Utilization of Truenat chips in defining XDR, pre-XDR and MDR in tuberculous meningitis.

SETTING AND OBJECTIVE: To develop and evaluate newer molecular tests that identify drug resistance according to contemporary definitions in Tuberculous meningitis (TBM), the most severe form of EPTB. DESIGN: 93 cerebrospinal fluid (CSF) specimens [41 culture-positive and 52 culture-negative], were subjected to Truenat MTB Plus assay along with chips for rifampicin, isoniazid, fluoroquinolones and bedaquiline resistance. The performance was compared against phenotypic drug susceptibility testing (pDST), Line probe assay (LPA) and gene sequencing. RESULTS: Against pDST, Truenat chips had a sensitivity and specificity of 100%; 94.47%, 100%; 94.47%, 100%; 97.14% and 100%; 100%, respectively for rifampicin, isoniazid, fluoroquinolones and bedaquiline. Against LPA, all Truenat chips detected resistant isolates with 100% sensitivity; but 2 cases each of false-rifampicin and false-isoniazid resistance and 1 case of false-fluoroquinolone resistance was reported. Truenat drug chips gave indeterminate results in ∼25% cases, which were excluded. All cases reported indeterminate were found to be susceptible by pDST/LPA. CONCLUSION: The strategic drug resistance chips of Truenat Plus assay can contribute greatly to TB elimination by providing rapid and reliable detection of drug resistance pattern in TBM. Cases reported indeterminate require confirmation by other phenotypic and genotypic methods.

Prioritization of sub-watersheds and subsequent site identification for soil water and conservation practices using the SWAT-AHP integrated model in the Lower Sutlej Sub-basin, India.

Prioritization of watersheds is a crucial step in integrated river basin management. It guides resource allocation, planning, decision-making, stakeholder engagement, targeted interventions, and monitoring and evaluation efforts. By identifying and addressing priority watersheds, comprehensive and sustainable management of water resources can be achieved within a river basin. The aim of the current study is to prioritize watersheds using the Soil and Water Assessment Tool (SWAT) and site suitability analysis for the implementation of soil and water conservation structures (SWCS) in the prioritized watersheds by using an analytical hierarchy process (AHP) of the Lower Sutlej Sub-basin, India. The model was calibrated with observed data from 2017 to 2019 with the first 2 years (2015-16) as a warm-up period. Furthermore, validation of the model was done using 2-year data from 2020 to 2021. The model showed successful performance in terms of the R2 range from 0.72 to 0.89, the NSE range from 0.67 to 0.73, the PBIAS range from - 26.70 to 11.30, and the RSR range from 0.51 to 0.57 for stream flow and sediment yield during calibration and validation period. The basin's average annual soil loss ranged from 3.08 to 21.63 t/ha/year, a watershed with the WS2 index seeing the highest rate of soil erosion (21.63 t/ha/year). Hence, WS2 was found to be a top priority. In addition, the site suitability analysis of the prioritized watershed (WS2) reveals that about 1.42% of the area is extremely suitable, 16.14% is highly suitable, and 35.58% is moderately suitable for SWCS. According to the site suitability map validation, both dam locations were found in highly suitable areas, so the developed site suitability map is accurate. This research will help sustainability planners and managers make more informed decisions when building SWCS at suitable sites for better land and water conservation.

Iodine-PEG as a unique combination for the metal-free synthesis of flavonoids through iodonium-triiodide ion-pair complexation.

An efficient metal-free single-step protocol has been developed for the direct synthesis of flavones from 2-hydroxyacetophenone and substituted benzaldehydes. This chemical transformation is exclusively promoted by the iodonium-triiodide ion couple formed through iodine and PEG-400 complexation. The triiodide anion not only helps in the abstraction of a proton from the acetophenone but also promotes the cyclization of intermediate chalcone to the corresponding flavones. The flavones were obtained in very high yields without using any toxic metal catalysts or harsh reaction conditions. The reaction mechanism was established through a series of test reactions and entrapping of reaction intermediates. The developed protocol provides direct access to flavones in high yields under milder reaction conditions with great substrate compatibility, including hydroxylated derivatives.

Current veterinary regulations and way ahead.

This article aims to perform a comparative systematic review of regulations in veterinary medicine between the years 2016 to 2023. It explores the complex web of veterinary medicine regulations in various agencies and the nations, including USA (United States of America), EU (European Union), UK (United Kingdom), Japan, Australia, and India. Current article provides the comparative study on the veterinary regulations of different countries, including acts, directives, and drug approval processes. Such as, the specific legislation is needed to address zoonotic diseases. The strategic and regulated stockpiling of the veterinary drugs especially in chronic veterinary disease outbreak. It is essential to develop the dedicated Veterinary Pharmacopoeia for the regulated standardization of the raw materials as well as the formulations. Veterinary medical device is a field which is highly unregulated. There is a need to have regulations for the same. It is important to have dedicated veterinary pharmacovigilance centers which help in improving quality of medications to the livestock farms. After comparing the regulations of different countries. We observed that there is the absence of the zoonotic diseases and pharma stockpiling in every country. There is also an absence of the dedicated veterinary pharmacopoeia in every country. USA and Australia have the veterinary medical device regulation which is not there in other countries. Around the globe only Australia has the dedicated pharmacovigilance center. Including these recommendations into regulatory framework enhances the quality and safety of veterinary medicine. The current article adds a valuable resource for policymakers, veterinarians, and stakeholders in the field of animal health care.

Real-time loop-mediated isothermal amplification (real-time LAMP) assay for rapid diagnosis of amoebic liver abscess.

Among the parasitic diseases, amoebic liver abscess (ALA) ranks second to malaria in terms of mortality. Due to the poor sensitivity of conventional diagnostic methods, there is a need for the development of effective and rapid diagnostic methods for ALA. Thus, the purpose of this work was to develop a real-time loop-mediated isothermal amplification (RT-LAMP) assay specific to Entamoeba histolytica. Further, we compared the performance of real-time LAMP with conventional and real-time PCR (RT-PCR) targeting 18S small subunit ribosomal RNA (18S SSU rRNA) gene of E. histolytica in patients with ALA. A total of 126 liver samples were obtained for the study. Of these, 96 aspirated pus samples were obtained from patients suffering from an ALA (serology confirmed, anti-amoebic immunoglobulin IgG positive), 19 aspirated pus samples from patients with pyogenic liver abscess (PLA, 16S RNA gene positive) and 11 autopsy liver tissues. The results showed that the DNA of E. histolytica was detected in 81 samples by conventional PCR, 93 by RT-PCR and 95 by RT-LAMP. The analytical sensitivity of the RT-LAMP assay was much higher than the other two techniques. RT-LAMP assay was able to amplify up to one copy of the targeted gene of E. histolytica while conventional PCR and RT-PCR could amplify up to 103 and 102 copies of the targeted gene of E. histolytica, respectively. In conclusion, RT-LAMP proved to be a sensitive, specific and rapid test which can be utilised as an effective tool for the diagnosis of ALA.

Novel diagnostic approach for amoebic liver abscess using cell free (cf) DNA: a prospective study.

BACKGROUND: Amoebic liver abscess (ALA) is commonly seen in tropical countries and diagnosis of ALA relies mainly on non-specific serological and imaging techniques as well as PCR from pus. OBJECTIVE: This study evaluated the potential of using cell free DNA (cfDNA) from serum and urine for diagnosing ALA. METHODS: We prospectively evaluated quantitative PCR (qPCR) for detection of cf DNA in serum and urine sample in all liver abscess patients. The samples were collected from patients reporting to emergency ward of Postgraduate Institute of Medical Education and Research, Chandigarh, India with symptoms suggestive of liver abscess. Real time PCR was done to detect cf DNA in serum and urine by targeting 99-bp unit of small subunit rRNA of Entamoeba histolytica and conventional PCR for pus. RESULTS: A total 113 samples (serum and urine) and 100 pus samples were analysed. A total of 62 ALA patients were confirmed; with maximum 57 patients detected by qPCR for cfDNA in the serum, 55 patients by PCR on pus aspirate and 50 ALA patients by qPCR for cfDNA in urine sample. Therefore, the sensitivity of qPCR for detection of cf DNA in serum was 91.94% and for urine was 80.65%. CONCLUSION: A total of 11.2% of ALA patients were diagnosed only through detection of E. histolytica cf DNA in their serum and urine. Detection of cfDNA from serum, urine of ALA has a potential role in future especially for developing countries as it is a rapid, sensitive and patient friendly diagnostic approach.

Changing spectrum of primary pyomyositis in North India.

Recent data have demonstrated the changing epidemiology of primary pyomyositis worldwide. Our hospital-based retrospective study investigated the clinical and microbiological spectrum of primary pyomyositis between 2013 and 2021 in PGIMER (Chandigarh), India. Over a quarter had predisposing conditions, mainly diabetes mellitus and immunosuppressive therapy. Fever, muscle pain, local swelling and breathlessness were the usual presentations, with quadriceps, iliopsoas and gluteal muscles commonly affected. Staphylococcus aureus was the predominant cause, with c.50% methicillin-resistant strains. Almost two-thirds presented with metastatic infection (stage 3 pyomyositis), frequently with septic lung emboli. Patients with methicillin-sensitive and resistant Staphylococcus aureus had a similar incidence of metastatic infection. In-hospital mortality was c.10% and was strongly associated with a high international normalised ratio. Primary pyomyositis remains a significant problem, with a dramatic increase in community-associated methicillin-resistant Staphylococcus aureus.

A Case Series of Scrub Meningoencephalitis from a Tertiary Care Center in North India.

Scrub typhus infection is reemerging leading cause of acute febrile illnesses in post-rainy or monsoon season in Southeast Asia. It is caused by Orientia tsutsugamushi and spread by the bite of chiggers, larval forms of trombiculid mites. The clinical picture can range from simple acute febrile illness to multiorgan dysfunction. Neurological manifestations also vary from aseptic meningitis, meningoencephalitis, cerebral infarction, acute disseminated encephalomyelitis, transverse myelitis, and psychiatric manifestations. Here, we present a case series of eight cases of scrub meningoencephalitis diagnosed based on clinical, laboratory, and radiological criteria.

Comparative study of diabetic ketoacidosis in the elderly and non-elderly patients: A nine-year experience from an academic hospital in North India.

BACKGROUND AND AIMS: Despite an increasing prevalence of the aged population with diabetes in low-middle-income countries, there is limited literature on geriatric hyperglycemic emergencies. The present study aimed to compare the spectrum and outcomes of diabetic ketoacidosis (DKA) between elderly and non-elderly adult patients in India. METHODS: Seventy-seven elderly patients (≥60 years) were compared to 477 non-elderly patients (13-59 years) with DKA admitted to the medical emergency, Postgraduate Institute of Medical Education and Research, Chandigarh, India, between January 2014 and December 2022. Clinical features, laboratory parameters, precipitating factors, and in-hospital outcomes were reviewed. RESULTS: Elderly patients less commonly had vomiting and abdominal pain than non-elderly patients (31.3 % vs. 66.2 %, 27.3 % vs. 60.1 %, respectively) and typically presented with dyspnea (48.5 %), altered mental status (47.8 %), and fever (46.3 %). Ketonemia and metabolic acidosis were significantly more marked in non-elderly patients, whereas elderly patients frequently had anemia, hypoalbuminemia, and renal dysfunction. The most common precipitations of geriatric DKA were infections (70.1 %), followed by treatment non-adherence (66.2 %) and non-infectious disorders (35.1 %). Infections and non-infectious disorders were significantly more frequent in elderly patients than in non-elderly patients. Respiratory and urinary tract infections were prevalent in both age groups. In-hospital survival was 74.9 % (n = 415) and remained lower in older patients (48.1 % vs. 79.2 %, P-value <0.001). The independent prognostic factors were age (OR 1.030, 95 % CI 1.006-1.054, P = 0.014), Glasgow coma scale (OR 0.789, 95 % CI 0.717-0.869, P <0.001), and infection trigger (OR 6.635, 95 % CI 2.852-15.441, P <0.001). CONCLUSION: Older patients with DKA present atypically, frequently have precipitation with infections and noninfectious disorders, and have poor outcomes.

Molecular characterization of Orientia tsutsugamushi causing fatal scrub typhus in a young male affected by so-called "mystery fever" in North India.

Scrub typhus is a zoonotic disease caused by Orientia tsutsugamushi. Although the presence of eschar is considered pathognomic, diagnosis of scrub typhus is challenging due to overlapping presentation. The diagnosis is based on the serological and molecular assay. Here, we describe a case of a young male patient who was diagnosed with scrub typhus and developed complications in the course of the disease. We also performed molecular characterization of the strain which revealed a close relatedness to Karp-like Linh.DT strains were previously reported from Vietnam.

Mycobacterium abscessus Complex-Associated Chronic Meningitis: Time to Think Beyond Tuberculosis.

Background: Mycobacterium abscessus complex (MabC) has emerged as an important cause of human infections, including meningitis. In the absence of correct microbiological identification, cases of MabC meningitis are treated with conventional anti-tubercular therapy, thereby worsening the outcome. Objective: The current study was conducted to determine the clinical features, antimicrobial susceptibility, and outcome of patients with MabC meningitis. Material and Methods: Cerebrospinal fluid specimens processed between 2011 and 2021 were subjected to smear, culture, MALDI TOF identification, hsp65 gene sequencing, and susceptibility testing using Sensititre™ RAPMYCOI plates along with a literature review. Results: 12 cases of MabC meningitis were identified between 2011 and 2021, 11 of which were M. abscessus subspecies abscessus on hsp65 gene sequencing. A pioneer case of meningitis with M. abscessus subspecies bolletii was also identified. The common predispositions were TB elsewhere, HIV positivity, and head injury. Two patients had dual infections, both MabC and TB. Ten patients succumbed to infection with a mean survival of 11 months. All isolates were susceptible to amikacin and tigecycline and subspecies bolletii had a higher minimum inhibitory concentration (MIC) than subspecies abscessus. A combined analysis with the available literature, reporting 19 more cases, revealed that the overall mortality of MabC meningitis was 61.3% (19/31) and that of shunt-associated/neurosurgical intervention-related MabC meningitis was 66.7% (12/20). To date, out of 20 MabC meningitis isolates in which subspecies identification was carried, 13 were M. abscessus, six were M. massiliense, and one was M. bolletii. Conclusion: MabC is an important differential diagnosis of chronic meningitis. Prompt identification and speciation are imperative for targeted therapy, thus improving the overall patient outcome.

Changing Clinical Profile and Predictors of Mortality in Patients of Acute Febrile Encephalopathy from North India.

Introduction: Acute encephalitis syndrome (AES) or acute febrile encephalopathy is a clinical condition characterized by altered mental status occurring after or along with a short febrile illness. In developing countries, infections are the predominant cause of AES. Prominent infections known to cause AES include viruses (such as herpes simplex virus [HSV], Japanese Encephalitis [JE] virus, dengue, enteroviruses [EVs]), bacteria, fungus, and parasites. In the present study, we aim to analyze the etiology, clinical features, and predictors of mortality in patients presenting with acute febrile encephalopathy or acute encephalitic syndrome. The present study was a prospective observational study conducted at Post Graduate Institute of Medical Education and Research a tertiary care center in Chandigarh, India. Methods: A total of 105 patients with ≥18 years of age with fever (body temperature >101° F for duration ≤14 days) and altered sensorium (Glasgow coma scale [GCS] score ≤10) lasting for more than 24 h, either accompanying the fever or following it were enrolled. Demographic and clinical details were recorded on pro forma. Cerebrospinal fluid (CSF) analysis was performed for all the enrolled patients at admission for cytology, CSF glucose to blood glucose ratio, protein levels, gram stain and culture sensitivity, adenosine deaminase levels, polymerase chain reaction for HSV/EV/mycobacterium tuberculosis (TB) and immunoglobulin M Enzyme-linked immune assay for JE. Computed tomography of the brain was done in all patients while magnetic resonance imaging (MRI) of the brain was carried out in 75 patients. Results: Among the 105 patients, tubercular meningitis was seen in 27 (25.7%) patients followed by acute pyogenic meningitis in 18 (17.1%) patients. Probable viral encephalitis was present in 12 (11.4%) cases. Septic encephalopathy (n = 10) and scrub typhus encephalitis (n = 8), HSV encephalitis (n = 6), dengue encephalitis (n = 4), leptospirosis (n = 3) were the other infections causing acute febrile encephalitis in our study. In addition to fever and altered sensorium common symptoms observed were headache (52.4%), vomiting (35.2%), and seizures (29.5%). The factors predicting increased mortality were female gender, fever of more than 38°C at admission, GCS <7, MRI showing disease-related findings like altered signal intensity bilateral medial temporal and insular area in herpes simplex encephalitis, etc., changes, and the group of patients where a definite diagnosis could not be established during the hospital stay. Conclusions: Tubercular meningitis/central nervous system TB is the predominant cause of acute febrile encephalopathy in developing countries. Scrub and dengue encephalitis are emerging as an important cause of acute febrile encephalopathy and occur predominantly in postmonsoon seasons. Acute febrile encephalopathy remains an important cause of mortality in patients presenting to Emergency Department (ER). The strongest predictors of mortality are low GCS and undiagnosed cases of AES.

Pd/C-Catalyzed Carbonylative Amidation for the Synthesis of 2-Carboxamidocyclohexane-1,3-diones.

Herein, a first-ever heterogeneous Pd/C-catalyzed single-step tandem approach for the synthesis of 2-carboxamidocyclohexane-1,3-diones via direct carbonylative C-H amidation of cyclohexane-1,3-diones is reported. The reaction progressed under base-, oxidant-, and ligand-free conditions employing oxalic acid as a CO surrogate and sodium azide as a nitrogen precursor in a double-layer vial system.

Comparison of Dual-Energy Computed Tomography Pulmonary Angiography-Derived Contrast Enhancement with Standard Dual-Energy Pulmonary Angiography in Diagnosing Subsegmental Pulmonary Embolism: A Prospective Study.

Objective In this study, we compare the diagnostic accuracy of dual-energy (DE) computed tomography pulmonary angiography (CTPA) derived contrast enhancement (DECTPA, CTPA images with iodine maps) with standard dual-energy pulmonary angiography (SCTPA) for diagnosis of subsegmental pulmonary embolism in the cases with clinical suspicion of acute pulmonary embolism (APE). Materials and Methods We included 50 cases with clinical suspicion of APE that were referred for CTPA. All the patients underwent CTPA in the dual-energy protocol. Two radiologists evaluated the images. The first radiologist interpreted the SCTPA images (vascular images) and the second radiologist interpreted the DECTPA (CTPA images with iodine maps) for findings of APE. We calculated the sensitivity, specificity, and negative predictive value of DECTPA vis-à-vis SCTPA images. Results The DECTPA with the advantage of iodine map utilization yielded higher detection of thrombi in peripheral subsegmental arteries (72 vs. 99; p = - 0.001) as compared to the SCTPA images by identification of 18 new perfusion defects (interquartile range [IQR]: 0-1) that were consistent with APE. Filling defects were identified in 27 (IQR: 0-4) more subsegmental arteries supplying these 18 areas, which were not detected on SCTPA alone. These 18 perfusion defects were identified in 13 cases. In these 13 cases, 4 new cases were diagnosed that were negative on CTPA ( p = -0.125). In the evaluation of the APE, sensitivity and specificity were calculated and it was found that DECTPA showed 100% sensitivity and 86% specificity with 100% negative predictive value in the detection of thrombi as compared to the routine CTPA. Conclusion DECTPA has higher sensitivity and negative predictive value in the detection of the subsegmental perfusion defect identification as compared to SCTPA.

Cirrhotic cardiomyopathy influences clinical outcomes and enhances performance of conventional risk prediction models in acute-on-chronic liver failure with severe sepsis.

BACKGROUND: Point-of-care echocardiography (POC-Echo) is an essential intensive care hemodynamic monitoring tool. AIMS: To assess POC-Echo parameters [i.e., cardiac index (CI), systemic vascular resistance index (SVRI) and cirrhotic cardiomyopathy (CCM) markers] and serum biomarkers in predicting circulatory failure (need for vasopressors) and mortality in patients with acute-on-chronic liver failure (ACLF) having sepsis-induced hypotension. METHODS: We performed serial POC-Echo within 6 hours (h) of presentation and subsequently at 24, 48 and 72 h in patients with ACLF and sepsis-induced hypotension admitted to our liver intensive care unit. Clinical data, POC-Echo data and serum biomarkers were collected prospectively. RESULTS: We enrolled 120 patients [59% men, aged 49 ± 12 years, 56% alcohol-related disease and median MELDNa of 30 (27-32)], of whom 68 (56.6%) had circulatory failure, with overall mortality of 60%. CCM was present in 52.5%. The predictors of circulatory failure were CI (aHR -1.5; p = 0.021), N-terminal brain natriuretic peptide (aHR -1.1; p = 0.007) and CCM markers; e' septal mitral velocity (aHR -0.5; p = 0.039) and E/e' ratio (aHR -1.2; p = 0.045). Reduction in CI by 20% and SVRI by 15% at 72 h predicted mortality with a sensitivity of 84% and 72%, and specificity 76% and 65%, respectively (p < 0.001). The MELD-CCM model and CLIF-CCM model were computed as MELDNa + 1.815 × E/e' (septal) + 0.402 × e' (septal) and CLIF-C ACLF + 1.815 × E/e' (septal) + 0.402 × e' (septal), respectively, based on multivariable logistic regression. Both scores outperformed MELDNa (z-score = -2.073, p = 0.038) and CLIF-C ACLF score (z score = -2.683, p-value = 0.007), respectively, in predicting 90-day mortality. CONCLUSION: POC-Echo measurements such as CCM markers (E/e' and e' velocity) and change in CI reliably predict circulatory failure and mortality in ACLF with severe sepsis. CCM markers significantly enhanced the CLIF-C ACLF and MELDNa predictive performance.

Role of vascular endothelial growth factor in tuberculous meningitis: A prospective study from a tertiary care center in North India.

INTRODUCTION: The status of vascular endothelial-derived growth factor (VEGF) in the pathogenesis of tuberculous meningitis (TBM) remains far from clear. We prospectively evaluated the role of serum and cerebrospinal fluid (CSF) VEGF in TBM. PATIENTS AND METHODS: This prospective study was conducted at a tertiary care center in North India from January 2018 to June 2019. Consecutive drug-naive patients (n = 82) of TBM diagnosed on the basis of modified Ahuja's criteria were included in the study. The results were compared with 49 control subjects (n = 49). Serum and CSF VEGF were done in all the cases and controls. Follow-up serum VEGF levels were done in 34 patients after 3 months of completion of antitubercular therapy. The VEGF levels were estimated using the human VEGF enzyme-linked immunosorbent assay kit. RESULTS: The mean age was 29.9 ± 13.1 years. The study group consisted of 33 (40.2%) men and 49 (59.8%) women. BACTEC MGIT960 was positive in 15 (18%) patients while multiplex tuberculosis polymerase chain reaction was positive in 73 (89%) patients. Levels of VEGF in serum and CSF of TBM patients were not elevated when compared to controls. There was no association between final outcome in TBM and decrease in serum levels of VEGF at follow-up. CONCLUSION: VEGF may not be playing a significant role in the pathogenesis of TBM. Future studies with larger sample size may clarify the status of VEGF further in TBM.