Onychomycosis caused by dematiaceous fungi: A four-year study on agricultural workers of Assam, India.

Background and Purpose: Onychomycosis caused by dematiaceous fungi is rarely reported and the identification is also quite tricky due to poor sporulation. Recent emergence of dematiaceous fungi as a major cause of onychomycosis is a matter of concern in the field of mycology. Therefore, this study aimed to understand the dematiaceous fungi as a possible cause of onychomycosis, especially among agricultural workers. In addition, the evaluation of the antifungal susceptibility patterns led to the idea of an accurate drug that will help to treat and prevent antifungal resistance. Materials and Methods: The standard procedure was followed for direct microscopic examination and fungi isolation. Furthermore, antifungal susceptibility testing was conducted in accordance with the Clinical and Laboratory Standards Institute M-38-A2 protocol. Results: Both potassium hydroxide and fungal positivity were found in 275 out of 356 suspected cases, 52%, 4.3%, 28.7%, and 14.9% of which were non-dermatophytic molds (NDMs), yeast, dermatophytes, and sterile hyphae, respectively. Among NDMs (52%, n=143), 45.5% (n=65) were hyaline hyphomycetes and 54.5% (n=78) were dematiaceous hyphomycetes. Among dematiaceous fungi, Pestalotiopsis spp. and Arthrinium spp. were the commonly isolated ones. Additionally, azoles, amphotericin-B, and anidulafungin showed excellent antifungal activity against tested isolates. Conclusion: Dematiaceous fungi are now becoming a potential cause of onychomycosis. A more detailed study is needed on the identification of these emerging isolates and the mode of action of antifungal drugs for a better treatment strategy.

Perception of health care students towards lectures as a teaching and learning method in the COVID era - A multicentric cross-sectional study from India.

The sudden precipitation of the pandemic forced undergraduates to take refuge at home, deserting the campus. Consequently, the age-old classroom in person teaching-learning (T-L) method shifted and lessons had to be conducted online. In previous decades, archetypical classroom lectures survived a lot of criticism in the face of the quasi-passive nature of T-L  methodology. There are very few studies that reflect undergraduate students' perceptions of lectures. This study aimed to evaluate undergraduate students' perceptions of lectures using an online questionnaire with 13 items, which was circulated to undergraduate students of medical, physiotherapy, and nursing courses in three settings at different locations of private and public health schools. There was a total of 877 responses. The surveyed students were in favor of lectures and considered them indispensable for undergraduate learning. They preferred it as a kind of organized learning through the teacher's own experiences. Our study suggests that it is not the 'lecture' that requires mending but possibly teachers require better training, application of effective audio-visual aids, and innovative techniques to sustain students' interest in the class.

Stages of Concern of Medical Faculty toward Adoption of Competency-based Medical Education in India: A Multicentric Survey.

Context: Currently, a major curricular reform in the form of competency-based medical education (CBME) curriculum is being rolled out across all medical colleges in India. However, it is important to find out and address the concerns of faculty regarding various aspects of this new curriculum. Aim: To analyze the concerns of the faculty members of medical colleges in India in response to the changes emerging from the adoption and implementation of the new curriculum through the concerns-based adoption model by applying the stages of concern (SoC) questionnaire. Methodology: A multicentric, cross-sectional quantitative study involving faculty members currently working in medical colleges and with more than 2 years of teaching experience was conducted using SoC questionnaire (SoCQ). The questionnaire was delivered as Google Form. Results: Of the 744 faculty participants, 41.1% (306) of faculty belonged to the 31-40 years age group followed by the 41-50 years age group (267, 35.9%). Respondents rated their level of concern differently among the seven SoC - percentile scores were highest in Stage 0- awareness (94) and least in Stage 4- consequences (59). An appreciably higher percentile scores were seen at the consequences stage (63 vs. 54), collaboration stage (80 vs. 68), and refocusing stage (77 vs. 69) in those faculty members who were trained in curriculum implementation support program (CISP) compared to the untrained group. However; the SoCQ profiles of CISP trained and untrained faculty were very much similar. SoCQ profiles of holders of advanced training in medical education and non-holders were also the same. Conclusion: Almost after 2 years of well-planned introduction of the CBME curriculum in India, the generalized faculty profile is still suggestive of interested but non-user type for the adoption of CBME. However; compared to untrained faculty, CISP trained faculty is more concerned about the impact of CBME on students, collaborating with colleagues for its proper implementation and exploring more benefits from the implementation of CBME, indicating that more hand-holding is required for faculty development beyond CISP.

Clinical Characterization and Genomic Analysis of Samples from COVID-19 Breakthrough Infections during the Second Wave among the Various States of India.

From March to June 2021, India experienced a deadly second wave of COVID-19, with an increased number of post-vaccination breakthrough infections reported across the country. To understand the possible reason for these breakthroughs, we collected 677 clinical samples (throat swab/nasal swabs) of individuals from 17 states/Union Territories of the country who had received two doses (n = 592) and one dose (n = 85) of vaccines and tested positive for COVID-19. These cases were telephonically interviewed and clinical data were analyzed. A total of 511 SARS-CoV-2 genomes were recovered with genome coverage of higher than 98% from both groups. Analysis of both groups determined that 86.69% (n = 443) of them belonged to the Delta variant, along with Alpha, Kappa, Delta AY.1, and Delta AY.2. The Delta variant clustered into four distinct sub-lineages. Sub-lineage I had mutations in ORF1ab A1306S, P2046L, P2287S, V2930L, T3255I, T3446A, G5063S, P5401L, and A6319V, and in N G215C; Sub-lineage II had mutations in ORF1ab P309L, A3209V, V3718A, G5063S, P5401L, and ORF7a L116F; Sub-lineage III had mutations in ORF1ab A3209V, V3718A, T3750I, G5063S, and P5401L and in spike A222V; Sub-lineage IV had mutations in ORF1ab P309L, D2980N, and F3138S and spike K77T. This study indicates that majority of the breakthrough COVID-19 clinical cases were infected with the Delta variant, and only 9.8% cases required hospitalization, while fatality was observed in only 0.4% cases. This clearly suggests that the vaccination does provide reduction in hospital admission and mortality.

Lasiodiplodia theobromae onychomycosis among agricultural workers: A case series.

Lasiodiplodia theobromae is a dematiaceous non-dermatophyte mold (NDM), rarely reported to cause onychomycosis. Here, we report three cases of toenail onychomycosis caused by L. theobromae in agricultural workers. Two patients presented with total dystrophic onychomycosis and one with distal and lateral subungual onychomycosis. These cases have unique importance that besides traumatized nail infection, its rarity has adversely affected the agricultural workers livelihood as L. theobromae sporulates poorly, resistant to commonly used antifungal therapy. From the literature search, we assume that this is the first case series of onychomycosis caused by L. theobromae from a tropical country like India.

Pestalotioid fungi: A rare agent of onychomycosis among agriculture workers.

BACKGROUND AND PURPOSE: Pestalotioid fungi are ubiquitous environmental molds that have received considerable attention in recent times not only because of their role as a plant pathogen but also owing to their high frequency of retrieval from human diseases. Regarding this, the present study was conducted to investigate onychomycosis caused by pestalotioid fungi, commonly considered important phytopathogens causing grey blight disease in Camellia sinensis. MATERIALS AND METHODS: A total of 122 agriculture workers were enrolled from Assam, India. Direct microscopic examination was carried out using 40% KOH to determine the presence of any fungal element. Further processing of the specimens for the isolation of fungi was performed using the standard protocol. In addition, the keratinolytic potential of the isolates was evaluated by means of the in vitro hair perforation test. RESULTS: Out of 103 culture-positive samples, non-dermatophyte and dermatophyte molds constituted 82.52% (n=85) and 6.79% (n=7) of the samples, followed by yeasts (n=1, 0.9%) and sterile hyphae (n=10, 9.7%). With regard to the isolated non-dermatophyte molds (82.69%), 4 cases belonged to pestalotioid fungi, such as Neopestalotiopsis piceana (n=1), Pestalotiopsis species (n=1), and Pseudopestalotiopsis theae (n=2). The keratinolytic activity of Pestalotiopsis species showed perforation by disrupting the hair cortex; furthermore, macroconidia were found to be present inside the human hair. CONCLUSION: A high rate of NDM isolation may be attributed to constant exposure to adverse environmental and occupational hazards. This study highlighted the importance of "pestalotioid fungi" as the rare etiologic agent of onychomycosis. Another remarkable finding was the keratinolytic potential of Pestalotiopsis species, which is unique in this study.

Transformational learning for health professionals through a Theatre of the Oppressed workshop.

Theatre of the Oppressed (TO) is a powerful participatory tool for communities to examine their struggles against oppression. The healthcare community has problems inherent to complex, unequal power equations, and TO may be a useful means to understand and respond to their struggle. A 3-day workshop on TO was facilitated by the authors in the Himalayan Institute of Medical Sciences (HIMS) in Dehradun, India, in August 2017. The workshop culminated in the 'Forum Theatre', which included five short plays, each depicting a struggle due to real-life oppression faced by one or the other participant. The audience (about 200 invited members of the HIMS community) chose one play depending on the struggle with which they identified most. That play was 'forumed': spectators were invited to replace the struggling person and demonstrate how they would handle the oppression. Over the next week, participants reflected on the workshop through a structured online questionnaire. The feedback (n=16/27 participants; response rate 59.3%) was subjected to descriptive statistics and to qualitative analysis. The highest average Likert score (out of a maximum of 5) was given to the following items: TO engages senses and emotions (4.6±0.50), can help inculcate ethical behaviour (4.4±0.81), identifies conflict (4.4±0.51), and resolves issues of attitude, behaviour, communication, diversity and empathy (4.4±0.73). The Forum Theatre was reported to be a means to "express emotions and opinions and to simultaneously gather the same from others"; "make people push their own limits"; "bring out social problems in public"; "examine the root causes behind lived experience"; "provide context for understanding and for exploring alternatives"; and "convert thoughts to action." In conclusion, TO is an engaging activity that identifies conflict; participants' initial reactions suggest that it may initiate change in the ABCDE attributes (attitude, behaviour, communication, diversity, ethics and empathy) of medical professionals.

Onychomycosis Associated with Superficial Skin Infection Due to Aspergillus sydowii in an Immunocompromised Patient.

Opportunistic fungal infections of the skin and nail are frequently encountered in human. Recent years have shown increased incidence of fungal infections especially in immunocompromised patients. Onychomycosis in HIV-infected patients is reported to occur in 15-40%, four times more than in the general population. Here, we report a case of fingernail proximal subungual onychomycosis with associated skin infection caused by an opportunistic mold, Aspergillus sydowii, in a HIV positive individual. Isolation of A. sydowii from nail and skin of an immunocompromised person needs accurate identification for successful treatment.

Geographical distribution of primary & secondary dengue cases in India - 2017: A cross-sectional multicentric study.

Background & objectives: Dengue virus infection is endemic in India with all the four serotypes of dengue virus in circulation. This study was aimed to determine the geographic distribution of the primary and secondary dengue cases in India. Methods: A multicentre cross-sectional study was conducted at Department of Health Research / Indian Council of Medical Research (DHR)/(ICMR) viral research and diagnostic laboratories (VRDLs) and selected ICMR institutes located in India. Only laboratory-confirmed dengue cases with date of onset of illness less than or equal to seven days were included between September and October 2017. Dengue NS1 antigen ELISA and anti-dengue IgM capture ELISA were used to diagnose dengue cases while anti-dengue IgG capture ELISA was used for identifying the secondary dengue cases. Results: Of the 1372 dengue cases, 897 (65%) were classified as primary dengue and 475 (35%) as secondary dengue cases. However, the proportion varied widely geographically, with Theni, Tamil Nadu; Tirupati, Andhra Pradesh and Udupi-Manipal, Karnataka reporting more than 65 per cent secondary dengue cases while Srinagar, Jammu and Kashmir reporting as low as 10 per cent of the same. The median age of primary dengue cases was 25 yr [interquartile range (IQR 17-35] while that of secondary dengue cases was 23 yr (IQR 13.5-34). Secondary dengue was around 50 per cent among the children belonging to the age group 6-10 yr while it ranged between 20-43 per cent among other age groups. Interpretation & conclusions: Our findings showed a wide geographical variation in the distribution of primary and secondary dengue cases in India. It would prove beneficial to include primary and secondary dengue differentiation protocol in the national dengue surveillance programme.

Harnessing the medical humanities for experiential learning.

A month-long workshop on medical humanities was held in the Jorhat Medical College, Assam in September 2015. It employed experiential learning (both online and onsite) using humanities tools, such as the theatre of the oppressed, art, literature, reflective narratives, movies, the history of medicine, graphic medicine, poetry and diversity studies. As a result of the interactions, 28 volunteer participants, comprising students and faculty members, wrote reflective narratives on doctor​-patient relationships, produced a newsletter and a logo for their medical humanities group, and staged cultural performances and forum theatre. The narratives, participants' reflections and feedback received were subjected to qualitative analysis; the workshop was evaluated using Kirkpatrick's model. The participants learned to examine their attitudes and behaviour, communicate with their bodies, and experience respect for diversity. There was an improvement in their understanding of empathy, ethics and professionalism. The workshop achieved level-3 (behaviour) on Kirkpatrick's model, suggesting that such workshops can initiate a change in the ABCDE attributes (attitude, behaviour, communication, diversity, ethics and empathy) of medical professionals.

Poetry in teaching pharmacology: Exploring the possibilities.

OBJECTIVES: To explore poetry as a tool for active learning in linking knowledge and affective domains and to find if correlating learning with imagination can be used in "assessment for learning." MATERIALS AND METHODS: After taking a conventional lecture on Asthma, a creative writing assignment in the form of poetry writing was given to the students. Different triggers were given to the students to channelize their thought pattern in a given direction that was linked to specific areas of academic relevance. Students were asked to reflect on this learning experience and the faculty was asked to evaluate the student assignment on a 5-point Likert scale. RESULTS: Most student groups scored well in the "overall assessment" of creative assignments and were rated as good or fair by the faculty. Students reflections were very informative and revealed that more than 90% of the students liked the exercise and many were too exuberant and liberal with emotional reactions that breathed positive. Around 5% students found the exercise average and another 5% found it very childish. CONCLUSION: Poetry writing turned out to be like a simulation exercise that linked academic knowledge, creativity, and the affective domain in an assumed scenario, rehearsed in free locales of mind. The metaphorical transition embedded in its subtle creation helped assess deeper understanding of the subject and the logical sequence of thought pattern.

Acremonium strictum: Report of a Rare Emerging Agent of Cutaneous Hyalohyphomycosis with Review of Literatures.

We present a case of cutaneous hyalohyphomycosis due to Acremonium strictum in an immunocompetent individual along with an overview of fungal infections caused by A. strictum. The diagnosis was confirmed by the presence of hyphae in microscopic examination of cutaneous biopsy and discharge, positive culture for A. strictum and sequencing of the isolate at reference centre. The infection resolved with itraconazole and terbinafine. Cutaneous or subcutaneous infections of A. strictum have rarely been reported. Fungemia or disseminated infection often with fatal outcome in immunocompromised patients was the most common presentation of A. strictum infection found in the literatures. The studies also reveal worldwide variation in the treatment regime and outcome of the treatment.

A rare case of ocular onchocerciasis in India.

Onchocerca volvulus is a spirurid nematode that mainly affects the rural poor of Sub-Saharan Africa, Yemen and parts of Central and South Africa. River blindness, caused by Onchocerca volvulus, is considered to be the second commonest infectious cause of blindness worldwide. We report a rare case of ocular onchocerciasis where a live adult worm was extracted from the eye of a patient from a nonendemic region. The worm was identified as Onchocerca volvulus based on morphological features. The patient was treated with Ivermectin (0.2 mg/kg). At six months follow-up she had complete remission of symptoms.

Onychomycosis by Scytalidium dimidiatum in green tea leaf pluckers: report of two cases.

Two cases of onychomycosis in green tea leaf pluckers caused by Scytalidium dimidiatum, a dematiaceous non-dermatophytic mold has been described. Onychomycosis caused by Scytalidium dimidiatum is clinically indistinguishable from that caused by dermatophytes and responds poorly to antifungals. The clinical presentations in the cases were of distal subungual type with associated melanonychia involving thumbnails. These cases have unique importance, because besides disfigurement, this has adversely affected the livelihood of the patient and poor response to antifungal dissuaded them from treatment compliance. To the best of our knowledge, this is the first report of onychomycosis caused by Scytalidium dimidiatum in green tea leaf pluckers.