPCC families, whereas mutations in MSH3 and MSH6 are rare. We have identified novel missense mutations in Saccharomyces cerevisiae MSH6 that appear to inactivate both Msh2p-Msh6p- and Msh2p-Msh3p-dependent MMR. Our work suggests that such mutations may underlie some cases of inherited cancer susceptibility similar to those caused by MSH2 mutations.

Polyvinylsiloxane dental bite registration material used to splint a composite graft of the nasal rim.

We describe the construction of a nostril splint made from heavy body silicone-based dental impression material. This bio-compatible material supported a large chondrocutaneous auricular graft during early healing. The splint immobilized and maintained the shape of the alar rim and was further used nightly during the expected period of wound contraction.

Acute nonspecific carditis in adolescents presenting with Stokes-Adams attacks.

Three patients, aged between 12 and 17 years presented with Stokes-Adams attacks as a result of atrioventricular block, atrioventricular silence and ventricular arrhythmias, complicating acute myocarditis. All the patients required temporary pacing for a few days. One patient required hemodialysis for anuria. All the patients made complete recovery.

Reconstruction of acquired sub-total ear defects with autologous costal cartilage.

Acquired sub-total ear defects are common and challenging to reconstruct. We report the use of an autologous costal cartilage framework to reconstruct sub-total defects involving all anatomical regions of the ear. Twenty-eight partially damaged ears in 27 patients were reconstructed with this technique. The defects resulted from bites (14), road traffic accidents (five), burns (four), iatrogenic causes (four) and chondritis following minor trauma (one). Computerised image analysis revealed a median of 31% (range 13-72%) ear loss. An autologous costal cartilage framework was fashioned in all cases. If adequate local skin was available, this was draped over the framework, but in nine cases preliminary tissue expansion was used and in a further three cases with significant scarring, the framework was covered with a temporoparietal fascial flap. Clinical assessment after ear reconstruction was undertaken, scoring for symmetry, the helical rim, the antihelical fold, the lobe position and a 'natural look' to produce a four-point scale; 11 were excellent, 12 were good, two were fair and three were poor. Our experience suggests that formal delayed reconstruction with autologous costal cartilage is to be recommended when managing acquired, sub-total ear deformity.

Purification and physicochemical studies of human plasma thiol proteinase inhibitors.

The physicochemical properties of thiol proteinase inhibitors (TPI) isolated from outdated human blood have been studied. A simple technique which includes ammonium sulphate precipitation, Sephadex G-200 gel filtration and ion-exchange chromatography led to the isolation of 4 isolates namely TPI-1, TPI-2, TPI-3 and TPI-4 having molecular mass of 70, 155, 195 and 497 kDa respectively. The latter two forms are the new isolates unreported previously. They exhibit similar pH stability, inhibition spectra with papain, cathepsin B and trypsin, antigenic properties and glycoprotein nature. The TPI-4, however, was found to be most heat stable showing no decrease in inhibitory activity when heated upto 70 degrees C for 30 min. Our work suggests that TPI-3 and TPI-4 are the oligomers of TPI-1.

Susceptibility status of malaria vectors to insecticides in India.

The use of chemical insecticides for control of malaria vector populations continues to be the mainstay of malaria control strategy in India. Monitoring vector susceptibility to chemical insecticides is an important activity under the National Malaria Eradication Programme to ensure judicious and effective use of chemical Insecticides. 72 entomological zones were established under NMEP in 1977 for undertaking entomological studies in the malaria problematic areas. These zones have been generating insecticide susceptibility data in respect of the various malaria vectors. In this paper the insecticide susceptibility data, in respect of major vectors of malaria as on 1997, is presented.

Characterisaton of human plasma thiol proteinase inhibitors.

Earlier, we had reported purification of three thiol proteinase inhibitors (TPI-1 of 70 kDa, TPI-3 of 195 kDa and TPI-4 of 497 kDa) from human plasma. In the present study we report that TPI-1 binds to papain in the stoichiometry ratio (E/I) of 1:1 while TPI-3 and TPI-4 bind in the ratio of 1.5:1 and 3.2:1 respectively. The K(m) for papain with BAPNA as substrate and Kcat/K(m) values for TPI-1, TPI-3 and TPI-4 were 2.7 x 10(-6) M, 0.84 nM/sec; 3.2 x 10(-6) M, 0.75 nM/sec; and 3.6 x 10(-6) M, 0.72 nM/sec respectively. The Ki values were found to be 1.48 nM for TPI-1, 0.133 nM for TPI-3 and 0.117 nM for TPI-4. The UV absorption and fluorescence emission spectra study suggest involvement of aromatic residues in the binding process. This study suggests that TPI-4 is the most potent inhibitor of thiol proteinases.

Identification, characterization, and precise mapping of a human gene encoding a novel membrane-spanning protein from the 22q11 region deleted in velo-cardio-facial syndrome.

Velo-cardio-facial syndrome (VCFS) and DiGeorge syndrome (DGS) are characterized by a wide spectrum of phenotypes including cleft palate, conotruncal heart defects, and facial dysmorphology. Hemizygosity for a portion of chromosome 22q11 has been detected in 80-85% of VCFS/DGS patients. Using a cDNA selection protocol, we have identified a new gene, TMVCF (transmembrane protein deleted in VCFS), which maps to the deleted interval. The genomic locus is positioned between polymorphic markers D22S944 and D22S941. TMVCF encodes a small protein of 219 amino acids that is predicted to contain two membrane-spanning domains. TMVCF is expressed abundantly in human adult lung, heart, and skeletal muscle, and transcripts can be detected at least as early as Day 9 of mouse development.