Species-specific PCR primers for simultaneous detection of Aspergillus fumigatus, Aspergillus terreus, Candida albicans and Candida glabrata in invasive fungal infections.

A rapid and accurate diagnosis of invasive fungal infections (IFIs) has been a great challenge particularly in cases requiring prompt antifungal treatment. In this study, four primer pairs were designed for a quadruplex PCR assay, which was developed for detection of four fungal species simultaneously. DNA extraction of cultured colonies and spiked blood samples were performed using conventional (phenol-chloroform) techniques and commercial DNA extraction kit. The optimum annealing temperature for this assay was 60°C. The assay was able to amplify all four genes and showed 100% specificity. No amplification of any genes was obtained against other species (n=14), which included two bacteria species. In conclusion, this quadruplex PCR assay is specific, rapid and reliable to detect A. fumigatus, A. terreus, C. albicans and C. glabrata simultaneously.

In-vitro activity of ß-lactams/trimethoprim-sulfamethoxazole combinations against different strains of Burkholderia pseudomallei.

Trimethoprim-sulfamethoxazole is an active agent against Burkholderia pseudomallei and is being used in intensive and maintenance phases of melioidosis therapy. In this study, we evaluated the bactericidal activities of ß-lactams (imipenem, ceftazidime and amoxicillin- clavulanate) alone and in combinations with trimethoprim-sulfamethoxazole against B. pseudomallei . Four clinical strains of B. pseudomallei were selected based on different genotypes that are frequently found in Malaysia. The minimum inhibitory concentrations of trimethoprim-sulfamethoxazole, ceftazidime, imipenem and amoxicillin-clavulanate were determined using microdilution broth method. The bactericidal activities and synergy effects of ß-lactams and/or trimethoprim-sulfamethoxazole were evaluated by checkerboard and static time-kill analyses at 1×MIC concentration of each antibiotic. Using checkerboard method, the ß-lactam/trimethoprim-sulfamethoxazole combinations exhibited ΣFIC of 0.75-4.00. In time-kill analysis, ceftazidime/trimethoprim-sulfamethoxazole combination demonstrated synergy against three strains (less 2.25-2.41 log 10 CFU/mL compared to the most active antibiotic monotherapy) whereas imipenem/trimethoprim-sulfamethoxazole combination regimen showed synergy against one strain (less 3.32 log 10 CFU/mL). No antagonist effect or major re-growth was observed in all combination regimens, whereas 11 out of 12 of ß-lactam monotherapy regimens were associated with re-growth of bacteria. However, all ß-lactam monotherapy regimens exhibited rapid and stronger killing activities against BUPS/07/14, in the initial 12 hours compared to ß-lactam/ trimethoprim- sulfamethoxazole combination regimens. The combination of ß-lactams with trimethoprim- sulfamethoxazole demonstrated better killing effect at 24 hours compared to monotherapy and no major bacterial regrowth was observed. Nevertheless, delay in killing activities of ß-lactam/trimethoprim-sulfamethoxazole combination regimens against BUPS/07/14 need further examination because this phenomenon can lead to treatment failure in some patients.

In-vitro activity of β-lactams/trimethoprim-sulfamethoxazole combinations against different strains of Burkholderia pseudomallei

@#Trimethoprim-sulfamethoxazole is an active agent against Burkholderia pseudomallei and is being used in intensive and maintenance phases of melioidosis therapy. In this study, we evaluated the bactericidal activities of β-lactams (imipenem, ceftazidime and amoxicillinclavulanate) alone and in combinations with trimethoprim-sulfamethoxazole against B. pseudomallei. Four clinical strains of B. pseudomallei were selected based on different genotypes that are frequently found in Malaysia. The minimum inhibitory concentrations of trimethoprim-sulfamethoxazole, ceftazidime, imipenem and amoxicillin-clavulanate were determined using microdilution broth method. The bactericidal activities and synergy effects of β-lactams and/or trimethoprim-sulfamethoxazole were evaluated by checkerboard and static time-kill analyses at 1×MIC concentration of each antibiotic. Using checkerboard method, the β-lactam/trimethoprim-sulfamethoxazole combinations exhibited ΣFIC of 0.75-4.00. In time-kill analysis, ceftazidime/trimethoprim-sulfamethoxazole combination demonstrated synergy against three strains (less 2.25-2.41 log10CFU/mL compared to the most active antibiotic monotherapy) whereas imipenem/trimethoprim-sulfamethoxazole combination regimen showed synergy against one strain (less 3.32 log10CFU/mL). No antagonist effect or major re-growth was observed in all combination regimens, whereas 11 out of 12 of β-lactam monotherapy regimens were associated with re-growth of bacteria. However, all β-lactam monotherapy regimens exhibited rapid and stronger killing activities against BUPS/07/14, in the initial 12 hours compared to β-lactam/ trimethoprimsulfamethoxazole combination regimens. The combination of β-lactams with trimethoprimsulfamethoxazole demonstrated better killing effect at 24 hours compared to monotherapy and no major bacterial regrowth was observed. Nevertheless, delay in killing activities of β-lactam/trimethoprim-sulfamethoxazole combination regimens against BUPS/07/14 need further examination because this phenomenon can lead to treatment failure in some patients.

A rare and unusual cause of Vibrio cholerae non-O1, non-O139 causing spontaneous peritonitis in a patient with cirrhosis.

Spontaneous bacterial peritonitis caused by Vibrio cholerae non-O1/ non-O139 is a rare phenomenon. V. cholerae is known as a common aetiology of epidemic diarrheal disease and rarely causes extra-gastrointestinal infections. In this report, a 52-year-old man presented to our hospital with a clinical scenario for chronic liver cirrhosis with low grade fever and loose stools. V. cholerae was isolated from peritoneal fluid culture, which was further confirmed as non-O1/ non-O139 strain by multiplex polymerase chain reaction. The patient was successfully treated with antimicrobial therapy and peritoneal drainage. This case represents the first isolation of V. cholerae non-O1/ non-O139 strain from peritoneal fluid.

Improved blood pressure control via a novel chronic disease management model of care in sub-Saharan Africa: Real-world program implementation results.

A chronic disease management model of care (Empower Health) was launched in rural and urban areas of Ghana and Kenya in 2018. The goal was to improve disease awareness, reduce the burden of disease, and improve the clinical effectiveness and efficiency of managing hypertension. Leveraging the model, clinicians provide patients with tailored management plans. Patients accessed regular blood pressure checks at home, at the clinic, or at community-partner locations where they received real-time feedback. On the mobile application, clinicians viewed patient data, provided direct patient feedback, and wrote electronic prescriptions accessible through participating pharmacies. To date, 1266 patients had been enrolled in the "real-world" implementation cohort and followed for an average of 351 ± 133 days across 5 facilities. Average baseline systolic blood pressure (SBP) was 145 ± 21 mmHg in the overall cohort and 159 ± 16 mmHg in the subgroup with uncontrolled hypertension (n = 743) as defined by baseline SBP ≥ 140 mmHg. SBP decreased significantly through 12 months in both the overall cohort (-9.4 mmHg, p < .001) and in the uncontrolled subgroup (-17.6 mmHg, p < .001). The proportion patients with controlled pressure increased from 46% at baseline to 77% at 12 months (p < .001). In summary, a new chronic disease management model of care improved and sustained blood pressure control to 12 months, especially in those with elevated blood pressure at enrollment.

A rare and unusual cause of Vibrio cholerae non-O1, non-O139 causing spontaneous peritonitis in a patient with cirrhosis

@#Spontaneous bacterial peritonitis caused by Vibrio cholerae non-O1/ non-O139 is a rare phenomenon. V. cholerae is known as a common aetiology of epidemic diarrheal disease and rarely causes extra-gastrointestinal infections. In this report, a 52-year-old man presented to our hospital with a clinical scenario for chronic liver cirrhosis with low grade fever and loose stools. V. cholerae was isolated from peritoneal fluid culture, which was further confirmed as non-O1/ non-O139 strain by multiplex polymerase chain reaction. The patient was successfully treated with antimicrobial therapy and peritoneal drainage. This case represents the first isolation of V. cholerae non-O1/ non-O139 strain from peritoneal fluid.

Factors affecting ENSO predictability in a linear empirical model of tropical air-sea interactions.

Understanding and extending the predictability of El Niño‒Southern Oscillation (ENSO) has been an important research topic because of ENSO's large influence on global weather and climate. Here, we develop an empirical model of tropical atmosphere-ocean interactions that has high ENSO prediction skill, comparable to the skills of well performing dynamical models. The model is used to investigate the effects of the main atmosphere-ocean interaction processes-thermocline and zonal wind feedbacks and zonal wind forcing-on its ENSO predictability. We find that all these processes significantly affect ENSO predictability and extend the predictability limit by up to four months, with the largest effect coming from the thermocline feedback followed by the total zonal wind forcing. The other processes with progressively smaller effects are the external zonal wind forcing and zonal wind feedback. The two most influential processes, however, affect ENSO predictability in the VAR model differently. The thermocline feedback improves the forecast skill by predominantly maintaining the correct phase, whereas the total zonal wind forcing improves the skill by maintaining the correct amplitude of the forecast ENSO events. This result suggests that the dynamical seasonal prediction models must have good representations of the major ENSO processes to make skilful ENSO predictions.

Distribution of candidemia in Malaysian tertiary care hospital revealed predominance of Candida parapsilosis.

Candida parapsilosis is an important pathogen of healthcare-associated bloodstream infections (BSI) causing high mortality and morbidity in immunocompromised patients in addition to other Candida species including C. albicans, C. tropicalis, C. glabrata, and C. krusei. Knowledge on recent local species distribution and trend is essential. An increase in the proportion of C. parapsilosis candidemia has been recently observed as a result of many risk factors. The distribution of candidemia has been changing in the last three decades. To determine the proportion of different Candida species causing candidemia in a tertiary-care hospital during January 2001 - December 2018, a retrospective study performed in a 853-bedded tertiary-care hospital in north-eastern Malaysia. All cases of candidemia from January-2001 to December-2018 were included, and the review was performed based on patients' medical records and laboratory database. The frequency of different Candida species was determined. This study showed that out of 1175 patients with candidemia, C. parapsilosis was the most common species contributing to 29.2% (343/1175) of candidemia, followed by C. albicans 20.1% (236/1175), C. tropicalis 18.7% (220/1175), C. glabrata 6.0% (71/1175), C. guilliermondii 3.7% (43/1175), C. rugosa 1.9% (22/1175), C. famata 1.7% (20/1175), C. krusei 1.4% (16/1175), C. dubliniensis 0.8% (9/1175), C. lusitaniae 0.7% (8/1175), C. lipolytica 0.3% (4/1175), C. pelliculosa 0.3% (4/1175), C. haemulonii, C. kefyr, C. utilis and C. inconspicua (1/1175 each). In addition, 14.9% (175/1175) belonged to Candida spp. which were not identified to species level. In conclusion, a different scenario for the proportion of Candida species with C. parapsilosis predominates over C. albicans as a nosocomial pathogen leading to candidemia has been shown in this study.

Reduced susceptibility of Burkholderia pseudomallei following exposure to carbapenem.

Reduced susceptibility in Burkholderia pseudomallei during carbapenem therapy may lead to treatment failure. We isolated a clinical strain that had developed reduced susceptibility to carbapenems while on treatment. After reviewing the patient's clinical notes, the initial isolate (BUPS01/14) was exposed to carbapenem in vitro to mimic the clinical scenario. The stability of susceptibility of the carbapenem-exposed strain (BUPS01/14R) was examined by serial subculture in antibiotic-free broth. Biochemical and morphological comparison was performed by the VITEK® system and electron microscopy. MICs increased 32-fold following carbapenem exposure and became stable in the antibiotic-free environment. On electron microscopic examination, the BUPS01/14R cells were smoother and less wrinkled compared to BUPS01/14 cells. This report highlights a potential anti-melioidosis treatment failure due to the emergence of resistance while on carbapenem monotherapy. Further study of this strain is necessary to understand the mechanism of resistance at a molecular level.

Distribution of candidemia in Malaysian tertiary care hospital revealed predominance of Candida parapsilosis

@#. Candida parapsilosis is an important pathogen of healthcare-associated bloodstream infections (BSI) causing high mortality and morbidity in immunocompromised patients in addition to other Candida species including C. albicans, C. tropicalis, C. glabrata, and C. krusei. Knowledge on recent local species distribution and trend is essential. An increase in the proportion of C. parapsilosis candidemia has been recently observed as a result of many risk factors. The distribution of candidemia has been changing in the last three decades. To determine the proportion of different Candida species causing candidemia in a tertiary-care hospital during January 2001 – December 2018, a retrospective study performed in a 853-bedded tertiary-care hospital in north-eastern Malaysia. All cases of candidemia from January-2001 to December-2018 were included, and the review was performed based on patients’ medical records and laboratory database. The frequency of different Candida species was determined. This study showed that out of 1175 patients with candidemia, C. parapsilosis was the most common species contributing to 29.2% (343/1175) of candidemia, followed by C. albicans 20.1% (236/1175), C. tropicalis 18.7% (220/1175), C. glabrata 6.0% (71/1175), C. guilliermondii 3.7% (43/1175), C. rugosa 1.9% (22/1175), C. famata 1.7% (20/1175), C. krusei 1.4% (16/1175), C. dubliniensis 0.8% (9/1175), C. lusitaniae 0.7% (8/1175), C. lipolytica 0.3% (4/1175), C. pelliculosa 0.3% (4/1175), C. haemulonii, C. kefyr, C. utilis and C. inconspicua (1/1175 each). In addition, 14.9% (175/1175) belonged to Candida spp. which were not identified to species level. In conclusion, a different scenario for the proportion of Candida species with C. parapsilosis predominates over C. albicans as a nosocomial pathogen leading to candidemia has been shown in this study

Reduced susceptibility of Burkholderia pseudomallei following exposure to carbapenem

@#Reduced susceptibility in Burkholderia pseudomallei during carbapenem therapy may lead to treatment failure. We isolated a clinical strain that had developed reduced susceptibility to carbapenems while on treatment. After reviewing the patient’s clinical notes, the initial isolate (BUPS01/14) was exposed to carbapenem in vitro to mimic the clinical scenario. The stability of susceptibility of the carbapenem-exposed strain (BUPS01/14R) was examined by serial subculture in antibiotic-free broth. Biochemical and morphological comparison was performed by the VITEK® system and electron microscopy. MICs increased 32-fold following carbapenem exposure and became stable in the antibiotic-free environment. On electron microscopic examination, the BUPS01/14R cells were smoother and less wrinkled compared to BUPS01/14 cells. This report highlights a potential anti-melioidosis treatment failure due to the emergence of resistance while on carbapenem monotherapy. Further study of this strain is necessary to understand the mechanism of resistance at a molecular level.

Diagnosing and managing diabetic somatic and autonomic neuropathy.

The diagnosis and management of diabetic neuropathy can be a major challenge. Late diagnosis contributes to significant morbidity in the form of painful diabetic neuropathy, foot ulceration, amputation, and increased mortality. Both hyperglycaemia and cardiovascular risk factors are implicated in the development of somatic and autonomic neuropathy and an improvement in these risk factors can reduce their rate of development and progression. There are currently no US Food and Drug Administration (FDA)-approved disease-modifying treatments for either somatic or autonomic neuropathy, as a consequence of multiple failed phase III clinical trials. While this may be partly attributed to premature translation, there are major shortcomings in trial design and outcome measures. There are a limited number of partially effective FDA-approved treatments for the symptomatic relief of painful diabetic neuropathy and autonomic neuropathy.

Knowledge, Attitude and Practice of Bangladeshi Women towards Breast Cancer: A Cross Sectional Study.

In Bangladesh incidence rate of breast cancer was about 22.5 per 100000 females. Breast cancer has been reported as the highest prevalence rate (19.3 per 100,000) among Bangladeshi women between 15 and 44 years of age. For this prevailing situation a cross-sectional study was designed to assess the knowledge, attitude and practices of community-dwelling women in Bangladesh towards breast cancer at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from July 2013 to June 2014. All female participants attending at outpatient department of BSMMU having age more than 20 years and education at least JSC, purposively selected until the sample size achieved 500. Only applying simple cost free method like self breast examination (SBE) and clinical breast examination (CBE) one can asses her breast. Thereby awareness develops regarding her breast so any mass newly appear can be assessed by the lady herself. Early diagnosis of the breast cancer will reduce the burden of treatment cost, mortality & morbidity. Research and development strategy of the project is to enhance the awareness of the community people about breast cancer prevention. Mean age of the study population was 36.16 years. Regarding education nearly 30% (n=150) of them studied up to Junior School, 16% (n=80) respondents completed masters and above remaining in between. Regarding occupation, almost 60% (n=300) were house wife, 32% (n=160) were service holder and only 8% (n=40) of them were students. Knowledge about common female cancer 60% (n=300) were aware about the cervical cancer, 24% (n=120) mentioned breast cancer, 4% (n=20) mentioned ovarian cancer, and 12% (n=60) don't know anything regarding common women cancer. Knowledge about early symptoms of breast cancer, majority of the respondents 66% (n=330) were aware that mass in the breast is the main symptom, 2% (n=10) mentioned pain in breast, 32% (n=160) mentioned that they don't know anything regarding the early symptoms. About the cause of breast cancer 60% (n=300) mentioned that, they don't know anything regarding the cause of breast cancer, 36% (n=180) were aware that non lactation is a cause of breast cancer. About 4% (n=20) of the study population mentioned others, like due to some ones bad did cancer occur as punishment. Knowledge about risk factor of breast cancer, 65% (n=325) have no idea about the risk of breast cancer, 32% (n=160) mentioned few risk factors which have relation with breast cancer and 3% (n=15) did not mention anything. Regarding diagnosis of cancer breast 72% (n=360) mentioned they don't know anything, 16% (n=80) by doing ultra sonogram of breast, 6% (n=30) mentioned about Mammography and 6% (n=30) MRI & others. Regarding screening for prevention of breast cancer 60% (n=300) mentioned that they don't know anything regarding screening. Thirty percent (n=150) were aware that there is screening method but they are not aware specifically regarding this method and they also not aware that breast cancer is a preventable disease. 10% (n=50) were fully aware about screening method like CBE & SBE. About the cause of not seeking medical advice for prevention of Breast cancer, majority of the respondents 40% (n=200) mentioned expenditure problems, 32% (n=160) they don't have any knowledge about this type of medical advice, 8% (n=40) mentioned communication problems and 20% (n=100) others. Regarding Practice of CBE & SBE 68% (n=340) never practice CBE & SBE, 30% (n=150) occasionally practiced CBE & SBE. Only 2% (n=10) mentioned that they were regularly practicing CBE & SBE.

African neuroscience on the global stage: Nigeria as a model.

Of the 572 neuroscience-related studies published in Nigerian from 1996 to 2017, <5% used state-of-the-art techniques, none used transgenic models, and only one study was published in a top-tier journal.

Development and validation of TaqMan real-time PCR for the detection of Burkholderia pseudomallei isolates from Malaysia.

Rapid detection of Burkholderia pseudomallei, the etiologic agent of melioidosis, allows for timely initiation of appropriate treatment and better clinical outcomes. In the current gold standard, the culture method is time consuming and suffers from low sensitivity. Meanwhile, previously reported molecular assays are fast and sensitive, but their performance on isolates from Malaysia, an endemic region of melioidosis is under reported. This study designed oligonucleotides targeting orf2 of Type III secretion system (TTSS) genes cluster for the detection of Malaysian B. pseudomallei isolates and evaluated the assay on 95 local B. pseudomallei strains, 58 other microorganisms and 71 clinical specimens from patients. The developed assay exclusively detected all tested B. pseudomallei isolates with a detection limit of 20 fg per reaction (equivalent to ~2.5 copies). Subsequent testing on clinical samples showed that the assay detected all confirmed specimens with the growth of B. pseudomallei (n = 10/10). None of the negative specimens had a detectable signal of our TTSS-orf2 assay (n = 0/61). In conclusion, the present study provides crucial preliminary data for a subsequent study and should be considered as a potential alternative to current time-consuming culture method for the detection of B. pseudomallei.

Development and validation of TaqMan real-time PCR for the detection of Burkholderia pseudomallei isolates from Malaysia

@#Rapid detection of Burkholderia pseudomallei, the etiologic agent of melioidosis, allows for timely initiation of appropriate treatment and better clinical outcomes. In the current gold standard, the culture method is time consuming and suffers from low sensitivity. Meanwhile, previously reported molecular assays are fast and sensitive, but their performance on isolates from Malaysia, an endemic region of melioidosis is under reported. This study designed oligonucleotides targeting orf2 of Type III secretion system (TTSS) genes cluster for the detection of Malaysian B. pseudomallei isolates and evaluated the assay on 95 local B. pseudomallei strains, 58 other microorganisms and 71 clinical specimens from patients. The developed assay exclusively detected all tested B. pseudomallei isolates with a detection limit of 20 fg per reaction (equivalent to ~2.5 copies). Subsequent testing on clinical samples showed that the assay detected all confirmed specimens with the growth of B. pseudomallei (n = 10/10). None of the negative specimens had a detectable signal of our TTSS-orf2 assay (n = 0/61). In conclusion, the present study provides crucial preliminary data for a subsequent study and should be considered as a potential alternative to current time-consuming culture method for the detection of B. pseudomallei.

Prevalence and characterisation of Staphylococcus aureus causing community-acquired skin and soft tissue infections on Java and Bali, Indonesia.

OBJECTIVES: To define the role of Staphylococcus aureus in community settings among patients with skin and soft tissue infections (SSTI) in Indonesia. METHODS: Staphylococcus aureus were cultured from anterior nares, throat and wounds of 567 ambulatory patients presenting with SSTI. The mecA gene and genes encoding Panton-Valentine leukocidin (PVL; lukF-PV and lukS-PV) and exfoliative toxin (ET; eta and etb) were determined by PCR. Clonal relatedness among methicillin-resistant S. aureus (MRSA) and PVL-positive S. aureus was analysed using multilocus variable-number tandem-repeat analysis (MLVA) typing, and multilocus sequence typing (MLST) for a subset of isolates. Staphylococcal cassette chromosome mec (SCCmec) was determined for all MRSA isolates. Moreover, determinants for S. aureus SSTI, and PVL/ET-positive vs PVL/ET-negative S. aureus were assessed. RESULTS: Staphylococcus aureus were isolated from SSTI wounds of 257 (45.3%) patients, eight (3.1%) of these were MRSA. Genes encoding PVL and ETs were detected in 21.8% and 17.5% of methicillin-susceptible S. aureus (MSSA), respectively. PVL-positive MRSA was not detected. Nasopharyngeal S. aureus carriage was an independent determinant for S. aureus SSTI (odds ratio [OR] 1.8). Primary skin infection (OR 5.4) and previous antibiotic therapy (OR 3.5) were associated with PVL-positive MSSA. Primary skin infection (OR 2.2) was the only factor associated with ET-positive MSSA. MLVA typing revealed two more prevalent MSSA clusters. One ST1-MRSA-SCCmec type IV isolate and a cluster of ST239-MRSA-SCCmec type III were found. CONCLUSIONS: Community-acquired SSTI in Indonesia was frequently caused by PVL-positive MSSA, and the hospital-associated ST239-MRSA may have spread from the hospital into the community.

How to Train to Discharge a Dermatology Outpatient: A Review.

BACKGROUND/AIMS: The decision to discharge is a critical and common outpatient consultation event. However, little guidance exists over how discharge decision-making can be taught. We aimed to provide educational recommendations concerning outpatient discharge decision-making. METHODS: Recommendations were drawn from prior interviews with 40 consultant dermatologists and 56 dermatology outpatients, and from the "traffic light" design discharge information checklist, developed using the Delphi technique. RESULTS: The key strategies to follow to appropriately manage the outpatient discharge process are: to warn patients in advance, to understand patients' agendas, to allow extra time for the discharge process, to prepare patients to self-manage, to provide a "safety net" and provide the GP with a clear management plan. Aspects to be considered include patient mobility, presence of carer, type of employment, diagnostic certainty, and use of the checklist or guidelines. Key training aspects include teaching structured thought processes when discharging, discharging according to context, developing communication and negotiation skills, avoiding decision biases and encouraging good interprofessional collaboration. Training should include the consideration of the possibility of discharge at each consultation. Novel training strategies have been developed on how to appropriately manage the outpatient discharge process, including involving and informing patients. These strategies focus on safe decision-making, being patient-centred and organizing an efficient health care service framework. CONCLUSION: Structured outpatient discharge training for dermatologists is now possible, based on information from detailed doctor- and patient-based qualitative studies.