Proband only exome sequencing in 403 Indian children with neurodevelopmental disorders: Diagnostic yield, utility and challenges in a resource-limited setting.

Whole exome sequencing is recommended as the first tier test for neurodevelopmental disorders (NDDs) with trio being an ideal option for the detection of de novo variants. Cost constraints have led to adoption of sequential testing i.e. proband-only whole exome followed by targeted testing of parents. The reported diagnostic yield for proband exome approach ranges between 31 and 53%. Typically, these study designs have aptly incorporated targeted parental segregation before concluding a genetic diagnosis to be confirmed. The reported estimates however do not accurately reflect the yield of proband only standalone whole -exome, a question commonly posed to the referring clinician in self pay medical systems like India. To assess the utility of standalone proband exome (without follow up targeted parental testing), we retrospectively evaluated 403 cases of neurodevelopmental disorders referred for proband-only whole exome sequencing at Neuberg Centre for Genomic Medicine (NCGM), Ahmedabad during the period of January 2019 and December 2021. A diagnosis was considered confirmed only upon the detection of Pathogenic/Likely Pathogenic variants in concordance with patient's phenotype as well as established inheritance pattern. Targeted parental/familial segregation analysis was recommended as a follow up test where applicable. The diagnostic yield of the proband-only standalone whole exome was 31.5%. Only 20 families submitted samples for follow up targeted testing, and a genetic diagnosis was confirmed in twelve cases increasing the yield to 34.5%. To understand factors leading to poor uptake of sequential parental testing, we focused on cases where an ultra-rare variant was detected in hitherto described de novo dominant neurodevelopmental disorder. A total of 40 novel variants in genes associated with de novo autosomal dominant disorders could not be reclassified as parental segregation was denied. Semi-structured telephonic interviews were conducted upon informed consent to comprehend reasons for denial. Major factors influencing decision making included lack of definitive cure in the detected disorders; especially when couples not planning further conception and financial constraints to fund further targeted testing. Our study thus depicts the utility and challenges of proband-only exome approach and highlights the need for larger studies to understand factors influencing decision making in sequential testing.

Relative risk of postpartum maternal morbidity among cesarean-delivered women: A multisite prospective cohort study in a large district, India.

Introduction: Family doctors manage mild to moderate postpartum morbidities that do not receive attention. The morbidities are higher after cesareans, which are increasing in number. The aim was to calculate the relative risk of various maternal morbidities occurring during 6 months postpartum among cesarean-delivered women in Pune District, India. Material and Methods: This was a large multisite study, which included all 11 non-teaching government hospitals performing at least five cesarean sections per month, one teaching government hospital, and one private teaching hospital. All eligible cesarean delivered and an equal number of age and parity matched vaginally delivered women were the participants. The obstetricians interrogated women before discharge, after 4 weeks, 6 weeks, and 6 months. Results: In this study 3,112 women participated. At any visit and among any group lost to follow-up proportion was <10%. There was no major intra-operative complication among vaginally delivered women. The relative risks of acute and severe morbidity as intensive care unit admission and blood transfusion among cesarean-delivered women were 2.59 [95% confidence interval (CI) = 1.96 to 3.44], 4.33 (95% CI = 2.17 to 8.92), respectively. The adjusted relative risk of surgical site pain and infection at 4 weeks; surgical site pain at 6 weeks; and lower abdominal pain, breast engorgement/mastitis, urinary incontinence, and weakness at 6 months among cesarean-delivered women was higher (P < 0.05). Vaginally delivered women resumed family activities earlier. Conclusion: Health care workers, including family doctors, during follow-up of cesarean-delivered women, must assess for pain, induration/discharge at the surgical site, urinary incontinence, and breast engorgement/mastitis.

Assessment of difference in postpartum depression among caesarean and vaginally delivered women at 6-week follow-up in hospitals in Pune District, India: an observational cohort study.

OBJECTIVES: To compare the proportion of postpartum depression at 6 weeks among women who had caesarean delivery and women who had vaginal delivery and to assess its association with some sociodemographic factors. DESIGN: This is a descriptive comparative study with prospective enrolment. We followed the enrolled women and assessed them for postpartum depression 6 weeks after delivery. SETTING: We conducted the study in Pune District, India from July 2017 to December 2018. The study sites were all non-teaching government hospitals performing five or more caesarean sections per month and two teaching hospitals: one government and one private. PARTICIPANTS: We included in the study group women who have undergone caesarean section in the participating hospitals and were residents of Pune District. Women who delivered vaginally and matched in age and parity were included in the comparison group. We followed 1556 women in each group. MAIN OUTCOME MEASURES: An Edinburgh Postnatal Depression Scale score of 10 or more for each woman was the primary outcome. χ2 test and multivariable binary logistic regression were performed to assess the effect of mode of delivery on postpartum depression. RESULTS: The proportion of postpartum depression at 6 weeks was 3.79% among women who had caesarean delivery and 2.35% among those who had vaginal delivery (χ2=4.50, p=0.03). The adjusted OR was 1.86 (95% CI 1.14 to 3.03). Women of age less than 25 years had higher risk of postpartum depression. The adjusted OR was 2.10 (95% CI 1.21 to 3.65). The study did not observe any association between postpartum depression and income, education, occupation or sex of the newborn child. CONCLUSIONS: We conclude that young women particularly those who had caesarean delivery should be screened 6 weeks after delivery.

Risk of non-resumption of vaginal sex and dyspareunia among cesarean-delivered women.

CONTEXT: Many women have postpartum sexual dysfunction. The mode of delivery is an important determinant. AIMS: To calculate the risk ratio of non-resumption of vaginal sex and dyspareunia during the postpartum period among cesarean-delivered women. SETTINGS AND DESIGN: This large multisite study was conducted in 13 selected hospitals in Pune District during 2017-19. METHODS AND MATERIAL: A total of 3,112 women (half cesarean delivered and half vaginally) were interviewed by trained health workers using a structured questionnaire. Women were interviewed at 4 weeks, 6 weeks, and 6 months. STATISTICAL ANALYSIS USED: Chi-square test was applied. A risk ratio with a 95% confidence interval was calculated. RESULTS: At 6 weeks, the risk ratio of non-resumption of vaginal sex was significantly high among cesarean-delivered participants (1.14). Cesarean-delivered women had a lesser risk ratio of dyspareunia at both follow-ups (0.59, 0.49). Even at 6 months, about one-third vaginally delivered women had dyspareunia. The proportion of women non-resuming vaginal sex gradually decreased from 6 weeks to 6 months. The proportion of women having dyspareunia also decreased from 6 weeks to 6 months following childbirth. Residence in the rural area and cesarean delivery were the significant determinants of an early resumption of vaginal sex. Dyspareunia was significantly high among vaginal delivered than cesarean. About 25% of women continued to have dyspareunia up to 6 months. CONCLUSIONS: A large number of women suffer from dyspareunia; hence antenatal and postnatal care should include some counseling and management about the resumption of sex and dyspareunia.

Stratified sero-prevalence revealed overall high disease burden of dengue but suboptimal immunity in younger age groups in Pune, India.

BACKGROUND: In India, dengue disease is emerging as the most important vector borne public health problem due to rapid and unplanned urbanization, high human density and week management of the disease. Clinical cases are grossly underreported and not much information is available on prevalence and incidence of the disease. METHODOLOGY: A cross sectional, stratified, facility based, multistage cluster sampling was conducted between May 4 and June 27, 2017 in Pune city. A total of 1,434 participants were enrolled. The serum samples were tested for detection of historical dengue IgG antibodies by ELISA using the commercial Panbio Dengue IgG Indirect ELISA kit. Anti-dengue IgG-capture Panbio ELISA was used for detection of high titered antibodies to detect recent secondary infection. We used this data to estimate key transmission parameters like force of infection and basic reproductive number. A subset of 120 indirect ELISA positive samples was also tested for Plaque Reduction Neutralizing Antibodies for determining serotype-specific prevalence. FINDINGS: Overall, 81% participants were infected with dengue virus (DENV) at least once if not more. The positivity was significantly different in different age groups. All the adults above 70 years were positive for DENV antibodies. Over 69% participants were positive for neutralizing antibodies against all 4 serotypes suggesting intense transmission of all DENV serotypes in Pune. Age-specific seroprevalence was consistent with long-term, endemic circulation of DENV. There was an increasing trend with age, from 21.6% among <36 months to 59.4% in age group 10-12 years. We estimate that 8.68% of the susceptible population gets infected by DENV each year resulting into more than 3,00,000 infections and about 47,000 to 59,000 cases per year. This transmission intensity is similar to that reported from other known hyper-endemic settings in Southeast Asia and the Americas but significantly lower than report from Chennai. CONCLUSIONS: Our study suggests that Pune city has high disease burden, all 4 serotypes are circulating, significant spatial heterogeneity in seroprevalence and suboptimal immunity in younger age groups. This would allow informed decisions to be made on management of dengue and introduction of upcoming dengue vaccines in the city.

Various indications for a modified Atkins diet in intractable childhood epilepsy.

PURPOSE: We reviewed retrospectively our experiences with children with intractable epilepsy who were indicated for a modified Atkins diet (MAD). METHODS: Twenty children (8 female, 12 male) who were aged 2-17 years with intractable epilepsy and tried the MAD between September 2008 and December 2010 were enrolled. Outcome measures included seizure frequency, adverse reactions and tolerability of the diet. RESULTS: Finally 9 patients maintained the MAD with favorable seizure outcomes (a reduction of seizure frequency by over 50%) or successfully completed the diet therapy. Two patients who required a long-term trial of the diet therapy respectively due to Leigh's syndrome and uncategorized mitochondrial cytopathy derived from cytochrome c oxidase defect, respectively, successfully maintained the diet treatment without any significant complications. In 7 patients, the ketogenic diet (KD) was not only effective but also too restrictive or caused serious unwanted events. Five of them maintained the seizure outcome previously achieved by the KD with the MAD. Ten patients began the MAD because they were reluctant to start the KD. Unfortunately, only 2 patients maintained the MAD with favorable seizure outcomes. One patient who chose the MAD to bridge the KD and complete discontinuation of the treatment successfully completed the diet therapy. CONCLUSION: A long-term treatment with the MAD was well tolerated. Moreover, the MAD can successfully substitute the classic KD in patients who showed improvement in seizure outcomes by the KD but could not tolerate it.

Horizontal Transfer of Antimicrobial Resistance by Extended-Spectrum ß Lactamase-Producing Enterobacteriaceae.

BACKGROUND: The purpose of this work was to study the acquisition of new antibiotic-resistant genes carried by extended spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae via horizontal transfer to understand their rampant spread in the hospitals and in the community. MATERIALS AND METHODS: A retrospective analysis of 120 ESBL screen-positive isolates of Escherichia coli and Klebsiella pneumoniae, which were subjected to antimicrobial susceptibility testing, was carried out. The Double Disc Synergy Test (DDST) and Inhibitor-Potentiation Disc Diffusion Test (IPDD) were employed for confirmation of ESBL activity. The transferability of the associated antibiotic resistance for amoxicillin, amikacin, gentamicin, cefotaxime and ceftriaxone was elucidated by intra- and intergenus conjugation in Escherichia coli under laboratory as well as under simulated environmental conditions. Transformation experiments using plasmids isolated by alkaline lysis method were performed to study the transferability of resistance genes in Klebsiella pneumoniae isolates. RESULTS: ESBL production was indicated in 20% each of the Escherichia coli and Klebsiella pneumoniae isolates. All the ESBL isolates showed co- resistance to various other groups of antibiotics, including 3GC antibiotics, though all the isolates were sensitive to both the carbapenems tested. Conjugation-mediated transfer of resistance under laboratory as well as environmental conditions at a frequency of 3-4 × 10(-5), and transformation-mediated dissemination of cefotaxime and gentamicin resistance shed light on the propensity of ESBL producers for horizontal transfer. CONCLUSIONS: The transfer of resistant markers indicated availability of a large pool of resistance genes in the hospital setting as well as in the environment, facilitating long-term persistence of organisms.

Role of functional groups on Aspergillus niger biomass in the detoxification of hexavalent chromium.

Chromium (VI) contamination is not uncommon, especially near industries involved in leather tanning, chrome painting, metal cleaning and processing, wood preservation and alloy preparation. The mutagenic and carcinogenic properties of Chromium (VI) necessitate effective remedial processes. Difficulties associated with chemical and physical techniques to remediate a Chromium (VI) contaminated site to EPA recommended level (50 ppm), in addition to higher costs involved, assert the need for bioremedial measures. Biosorption can be one such solution to clean up heavy metal contamination. The objective of this study was to examine the main aspects of a possible strategy for the removal of Chromium (VI), employing Aspergillus niger biomass. The roles played by amines, carboxylic acids, phosphates, in Chromium (VI) biosorption were studied. Amino and the carboxy groups on the fungal cell wall play an important role in sorption. However, the role of carboxy group was far less than amino group. Surface adsorption of Chromium (VI) was also seen by scanning electron microscopy (SEM) thus indicating involvement of ion-exchange and surface adsorption mechanism in removal of Chromium (VI) ions.

Mood disorders affect drug treatment success of drug-dependent pregnant women.

This study examined the impact of co-occurring Axis I disorders on drug treatment outcomes of drug-dependent pregnant women. Participants (N = 106) were women who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for opioid dependence and were receiving methadone. Based on DSM-IV Axis I criteria, participants were categorized into three groups: (1) absence of mood/anxiety disorder (ND, n = 29), (2) primary mood disorder (MD, n = 39), or (3) primary anxiety disorder (AD, n = 38). Demographically, the groups were similar. The MD group was significantly more likely to be positive for drugs while in treatment compared with both the ND and AD groups. The MD and AD groups had more psychosocial impairment and higher incidence of suicidal ideation compared with the ND group. Interestingly, the AD group spent more days in treatment compared with the ND or MD group. These findings highlight the need to treat co-occurring Axis I disorders, particularly given the higher relapse risk for those with mood disorders.

Psychosocial aspects of obesity.

Obese patients have many physical limitations and much psychiatric burden to overcome. Several studies have shown that the prevalence of psychiatric morbidity in the obese is similar to those with normal weight. However, in obese patients seeking treatment there is an increased prevalence (40-60%) of psychiatric morbidity, most commonly depression. It is difficult to separate the effects of depression on obesity and, on the contrary, the neuroendocrine changes associated with stress and depression may cause metabolic changes that predispose and perpetuate obesity. The stigma associated with obesity causes bullying in school as well as childhood psychiatric morbidity. Prejudice is not limited to the general public but exists among health professionals too. This chapter discusses the treatment of depression in obesity and the psychiatric evaluation of the pre-bariatric surgery patient. Education of society, starting with schools and including healthcare professionals will reduce bias and stigma as well as assist this vulnerable group of patients to seek help for their obesity and the many problems that come with it. Given that by the year 2025 obesity will be the world's number one health problem with the US leading the way, it is very important that we pursue preventive measures as well as encourage research for treatments of obesity.

Cognitive behavior therapy of binge eating disorder.

Binge eating disorder (BED) is characterized by recurrent episodes of uncontrollable eating, even when not hungry, until uncomfortably full, occurring at least twice a week for a 6-month period. This is differentiated from bulimia nervosa (BN) by the lack of compensatory mechanisms such as purging/laxative abuse. There are significantly higher levels of psychiatric symptoms in patients with BED as compared to those without BED. Furthermore, depressive symptomatology may increase the patient's vulnerability to binge eating as well as to relapse after treatment. Grazing is defined as eating small amounts of food continuously. BED in the pre-bariatric patient can manifest as 'grazing' about 2 years post-bariatric surgery. Treatment should be directed at eating behavior, associated psychopathology, weight and psychiatric symptoms. Cognitive behavior therapy is based on changing the patient's erroneous ways of thinking about themselves, the world and how others perceive them. This includes a focus on normalizing food intake as well as challenging dysfunctional thinking, identifying feelings, and developing non-food coping skills. It increases a sense of control and therefore helps the patient adhere to behavior change strategy, as well as improving mood and reducing associated psychopathology. Interpersonal therapy is based on the relationship between negative mood low self-esteem traumatic life events, interpersonal functioning and the patient's eating behavior. The rationale being that eating represents maladaptive coping with underlying difficulties. While psychotherapy either CBT or IPT leads to decrease in disordered eating behaviors and improved psychiatric symptoms, it has little effect on weight hence; its benefit is optimal when used in conjunction with bariatric surgery.