A Retrospective Analysis of Apheresis Donor Deferral and Adverse Reactions at a Tertiary Care Centre in India.

INTRODUCTION: With increasing demand of platelet component each day, blood bank plays a pivotal role in ensuring supply of safe blood as and when required. Plateletpheresis procedure is a relatively simple, safe and important adjunct to blood bank inventory. However, recruitment of healthy blood donors is a challenge that the health industry is facing today. AIM: To determine the reasons and rates of apheresis donor deferral along with investigation of adverse reactions encountered during the procedure. MATERIALS AND METHODS: Records of single donor apheresis were retrospectively analysed from 1st January 2010 to 31st December 2014. The study was carried out at Blood Bank, Safdarjung Hospital, New Delhi, India. The donor details that were studied included - age, sex, type of donation (voluntary/replacement/ repeat), reason for donor deferral and type of adverse reaction, if encountered during the procedure. RESULTS: Among the 478 donors screened for plateletpheresis procedure during a study period of 5 years, 134 (28.03%) were deferred. Temporary deferrals accounted for majority (93.28%) of the deferrals. Low platelet count (50.75%) was the main reason of donor deferral followed by low haemoglobin (20.89%). Amongst the 344 selected donors, 15 (4.36%) had some type of adverse reaction associated with the procedure. CONCLUSION: We suggest that the selection criteria for plateletpheresis donors should be revised to deal with shortage of apheresis donors. The criteria regarding minimum pre-procedure platelet count (above1.5 lac/µl) and haemoglobin (above 12.5 g/dl) need to be lowered so as to suit the Indian scenario. The lower adverse reaction rates, 14/344 (4.06%) associated with this procedure encourages safety of donors and is important in recruitment of new donors.

Asymptomatic reproductive tract infections/sexually transmitted infections among HIV positive women.

This study aims to highlight the importance of screening all HIV positive women for various reproductive tract infections/sexually transmitted infections (RTIs/STIs) irrespective of symptoms and to determine its occurrence in asymptomatic HIV positive women. Relevant specimens were collected for diagnosis of various RTIs/STIs. STIs were diagnosed in nearly one-third of the HIV positive asymptomatic patients which is quite high. The national strategy for STIs/RTIs control misses out large number of asymptomatic RTIs/STIs in HIV positive women which is responsible for silently transmitting these infections in the community. So this strategy should be modified to include screening of all HIV positives women irrespective of symptoms of STIs/RTIs.

Rising trend of antimicrobial resistance among Neisseria gonorrhoeae isolates and the emergence of N. gonorrhoeae isolate with decreased susceptibility to ceftriaxone.

CONTEXT: Gonorrhoea is one of the most common sexually transmitted infections (STI) in developing countries and is a global health problem. AIMS: To analyze the trend of antimicrobial susceptibility of Neisseria gonorrhoeae isolates over the years, in a tertiary care hospital of North India. SETTINGS AND DESIGN: The study population comprised males with urethritis and females with endocervicitis attending STI clinic of our hospital. MATERIALS AND METHODS: In our STI laboratory, all gonococcal isolates are subjected to antimicrobial susceptibility testing by disc diffusion method as per CLSI guidelines. ß-Lactamase production is determined by chromogenic cephalosporin test. Minimum Inhibitory Concentration (MIC) for ceftriaxone is determined by E-test. STATISTICAL ANALYSIS USED: Data were expressed as percentages. The differences in percentages were tested for statistical significance by using χ2 test and P values were determined. RESULTS: The percentage of penicillinase producing N. gonorrhoeae (PPNG) increased from 8% in 1995-96 to 20% in 2004-05 and 88% in 2011-2013. Quinolone-resistant N. gonorrhoeae (QRNG) showed a significant increase from 12% in 1995-96 to 98.3% in 2004-05, while 84% isolates were found to be QRNG by 2011-2013. In January 2013 we detected our first gonococcal isolate with decreased susceptibility to third-generation cephalosporins; Ceftriaxone, Cefixime and Cefpodoxime (MIC for ceftriaxone = 0.19 µg/ml). CONCLUSIONS: The results of our study highlighted an alarming increase in the percentage of PPNG and QRNG strains over the years. Emergence of N. gonorrhoeae isolates with decreased susceptibility to third-generation cephalosporins is a cause of concern and thus emphasises the importance of antimicrobial susceptibility testing.

Medicinal plants of the family Caryophyllaceae: a review of ethno-medicinal uses and pharmacological properties.

Several species of the family Caryophyllaceae are widely used by many ethnic communities as traditional medicine throughout the world. The highest number of plants of the family are used in Chinese traditional medicine. The ethnopharmacologial studies of this family indicate that plants of the family possess anticancer, antibacterial, antifungal, antiviral, antioxidant, and anti-inflammatory properties. Other miscellaneous properties reported are ribosome inactivation properties, inhibition of prostatic enlargement in rats, and inhibition of intestinal enzyme carboxyelasterase in rats, cerebro-protective activity, and antiobesity in rats. Few reviews have been published yet, providing information regarding medicinal plants of the family and their biomedical properties. All published reviews have focused either on a particular taxa or a few species. The present review is focused on the traditional medicinal uses of the plants of the family Caryophyllaceae along with phytochemical and pharmacological studies of the family. A study of the literature revealed significant traditional medicinal importance of the family. Major chemical constituents of Caryophyllceae are saponins, Phytoecdysteroids, benzenoids, phenyl propanoids, and nitrogen containing compounds. The most important property of plants of the family is anticancer activity and is shown by the large number of plant species studied. This review of traditional medicinal and pharmacological uses of plants of the family, provide a ground for future research in the family.

Synthesis, characterization and in vitro anticancer activity of C-5 curcumin analogues with potential to inhibit TNF-α-induced NF-κB activation.

In a search of new compounds active against cancer, synthesis of a series of C-5 curcumin analogues was carried out. The new compounds demonstrated good cytotoxicity against chronic myeloid leukemia (KBM5) and colon cancer (HCT116) cell lines. Further, these compounds were found to have better potential to inhibit TNF-α-induced NF-κB activation in comparison to curcumin, which show their potential to act as anti-inflammatory agents. Some compounds were found to show higher cytotoxicity against cancer cell lines in comparison to curcumin used as standard.

Emergence of pandemic 2009 influenza A H1N1, India.

BACKGROUND & OBJECTIVES: Pandemic H1N1 caused deluge of cases from 74 countries and prompted World Health Organization to raise warning to phase 6. The present study was conducted on throat and nasal swab samples received and tested at National Centre for Disease Control, Delhi, India during 2009-2010 to collect epidemiological and clinical information on positive cases. METHODS: Throat and nasopharyngeal swabs from category C influenza A H1N1 patients during May 2009-September 2010 along with their clinico-epidemiological details were collected from identified hospitals from Delhi and other States. Samples were tested by Real time reverse transcriptase PCR using primers and probes developed at CDC, Atlanta for four influenza target genes. RESULTS: A total of 33,751 samples, both throat and nasal swab samples from each patient were tested for H1N1 influenza virus, of which, 7943 (23.5%) were positive for pandemic influenza A H1N1 and 3759 (11.1%) were positive for influenza A (seasonal flu). Maximum number of positive cases (N=2792, 35.1%) were from 20-39 yr age group, comprising 1790 (22.5%) males and 1182 (14.8%) females. Only 2620 (33%) positive cases were close contact of influenza A H1N1 positive patient. Majority cases presented (N=2792, 35.1%) with fever 7005 (88.1%), followed by 6133 cases (77.2%) exhibiting fever and cough, 377 (4.7%) complained of fever, cough, nasal catarrh and 362 (4.5%) cases had fever with shortness of breath. INTERPRETATION & CONCLUSIONS: The study showed a peak of cases of pandemic influenza A H1N1 in December 2009 and indicated predominance of H1N1 positive cases among 20-39 yr age group and among males compared to females.

Genetic analysis of precore/core and partial pol genes in an unprecedented outbreak of fulminant hepatitis B in India.

We investigated an unprecedented outbreak of fulminant hepatitis B virus (HBV) that occurred in Modasa, Gujarat (India) in 2009. Genomic analysis of all fulminant hepatic failure cases confirmed exclusive predominance of subgenotype D1. A1762T, G1764A basal core promoter (BCP) mutations, insertion of isoleucine after nt 1843, stop codon mutation G1896A, G1862T transversion plus seven other mutations in the core gene caused inhibition of HBeAg expression implicating them as circulating precore/BCP mutant virus. Two rare mutations at amino acids 89 (Ile→Ala) and 119 (Leu→Ser) in addition to other mutations in the polymerase (pol) gene may have caused some alteration in either of four pol gene domains to affect encapsidation of pregenomic RNA to enhance pathogenicity. Sequence similarity among patients' sequences suggested an involvement of a single hepatitis B mutant strain/source to corroborate the finding of gross and continued usage of HBV mutant-contaminated syringes/needles by a physician which resulted in this unprecedented outbreak of fulminant hepatitis B. The fulminant exacerbation of the disease might be attributed to mutations in the BCP/precore/core and pol genes that may have occurred due to selection pressure during rapid spread/mutation of the virus.

Correlation of partial env gene sequences with disease progression parameters in HIV-positive pregnant women from India.

Ever since the beginning of the epidemic of HIV, one of the poignant aspects of HIV infection is transmission of the virus from mother to child. It is not known whether pregnancy accelerates the progression of HIV infection from a clinically asymptomatic stage to a progressive clinical phase. Present study was carried out to understand disease progression in pregnant women from India. We studied co-receptor utilization (the major determinant of HIV disease progression), N-glycosylation sites, and sequence variability. Blood samples were collected from 25 HIV sero-positive patients, eleven from the antenatal risk group (experimental group), nine from heterosexual male, and five from heterosexual female risk group (control group). Partial env gene was amplified by PCR and sequenced. BLAST search and phylogenetic analysis were used to determine the subtype. The deduced amino acid sequence of the V3 region was used to predict co-receptor, determine sequence variability and N-glycosylation site. The experimental group comprising the antenatal risk group did not exhibit any difference in terms of co-receptor, N-glycosylation, and sequence variability when compared with the control, non-pregnant group. Pregnancy does not seem to accelerate the clinical course of HIV infection. The female body during the gestation phase possibly acquires certain strategies to impede or at least alleviate the disease progression during the crucial immune-compromised pregnancy phase, which would otherwise adversely affect the mother as well as the fetus during the infection.

The first dominant co-circulation of both dengue and chikungunya viruses during the post-monsoon period of 2010 in Delhi, India.

Independent outbreaks of dengue virus (DENV) infection and sporadic cases of chikungunya virus (CHIKV) have been recorded in the metropolitan city of Delhi on several occasions in the past. However, during a recent 2010 arboviral outbreak in Delhi many cases turned negative for DENV. This prompted us to use duplex reverse transcriptase-polymerase chain reaction (D-RT-PCR) to establish the aetiology of dengue/chikungunya through sequencing of CprM and E1 genes of dengue and chikungunya viruses. Interestingly, for the first time, both DENV and CHIKV co-circulated simultaneously and in equally dominant proportion during the post-monsoon period of 2010. DENV-1 genotype III and the East Central South African genotype of CHIKV were associated with post-monsoon spread of these viruses.

Development of TaqMan real-time polymerase chain reaction for the detection of the newly emerging form of carbapenem resistance gene in clinical isolates of Escherichia coli, Klebsiella pneumoniae, and Acinetobacter baumannii.

PURPOSE: The newly emerging form of the so-called New Delhi Metallo-beta-lactamases (NDM-1) has been reported recently from patients worldwide and broadly thought as a potential source for the major global health problem. Thus, it is important to study the epidemiology of the so-called NDM-1 harbouring bacteria to prevent its further spread and to place effective control measures. The present study describes the use of the real-time polymerase chain reaction (PCR) assay for the detection of the bla NDM-1 gene using TaqMan probes among clinical isolates. MATERIALS AND METHODS: Clinical isolates of Escherichia coli (11 strains), Klebsiella pneumoniae (17 strains) and Acinetobacter baumannii (six strains) that were resistant to either of the carbapenems (meropenem or imipenem) were included in the study. The presence of carbapenemases in such strains was confirmed using the modified Hodge test. A real-time PCR assay was optimized for the detection of NDM-1 using a cloned synthetic gene fragment followed by testing of the clinical isolates. The findings were further confirmed using PCR and gene sequencing. RESULTS: TaqMan probe assay displayed a good detection limit with analytical sensitivity of the assay up to 10 copies of bla NDM-1 gene per reaction. The isolates of E. coli and K. pneumoniae revealed narrow range crossing point values (Cp values) between (12-17) cycles (mean Cp value 14), indicating number of bla NDM-1 gene copies of 106-108. The wider range of Cp values (15-34) cycles with a higher mean Cp value (23.6) was observed in A. baumannii with number of bla NDM-1 gene copies of 103-108. CONCLUSIONS: The study demonstrates that real-time PCR assay based on TaqMan chemistry is a useful technique for the detection of bla NDM-1 harbouring clinical isolates of E. coli, K. pneumoniae and A. baumannii. The assay has great precision in measuring the number of bla NDM-1 gene copies per specimen of DNA.

Assessment of trends of ofloxacin resistance in Mycobacterium tuberculosis.

PURPOSE: Ofloxacin (OFX) is one of the potent fluoroquinolone (FQ) recommended to treat MDR-TB. Over a decade, the preexposure of this drug for the treatment of other bacterial infections has resulted in acquisition of FQ resistance among Mycobacterium tuberculosis strains. Considering this possibility, a study was undertaken in a tertiary care center in the capital city (India) to assess the drug resistance trends of OFX among susceptible and multidrug resistant (MDR) strains of M. tuberculosis. MATERIALS AND METHODS: A total of 102 M. tuberculosis isolates (47 susceptible to first-line drugs and 55 MDR isolates) were screened for susceptibility testing of OFX with a critical concentration of 2 µg/ml by Lowenstein Jensen (LJ) proportion method. RESULTS: The results showed 40 (85.1%) isolates among 47 susceptible isolates and 34 (61.8%) isolates among 55 MDR isolates, were found to be susceptible to OFX. Fisher's exact test showed significant P-value (0.0136) demonstrating 1.377 fold (95% confidence interval) increased risk to become resistant to OFX than susceptible isolates. These finding shows decreased OFX susceptibility is not only limited to MDR isolates but also increasingly seen in susceptible strains as a result of drug abuse. CONCLUSIONS: Our finding were not alarming, but highlights the general risk of acquiring resistance to OFX, jeopardizing the potential for these drugs to be used as second-line anti-TB agents in the management of drug-resistant TB and creating incurable TB strains .

Medicinal chemistry perspectives of trioxanes and tetraoxanes.

Trioxane based compounds such as artemisinin and its synthetic and semi-synthetic analogues constitute promising class of antimalarial agents. The pharmaceutical development of artemisinin was started in 1971 after the isolation from Chinese medicinal plant Artemisia annua and this compound has drawn much attention from medical chemist and pharmacologist worldwide. Researchers from across the globe have independently and collaboratively conducted various studies on the artemisinin system in an attempt to identify lead molecules for malaria chemotherapy. This systematic study led to the discovery of artemether, arteether, dihydroartemisinin, and sodium artesunate which are being used as antimalarial drug for the treatment of Plasmodium falciparum related infections. These studies also revealed that the trioxane bridge is essential for the antimalarial activity of this class of compounds. Another class of structurally simple peroxides that emerged from these studies was the 1,2,4,5-tetraoxanes. Some of the tetraoxane based compounds have shown promising antimalarial potential, and much of work has been done on this type of compound in recent years. Apart from their antimalarial activity, these classes of compounds have also shown promising anticancer and antibacterial activity. To this end, an attempt has been made to describe the medicinal potential of trioxane and tetraoxane-based compounds. Literature from 1999 has been critically reviewed and an attempt has been made to discuss structure activity relationship study among the series of trioxane and tetraoxane based compounds.

Blood tests and histological correlates in children with eosinophilic oesophagitis.

AIM: To determine the relationship between blood tests and oesophageal histology in Eosinophilic oesophagitis (EoE). METHODS: All children diagnosed with EoE at one hospital from 2000 to 2009 were considered for inclusion in this study. Three blood test results were analysed, blood eosinophil count, serum total immunoglobulin E (IgE) and radioallergosorbent tests (RAST) to common food allergens. Oesophageal histology was prospectively re-reviewed, and mean eosinophil counts were enumerated. Blood test results were correlated with oesophageal eosinophil counts using Spearman's rank test. RESULTS: Forty children (70% boys) were included in this study, median age at diagnosis 6.5 years (range 0-15). At the time of diagnosis, 78% of children had a raised blood eosinophil count, 90% had a raised serum total IgE and 83% had one or more positive RAST tests. The mean oesophageal eosinophil count was significantly correlated with both blood eosinophil count (p=0.008) and serum total IgE level (p=0.008). CONCLUSION: This study shows that blood tests are often abnormal in children with EoE at the time of diagnosis. Our data demonstrate an association between histological abnormalities and blood test results in children with EoE.

Pandemic Influenza A (H1N1) 2009 in India: duration of virus shedding in patients under antiviral treatment.

BACKGROUND: National Centre for Disease Control (NCDC), Delhi, is a national nodal centre for surveillance of pandemic Influenza A (H1N1) in India. The present study was undertaken to see the period of infectivity in positive cases undergoing antiviral therapy. OBJECTIVE: To assess the duration of virus shedding by real-time polymerase chain reaction (real-time PCR) in some of the positive patients taking Oseltamivir treatment. MATERIALS AND METHODS: Clinical samples (throat swabs, nasal swabs and nasopharyngeal swabs) collected by the clinicians from patients quarantined in government hospitals in different parts of India are being sent to the designated reference laboratory at Delhi for screening presence of pandemic Influenza virus. The samples are tested by Real-Time PCR using CDC recommended reagents and protocol for confirmation of the H1N1 novel influenza virus. In 150 of the positive cases, we requested the clinicians to send samples for 5 consecutive days after administration of antiviral therapy, to see the trend of therapy response on viral shedding. Samples for more than 5 days were received from patients till they showed no amplification for any of the three target genes (Influenza A, Swine Influenza A or Swine H1). RESULTS AND CONCLUSION: In 99.33% (149/150) cases, the influenza infection resolved within 10 days. Sixty-four percent (96/150) of the positive patients turned negative within 5 days of the start of antiviral treatment. Only one patient belonging to high risk group showed prolonged virus shedding (19 days).

Modified method of T-tube placement in cases of ruptured choledochal cyst having complete loss of anterior wall.

Survival rates for infants and children who have choledochal cyst with or without spontaneous rupture have improved dramatically in the past decades. Despite excellent long-term survival for patients with choledochal cyst who undergo elective surgery, many significant complications can occur in the patients being operated in emergency for rupture of the cyst. Spontaneous rupture of the cyst is one such problem resulting in considerable morbidity and mortality in these patients. Majority of surgeons manage these cases with T-tube external drainage. The conventional methods of T-tube placement for long period has remained simple as described in choledochotomies where there is no deficit of the walls of common bile duct (CBD). The present technique has been designed specially for the cases of ruptured choledochal cyst, where the wall of the CBD gets necrosed leaving behind a long gap between the two ends. In these cases, placement of T-tube with conventional method is not possible because there is no wall to suture together, and make the CBD water tight again to prevent leakage of bile. We found only two patients of spontaneous rupture of choledochal cyst with a long gap between two ends of CBD because of necrosed anterior wall. In both of these patients, it was not possible to put T-tube with traditional method and one would have to opt for primary definitive repair despite poor general condition of patients.

UK incidence of achalasia: an 11-year national epidemiological study.

AIM: To determine the incidence and examine the epidemiology of achalasia before the age of 16 years in the UK from 1998 to 2008. METHODS: 25 regional paediatric surgery referral centres were asked to provide demographic and epidemiological data on cases of childhood achalasia from 1998 to 2008. Incidence rates were calculated from national population estimates. The data collection method was validated in one centre. RESULTS: 228 patients from 24 centres were diagnosed with achalasia before 16 years in the UK from 1998 to 2008. The mean incidence from 1998 to 2008 was 0.18/10(5) children/year. Where additional data was provided (69-81% of cases) 56% of children were male and the mean age of diagnosis was 10.9 years. Logistic regression analysis showed a rising incidence, with an OR of 1.12 (95% CI 1.06 to 1.16) for having achalasia in each successive year. The validation of this methodology showed that 95% of true cases and no false cases were identified. CONCLUSIONS: The mean incidence of childhood achalasia in the UK from 1998 to 2008 is at least 0.18/10(5) children/year; this has risen over the last 11 years and compared to the only other study published in 1988.

Evaluation of nucleic acid probe for rapid identification of Mycobacterium tuberculosis complex in extra-pulmonary culture isolates.

Patients infected with Non-tuberculous mycobacteria (NTM) usually do not respond to conventional anti-tubercular treatment and are misdiagnosed as infection with multi-drug resistant strains of mycobacterium tuberculosis (M.tb) due to lack of correct species identification, particularly in the developing countries like India. One of the challenges faced by clinicians in the treatment of tuberculosis is the absence of an easy, reliable and rapid identification tool that can accurately differentiate disease caused by M.tb complex from NTM. Keeping this in consideration, the performance of species specific nucleic acid probe i.e. Accuprobe was assessed and compared with conventional niacin production, nitrate reductase assay techniques for identification of M.tb complex in 80 mycobacterial isolates obtained from different extra-pulmonary sites. Accuprobe identified 62 isolates (77.5%) as M. tuberculosis complex and remaining 18 isolates (22.5%) as NTM whereas 64 isolates (80%) were identified as M.tb and rest 16 (20%) were interpreted as NTM by conventional biochemical techniques. The overall agreement between both techniques was 96.9% The sensitivity, specificity, positive predictive value(PPV) and negative predictive value (NPV) shown by accuprobe were 96.9%, 100%, 96.9%, and 88.9% respectively. Thus, accuprobe has showed impressive sensitivity and specificity giving results in < 3 hrs from culture-positive isolates and have sure edge over conventional biochemical methods which are, nonetheless, labour intensive and cumbersome to perform thus delaying prompt mycobacterial identification.

Development and validation of a disease-specific quality-of-life measure for children with achalasia.

BACKGROUND: Achalasia is an uncommon oesophageal motility disorder occasionally affecting children. Children with achalasia can experience significant morbidity, and quality-of- life (QoL) has never been studied in this population. AIM: The aim was to develop a disease-specific quality-of-life (DS-QoL) measure for children with achalasia. METHODS: Item response theory methods were used to develop the DS-QoL measure. The construct validity of this measure was assessed by comparing items and domains with the generic PedsQL questionnaire. Reliability was assessed using Cronbach's alpha coefficient for internal consistency. RESULTS: 17 children completed the final DS-QoL measure, which consisted of 20 items in three domains. The completion rate for items was 99%. "Floor and ceiling effects" ranged from 0-19%. Construct validity was good with significant correlation between 2 domains and 2 items on the PedsQL. Reliability was excellent, with Cronbach's alpha coefficient ranging from 0.78-0.93. CONCLUSIONS: This DS-QoL measure is appropriate for use in children with achalasia and has shown good results in this validation study. Further work in higher numbers is necessary to determine discriminant validity and test-retest reliability.

The use of E-test for the drug susceptibility testing of Mycobacterium tuberculosis - a solution or an illusion?

AIM: To evaluate E-test as a tool for rapid determination of drug susceptibility against the conventional LJ method focusing on reliability, expense, ease of standardization and performance of the technique in low resource settings. MATERIALS AND METHODS: A total of 74 clinical isolates (2004-2005) of Mycobacterium tuberculosis were tested using E-test for susceptibility to streptomycin (STM), isoniazid (INH), rifampicin (RIF) and ethambutol (EMB) by E-strip and LJ (LJPM) proportion methods. RESULTS: The LJPM method, the gold standard, detected resistance against STM in 16.2%, INH in 40.5%, RIF in 18.9% and EMB in 27% cases. In comparison, the resistance values showed by E-test was 66.67% for STM, 57.14% for INH 71.43% for RIF and 80% for EMB. The susceptible correlation was 90.32% for STM, 73.91% for INH, 93.33% for RIF and 59.26% for EMB. E-test correctly identified only eight of the 12 (66.6%) MDR isolates and wrongly identified four isolates which were not MDR. The overall agreement between the two methods was only 48.6%. Resistant isolates showed false positive resistance observed while using E-strip towards all the drugs. CONCLUSION: E-strips are not quite feasible as a replacement for LJ-proportion method on a large scale due to high risk of cross contamination, laboratory infection, expense associated with it and high false positive resistance observed to all first line drugs. However, the good correlation observed for RIF between the two methods indicates that E-test could contribute to the role in rapid screening of MDR TB isolates as rifampicin mutations are invariably observed in MDR TB isolates.