COVID-19 and Global Distributive Justice: 'Health Diplomacy' of India and South Africa for the TRIPS waiver.

The second wave of the COVID-19 pandemic had left heart-wrenching impacts on all facets of life in general and the availability, accessibility, and affordability of medicines and vaccines in particular. Rather, the world has been divided into two groups regarding access to medicine and vaccines as haves and have-nots. The rich countries had pre-ordered the vaccines of COVID-19 along with the holding of the same. The pandemic situation was further worsened, given the Trade-Related Intellectual Property Rights (TRIPS) in practice and restrictions on sharing technology of vaccines, medicines, and life-saving equipment. In this context, India and South Africa have proposed the joint proposal and garnered support for waiving off TRIPS to ensure equity, accessibility, and affordability of vaccines and the same as public goods. In this review, we emphasize that global justice is one of the important elements of normative international theories, which focus on all the moral obligations from the world's rich to the world's poor. The paper also questions and argues that if the rich countries fail to go by the principles of global justice, can the Indian and South African (SA) patent diplomacy play a catalyst role in global justice? The review concludes with an emphasis on global solidarity, and the acceptance of joint India-South Africa's "patent diplomacy" for TRIPS waiver would result in mass production and fair distribution, making the COVID-19 medicines and technologies available to everyone regardless of their poor-rich status.

Stripe rust resistance gene(s) postulation in wheat germplasm with the help of differentials and tagged molecular markers.

Thirteen known Yr gene-associated markers pertaining to genes (Yr5, Yr10, Yr15, Yr24/Yr26) were used to identify the genes in selected wheat germplasm which were found resistant under field conditions at two locations in Punjab, India against stripe rust. In field evaluation, 38 genotypes exhibited highly resistant response, with a final rust severity (FRS) ranging from 0 to TR. Seven genotypes expressed a resistant to moderately resistant response with FRS ranging from 5MR-10S. In race-specific phenotying against most prevalent pathotypes of Puccinia striiformis tritici (46S119,110S119 &238S119) by seedling reaction test (SRT) 14 genotypes (29.2%) were found to be immune (IT = 0), 28 genotypes (58.3%) were resistant (IT = 1), and 3 genotypes (6.3%) were moderately resistant (IT = 2). Yr5 was detected in sixteen lines with the help of two markers Xwmc175 and Xgwm120 linked with Yr5. Yr10 was detected in ten lines with the marker Xpsp3000 and Yr15 was detected in fourteen lines with two linked markers; Xgwm413 and Xgwm273. Likewise, Yr24/26 was detected in 15 lines with two linked markers, namely Xbarc181 and Xbarc187. Based on the race specific phenotyping data and marker data, fourteen lines were found to carry a single gene, 16 showed the presence of two gene combinations, and seven genotypes were found to have a combination of three genes. Frequencies of Yr5, Yr15 and Yr26/Yr24 was high among test wheat germplasm in comparison to Yr10.

Combining high carotenoid, grain protein content and rust resistance in wheat for food and nutritional security.

Globally, malnutrition has given birth to an alarming predicament, especially in developing countries, and has extensively shifted consumer preferences from conventional high-energy diets to a nutritionally balanced, cost-effective, sustainable, and healthy lifestyle. In keeping with this view and the mandate for developing high-yielding, disease-resistant biofortified staple food (wheat) for catering to the demand-driven market, the current research aimed at stacking together the enhanced grain protein content, carotenoid content, and disease resistance in an elite bread wheat background. The Y gene (PsyE1) and the GpcB1 gene were used as novel sources for enhancing the grain carotenoid and protein content in the commercial elite bread wheat cultivar HD2967. The combination also led to the stacking of resistance against all three foliar rusts owing to linked resistance genes. A stepwise hybridization using Parent 1 (HD2967 + PsyE1/Lr19/Sr25) with Parent 2 (PBW550 + GpcB1/Yr36+ Yr15), coupled with a phenotypic-biochemical selection, narrowed down 2748 F2 individuals to a subset of 649 F2 plants for molecular screening. The gene-specific markers PsyE1, PsyD1, Xucw108, and Xbarc8 for the genes PsyE1, PsyD1, GpcB1, and Yr15, respectively, were employed for forward selection. Four bread wheat lines positive for all the desired genes with high carotenoid (>8ppm) and protein (>13%) content were raised to the F5 generation and will be evaluated for yield potential after bulking. These improved advanced breeding lines developed following multipronged efforts should prove a valuable and unique source for the development of cultivars with improved nutritional quality and rust resistance in wheat breeding programs.

Whole genome resequencing and comparative genome analysis of three Puccinia striiformis f. sp. tritici pathotypes prevalent in India.

Stripe rust disease of wheat, caused by Puccinia striiformis f. sp. tritici, (Pst) is one of the most serious diseases of wheat worldwide. In India, virulent stripe rust races have been constantly evolving in the North-Western Plains Zone leading to the failure of some of the most widely grown resistant varieties in the region. With the goal of studying the recent evolution of virulent races in this region, we conducted whole-genome re-sequencing of three prevalent Indian Pst pathotypes Pst46S119, Pst78S84 and Pst110S119. We assembled 58.62, 58.33 and 55.78 Mb of Pst110S119, Pst46S119 and Pst78S84 genome, respectively and found that pathotypes were highly heterozygous. Comparative phylogenetic analysis indicated the recent evolution of pathotypes Pst110S119 and Pst78S84 from Pst46S119. Pathogenicity-related genes classes (CAZyme, proteases, effectors, and secretome proteins) were identified and found to be under positive selection. Higher rate of gene families expansion were also observed in the three pathotypes. A strong association between the effector genes and transposable elements may be the source of the rapid evolution of these strains. Phylogenetic analysis differentiated the Indian races in this study from other known United States, European, African, and Asian races. Diagnostic markers developed for the identification of three Pst pathotypes will help tracking of yellow rust at farmers field and strategizing resistance gene deployment.

A model for Tilletia indica (Karnal bunt)-Triticum aestivum (Wheat) system under changing environmental conditions.

Karnal bunt (KB) of wheat incited by Tilletia indica Mitra is now gaining importance from the last few years due to its increasing incidence. Regular surveys are conducted to collect wheat grains samples from different grain markets of Punjab, India. Since weather plays a significant role in the initiation as well as the development of Karnal bunt. Thus, the variation in Karnal bunt incidence worked out and is being interpreted in relation to the prevailing environmental conditions during the most susceptible stage for the two decades (1991-92 to 2014-15) for the Punjab, India. The incidence of Karnal bunt was correlated with the weather parameters during the February and March of the corresponding year. The correlation analysis revealed the positive role of rainfall, rainy days, evening relative humidity, and Humid thermal index of March and the negative role of sunshine hours of February in the development and incidence of Karnal bunt. By using these parameters, a multiple regression model was developed and validated for forecasting the disease. The regression analysis showed a coefficient of determination of 0.77 and a D.W value of 1.88. The detailed analysis of historical data for more than two decades divulged the amount of total rainfall as well as the number of rainy days of March as the most critical factor for the Karnal bunt development. Supplementary Information: The online version contains supplementary material available at 10.1007/s42360-022-00520-w.

Residual effect of defeated stripe rust resistance genes/QTLs in bread wheat against prevalent pathotypes of Puccinia striiformis f. sp. tritici.

The periodic breakdowns of stripe rust resistance due to emergence of new virulent and more aggressive pathotypes of Puccinia striiformis f. sp. tritici have resulted in severe epidemics in India. This necessitates the search for new and more durable resistance sources against stripe rust. The three bread wheat cultivars PBW 343 (carries Yr9 and Yr27), PBW 621 (carries Yr17) and HD 2967 (gene not known) were highly popular among the farmers after their release in 2011. But presently all three cultivars are highly susceptible to stripe rust at seedling as well as at adult plant stages as their resistance has been broken down due to emergence of new pathotypes of the pathogen (110S119, 238S119). In previous study, the crosses of PBW 621 with PBW 343 and HD 2967 and evaluation of further generations (up to F4) against pathotype 78S84 resulted in resistant segregants. In the present study, the F5 and F6 RIL populations have been evaluated against new pathotypes of Pst. The RILs categorized based on the disease severity on the P (Penultimate leaf) and F (flag) leaf into three categories i.e., high, moderate and low level of APR (adult plant resistance) having 1-200, 201-400 and >400 values of AUDPC, respectively, upon infection with stripe rust. The various APR components (latent period, lesion growth rate, spore production and uredial density) were studied on each category, i.e., resistant, moderately resistant and susceptible. The values of APR parameters decreased as the level of resistance increased. Based on molecular analysis, the lines (representing different categories of cross PBW 621 X PBW 343) containing the genes Yr9 and Yr17 due to their interactive effect provide resistance. Based on BSA using 35k SNPs and KASP markers association with phenotypic data of the RIL population (PBW 621 X HD 2967) showed the presence of two QTLs (Q.Pst.pau-6B, Q.Pst.pau-5B) responsible for the residual resistance and two SNPs AX-94891670 and AX-94454107 were found to be associated with the trait of interest on chromosome 6B and 5B respectively. The present study concludes that in the population of both the crosses (PBW 621 X PBW 343 and PBW 621 X HD 2967) major defeated gene contributed towards residual resistance by interacting with minor gene/QTLs.

Identification of a novel stripe rust resistance gene from the European winter wheat cultivar 'Acienda': A step towards rust proofing wheat cultivation.

All stage resistance to stripe rust races prevalent in India was investigated in the European winter wheat cultivar 'Acienda'. In order to dissect the genetic basis of the resistance, a backcross population was developed between 'Acienda' and the stripe rust susceptible Indian spring wheat cultivar 'HD 2967'. Inheritance studies revealed segregation for a dominant resistant gene. High density SNP genotyping was used to map stripe rust resistance and marker regression analysis located stripe rust resistance to the distal end of wheat chromosome 1A. Interval mapping located this region between the SNP markers AX-95162217 and AX-94540853, at a LOD score of 15.83 with a phenotypic contribution of 60%. This major stripe rust resistance locus from 'Acienda' has been temporarily designated as Yraci. A candidate gene search in the 2.76 Mb region carrying Yraci on chromosome 1A identified 18 NBS-LRR genes based on wheat RefSeqv1.0 annotations. Our results indicate that as there is no major gene reported in the Yraci chromosome region, it is likely to be a novel stripe rust resistance locus and offers potential for deployment, using the identified markers, to confer all stage stripe rust resistance.

Bread wheat with enhanced grain carotenoid content: a novel option for wheat biofortification.

Colored wheat has piqued the interest of breeders and consumers alike. The chromosomal segment from 7E of Thinopyrum ponticum, which carries a leaf rust resistant gene, Lr19, has been rarely employed in wheat breeding operations due to its association with the Y gene, which gives a yellow tint to the flour. By prioritizing nutritional content over color preferences, consumer acceptance has undergone a paradigm change. Through marker-assisted backcross breeding, we introduced an alien segment harboring the Y (PsyE1) gene into a high yielding commercial bread wheat (HD 2967) background to generate rust resistant carotenoid biofortified bread wheat. Agro-morphological characterization was also performed on a subset of developed 70 lines having enhanced grain carotene content. In the introgression lines, carotenoid profiling using HPLC analysis demonstrated a considerable increase in ß-carotene levels (up to 12 ppm). Thus, the developed germplasm caters the threat to nutritional security and can be utilized to produce carotenoid fortified wheat. Supplementary Information: The online version contains supplementary material available at 10.1007/s11032-022-01338-0.

Global vaccine inequities and multilateralism amid COVID-19: Reconnaissance of Global Health Diplomacy as a panacea?

Background: The ongoing COVID-19 pandemic has shown a crystal-clear warning that nobody will be safe until everybody is safe against the pandemic. However, how everyone is safe when the pandemic's fat tail risks have broken every nerve of the global economy and healthcare facilities, including vaccine equity. Vaccine inequity has become one of the critical factors for millions of new infections and deaths during this pandemic. Against the backdrop of exponentially growing infected cases of COVID-19 along with vaccine in-equity, this paper will examine how multilateralism could play its role in mitigating vaccine equity through Global Health Diplomacy (GHD). Second, given the most affected developing countries' lack of participation in multilateralism, could GHD be left as an option in the worst-case scenario?. Methods: In this narrative review, a literature search was conducted in all the popular databases, such as Scopus, Web of Science, PubMed and Google search engines for the keywords in the context of developing countries and the findings are discussed in detail. Results: In this multilateral world, the global governance institutions in health have been monopolized by the global North, leading to COVID-19 vaccine inequities. GHD aids health protection and public health and improves international relations. Besides, GHD facilitates a broad range of stakeholders' commitment to collaborate in improving healthcare, achieving fair outcomes, achieving equity, and reducing poverty. Conclusion: Vaccine inequity is a major challenge of the present scenario, and GHD has been partly successful in being a panacea for many countries in the global south.

COVID-19 Vaccine, TRIPS, and Global Health Diplomacy: India's Role at the WTO Platform.

In light of the devastation caused by COVID-19, the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) and vaccine research and development (R&D) have been occupying a prominent position in the field of global health diplomacy (GHD). Most countries, international organizations, and charitable organizations have been engaged in the R&D of COVID-19 vaccines to ensure timely affordability and accessibility to all countries. Concomitantly, the World Trade Organization (WTO) provides some provisions and enforcements regarding copyrights, patents, trademarks, geographical indications, and industrial designs. Given these safeguards, it is considered that intellectual property rights (IPRs) have become major barriers to the affordability and accessibility of vaccines/medicines/technology, particularly to the developing/least developed countries. Realizing the gravity of the pandemic impact, as well as its huge population and size, India has elevated this issue in its global health diplomacy by submitting a joint proposal with South Africa to the World Trade Organization (WTO) for a temporary waiver of IPRs to ensure timely affordability and accessibility of COVID-19 medical products to all countries. However, the issue of the temporary waive off had become a geopolitical issue. Countries that used to claim per se as strong advocates of human rights, egalitarianism, and healthy democracy have opposed this proposal. In this contrasting milieu, this paper is aimed at examining how the TRIPS has become a barrier for developing countries' development and distribution of vaccines/technology; secondly, how India strategizes its role in the WTO in pursuant of its global health diplomacy? We conclude that the IPRs regime should not become a barrier to the accessibility/affordability of essential drugs and vaccines. To ensure access, India needs to get more engaged in GHD with all the involved global stakeholders to get strong support for their joint proposal. The developed countries that rejected/resisted the proposal can rethink their full support.

Characterization and Mapping of Spot Blotch in Triticum durum-Aegilops speltoides Introgression Lines Using SNP Markers.

Spot blotch (SB) of wheat is emerging as a major threat to successful wheat production in warm and humid areas of the world. SB, also called leaf blight, is caused by Bipolaris sorokiniana, and is responsible for high yield losses in Eastern Gangetic Plains Zone in India. More recently, SB is extending gradually toward cooler, traditional wheat-growing North-Western part of the country which is a major contributor to the national cereal basket. Deployment of resistant cultivars is considered as the most economical and ecologically sound measure to avoid losses due to this disease. In the present study, 89 backcross introgression lines (DSBILs) derived from Triticum durum (cv. PDW274-susceptible) × Aegilops speltoides (resistant) were evaluated against SB for four consecutive years, 2016-2020. Phenotypic evaluation of these lines showed a continuous variation in disease severity indicating that the resistance to SB is certainly quantitative in nature. Phenotypic data of DSBILs were further used for mapping QTLs using SNPs obtained by genotyping by sequencing. To identify QTLs stable across the environments, Best Linear Unbiased Estimates (BLUEs) and Predictions (BLUPs) were used for mapping QTLs based on stepwise regression-based Likelihood Ratio Test (RSTEP-LRT) for additive effect of markers and single marker analysis (SMA). Five QTLs, Q.Sb.pau-2A, Q.Sb.pau-2B, Q.Sb.pau-3B, Q.Sb.pau-5B, and Q.Sb.pau-6A, linked to SB resistance were mapped across chromosomes 2A, 2B, 3B, 5B, and 6A. Genes found adjacent to the SNP markers linked to these QTLs were literature mined to identify possible candidate genes by studying their role in plant pathogenesis. Further, highly resistant DSBIL (DSBIL-13) was selected to cross with a susceptible hexaploidy cultivar (HD3086) generating BC2F1 population. The QTL Q.Sb.pau-5B, linked to SNP S5B_703858864, was validated on this BC2F1 population and thus, may prove to be a potential diagnostic marker for SB resistance.

Resurrection of Wheat Cultivar PBW343 Using Marker-Assisted Gene Pyramiding for Rust Resistance.

Wheat variety PBW343, released in India in 1995, became the most widely grown cultivar in the country by the year 2000 owing to its wide adaptability and yield potential. It initially succumbed to leaf rust, and resistance genes Lr24 and Lr28 were transferred to PBW343. After an unbroken reign of about 10 years, the virulence against gene Yr27 made PBW343 susceptible to stripe rust. Owing to its wide adaptability and yield potential, PBW343 became the prime target for marker-assisted introgression of stripe rust resistance genes. The leaf rust-resistant versions formed the base for pyramiding stripe rust resistance genes Yr5, Yr10, Yr15, Yr17, and Yr70, in different introgression programs. Advanced breeding lines with different gene combinations, PBW665, PBW683, PBW698, and PBW703 were tested in national trials but could not be released as varieties. The genes from alien segments, Aegilops ventricosa (Lr37/Yr17/Sr38) and Aegilops umbellulata (Lr76/Yr70), were later pyramided in PBW343. Modified marker-assisted backcross breeding was performed, and 81.57% of the genetic background was recovered in one of the selected derivative lines, PBW723. This line was evaluated in coordinated national trials and was released for cultivation under timely sown irrigated conditions in the North Western Plain Zone of India. PBW723 yields an average of 58.0 qtl/ha in Punjab with high potential yields. The genes incorporated are susceptible to stripe rust individually, but PBW723 with both genes showed enhanced resistance. Three years post-release, PBW723 occupies approximately 8-9% of the cultivated area in the Punjab state. A regular inflow of diverse resistant genes, their rapid mobilization to most productive backgrounds, and keeping a close eye on pathogen evolution is essential to protect the overall progress for productivity and resistance in wheat breeding, thus helping breeders to keep pace with pathogen evolution.

Introgression and genetic mapping of leaf rust and stripe rust resistance in Aegilops triuncialis.

The growing and cultivating resistant wheat crop varieties is important to meet the demands of the growing population and minimizing the yield losses due to foliar diseases. More important is the identification of novel resistance sources and transfer of resistance in ready to use form. In the current study, leaf rust (LR) and stripe rust (YR) resistant tetraploid nonprogenitors of wheat Aegilops triuncialis (UtUtCtCt) acc pau 3462 was crossed and backcrossed susceptible cultivar WL711(NN) by inducing homeologous pairing using CS ph1. Recurrent parent type plants were selected in subsequent generation with resistance to LR and YR and BC2F7 introgression line (2n=42) named ILtri have been developed. To understand the nature and inheritance of LR and YR resistance genes and to map their genomic location, F2 and F2:3 mapping populations were developed by crossing ILtri with WL711(NN). In F2 and F2:3, the seedlings and adult plants segregated into 3R:1S and 1HR:2Seg:1HS ratios, respectively for both LR and YR, indicating inheritance of single dominant all stage resistance gene working against both the rusts. These genes were temporary designated as Lrtri and Yrtri and were inherited independently.Molecular mapping of 614 SSR markers mapped the Lrtri at a distance of 11.2 cM from SSR marker Xwmc606.

Metabolic adjustments during compatible interaction between barley genotypes and stripe rust pathogen.

Stripe rust is a fungal disease that has devastated the barley production for a long time. The present study focused on the role of ß-glucan, PR proteins, diamine oxidase (DAO), polyamine oxidase (PAO), key enzymes and metabolites of phenol and proline metabolism in the stripe rust resistance of barley. RD2901 with resistant behavior against stripe rust showed increased levels of PR proteins, phenylalanine ammonia lyase (PAL), tyrosine ammonia lyase (TAL) along with the accumulation of ß-glucan and lignin which strengthen the plant cell wall during plant-pathogen interaction. It also depicted the enhanced activities of glutamate dehydrogenase (GDH) and ornithine aminotransferase (OAT) coupled with the increased amounts of proline, glycine betaine and choline after infection with M-race of P. striiformis f. sp. hordei. On the contrary, the sensitive genotype Jyoti was unable to enhance the activities of most of these enzymes except PAL and OAT so that it showed an increase in lignin and choline contents only. Secondly, the increase in lignin content was less as compared to the tolerant genotype. Hence, it can be inferred that these key metabolites and enzymes of various metabolic pathways may contribute to the resistance of barley against stripe rust pathogen. This study suggested that these key enzymes and their metabolites could serve as markers for the characterization of plant defensive state that is essential for crop protection.

Stripe rust induced defence mechanisms in the leaves of contrasting barley genotypes (Hordeum vulgare L.) at the seedling stage.

Puccinia striiformis f. sp. hordei, the causal organism of stripe rust in barley poses serious threats to its production. The present study examined the seedling response and changes in antioxidant defence system along with NADPH oxidase, hydrogen peroxide, and lipid peroxidation marker-malondialdehyde (MDA) in the four barley genotypes namely Jyoti, RD2900, RD2901, and RD2552 in response to M and G-races of stripe rust pathogen. Disease reaction showed Jyoti as susceptible genotype, RD2901 and RD2552 as resistant, whereas RD2900 behaved differentially to both the races. M-race which is predominant was found to be more virulent than G-race of barley stripe rust pathogen. RD2901 showed an increase in activities of NADPH oxidase, catalase, peroxidase, and enzymes of ascorbate-glutathione pathway along with ascorbate and glutathione pool on inoculation with M-race, which was accompanied by the decrease in hydrogen peroxide and MDA contents. Jyoti, on the other hand, showed an increase in peroxidase and glutathione-S-transferase activities only which were unable to maintain redox homeostasis. The scrutiny of data indicated an increase in ASA/DHA ratio on infection in all the genotypes irrespective of their behaviour towards the races. However, GSH/GSSG ratio significantly declined in Jyoti and increased or remained unaffected in the resistant genotypes which suggested that GSH/GSSG might be playing a vital role in imparting tolerance against stripe rust. Further, correlation studies also revealed that leaf damage was positively correlated with H2O2 and MDA contents.

Antioxidant potential of barley genotypes inoculated with five different pathotypes of Puccinia striiformis f. sp. hordei.

The stripe rust caused by the fungal pathogen, Puccinia striiformis f. sp. hordei in barley (Hordeum vulgare L.) is a global problem that threatens the production of barley. The present study examined the disease reaction, free radical scavenging potential, non-enzymatic antioxidants like total phenols, o-dihydroxy phenols, flavonoids along with total chlorophyll, chlorophyll a, chlorophyll b and total carotenoids of the four barley genotypes viz. Jyoti (susceptible), RD2900, RD2901 and RD2552 (resistant) infected with five different pathotypes (M, G, 57, Q and 24) of P. striiformis f. sp. hordei. The disease reaction showing RD2901 in the category of immune to very resistant genotype followed by RD2552 in immune to resistant and RD2900 as moderately resistant and Jyoti as susceptible, which was well correlated with biochemical studies. RD2901 possessed higher antioxidant potential in terms of 2,2-diphenyl-1-picrylhydrazyl radical (DPPH·) scavenging activity, ferric reducing antioxidant power, reducing power and nitric oxide scavenging activity under control conditions and were maintained sufficiently high on inoculation with different pathotypes (M, G, 57, Q and 24) of P. striiformis f. sp. hordei. Further, these free radical scavenging activities showed the positive correlation with total phenols, o-dihydroxy phenols, flavonoids which in turn might be contributing in tolerance behaviour of this genotype. However, Jyoti with sensitive behaviour towards M, G, and 24 pathotypes depicted minimum DPPH activity and reducing power under control conditions.

Patient satisfaction on the utilization of traditional and complementary medicine services at public hospitals in Malaysia.

BACKGROUND: Traditional and complementary medicine (T&CM) has been integrated into the Malaysian public healthcare system since the establishment of the first T&CM unit at a public hospital in 2007. Assessing patient satisfaction is a vital component of health service evaluation. The main objective of this study is to determine the level of patient satisfaction with the utilization of T&CM services at public hospitals in Malaysia and assess the sociodemographic influence on the overall reporting of satisfaction. This study also aims to analyze the response of the patients towards expansion of T&CM services in the public sector in Malaysia. MATERIALS AND METHODS: A study was conducted to analyze data on the utilization of T&CM services within public hospitals. Secondary data on 822 patients' satisfaction with services offered at 15 T&CM units was analyzed to examine the overall levels of satisfaction with T&CM services in public hospitals in Malaysia. RESULTS: Overall, 99.4% of patients were satisfied with T&CM services and most patients (91.8%) felt that T&CM treatment positively impacted their health. Overall satisfaction was not affected by lower levels of satisfaction with subcategories of service, such as the number of treatment sessions received (90.7% satisfied), date to the next appointment (90.7% satisfied), and the absence of adverse effects of treatment received (87.1% satisfied). There were no significant associations between the socioeconomic status of the respondents and the level of satisfaction reported; however, respondents with a monthly salary of Ringgit Malaysia (RM) 1000 to RM 3000 were more than twice as likely to be strongly satisfied with services received (adjusted odds ratios [AOR]: 2.12, 95% CI: 1.19-3.78). CONCLUSION: This study revealed a high level of satisfaction among patients who had received T&CM treatment at public hospitals in Malaysia. High satisfaction with T&CM treatment validates the integrative management approach adopted in patient care within the public hospitals in Malaysia.

Enhancing Phenotypic Detection of ESBL in AmpC co-producers by using Cefepime and Tazobactam.

INTRODUCTION: Routine phenotypic methods employing clavulanate and third generation cephalosporins to detect ESBL are not promising for isolates that co-produce an inhibitor-resistant beta lactamase like AmpC. AIM: Enhancing phenotypic detection of ESBL in AmpC co-producers by using cefepime and tazobactam. MATERIALS AND METHODS: A total of 245 isolates of Escherichia coli (123), Klebsiella spp. (87), Proteus spp.(20), Enterobacter spp. (9) and Citrobacter spp.(6) obtained over a period of 2 years from January 2013 to December 2014 from urine samples of hospitalized patients were studied. The isolates were simultaneously screened for ESBL and AmpC production. AmpC production was confirmed by modified three -dimensional test (MTDT). ESBL production was confirmed by original double disc synergy test, phenotypic disc confirmatory test (PDCT) and modified double disc synergy test (MDDST) and the results compared. RESULTS: AmpC production was confirmed in 113 (46.1%) isolates by modified three dimensional test out of 143 screened positive for AmpC. Of the 192 isolates screened positive for ESBL, ESBL production was confirmed in 162 (66.1%). DDST detected ESBLs in only134 (54.7%) while additional 28 (11.4%) ESBL positive isolates were detected by MDDST. PDCT detected total 145(59.2%) ESBL positive isolates, with cefotaxime and cefotaxime + clavulanate detecting 139 (56.7%) and ceftazidime and ceftazidime + clavulanate detecting additional 6 isolates. All the 28 (11.4%) isolates which were additionally detected ESBL producers by MDDST showed positive three dimensional test i.e. AmpC co producers. DDST detected ESBL in none of AmpC positive isolates while PDCT detected ESBL in 11 isolates showing AmpC co-production. In MDDST cefepime was the best cephalosporin in detecting ESBL in presence of AmpC production. It showed synergism with amoxicillin-clavulanate in 11(39.3%) isolates and in 24(85.7%) isolates with piperacillin-tazobactam. Third generation cephalosporins -cefotaxime, ceftazidime and cefpodoxime were not able to detect ESBL in AmpC-co producers. CONCLUSION: Modification of double disc synergy tests that combine piperacillin-tazobactum with cefepime enhances the possibility of ESBL detection.

Modified Double Disc Synergy Test to Detect ESBL Production in Urinary Isolates of Escherichia coli and Klebsiella pneumoniae.

BACKGROUND AND OBJECTIVES: Various phenotypic methods are recommended in the routine practice to detect the ESBL production in gram negative bacilli. Among them, the Double Disc Synergy Test (DDST) which uses the third generation cephalosporins (3GC), is a simple and a reliable method. But the coexistence of AmpC may give false negative results. In such cases, the ESBL detection can be improved by using cefepime along with the third generation cephalosporins in DDST. METHODS: A total of 350 urinary isolates (224 Escherichia coli and 126 Klebsiella pneumoniae) were studied for ESBL production by the modified double disc test (MDDST) i.e. by using cefotaxime, ceftriaxone, cefpopdoxime (third generation cephalosporins) and cefepime ( fourth generation cephalosporin) along with a amoxicillin-clavulanate disc. RESULTS AND INTERPRETATION: ESBL production was seen in 63.4% (142/224) Escherichia coli and in 60.3% (76/126) Klebsiella pneumoniae isolates by MDDST. Among these, in twelve E.coli and five K.pneumoniae strains, only cefepime but none of the third generation cephalosporins showed synergism with amoxicillin-clavulanate. All these seventeen strains showed a clear extension of the edge of inhibition which was produced by cefepime towards the amoxicillin-clavulanate disc. These strains were further tested for AmpC co-production by the AmpC disc test and all these strains were found to be AmpC positive, thus revealing the superior activity of cefepime in detecting ESBLs in the bacteria which co-produced AmpC. A high degree of coresistance was found in the ESBL producers. CONCLUSION: The ESBL detection can be improved by MDDST by using cefepime along with the third generation cephalosporins.