A Comparison Between Potassium Hydroxide (KOH) Microscopy and Culture for the Detection of Post-COVID-19 Rhino-Orbital-Cerebral Mucormycosis.

Background and objective Mucormycosis is an emerging and serious angioinvasive infection caused by filamentous fungi related to the order of Mucorales and the class of Mucormycetes. There was a marked increase in the number of cases of mucormycosis in India following the second wave of the coronavirus disease 2019 (COVID-19) pandemic in the year 2021. In this study, we aimed to compare potassium hydroxide (KOH) microscopy with culture for the detection of post-COVID-19 rhino-orbital-cerebral mucormycosis (ROCM). Materials and methods The KOH microscopy was performed with a 10% or 20% KOH-mounted slide with specimens collected from suspected cases of post-COVID-19 ROCM. Simultaneously, the culture was done on Sabouraud dextrose agar (SDA). These were incubated at 37 ℃ and 25 â„ƒ for 28 days. Diagnostic parameters were calculated by comparing KOH with gold standard culture. Results KOH mount was positive for broad aseptate fungal hyphae in 322 (54.1%) cases, while it was negative in 244 (41.0%) cases. KOH mount was positive for other fungi in 29 (4.8%) samples. The diagnostic accuracy of the KOH mount for Mucorales was 70.3%. KOH mount had a sensitivity of 84.9%, specificity of 61.5%, positive predictive value (PPV) of 56.9%, and negative predictive value (NPV) of 87.2%. Conclusions Based on our findings, the KOH microscopy positivity rate was higher in tissue samples compared to nasal swabs, with a sensitivity of 84.9%, specificity of 61.5%, PPV of 56.9%, and NPV of 87.2%. The overall diagnostic accuracy of the KOH mount for Mucorales was 70.3%.

Satellite Epidemic of Covid-19 Associated Mucormycosis in India: A Multi-Site Observational Study.

BACKGROUND: Sudden upsurge in cases of COVID-19 Associated Mucormycosis (CAM) following the second wave of the COVID-19 pandemic was recorded in India. This study describes the clinical characteristics, management and outcomes of CAM cases, and factors associated with mortality. METHODS: Microbiologically confirmed CAM cases were enrolled from April 2021 to September 2021 from ten diverse geographical locations in India. Data were collected using a structured questionnaire and entered into a web portal designed specifically for this investigation. Bivariate analyses and logistic regression were conducted using R version 4.0.2. RESULTS: A total of 336 CAM patients were enrolled; the majority were male (n = 232, 69.1%), literate (n = 261, 77.7%), and employed (n = 224, 66.7%). The commonest presenting symptoms in our cohort of patients were oro-facial and ophthalmological in nature. The median (Interquartile Range; IQR) interval between COVID diagnosis and admission due to mucormycosis was 31 (18, 47) days, whereas the median duration of symptoms of CAM before hospitalization was 10 (5, 20) days. All CAM cases received antifungal treatment, and debridement (either surgical or endoscopic or both) was carried out in the majority of them (326, 97.02%). Twenty-three (6.9%) of the enrolled CAM cases expired. The odds of death in CAM patients increased with an increase in HbA1c level (aOR: 1.34, 95%CI: 1.05, 1.72) following adjustment for age, gender, education and employment status. CONCLUSION: A longer vigil of around 4-6 weeks post-COVID-19 diagnosis is suggested for earlier diagnosis of CAM. Better glycemic control may avert mortality in admitted CAM cases.

Comparative evaluation of antifungal susceptibility testing methods for Rhizopus species isolates.

Background and Purpose: The mainstay of treatment for COVID-19-associated mucormycosis was liposomal Amphotericin B. Other antifungal agents, such as posaconazole and isavuconazole, were used as well. The Clinical and Laboratory Standards Institute (CLSI) and the European Committee on Antimicrobial Susceptibility Testing recommend broth microdilution methods for antifungal susceptibility testing. In this regard, the present study aimed to see what potency and zone diameters correlate with the gold standard broth microdilution method. Materials and Methods: All the isolates were identified by matrix-assisted laser desorption ionization-time-of-flight. In total, 127 isolates of 83 Rhizopus oryzae complex and 44 isolates of Rhizopus microsporus complex were selected. Anti-fungal susceptibility testing by disc diffusion and E-test was performed on Mueller Hinton Agar and compared with the CLSI broth microdilution method of Anti-fungal susceptibility testing. Results: Percentage agreement was found to be more in the case of the E test than the disc diffusion method. In the case of R. oryzae, posaconazole had 98.79% agreement with broth microdilution followed by Isavuconazole (97.59%), Itraconazole (96.38%), and Amphotericin B (91.56%). Conclusion: Disc diffusion correlates well with broth microdilution, although its correlation is weaker when compared to the E test. Effective concentration of Amphotericin B discs for antifungal susceptibility testing depends on the specific Rhizopus species.

Utility of itraconazole and terbinafine in mucormycosis: a proof-of-concept analysis.

An epidemic of mucormycosis followed the second wave of COVID 19 in the state of Uttar Pradesh, India in May 2021. This epidemic, however, had additional challenges to offer in the form of acute shortage of all forms of amphotericin B, posaconazole and isavuconazole. It was, therefore, planned to assess the trends in minimum inhibitory concentration (MIC) of antifungal agents, viz itraconazole and terbinafine, and provide a template for personalized therapy to see whether the results could be translated clinically. This is an observational, single-center study. Samples comprising nasal swab, nasal and paranasal sinus tissue, brain tissue, brain abscess and orbital content, derived from 322 patients from northern India with mucormycosis, of whom 215 were male and 107 were female, were used for analysis. Cultures were identified both by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) and conventional methods of identification. Antifungal susceptibility was done for amphotericin B, posaconazole, isavuconazole, itraconazole and terbinafine as per Clinical Laboratory Standard Institute M38-A2. The outcome was identification of the species of mucormycosis and susceptibility to itraconazole and terbinafine besides other primary antifungal agents. Patients or the public were not involved in the design, or conduct, or reporting or in the dissemination plans of our research. Of 322 patients, 203 were culture-positive, of whom 173 were positive by both MALDI-TOF and conventional methods of identification. Final antifungal susceptibility testing was available for 150 patients. The most common Mucorales found to cause this epidemic was Rhizopus oryzae, followed by R. microsporus Amphotericin B, posaconazole and isavuconazole had low MIC values in 98.8% of all Mucorales identified. The MIC of itraconazole was species-dependent. 97.7% of Roryzae had MIC ≤2 µg/mL. However, only 36.5% of Rmicrosporus had MIC ≤2 µg/mL. For terbinafine, 85.2% of R. microsporus had MIC ≤2 µg/mL. We conclude that identification at the species level is required as antifungal susceptibilities seem to be species-dependent. Assessment of the efficacy of itraconazole and terbinafine warrants further studies with clinical assessment and therapeutic drug monitoring as they seem to be potential candidates especially when the primary agents are not available.

Synergistic interaction of eugenol and antimicrobial drugs in eradication of single and mixed biofilms of Candida albicans and Streptococcus mutans.

In vitro eradication of the C. albicans and S. mutans mixed biofilms by eugenol alone and in combination with the antimicrobial drugs. Previously characterized strains of C. albicans (CAJ-01 and CAJ-12) and S. mutans MTCC497 were used to evaluate the eradication of biofilms using XTT reduction assay, viability assay, time dependent killing assay and scanning electron microscopy (SEM). Synergistic interaction was assessed by checkerboard method. Sessile MIC (SMIC) of eugenol was equivalent to the planktonic MIC (PMIC) against C. albicans and S. mutans mixed biofilms. SMIC of fluconazole and azithromycin was increased upto 1000-folds over PMIC. Eradication of single or mixed biofilms was evident from the viability assay and SEM. At 1 × MIC of eugenol, log10CFU count of C. albicans cells were decreased from 6.3 to 4.2 and 3.8 (p < 0.05) in single and mixed biofilms, respectively. SEM studies revealed the eradication of C. albicans and S. mutans cells from glass surface at 800 µg/mL concentration of eugenol. Time dependent killing assay showed dose dependent effect of eugenol on pre-formed CAJ-01, CAJ-12 and S. mutans biofilm cells. Eugenol was highly synergistic with fluconazole (FICI = 0.156) against CAJ-12 single biofilms. However, the combination of eugenol and azithromycin showed maximum synergy (FICI = 0.140) against pre-formed C. albicans and S. mutans mixed biofilms. These findings highlighted the promising efficacy of eugenol in the eradication of biofilms of two oral pathogens (C. albicans and S. mutans) in vitro and could also be exploited in synergy with fluconazole and azithromycin in controlling oral infections.

Stigma Associated with Sexually Transmitted Infections among Patients Attending Suraksha Clinic at a Tertiary Care Hospital in Northern India.

CONTEXT: Illnesses affecting sexual organs and its correlation with improper sexual behavior lead to a negative attitude and discriminating behavior towards people affected by such disorders. AIM: The aim was to study the stigma associated with sexually transmitted infections (STIs) among patients attending Suraksha clinic at a tertiary care hospital in northern India. SETTINGS AND DESIGN: This was a hospital-based cross-sectional study. SUBJECTS AND METHODS: The present study was conducted at Suraksha (STI) clinic, King George's Medical University, Uttar Pradesh. A total of 487 STI patients (clinically and/or laboratory-confirmed) were contacted telephonically, of which 49 finally participated in the study. Stigma was assessed using modified and pretested version of India HIV-related stigma scale adapted in context to sexually transmitted diseases. STATISTICAL ANALYSIS: Quantitative variables were expressed as mean with standard deviation, and independent sample t-test was used to compare the mean values. P < 0.05 was considered statistically significant. RESULTS: Mean scores of enacted, vicarious, felt normative, and internalized stigma for 49 patients (out 487) who finally participated in the study were 0.04±0.11, 0.55±0.70, 1.21±0.96, and 0.86±0.67, respectively. Unmarried/divorced/separated patients had significantly higher vicarious and felt normative stigma scores as compared to married individuals. Mean score for felt normative stigma was significantly higher among homosexual/bisexuals in comparison to heterosexual individuals. CONCLUSIONS: Efforts should be directed towards the provision of integrated services through sexual health-oriented campaigns to address the stigma associated with STI in a more comprehensive way.

Comparative evaluation of antimicrobial efficacy of triple antibiotic paste, calcium hydroxide, and a proton pump inhibitor against resistant root canal pathogens.

OBJECTIVE: The objective of this study is to compare the antimicrobial efficacy of triple antibiotic paste (TAP) and a proton pump inhibitor (PPI) (omeprazole) in combination with calcium hydroxide (CH) against Enterococcus faecalis and Candida albicans. MATERIALS AND METHODS: E. faecalis and C. albicans were subcultured and inoculated at 37° overnight and were treated with different dilutions of TAP, 25 µg/ml (Group 1), CH (Group 2, control), CH 16 mg/ml + omeprazole 2 mg/ml (Group 3a) (CH 16 mg/ml + omeprazole 4 mg)/ml (Group 3b) for 24, 48, and 72 h in sterile uncoated 96-well microtiter plates. Minimum concentration at which the medicaments produced least optical density was determined using ELISA reader (ELx 808 BioTek Inc., USA) device set at optical density of 630 nm. Results were analyzed statistically by one-way analysis of variance followed by Tukey's multiple comparison tests. The significance level was set at 0.05. RESULTS: Mean concentration (irrespective of time) for TAP at which mean minimum optical density was recorded at 1.25 µg/ml (1:20 dilution) and 25 µg/ml (0 dilution) against E. faecalis and C. albicans, respectively. Least optical density for CH plus PPI group was obtained 1.6 µg/ml (1:10 dilution) and 16 µg/ml (0 dilution) for E. faecalis and C. albicans, respectively. However, CH alone showed a weaker antimicrobial action against either of the strains even at full concentration. CONCLUSIONS: PPI enhanced the antibacterial efficacy of CH against E. faecalis and C. albicans. However, TAP showed the best antibacterial property followed by CH plus PPIs against both the selected strains.

Comparative evaluation of pan-fungal real-time PCR, galactomannan and (1-3)-ß-D-glucan assay for invasive fungal infection in paediatric cancer patients.

Limited specific data and investigations are available for the diagnosis of Invasive Fungal Infection (IFI) in paediatrics cancer patients. Three non-invasive tests; Platelia Aspergillus EIA for galactomannan (GM), ß-D-glucan (BDG) assay and pan-fungal real-time PCR for fungal DNA in blood were evaluated. One hundred twenty-five paediatrics cancer patients at the high risk of IFI were enrolled. Single blood and serum samples were evaluated by all the three methods. Patients were classified into 10 proven, 52 probable and 63 no IFI cases in accordance with EORTC MSG 2008 revised guidelines. The sensitivity, specificity, PPV and NPV of all the three tests in proven, probable and no IFIs cases were analysed singly and in combination. The sensitivity, specificity, PPV and NPV of GM, BDG and pan-fungal real-time PCR were: 87%, 61%, 81%, 69.5% for GM, 88%, 59.5%, 81%, 71.4% for BDG and 89%, 69.2%, 85%, 67.5% for PCR (95% CI). Among different combinations, best combination was found to be GM and PCR with sensitivity, specificity, PPV and NPV of 98.2%, 89.3%, 97.1% and 90% respectively. Single samples must be evaluated by combination of tests.

Comparative Analysis of Disc Diffusion and E-test with Broth Micro-dilution for Susceptibility Testing of Clinical Candida Isolates Against Amphotericin B, Fluconazole, Voriconazole and Caspofungin.

BACKGROUND: Antifungal susceptibility testing remains an area of intense interest because of the increasing number of clinical isolates resistant to antifungal therapy. Clinical and Laboratory Standards Institute has proposed reference broth micro dilution (BMD) method for susceptibility testing. The reference method is time-consuming and poorly suited for the routine clinical laboratory setting. Agar-based susceptibility testing methods, disk diffusion (DD) method and the E-test method can be an easier, reliable and less time consuming alternative for the BMD method. AIM: To compare the results of Amphotericin B, fluconazole, voriconazole, and Caspofungin susceptibility testing by DD, and the E-test method with the CLSI reference method for clinical Candida isolates. MATERIALS AND METHODS: Broth Microdilution (BMD), E-test and Disk diffusion testing of the various clinical Candida isolates was performed in accordance with CLSI documents. The results obtained were analysed and compared. RESULTS: The categorical agreement for Amphotericin B, fluconazole, voriconazole, and Caspofungin susceptibility results by E-test and DD method was 65.2%, 67.4%; 100%, 82.6%; 100%, 100%; 100%, 97.8% respectively. CONCLUSION: The agar-based E-test and disk diffusion methods are reliable alternatives to the BMD method for Candida isolates when test susceptible to fluconazole, voriconazole, and Caspofungin, however the susceptibility testing results must be interpreted with caution in case of Amphotericin B.

Comparative Evaluation of Disc Diffusion and E-test with Broth Micro-dilution in Susceptibility testing of Amphotericin B, Voriconazole and Caspofungin against Clinical Aspergillus isolates.

BACKGROUND: Clinical importance of Aspergillus has increased over the past few decades because of rise in immunosuppressive drugs and immune-modulating diseases. Antifungal susceptibility of Aspergillus is rarely performed by clinical laboratories because of lack of easier method. This study has investigated and compared susceptibility pattern of Aspergillus isolates by disc diffusion, E-test and broth micro-dilution for amphotericin B, voriconazole and caspofungin. MATERIALS AND METHODS: Disk diffusion (DD) method of antifungal susceptibility (AFS) was evaluated for three different classes of antifungals: amphotericin B (AMB), voriconazole (VCZ) and caspofungin (CAS). Forty four clinical isolates of Aspergillus were selected; these included 34 A.fumigatus, 8 A.flavus and 2 A. terreus. AFS by DD and E-test was done on non-supplemented Mueller Hinton Agar (MHA) and was compared to Clinical Laboratory Standard Institute(CLSI) broth micro-dilution (BMD) method of AFS. RESULTS: Disk diffusion method for amphotericin B showed 87.5% agreement while E-test showed 93.8% agreement with broth micro-dilution. The agreement with broth micro-dilution was similar for both disk diffusion and E-test in case of voriconazole (93.8%) and caspofungin (100%). 31.8% and 9.1% Aspergillus isolates were found to have amphotericin B and voriconazole MIC values above epidemiological cut off value (ECV) respectively. All isolates were within ECV for caspofungin. CONCLUSION: CLSI method of DD promises to be easier, reproducible and cost effective method of susceptibility testing, but this method must be interpreted with caution in case of amphotericin B susceptibility testing. E-test correlates better than DD with BMD.

Inhibition of biofilm formation and lipase in Candida albicans by culture filtrate of Staphylococcus epidermidis in vitro.

BACKGROUND: Candida spp. are fourth most common cause of bloodstream infection in developed countries and emerging agents of fungemia in developing countries, with considerable attributable mortality. Candidemia is associated with the formation of complex, structured microbial communities called biofilms. Biofilm formation makes treatment difficult due to improper drug penetration and factors like high cost and adverse effects of antifungal drugs available. Hence, low-cost alternatives are urgently required to treat device-associated invasive candidiasis. OBJECTIVES: To study the effect of culture filtrate of Staphylococcus epidermidis on biofilm formation and lipase expression of Candida albicans in vitro. MATERIALS AND METHODS: Yeast cells isolated from clinical samples were suspended to a turbidity of 10(6) in (a) Yeast extract-peptone-dextrose (YPD) broth and (b) culture filtrate, and 100 µl of each were dispensed in separate wells of microtiter plate. After repeated washing and reloading with respective liquid media, readings were taken spectrophotometrically. To check for lipase inhibition, yeasts were incubated overnight in YPD and filtrate and subcultured on media containing Tween-80 and CaCl2. Positive lipase activity was denoted by haziness around colonies. RESULTS: Mean reading of C. albicans in YPD broth was 0.579 while the same when yeasts were suspended in S. epidermidis culture filtrate was 0.281 (P < 0.05 by Z-test of significance). Lipase of C. albicans was inhibited by culture filtrate. Filtrate was found to be nontoxic to human cell line. CONCLUSIONS: Culture filtrate of S. epidermidis can hence pave the way for development of new strategies to inhibit biofilm formation in device-associated candidemia.

Comparative Study of Biofilm Formation in Pseudomonas aeruginosa Isolates from Patients of Lower Respiratory Tract Infection.

BACKGROUND: This study assessed biofilm formations of P.aeruginosa which was isolated from patients with Lower Respiratory Tract Infections (LRTIs). OBJECTIVE: This study was conducted to compare different methods of biofilm formations seen in P. aeruginosa which was obtained from LRTI patients. MATERIALS AND METHODS: In this cross-sectional study, we investigated a total of 80 P. aeruginosa isolates obtained from LRTI patients by different methods. Tube method (TM), tissue culture plate (TCP) method and modified tissue culture plate (MTCP) method. They were subjected to biofilm detection methods. RESULTS: The MTCP method produced a higher accuracy ratio than TCP method. In terms of sensitivity and specificity, the MTCP method was considered to be superior to TM. We observed a higher antibiotic resistance in biofilm producing bacteria than in non-biofilm producers. CONCLUSION: In our study, MTCP was found to be more sensitive and specific method for biofilm detection than TCP and TM.

In-vitro Inhibition of Biofilm Formation in Candida albicans and Candida tropicalis by Heat Stable Compounds in Culture Filtrate of Aspergillus flavus.

BACKGROUND: Invasive candidiasis, caused mostly by Candida albicans and C. tropicalis is one of the most common causes of bloodstream infection with a substantial attributable mortality. This disease is associated with formation of structured, multilayered microbial communities known as biofilms over indwelling devices. Treatment is rendered difficult owing to factors like poor drug penetration through biofilms and high cost of the available antifungal drugs. Hence there is imminent need of developing low-cost natural compounds inhibiting Candidal biofilm formation in vitro. Organohalgen compounds derived from crude culture filtrate of Aspergillus flavus have been documented to impair in vitro Candidal survival. AIM: We aimed to detect the effect of preheated and unheated crude culture filtrate of Aspergillus flavus on biofilm formation of Candida albicans and C. tropicalis in vitro. Setting and Designs: Ours was a laboratory-based observational study with clinical isolates of the microorganisms selected randomly. MATERIAL AND METHODS: In this study, we showed for the first time by microtitre plate method that heat stable compounds which were present in preheated and unheated culture filtrates of Aspergillus flavus inhibited biofilm formation of Candida albicans and C. tropicalis and also lipase activities of these pathogens, and filtrate was non-toxic on human cell line as checked microscopically. STATISTICAL ANALYSIS USED: Z-test of significance was used to calculate significant difference between Candidal biofilm formation in normal liquid medium and culture filtrate, respectively. RESULTS AND CONCLUSION: Heat stable compounds present in culture filtrate of Aspergillus flavus inhibit biofilm formation of Candida albicans and C. tropicalis and also in-vitro lipase activity of these pathogens and could pave the way for development of low-cost alternatives to treat invasive candidiasis.

A fatal case of meningitis caused by Cryptococcus neoformans var. grubii in an immunocompetent male.

The incidence of cryptococcal infection is high in developing countries such as India. Cryptococcal meningitis is considered rare in immunocompetent patients and is mainly a disease of immunocompromised patients. Prognosis in immunocompetent patients is generally considered good. We report a fatal case of cryptococcal meningitis in an immunocompetent male caused by Cryptococcus neoformans var. grubii. Whether the patient is immunocompromised or immunocompetent, the outcome of the disease can be severe unless the disease is diagnosed early in the course of illness.

Phenotypic and genotypic methods for the detection of methicillin resistant coagulase negative staphylococci: a comparative study.

CONS are the major cause of nosocomial infection in last decade and methicillin resistant CoNS has emerged as a major clinical problem. The present study was to compare different phenotypic methods with genotypic method PCR, for the detection of methicillin resistance in CoNS. 100 CoNS isolates from different samples were studied for the detection of mecA gene. PCR was considered as "gold standard". Oxacillin and cefoxitin antibiotics were used for different phenotypic tests (DD, Agar dilution and MHOX). The sensitivities of oxacillin and cefoxitin disks for all CONS were found to be 92.30% and 88.46% respectively and the specificities were 87.5% and 100% respectively. The sensitivities of the agar dilution test for oxacillin and cefoxitin were 86.53% and 80.76%, respectively, where as the specificities were 79.16% and 85.41%, respectively. The sensitivity of MHOX was observed to be 96.16% and specificity 72.91%. Cefoxitin D.D and oxacillin AD methods could be used as initial test for the determination of methicillin resistance in CoNS isolates. The result of MHOX shows that it could be the best single method for the evaluation of oxacillin resistance mediated by the mecA gene for all CoNS species.

Identification, characterization and antibiotic susceptibility pattern of non fermenters from clinical specimens in Lucknow, Uttar Pradesh.

Present study was an attempt to study the prevalence of nonfermenter and its antibiotic susceptibility pattern at CSM Medical University, Lucknow. All the isolates and samples were selected from clinical specimens received in Bacteriology section, P.G. Depart of Microbiology, for culture. The observation were made on the nonfermenter isolates that can be isolated from clinical specimen using simple Laboratory media e.g. Blood Agar & Mac Conkey agar. All relevant history & information were recorded from the subjects. A total of 8340 specimen were screened for a period of one year. The prevalence of nonfermenters came to be 19.09% among all isolates. Most of spp. belongs to oxidase+ve group (77%). P. aeruginosa was found to be most common isolate (53%). Overall sensitivity profile for ciprofloxacin was 60%, P/T 58% & Amikacin 56%. Sensitivity of imepenem was 60% for multi-resistant isolates. The most resistant isolate was Sachrolytic Acinetobacter spp. The knowledge of synergism between drugs in context to different isolates may aid in effective therapy for these isolates.

Randomized, controlled trial of oral ribavirin for Japanese encephalitis in children in Uttar Pradesh, India.

BACKGROUND: Japanese encephalitis is associated with high rates of mortality and disabling sequelae. To date, no specific antiviral has proven to be of benefit for this condition. We attempted to determine the efficacy of oral ribavirin treatment for reducing early mortality among children with Japanese encephalitis in Uttar Pradesh, India. METHODS: Children (age, 6 months to 15 years) who had been hospitalized with acute febrile encephalopathy (a < or =2-week history of fever plus altered sensorium) were tested for the presence of immunoglobulin M antibodies to Japanese encephalitis virus with commercial immunoglobulin M capture enzyme-linked immunosorbent assay. Children with positive results were randomized to receive either ribavirin (10 mg/kg per day in 4 divided doses for 7 days) or placebo syrup through nasogastric tube or by mouth. The primary outcome was early mortality; secondary outcome measures were early (at hospital discharge; normal or nearly normal, independent functioning, dependent, vegetative state, or death) outcome, time to resolution of fever, time to resumption of oral feeding, duration of hospitalization, and late outcome (> or =3 months after hospital discharge). The study was double-blind, and analysis was by intention to treat. RESULTS: A total of 153 patients were enrolled during a 3-year period; 70 patients received ribavirin, and 83 received placebo. There was no statistically significant difference between the 2 groups in the early mortality rate: 19 (27.1%) of 70 ribavirin recipients and 21 (25.3%) of 83 placebo recipients died (odds ratio, 1.10; 95% confidence interval, 0.5-2.4). No statistically significant differences in secondary outcome measures were found. CONCLUSIONS: For the dosage schedule used in our study, oral ribavirin has no effect in reducing early mortality associated with Japanese encephalitis. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00216268 .

123I-mIBG scintigraphy to predict risk for adverse cardiac outcomes in heart failure patients: design of two prospective multicenter international trials.

BACKGROUND: ADMIRE-HF (AdreView Myocardial Imaging for Risk Evaluation in Heart Failure) consists of two identical prospective open-label, multicenter, phase 3 studies (MBG311 and MBG312) evaluating the prognostic usefulness of (123)I-mIBG scintigraphy for identifying subjects with heart failure who will experience a major adverse cardiac event. METHODS: Subjects with NYHA class II and III heart failure and left ventricular ejection fraction < or = 35% were eligible for the trials. Subjects underwent planar and SPECT (123)I-mIBG myocardial imaging, as well as echocardiography and gated SPECT (99m)Tc-tetrofosmin myocardial perfusion imaging. Subjects are then monitored on a regular basis for 2 years. Time to first occurrence of one of the following--NYHA class progression; potentially life-threatening arrhythmic event (including ICD discharge); or cardiac death, as verified by an independent adjudication panel---will be analyzed in comparison to quantitative parameters derived from (123)I-mIBG imaging. The primary efficacy analysis will employ the heart/mediastinum ratio on 4-hour delayed planar imaging, while secondary efficacy analyses will examine quantitative results from both planar and SPECT (123)I-mIBG images, as well as from (99m)Tc-tetrofosmin SPECT and echocardiography. CONCLUSION: The results of the ADMIRE-HF trials will provide prospective validation of the potential role of (123)I-mIBG scintigraphy in assessing prognosis and developing management strategies for patients with heart failure.