Placental inflammation and pregnancy outcomes: A prospective, observational study in South Asia: The PURPOSe study.

OBJECTIVE: To examine inflammatory lesions in placentas of stillbirths, preterm neonatal deaths and term controls in India and Pakistan. DESIGN: Prospective, observational study. SETTING: Three hospitals in India and a large maternity hospital in Pakistan. POPULATION: The enrolled participants with placentas available for histology evaluation included stillbirths (n = 814), preterm live births who died within 28 days of birth (n = 618) and term live birth controls (n = 201). From this same population, polymerase chain reaction (PCR) analysis for pathogens was performed on 809 stillbirth placentas, 614 neonatal death placentas and the placentas of 201 term controls. Placentas from preterm infants who lived beyond day 28 (n = 1432) were only available from India. METHODS: A prospective observational study of placental inflammatory lesions defined by the Amsterdam criteria and on the same placentas, multiplex PCR evaluation for 75 pathogens using TaqMan Array Cards. MAIN OUTCOME MEASURES: Any placental inflammatory lesions, including chorioamnionitis, funisitis, villitis and intervillitis and their association with various pathogens. RESULTS: In the Indian liveborn preterm infants, placental inflammation of any kind was present in 26.2% of those who died versus 16.6% of those who lived (p = 0.0002). Chorioamnionitis was present in 25.8% of those who died versus 16.3% of those who lived (p = 0.0002) and funisitis was present in 4.1% of those who died versus 1.5% of those who lived, (p = 0.005). Across all three sites, in the placentas of the 201 term controls, 18.9% had any inflammation, 16.9% had chorioamnionitis, 5.5% had funisitis, 0.5% had intervillitis and none had villitis. Overall, for stillbirths, any inflammation was observed in 30.2%, chorioamnionitis in 26.9%, funisitis in 5.7%, intervillitis in 6.0% and villitis in 2.2%. For the neonatal deaths, any inflammation was present in 24.9%, chorioamnionitis in 23.3%, funisitis in 8.1%, intervillitis in 1.9% and villitis in 0.5%. Compared with the placentas of term controls, in neonatal deaths, only chorioamnionitis was significantly increased (23.3% versus 16.9%, p = 0.05). Among stillbirths, the rates of any inflammation, chorioamnionitis, intervillitis and villitis were similar across the birthweight groups. However, funisitis was more common in the placentas of stillborn fetuses weighing 2500 g or more (13.8%) compared with 1.0% for those weighing less than 1000 g and 4.8% for stillborn fetuses weighing 1000-2499 g. In the PCR studies, Ureaplasma spp. were by far the most common pathogens found and generally were more commonly found in association with inflammatory lesions. CONCLUSIONS: Chorioamnionitis was the most common type of placental inflammatory lesion regardless of whether the placentas evaluated were from term controls, stillbirths or neonatal deaths. For stillbirths, inflammation in each inflammation category was more common than in the term controls and significantly more so for any inflammation, chorioamnionitis, intervillitis and villitis. For neonatal deaths, compared with the placentas of term controls, all inflammation categories were more common, but only significantly so for chorioamnionitis. Ureaplasma spp. were the most common organisms found in the placentas and were significantly associated with inflammation.

Group B streptococcal prevalence in internal organs and placentas of deceased neonates and stillbirths in South Asia.

OBJECTIVE: Group B streptococcus (GBS) has been associated with adverse pregnancy outcomes, but few prospective studies have assessed its prevalence in low- and middle-income country settings. We sought to evaluate the prevalence of GBS by polymerase chain reaction (PCR) in internal organ tissues and placentas of deceased neonates and stillbirths. DESIGN: This was a prospective, observational study. SETTING: The study was conducted in hospitals in India and Pakistan. POPULATION: Pregnant women with stillbirths or preterm births were recruited at delivery, as was a group of women with term, live births, to serve as a control group. METHODS: A rectovaginal culture was collected from the women in Pakistan to assess GBS carriage. Using PCR, we evaluated GBS in various tissues of stillbirths and deceased neonates and their placentas, as well as the placentas of live-born preterm and term control infants. MAIN OUTCOME MEASURES: GBS identified by PCR in various tissues and the placentas; rate of stillbirths and 28-day neonatal deaths. RESULTS: The most obvious finding from this series of analyses from India and Pakistan was that no matter the country, the condition of the subject, the tissue studied or the methodology used, the prevalence of GBS was low, generally ranging between 3% and 6%. Among the risk factors evaluated, only GBS positivity in primigravidae was increased. CONCLUSIONS: GBS diagnosed by PCR was identified in <6% of internal organs of stillbirths and neonatal deaths, and their placentas, and control groups in South Asian sites. This is consistent with other reports from South Asia and is lower than the reported GBS rates from the USA, Europe and Africa.

The PURPOSe cause of death study in stillbirths and neonatal deaths in India and Pakistan: A review.

The PURPOSe study was a prospective, observational study conducted in India and Pakistan to determine the cause of death for stillbirths and preterm neonatal deaths, using clinical data together with minimally invasive tissue sampling (MITS) and the histologic and polymerase chain reaction (PCR) evaluation of fetal/neonatal tissues and the placenta. After evaluating all available data, an independent panel chose a maternal, a placental and a fetal/neonatal cause of death. Here, we summarise the major results. Among the most important findings were that most stillbirths were caused by fetal asphyxia, often preceded by placental malperfusion, and clinically associated with pre-eclampsia, placental abruption and a small-for-gestational-age fetus. The preterm neonatal deaths were primarily caused by birth asphyxia, followed by various infections. An important finding was that many of the preterm neonatal deaths were caused by a nosocomial infection acquired after neonatal intensive care (NICU) admission; the most common organisms were Acinetobacter baumannii, followed by Klebsiella pneumoniae, Escherichia coli/Shigella and Haemophilus influenzae. Group B streptococcus was less commonly present in the placentas or internal organs of the neonatal deaths.

Data usefulness in determining cause of stillbirth in South Asia.

OBJECTIVE: To evaluate the usefulness of data to determine cause of stillbirth in India and Pakistan. DESIGN: Prospective, observational study. SETTINGS: Study hospitals in India and Pakistan. POPULATION: 200 fetal deaths with placental evaluation and minimally invasive tissue sampling (MITS) of internal organs and polymerase chain reaction (PCR) test for 75 pathogens. MAIN OUTCOME MEASURES: Data defined as useful to determine stillbirth causes. RESULTS: Placental pathology was the most useful to determine cause of stillbirth. Comparing placental and fetal weight with standard weights was useful in 44.5% and 48.5%, respectively. Lung histology was useful in 42.5%. Most of the other findings of internal organ histology were only occasionally useful. Signs of abruption, by maternal history or placental evaluation, were always deemed useful. Placenta, brain and cord blood PCR were also useful, but less often than histology. CONCLUSION: Based on this analysis, maternal clinical history, placental histology and fetal examination were most informative. Comparing the placental and fetal weights with recognised standards was useful in nearly half the cases. Fetal tissue histology and PCR were also informative. Of all the potential tests of MITS-obtained specimens, we would first recommend histological evaluation of the lungs, and using a multiplex PCR platform would determine pathogens in blood and brain/CSF. We recognise that this approach will not identify some causes, including some genetic and internal organ anomalies, but will confirm most common causes of stillbirth and most of the preventable causes of stillbirth in low- and middle-income countries.

Pathogens identified in the internal tissues and placentas of stillbirths: results from the prospective, observational PURPOSe study.

OBJECTIVE: To examine internal organ tissues and placentas of stillbirths for various pathogens. DESIGN: Prospective, observational study. SETTINGS: Three study hospitals in India and a large maternity hospital in Pakistan. POPULATION: Stillborn infants delivered in a study hospital. METHODS: A prospective observational study. MAIN OUTCOME MEASURES: Organisms identified by pathogen polymerase chain reaction (PCR) in internal organs and placental tissues of stillbirths. RESULTS: Of 2437 stillbirth internal tissues, 8.3% (95% CI 7.2-9.4) were positive. Organisms were most commonly detected in brain (12.3%), cerebrospinal fluid (CSF) (9.5%) and whole blood (8.4%). Ureaplasma urealyticum/parvum was the organism most frequently detected in at least one internal organ (6.4% of stillbirths and 2% of all tissues). Escherichia coli/Shigella was the next most common (4.1% one or more internal organ tissue sample and 1.3% of tissue samples), followed by Staphylococcus aureus in at least one internal organ tissue (1.9% and 0.9% of all tissues). None of the other organisms was found in more than 1.4% of the tissue samples in stillbirths or more than 0.6% of the internal tissues examined. In the placenta tissue, membrane or cord blood combined, 42.8% (95% CI 40.2-45.3) had at least one organism identified, with U. urealyticum/parvum representing the most commonly identified (27.8%). CONCLUSIONS: In about 8% of stillbirths, there was evidence of a pathogen in an internal organ. Ureaplasma urealyticum/parvum was the most common organism found in the placenta and in the internal tissues, especially in the fetal brain.

Pathogens Identified by Minimally Invasive Tissue Sampling in India and Pakistan From Preterm Neonatal Deaths: The PURPOSE Study.

BACKGROUND: We identified pathogens found in internal organs and placentas of deceased preterm infants cared for in hospitals in India and Pakistan. METHODS: Prospective, observational study conducted in delivery units and neonatal intensive care units. Tissue samples from deceased neonates obtained by minimally invasive tissue sampling and placentas were examined for 73 different pathogens using multiplex polymerase chain reaction (PCR). RESULTS: Tissue for pathogen PCR was obtained from liver, lung, brain, blood, cerebrospinal fluid, and placentas from 377 deceased preterm infants. Between 17.6% and 34.1% of each type of tissue had at least 1 organism identified. Organism detection was highest in blood (34.1%), followed by lung (31.1%), liver (23.3%), cerebrospinal fluid (22.3%), and brain (17.6%). A total of 49.7% of the deceased infants had at least 1 organism. Acinetobacter baumannii was in 28.4% of the neonates compared with 14.6% for Klebsiella pneumoniae, 11.9% for Escherichia coli/Shigella, and 11.1% for Haemophilus influenzae. Group B streptococcus was identified in only 1.3% of the neonatal deaths. A. baumannii was rarely found in the placenta and was found more commonly in the internal organs of neonates who died later in the neonatal period. The most common organism found in placentas was Ureaplasma urealyticum in 34% of the samples, with no other organism found in >4% of samples. CONCLUSIONS: In organ samples from deceased infants in India and Pakistan, evaluated with multiplex pathogen PCR, A. baumannii was the most commonly identified organism. Group B streptococcus was rarely found. A. baumannii was rarely found in the placentas of these deceased neonates.

E-tutorials to accentuate - Clinical microbiology learning.

Competency-based medical education has challenged the educators to adopt new teaching modalities to instil self-directed learning among children. E-learning in the form of blended learning is studied to facilitate clinical microbiology learning. A class of 200 students was introduced to the process of Google Classroom. Two topics were discussed in online classrooms. The students attempted online tests on the topics, that were later discussed in small groups in offline class. Students found that analytical/interpretive questions accentuated learning. E-tutorials facilitate students' preparedness for small-group discussion.

A comparative evaluation of antibacterial effectiveness of sodium hypochlorite, Curcuma longa, and Camellia sinensis as irrigating solutions on isolated anaerobic bacteria from infected primary teeth.

CONTEXT: In endodontics, most of the commercial intra-canal medicaments have cytotoxic reactions and because of their inability to eliminate bacteria from dentinal tubules, recent medicine has turned its attention to the usage of biologic medication prepared from natural plants. The literature to testify the efficacy of natural alternatives in primary teeth is meagre and its effects as irrigating solutions need to be evaluated. AIM: To evaluate the antibacterial effectiveness of sodium hypochlorite, ethanolic extracts of Curcuma longa (turmeric) and Camellia sinensis (green tea) as irrigating solutions against the anaerobic bacteria isolated from the root canals of infected primary teeth. MATERIALS AND METHODS: Thirty patients were selected based on the selected inclusion and exclusion criteria. Preoperative radiographs were taken. Rubber dam isolation and working length estimation were done, following which thirty samples were taken from the root canals of infected primary teeth using sterile absorbent paper points and transferred to tubes containing thioglycolate transport medium. The bacteria were then isolated using standard microbiological protocols and were subjected to antibiotic sensitivity testing using the three test irrigants. STATISTICAL ANALYSIS: SPSS 18 software using Chi-square test was used for statistical analysis. RESULTS: The most commonly isolated bacteria included Porphyromonas sp., Bacteroides fragilis, Peptostreptococcus, and Staphylococcus aureus. Sodium hypochlorite and C. longa (turmeric) showed good antibacterial effect and were effective against most of the isolated bacteria. There was statistically significant difference in the antibacterial effect among the three tested groups (P < 0.001). The least effective was C. sinensis (green tea). CONCLUSION: The infected primary teeth almost always present with a polymicrobial structure with a wide variety of anaerobic bacteria. The chemo-mechanical preparation plays an important role in eradicating the population of predominant micro-organisms in treating these teeth with promising effects with the use of newer test irrigants while avoiding the side effects of sodium hypochlorite.

Effectiveness of team-based learning in microbiology: a non-randomized control study.

BACKGROUND: As per the present curriculum in India, pre- and paraclinical subjects are taught away from the clinical setting. Therefore, students fail to connect the subject taught through didactic lectures to the clinical setting. Team-based learning (TBL) can be used in conjunction with lectures to teach applied microbiology. This study aims to evaluate the effectiveness of TBL sessions in conjunction with lectures to enhance learning of applied microbiology, among Indian students. METHODS: All students enrolled in the study were taught systemic bacteriology through lectures. Of the 88 students, 49 students (study group) attended TBL sessions on the topics of diarrhea, fever of unknown origin, urinary tract infection and 39 students (control group) preferred self-study on the topics without attending the TBL sessions. Students' feedback on their perception on TBL sessions was collected using a questionnaire of 10 items. The performance of both the groups on the pre- and post-test were analyzed using unpaired t-test and analysis of variance (ANOVA). Gender-wise performance within the teams was analyzed by paired t-test using SPSS version 12. RESULTS: The TBL group outperformed the self-study group on the post-test [F 1 = 5.521, P = 0.021]. Female students as a whole performed better than males on the pre-test, scoring higher within both the TBL and self-study groups. Male students in the TBL group performed significantly better on the post-test than female students who participated in TBL sessions (P = 0.013). Students generally enjoyed and appreciated the TBL sessions. DISCUSSION: TBL sessions can be used judiciously in combination with the lectures to enhance learning of applied microbiology in India. In this study, TBL improved the performance of male students over self-study, but performance for female students following TBL was no better than when they simply studied by themselves.

Biofilm production by Candida: comparison of bloodstream isolates with cervical isolates.

The present study was undertaken to investigate biofilm formation among the clinical Candida isolates from blood and cervical swabs. A total of 16 Candida blood isolates from neonates and 21 cervical isolates from pregnant women with vulvovaginitis were included in the study. Each isolate was identified to species level by various phenotypic tests. Biofilm formation was detected by colorimetric method. C. glabrata and C. albicans were the major isolates from blood and cervical swab respectively. The biofilm formation was found in 14 (87.5 %) blood isolates and only in 4 (19.1 %) cervical isolates.