Strain diversity and relative transmission of Mycobacterium tuberculosis in south coastal Karnataka, India.

BACKGROUND: There are no published reports on the strain diversity and relative transmission of Mycobacterium tuberculosis isolates circulating in Karnataka State, India. OBJECTIVE: To explore the strain diversity of M. tuberculosis isolates and their relative transmission in south coastal Karnataka using spoligotyping and mycobacterial interspersed repetitive unit-variable number of tandem repeats (MIRU-VNTR) typing. DESIGN: A total of 108 clinical isolates of M. tuberculosis were processed for spoligotyping, and 12-locus MIRU-VNTR typing and cluster analysis was performed. RESULTS: Spoligotyping data of 108 isolates revealed 63 spoligotype patterns: 36 (80 isolates, 74.1%) patterns corresponded to spoligotype international types (SITs), whereas 27 (28 isolates, 25.9%) patterns were orphans. A further 57 (52.8%) isolates were clustered into 12 clusters; 51 (47.2%) isolates were unique. The largest spoligotype cluster comprised SIT 48 (L1.2.2), followed by SIT 1942 (L3) and SIT 11 (L1.1.2). Combined MIRU-VNTR typing and spoligotyping analysis further differentiated these 108 isolates into five clusters of two isolates each and 98 individual patterns. CONCLUSIONS: Combined use of spoligotyping and MIRU-VNTR typing is best suited for genotyping studies in this region. Very high genetic diversity was observed among the clinical isolates. Further elaborate studies are required for a better understanding of the genetic diversity and transmission dynamics of the strains circulating in this region.

Atypical Presentations of Melioidosis in North India: Report of Two Cases.

Melioidosis is an infection caused by Gram-negative bacterium, Burkholderia pseudomallei. This is a rare disease in India, more so in North India. We present two cases of melioidosis with unusual sites of infection. The first patient was a young diabetic male presenting to us with history of prolonged fever and upper abdominal discomfort, subsequently diagnosed as a case of pyogenic liver abscess. The second patient was a middle aged diabetic complaining of prolonged fever and headache and found to have right frontal lobe brain abscess.The pus cultured from the lesion in both cases showed growth of Burkholderia pseudomallei. These two cases are described to consider melioidosis as a differential diagnosis amongst pyrexia of unknown origin cases.

Comparison of periodontal open flap debridement versus closed debridement with Er,Cr:YSGG laser.

BACKGROUND: Traditional periodontal open flap debridement (OFD) results in reduced pocket depth (PD), clinical attachment loss (CAL), gingival recession (GR) and postoperative pain and discomfort. The quest to overcome these shortcomings has led to research into Er,Cr:YSGG laser assisted pocket therapy (ELAPT). This study was designed to compare the clinical outcomes of ELAPT versus OFD. METHODS: Fifteen patients with a PD of ≥5 mm and ≤8 mm at two sites were selected. Test sites (Group 1) were treated by ELAPT and the control (Group 2) by OFD. Clinical parameters were recorded at baseline, 3 and 6 months and included Plaque Index (PI), Gingival Index (GI), modified Sulcular Bleeding Index (mSBI), PD, CAL and GR. RESULTS: Both treatments produced a reduction in PI, GI, mSBI and PD, an increase in GR, and a gain in CAL at 3 and 6 months. The mean gain of CAL in Group 1 at 3 and 6 months (1.60 ± 0.78 and 1.80 ± 0.63) was similar (p > 0.05) to the value of Group 2 (1.93 ± 0.88 and 2.00 ± 0.54). GR increased significantly (p < 0.05) only in Group 2 at 3 and 6 months (1.80 ± 0.56 and 1.87 ± 0.64) compared to Group 1 (0.50 ± 0.68 and 0.60 ± 0.74). CONCLUSIONS: ELAPT compared with OFD results in similar CAL gains with less GR and significant reductions in PD, GI and mSBI, and may be considered as an alternative to surgical therapy.

Pulmonary melioidosis in febrile neutropenia: the rare and deadly duet.

We present the first two fulminant cases of pulmonary melioidosis in febrile neutropenic patients with acute and varied presentations seen in our institution and their fatal outcome. A high index of suspicion coupled with microbiological confirmation can facilitate the administration of the appropriate therapy in cases of melioidosis that differ from other bacterial infections in terms of presentation and the response to antimicrobials.

Molecular resurfacing of cartilage with proteoglycan 4.

Early loss of proteoglycan 4 (PRG4), a lubricating glycoprotein implicated in boundary lubrication, from the cartilage surface has been associated with degeneration of cartilage and early onset of osteoarthritis. Viscosupplementation with hyaluronic acid and other macromolecules has been proposed as a treatment of osteoarthritis. However, the efficacy of viscosupplementation is variable and may be influenced by the short residence time of lubricant in the knee joint after injection. Recent studies have demonstrated the use of aldehyde (CHO) modified extracellular matrix proteins for targeted adherence to a biological tissue surface. It is hypothesized that CHO could be exploited to enhance the binding of lubricating proteoglycans to the surface of PRG4-depleted cartilage. The objective of this study was to determine the feasibility of molecular resurfacing of cartilage with CHO-modified PRG4. PRG4 was chemically functionalized with aldehyde (PRG4-CHO) and aldehyde plus Oregon Green (OG) fluorophore (PRG4-OG-CHO) to allow for differentiation of endogenous and exogenous PRG4. Cartilage disks depleted of native PRG4 were then treated with solutions of PRG4, PRG4-CHO, or PRG4-OG-CHO and then assayed for the presence of PRG4 by immunohistochemistry, ELISA, and fluorescence imaging. Repletion of cartilage surfaces was significantly enhanced with the inclusion of CHO compared with repletion with unmodified PRG4. These findings suggest a generalized approach which may be used for molecular resurfacing of tissue surfaces with PRG4 and other lubricating biomolecules, perhaps leading in the future to a convenient method for overcoming loss of lubrication during the early stages of osteoarthritis.

Emerging extra-intestinal infections with Aeromonas hydrophila in coastal region of southern Karnataka.

BACKGROUND: Aeromonas species are gram-negative rods usually isolated from the gastrointestinal tract. They have been occasionally reported as a cause of extra-intestinal infections such as cellulitis, cholangitis, necrotizing fascitis, meningitis, bacteremia, or peritonitis in both immunocompetent and immunocompromised patients. AIM: To determine the role and possible pathogenesis of Aeromonas in extra-intestinal infections. SETTINGS AND DESIGN: Retrospective analysis carried out at Kasturba Hospital Manipal, Karnataka in the months of January and February 2007. MATERIALS AND METHODS: Clinical manifestations and management of eight cases of extra-intestinal infections caused by A. hydrophila , from the south Karnataka coastal region were reviewed. The isolates were identified with the help of biochemical tests using standard guidelines. RESULTS: All patients acquired Aeromonas infections in the community. Five (62.5%) had underlying illnesses, such as liver disease, diabetes mellitus or malignancy. Five (62.5%) had polymicrobial infections, and three (37.5%) were complicated with bacteremia. These included three patients with ulcers or abscess over the lower leg, two with cellulitis due to snake bite and one each with pelvic inflammatory disease, spontaneous bacterial peritonitis and pneumonia. A. hydrophila was found to be a causative agent of pelvic inflammatory disease or cellulitis following sea snake bite, and such a clinical scenario has not been previously described. Seven patients survived the illness. CONCLUSIONS: Isolation of A. hydrophila from extra-intestinal specimens demands utmost clinical and microbiological vigilance in diagnosis, since the organism can cause serious infections among immunocompromised as well as immunocompetent individuals.

Correlation of antioxidants and fitness levels in undergraduate medical students.

Fitness is the ability of the organism to maintain the various internal equilibriums as closely as possible to the resting state during strenuous exercise and to restore promptly after exercise. The aim of the present study was to evaluate the fitness and correlate it with anti-oxidant levels of 50 male medical students in the age group of 18 to 25 years. Fitness was assessed by Harvard Step Test. The antioxidant status was assessed by Vitamin C and Vitamin E levels in the blood. Three groups were formed on the basis of fitness score. The mean values of fitness scores were 95.33 +/- 7.66, 68.5 +/- 9.22 and 37 +/- 10.9, in-group A, B and C, respectively. Between the three groups, Vitamin E values were significantly different but not the Vitamin C levels. Thus, it is concluded that Vitamin E levels influence the fitness state of an individual.

An unusual case of neonatal brain abscess following Klebsiella pneumoniae septicemia.

A case of solitary brain abscess in a term neonate caused by Kiebsiella pneumoniae is described. K. pneumoniae, although a common cause of neonatal septicemia, is rarely implicated as an etiological agent for cerebral abscess in this age-group. The interest of this case lies in the rarity of the causative organism and atypical features. In the absence of predisposing factors in the neonate, we suspect that the infection was transmitted vertically from the mother before or at the time of delivery since there was evidence of asymtomatic urinary tract infection in the antenatal period.

Castleman's disease and superior vena cava thrombi: a rare presentation and a review of the literature.

Castleman's disease is a clinicopathological entity in which growth of lymphoid tissue is unregulated. It may present as asymptomatic involvement of one lymph node group or as a multicentric disease with systemic symptoms. Unlike localized disease, for which surgical excision is curative regardless of the histological type, multicentric disease often necessitates aggressive systemic therapy and portends a poor outcome. Superior vena caval thrombosis is an uncommon manifestation associated with Castleman's disease.

Isolation and characterization of MC3T3-E1 preosteoblast subclones with distinct in vitro and in vivo differentiation/mineralization potential.

A series of subclonal cell lines with high or low differentiation/mineralization potential after growth in the presence of ascorbic acid (AA) were derived from murine MC3T3-E1 cells. Subclones were characterized in terms of their ability to mineralize a collagenous extracellular matrix both in vitro and in vivo and express osteoblast-related genes. When compared with nonmineralizing cells, mineralizing subclones selectively expressed mRNAs for the osteoblast markers, bone sialoprotein (BSP), osteocalcin (OCN), and the parathyroid hormone (PTH)/parathyroid hormone-related protein (PTHrP) receptor. In contrast, alkaline phosphatase mRNA was present in certain nonmineralizing as well as mineralizing subclones, suggesting that its expression may be subject to different controls from other osteoblast markers. Only highly differentiating subclones exhibited strong AA-dependent induction of a transiently transfected OCN promoter-luciferase reporter gene, indicating that there was a good correlation between mRNA levels and transcriptional activity. Consistent with its postulated role in biomineralization, BSP as measured by Western blotting was only present in mineralizing subclones. After implantation into immunodeficient mice, highly differentiating subclones formed bone-like ossicles resembling woven bone, while poorly differentiating cells only produced fibrous tissue. Interestingly, subclones with both high and low differentiation potential produced similar amounts of collagen in culture and expressed comparable basal levels of mRNA encoding Osf2/Cbfa1, an osteoblast-related transcription factor. Although some strongly differentiating cells exhibited a modest AA-dependent up-regulation of Osf2/Cbfa1 mRNA, there was no clear relationship between levels of this message and induction of mRNAs for other differentiation markers. Thus, the mere presence of Osf2/Cbfa1 in a subclone was not sufficient for osteoblast differentiation. These subclones will be very useful for studying critical events in osteoblast differentiation and mineralization.

An open clinical trial of benazepril--a new ACE inhibitor in mild-moderate hypertension.

Benazepril hydrochloride, a new non-sulfhydryl ACE inhibitor (ACEI) was studied in a titrated dose of 10 mg-20 mg once a day for 6 weeks in 42 mild to moderate adult hypertensive patients with sitting diastolic blood pressure (SDBP) 95-114 mm Hg. The pre-drug SDBP(mean +/- SE) of 102.5 +/- 0.8 mm Hg showed a significant reduction to 87.5 +/- 0.93 mm Hg at the end of treatment. BP was controlled (SDBP < or = 90 mm Hg) in 34 (81%) patients and a drop of at least 10 mm Hg from the pre-treatment SDBP value was noted in 34 (81%) patients. Common adverse reaction was cough in 8(19%) patients. Clinically significant changes in laboratory evaluations were not seen in any patient. Study showed that benazepril in a dose range of 10 to 20 mg per day is an effective agent for treatment of mild to moderate hypertension.

HIV in intensive care--a 3 years experience.

A three year prospective study of a total of 62 critically ill HIV patients in MICU showed a rising percentage from 0.86 in 1992 to 3.17 in 1994. Four major presentations were observed, neurological-20 patients (32.5%), sepsis syndrome-18 (29%), poisoning-10 (16.1%) and miscellaneous-14 (22.6%). Acute poisoning emerged as the most important preventable indication for MICU admissions. Interventions like CVP and haemodynamic monitoring-25 patients, endotracheal intubation-18, mechanical ventilation-14, tracheostomy-3, haemodialysis-3 were done when indicated. The mortality of the 14 ventilated patients was high at 92.9% compared to the overall HIV mortality of 46.8%. This study shows that critically ill HIV patients do deserve intensive care management with optimum infection control precautions. Survival of 53.2% is noteworthy in a resource stretched set up.

Impact of nutrition education on food and nutrient intake of pregnant women.

PIP: Researchers compared data on 33 pregnant women attending nutrition education classes regularly over a 13-week period (nutrition education group) with data on 33 other pregnant women who did not receive such education (controls) to examine the impact of nutrition education on the pregnant women's food and nutrient intake. The 66 pregnant women were selected from two hospitals and two urban family welfare centers in Ludhiana city, India. All were from the low socioeconomic group (i.e., per capita income of Rs. 369/month). A dietary survey was conducted at 20 weeks gestation and again at 36 weeks gestation. At 20 weeks, the two groups were not statistically different. The intake of cereals, pulses, green leafy vegetables, fats and oils, and sugar and jagger were lower than the recommended daily intake (RDI). On the other hand, intake was more than RDI for milk and milk products, other vegetables, and roots and tubers. Except thiamine and ascorbic acid, intake of nutrients was inadequate. In both the nutrition education group and the control group, nutrient intake was higher at 36 weeks than at 20 weeks due to the increased food requirements of pregnancy. Women in the nutrition education group were more likely than the control group to consume more protein, vitamin A, thiamine, folic acid, and vitamin C. This likely reflects a higher consumption of pulses, milk and milk products, fruits, and vegetables as well as adopting favorable nutritional practices (e.g., use of sprouted grains). Nevertheless, intake was below RDIs for many nutrients, even for women in the nutrition education group. These findings suggest that nutrition education for pregnant women does improve nutrient intake but also that more needs to be done to bring intake levels up even higher.^ieng

Dual-beam imaging for online verification of radiotherapy field placement.

PURPOSE: Due to the poor quality of megavoltage (MV) radiographs, detection and assessment of discrepancies in radiation field placement are difficult. Furthermore, the high imaging dose required to produce the megavoltage radiograph prohibits frequent image acquisition, particularly for those fields that require the use of an "open-field" exposure. For these small, or conformal, radiation fields, an alternate method of verifying field placement is required if the out-of-field dose is to be minimized. An open-field image acquired with a kilovoltage (kV) source would (a) deliver a very low patient dose, (b) increase the visibility of bony landmarks, and (c) simplify intercomparison of portal and prescription images. This article describes the development of a dual-beam imaging system that produces diagnostic quality "double-exposure" portal images for verifying radiation field placement. METHODS AND MATERIALS: The dual-beam system consists of a kV x-ray tube mounted on the gantry of a medical linear accelerator. The kV beam shares the same isocenter (+/- 1 mm) as the treatment beam but is at 45 degrees to the central axis. Both the kilovoltage and megavoltage images are collected with a fluoroscopic imaging system that uses a low-noise CCD camera to accumulate the light emitted from a phosphor screen. Two 45 degrees mirrors are used to remove the CCD camera from the x-ray beam. The light integration on the CCD array is controlled by a mechanical shutter, allowing easy synchronization with the radiation exposures. The camera is shielded by a lead housing to reduce the number of x-rays reaching the CCD array. A conventional thickness phosphor screen is used for both the kV and MV exposures. In the dual-beam imaging procedure, an open-field kV radiograph is acquired with the patient in treatment position. Immediately following, a MV image is acquired with the beam-defining blocks in position. Summation of the two images produces an online double-exposure image. The anatomical information in either the kV or MV image can be emphasized by weighting the images appropriately. This system was used to acquire MV and kV images of both a contrast-detail phantom and a Rando head phantom. Dual-beam images were also acquired for a pituitary treatment, demonstrating the feasibility and usefulness of the dual-beam technique. RESULTS: Analysis of the contrast-detail images produced with the MV and kV beams shows the expected advantage of using the kV x-ray beam. Images of a Rando head phantom confirm these results. A clinical demonstration of the dual-beam system for verifying the delivery of a pituitary field is shown. The quality of the dual-beam image is similar to the prescription (simulation) image, contains a larger anatomical region, and delivers a lower integral dose to the patient. In addition, the kV beam also enhances the visibility of small markers implanted in the prostate. CONCLUSIONS: A dual-beam imaging system has been developed for the radiographic verification of small, conformal fields. This development demonstrates the advantages and feasibility of using a kV x-ray beam in combination with the treatment beam to improve the accuracy of detecting patient setup errors.