Cancer Cell Targeting Using Folic Acid/Anti-HER2 Antibody Conjugated Fluorescent CdSe/CdS/ZnS-Mercaptopropionic Acid and CdTe-Mercaptosuccinic Acid Quantum Dots.

CdSe/CdS/ZnS and CdTe quantum dots (QDs) were synthesized by successive ion layer adsorption and reaction (SILAR) technique and direct aqueous synthesis respectively using thiol stabilizers. Synthesized CdSe/CdS/ZnS and CdTe QDs stabilized with 3-mercaptopropionic acid (MPA) and mercaptosuccinic acid (MSA) were used as fluorescent labels after conjugation with folic acid (FA) and anti-HER2 antibodies. Photoluminescence quantum yield of folated CdSe/CdS/ZnS-MPA and CdTe-MSA QDs was 59% and 77% than that of non-folated hydrophilic QDs. The folate receptor-mediated delivery of folic acid-conjugated CdTe-MSA and CdSe/CdS/ZnS-MPA QDs showed higher cellular internalization as observed by confocal laser scanning microscopic studies. Folated and non-folated CdTe-MSA QDs were highly toxic and exhibited only 10% cell viability as compared to > 80% cell viability with CdSe/CdS/ZnS-MPA QDs over the concentration ranging from 3.38 to 50 pmoles. Immunohistochemistry (IHC) results of human breast cancer tissue samples showed positive results with anti-HER2 antibody conjugated CdSe/CdS/ZnS-MPA QDs with better sensitivity and specificity as compared to conventional IHC analysis using diaminobenzedene staining.

Cancer Cell Targeting Using Folic Acid/Anti-HER2 Antibody Conjugated Fluorescent CdSe/CdS/ZnS-MPA and CdTe-MSA Quantum Dots.

CdSe/CdS/ZnS and CdTe quantum dots (QDs) were synthesized by successive ion layer adsorption and reaction (SILAR) technique and direct aqueous synthesis respectively using thiol stabilizers. Synthesized CdSe/CdS/ZnS and CdTe QDs stabilized with 3-mercaptopropionic acid (MPA) and mercaptosuccinic acid (MSA) were used as fluorescent labels after conjugation with folic acid (FA) and anti-HER2 antibodies. Photoluminescence quantum yield of folated CdSe/CdS/ZnS-MPA and CdTe-MSA QDs was 59% and 77% than that of non-folated hydrophilic QDs. The folate receptor-mediated delivery of folic acid-conjugated CdTe-MSA and CdSe/CdS/ZnS-MPA QDs showed higher cellular internalization as observed by confocal laser scanning microscopic studies. Folated and non-folated CdTe-MSA QDs were highly toxic and exhibited only 10% cell viability as compared to > 80% cell viability with CdSe/CdS/ZnS-MPA QDs over the concentration ranging from 3.38 to 50 pmoles. Immunohistochemistry (IHC) results of human breast cancer tissue samples showed positive results with anti-HER2 antibody conjugated CdSe/CdS/ZnS-MPA QDs with better sensitivity and specificity as compared to conventional IHC analysis using diaminobenzedene staining.

Primary Malignant Melanoma of Tongue: Rare and Aggressive Malignant Tumor.

Primary melanoma of the oral cavity is extremely rare, accounting for 0.2-8% of all melanomas. Lesions arising from mucosal melanocytes occur most frequently on the gingiva or palate. Mucosal melanomas carry a worse prognosis than cutaneous melanomas. Very few studies have been published due to rarity of disease. 46 year old lady presented with black colored lesion over left side of her tongue for 6 weeks. On examination there was 3 × 2.5 cm black colored patch over left lateral part of tongue in middle 1/3rd, not crossing midline. Tip and base of tongue were free. Biopsy was suggestive of malignant melanoma of tongue. Patient underwent surgery (wide local excision of left lateral border of tongue lesion + left selective neck dissection). Final Histopathological report revealed malignant melanoma of tongue with all margins free, Depth of invasion 3 mm, Lympho-vascular invasion present, and no perineural invasion, left level III cervical lymph node metastases. Patient thus received adjuvant RT. Immunotherapy was also advised in multidisciplinary clinic, but patient was non-compliant. Early diagnosis will be promoted by careful oral examination and early biopsy of pigmented and non-pigmented masses. Early diagnosis and treatment will improve the prognosis of patients with oral malignant melanoma.

Lymphoepithelial carcinoma of tongue - Devil in garbs of Hodgkin lymphoma: A case report and review of literature.

Lymphoepithelial carcinoma (LEC) of head and neck region predominantly arises in salivary gland, oral cavity, oropharynx, nasal cavity, paranasal sinuses, and larynx; those arising from tongue are rare. Morphologically, it is a poorly differentiated squamous cell carcinoma, with early regional and distant metastasis. Diagnosis of LEC can sometimes be challenging especially in small biopsy and more so when seen at unusual location. Combination of morphology and immunohistochemistry (IHC) helps the diagnosis. Herein, we report a rare third case of LEC arising from lateral border tongue, diagnosed in a 36-year-old male. The presented case highlights challenges faced during diagnosis in small biopsy. Treatment of LECs comprises of surgery followed by radiotherapy or combined chemoradiation. Though, almost 70% of LEC of oral cavity region present with cervical nodal metastasis, their prognosis remains favorable.

Spindle epithelial tumor with thymus-like elements (SETTLE): a diagnostic challenge with distinct therapeutic implication; case report.

Spindle epithelial tumor with thymus-like elements (SETTLE) is a rare malignant neoplasm of the thyroid gland which is believed to arise from intrathyroidal thymic tissue. It predominantly affects young adults and children presenting with a thyroid mass of variable duration and rarely occurs in adults. It has a high overall survival with a tendency for delayed metastasis. SETTLE is a biphasic lobulated tumor composed of spindle shaped cells along with glandular formations seen on histopathological examination. Despite its typical morphology it is commonly misdiagnosed on histopathology due to its rarity and overlapping morphology with other close mimics such as a carcinoma, synovial sarcoma and thymoma. Herein we report such a case occurring in a middle aged female presenting with a neck mass. She had an initial diagnosis of metastatic poorly differentiated squamous cell carcinoma possibly with an orophayngeal primary in view of co expression of CK, p40 and p16 on immunohistochemistry. The patient underwent surgical resection with modified neck dissection. On review at our hospital it was diagnosed as SETTLE and she remains disease free after a follow-up period of 1 year. Diligent histopathological examination espoused with a judicious panel of IHC markers in conjunction with clinicoradiological findings forms the mainstay of diagnosis. Diffuse and strong p16 immunoexpression has not been documented or evaluated in literature so far, and needs to be explored for its diagnostic utility in this rare entity.

A Case of Myoepithelioma of Nasal Cavity and Short Review of Literature.

Introduction: Myoepithelioma is a rare neoplasm of the salivary glands and accounts for less than 1% of salivary gland neoplasms. Only 7 cases of myoepithelioma in the nasal cavity have been reported till date in literature. Case Report: A 61 year old male presented to us with epistaxis. There was a pinkish fleshy mass occupying the right nasal cavity. Biopsy showed evidence of an epithelial tumor of intermediate aggressiveness. We did an endoscopic complete excision of nasal cavity mass. Histopathological examination of the resected tumor was consistent with myoepithelioma. Due to its rarity, the nature of the tumor is not known and regular follow-ups are needed for early detection of recurrence and malignancy. There has been no evidence of tumor recurrence in the 18 months following surgery.

Collision Tumour of Combined Neuroendocrine and Squamous Cell Carcinoma of Nasal Cavity and Paranasal Sinus- Case Report and Review of Literature.

Background: There have been many disputes about the definition, diagnosis, therapy, and prognosis of collision tumours. Case Summary: We describe a rare patient with a collision tumour consisting of high-grade neuroendocrine carcinoma (NEC) and squamous cell carcinoma (SCC) in the right nasal cavity and paranasal sinus. She received surgery, concurrent chemoradiotherapy, and then two cycles of palliative chemotherapy. Follow-up at 26 months after diagnosis showed that this patient experienced a complete response with no signs of recurrence or metastasis. A literature review of previous 27 cases diagnosed with collision tumour of NEC and SCC in the head and neck was also undertaken. Conclusion: It is highly challenging to manage collision tumours because these are two morphologically and etiologically distinct tumours. Well-designed multimodality therapy including surgery and chemoradiotherapy might lead to a long survival in these patients.

Extremely Rare Case of Extra Skeletal Soft Tissue Chondroma of Masseteric Space: a Diagnostic Challengel.

Benign soft tissue chondroma is a rare type of extraskeletal chondrocytic tumour. It usually can be found in skeletal system in extremities. Head and neck region is one of the most uncommon sites for extraskeletal chondroma .Most common site is tongue and there has been paucity of cases arising from the other subsites .We present a case of 56 years gentleman who came to our OPD with a right masticator space swelling. It was nonmalignant on FNAC. He underwent wide local excision through a transparotid approach. Final biopsy & IHC report showed presence of benign chondrocytic neoplasm- soft tissue chondroma (extraskeletal). No further therapy was used and he has been in follow up since then. To our knowledge ,this is the third reported case of masseteric space chondroma. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03705-5.

Defeating diabetes in the desert: A community-based mHealth diabetes screening intervention in Jodhpur Rajasthan.

Background: There is a paucity of demonstrated models for mHealth-based diabetes screening and coordinated care in India, especially in western Rajasthan, which is the part of Thar desert. Materials and Methods: JSPH collaboratively developed and implemented an easy-to-use, noninvasive, mobile phone-based screening interview, to identify adults at high risk for diabetes. The high risk for diabetes was defined using multiple clinical and epidemiologic criteria, all based on the evidence for India and globally. Since participants above 35 years or older were only considered in the screening, the application was designed to categorize the participants as high and low risk. Results: Out of 4000 screened participants, the percentage of males and females were 51% and 50%, respectively. Participants found to be at high risk and low risk were n = 3600 (90%) and 400 (10%). The mean age of high- and low-risk participants was 52.2 (+12.8) and 36.2 (+4.2), respectively. Of the 3600 high-risk individuals who have been given a follow-up interview, 90.50% of high-risk individuals obtained diabetes testing, and of these, 65.67% had a written report showing they test positive for diabetes or prediabetes, requiring ongoing clinical care. Conclusions: JSPH mHealth application provided a novel noninvasive way to better identify those at high diabetes risk in the community and demonstrated how to optimize the use of mobile health methods in diabetes prevention and care services.

Severe sepsis and its impact on outcome in elderly and very elderly patients admitted in intensive care unit.

BACKGROUND: Elderly patients comprise an increasing proportion of intensive care unit (ICU) admissions. Advanced age and multiple comorbidities compromise their immunity and hence they may be more prone to succumbing to severe infection and have poorer outcome. We undertook this study to review impact of severe sepsis on mortality in the elderly patients. METHODS: All patients admitted to a medical ICU of a tertiary care institute with severe sepsis or septic shock were prospectively included. Patients were divided into young (age below 60 years), old (age between 60 and 80 years), and very old (age above 80 years) groups. Data regarding baseline patient characteristics, admission APACHE II score, and ICU course including need for organ support and ICU length of stay were noted. Categorical data were analyzed using χ(2) or Fisher Exact test as appropriate and continuous data were analyzed using Student t test. Primary outcome measure was the ICU mortality. RESULTS: Of 387 patients with sepsis, 132 patients who fulfilled the criteria for severe sepsis/septic shock were included in the analysis. The most common suspected site of infection was lungs (45.5%), followed by urinary tract (21.2%) and abdomen (16.7%). Intensive care unit mortality in younger patients was 45.6% as compared to 60.7% in old and 78.9% in very old patients (P = .035). The relative risk (RR) for dying in the old age was 1.125 and RR for dying in the very old age group was 1.487 as compared to the young patients. There was an increased need for organ support in the elderly and very elderly population as compared to the younger population. On multivariate analysis, only age of the patient was found to be independently predicting ICU mortality (P = .002, OR: 1.038, 95% CI: 1.014-1.062). CONCLUSIONS: The risk of dying from severe sepsis is considerably higher in the elderly and very elderly subgroup of patients with age as an independent risk factor for mortality. Hence, early aggressive care to recognize and manage severe sepsis is required to improve outcome.

Identification of high-risk group and therapeutic options in children with liver abscess.

The outcome of children with liver abscess (LA) depends upon prompt diagnosis and intervention. We evaluated the etiology, clinical profile, various interventional modalities of management and outcome of children with LA. A total of 39 hospitalized children (mean age 7.2 ± 3.9 years) with radiologically proven LA were analyzed. Parenteral antibiotics, percutaneous drainage (PD) or open surgical drainage (OSD) was done as required. Cases with ruptured or impending rupture of LA, upper gastrointestinal bleed, jaundice, pleural effusion or consolidation were labeled as "high risk" cases. Triad of fever, pain and hepatomegaly was the most common presentation. Single abscess was present in 66.7% and right lobe was involved in 69.2% of cases. Majority of LA were pyogenic (PLA, 25/39). Amebic liver abscess (ALA) and PLA had similar clinical and laboratory profile except that multiloculated abscess on ultrasonography was a feature of PLA (12/25 vs. 0/11; p = 0.006). Cases with ALA settled significantly more often with antibiotics alone (5/11 vs. 3/25; p = 0.04) than PLA and none required surgery (0/11 vs. 7/25; p = 0.03). Subjects with "high-risk" LA (n - 26) had significantly larger abscesses, more polymorphonuclear leucocytosis (74 ± 15% vs. 61 ± 13%; p = 0.01) in peripheral blood and need of drainage (24/26 vs. 7/13; p = 0.03) than patients with average-risk LA. Based on the results, 38/39 children recovered, with complete abscess resolution in 28, over 48 ± 63.8 days. In conclusion, ALA, although similar in presentation, are uniloculated, and patients with ALA recover more often without drainage than patients with PLA. Patients with "high risk" LA are more common and have a good outcome with drainage. PD, being safe, efficacious and less invasive than OSD, should be the preferred drainage procedure.

An Unusual Case Report of Malignant Melanoma of the Sphenoid Sinus with Review of Literature.

Non skin malignant melanomas are known to be more aggressive than the skin counterpart. A 50-year lady with recurrent epistaxis, had mass in right sphenoid, which was resected by endoscopic sinus surgery. After histopathological confirmation of malignant melanoma radiotherapy was given. She later developed metastasis in liver.

Adenoid Cystic Carcinoma of the Nasopharynx-a Rare Entity: Our Institutional Experience and Therapeutic Approach.

Adenoid cystic carcinoma of the nasopharynx is a rare, slow growing, and locally aggressive neoplasm. Three cases presented with recurrent epistaxis. Endoscopy-guided biopsy proved the diagnosis of adenoid cystic carcinoma. The location and the extent of the tumor were confirmed on imaging. Surgery followed by radiation therapy was the treatment modality used. All three cases showed good clinical response. The aim is to discuss the surgical approach and review of literature concerning this malignancy.

Dengue encephalopathy in children in Northern India: clinical features and comparison with non dengue.

BACKGROUND: Acute febrile encephalopathy (AFE) is a common cause of childhood hospital admissions in Lucknow. In recent years, many patients have been hospitalized with AFE and hemorrhagic manifestations, some of whom were proven to have dengue viral infection. OBJECTIVES: To (i) define the role of dengue encephalopathy (DE) as a cause of AFE in children in Lucknow, (ii) document features of dengue hemorrhagic fever (DHF) in them and (iii)compare clinical features of definite dengue and non dengue AFE. STUDY DESIGN: Prospective study at a teaching hospital in northern India. Children between 1-12 years of age hospitalized with fever and altered consciousness of 2 weeks or less duration were enrolled after excluding bacterial and tuberculous meningitis and frank hepatic encephalopathy. Clinical and laboratory details were charted. Haemagglutination inhibition (HI) test for dengue and Japanese encephalitis viruses in paired sera and IgM antibody capture ELISA for dengue were done. Real time PCR was done in those samples testing positive for dengue IgM. Those with either positive HI test or positive dengue PCR in CSF or serum were considered definite dengue infection and features of DHF were charted in them. Those negative for IgM antibodies after 5 days of illness or whenever done, HI test, were considered definite non dengue. Clinical and laboratory features were compared between definite dengue and non dengue groups. RESULTS: A total of 265 patients of AFE were enrolled over a 2 year period. HI test was positive in 15/49 (30.6%) and IgM in 52/238 (21.8%) patients thus tested. A total of 62 patients were positive for dengue antibodies by either test. Real time PCR assay for dengue virus genome was positive in 28/42 (69%) tested -- 21/29 (72.4%) in CSF and 9/15 (60%) in serum. A total of 39 patients met the criteria for definite dengue infection of which only 2 fulfilled the WHO criteria for DHF. Comparing DE and non DE, rash, bleeding, swelling over body, and hepatomegaly were significantly more common and meningeal signs less frequent in DE. Mean platelet counts and serum albumen were lower and liver enzymes and INR were significantly higher in DE. CONCLUSIONS: Dengue viral infection is a cause of AFE in children in this region. Majority of DE here appears to be due to viral invasion of brain as suggested by high PCR positivity in CSF and lack of WHO criteria for DHF. Differentiating features of DE include swelling and hepatic dysfunction.

Synthesis of trap emission free cadmium sulfide quantum dots: Role of phosphonic acids and halide ions.

Changing the capping ligands of CdS nanocrystals during their synthesis controls the optical properties of these nanocrystals. Addition of a little amount of CdCl2:Phosphonic Acid (PA) completely eliminates the surface state emission with an increase in quantum yield of band edge emission from these nanocrystals. The role of halide ions in surface passivation along with the structural dependance of these nanocrystals on surface states has also been studied. These as prepared nanocrystals are uniform as well as monodispersed and their size can be tuned by varying the reaction time. These nanocrystals have been well characterized using a combination of optical and structural techniques.

Magnetic removal of Entamoeba cysts from water using chitosan oligosaccharide-coated iron oxide nanoparticles.

Amebiasis, a major health problem in developing countries, is the second most common cause of death due to parasitic infection. Amebiasis is usually transmitted by the ingestion of Entamoeba histolytica cysts through oral-fecal route. Herein, we report on the use of chitosan oligosaccharide-functionalized iron oxide nanoparticles for efficient capture and removal of pathogenic protozoan cysts under the influence of an external magnetic field. These nanoparticles were synthesized through a chemical synthesis process. The synthesized particles were characterized by transmission electron microscopy, Fourier transform infrared spectroscopy, X-ray diffraction, and zeta potential analysis. The particles were found to be well dispersed and uniform in size. The capture and removal of pathogenic cysts were demonstrated by fluorescent microscopy, transmission electron microscopy, and scanning electron microscopy (SEM). Three-dimensional modeling of various biochemical components of cyst walls, and thereafter, flexible docking studies demonstrate the probable interaction mechanism of nanoparticles with various components of E. histolytica cyst walls. Results of the present study suggest that E. histolytica cysts can be efficiently captured and removed from contaminated aqueous systems through the application of synthesized nanoparticles.

In vitro toxicity assessment of chitosan oligosaccharide coated iron oxide nanoparticles.

Iron oxide nanoparticles (INPs) have potential biological, biomedical and environmental applications. These applications require surface modification of the iron oxide nanoparticles, which makes it non-toxic, biocompatible, stable and non-agglomerative in natural and biological surroundings. In the present study, iron oxide nanoparticles (INPs) and chitosan oligosaccharide coated iron oxide nanoparticles (CSO-INPs) were synthesized to evaluate the effect of surface coating on the stability and toxicity of nanoparticles. Comparative in vitro cytotoxicity of nanoparticles was evaluated in HeLa (human cervix carcinoma), A549 (human lung carcinoma) and Hek293 (human embryonic kidney) cells by using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay along with flow cytometry study for cell viability, membrane integrity, mitochondrial membrane potential (MMP) and reactive oxygen species (ROS) production. Morphological alteration in nanoparticles treated cells was analyzed by Acridine orange/ethidium bromide double staining and electron microscopy. Synthesized nanoparticles were found to be spherical in shape, well dispersed and stable at various pH values, making them suitable for biomedical and environmental applications. The present study also indicates that the chitosan oligosaccharide coating on iron oxide nanoparticles results in the decrease in cellular damage and moderate ROS production, thereby, significantly decreasing the cytotoxic impact of bare iron oxide nanoparticles.

Intracellular delivery of peptide cargos using iron oxide based nanoparticles: studies on antitumor efficacy of a BCL-2 converting peptide, NuBCP-9.

Delivering peptides into cells targeting the undruggable oncoproteins is an emerging area in cancer therapeutics. Here we report a novel nanoparticle-based delivery system that can transport therapeutic cargos to the intracellular sites without the need for a cell transduction or penetration domain (CPP). In the present study, we have used iron oxide nanoparticles to deliver an oncopeptide, NuBCP-9, targeting the BCL-2 BH3 domain. Citric acid/2-bromo 2-methylpropanoic acid (CA/BMPA)-capped SPIONs were used to immobilize and deliver the NuBCP-9 peptide to the cancer cells without any noticeable off-target effects. Our results have demonstrated that NuBCP-9-SPIONs efficiently penetrate into cancer cells and bind to its intracellular target protein BCL-2. Moreover, significant inhibition of proliferation and substantial induction of cell death were observed when cancer cells were treated with NuBCP-9-SPIONs at different time intervals. Importantly, the IC50 values for killing of breast cancer cells with NuBCP-9-SPIONs were much lower compared to cells treated with the NuBCP-9 peptide linked with a CPP (Arg-8; NuBCP-9-R8). Molecular and biochemical analyses further supported that NuBCP-9-SPIONs killed breast cancer cells by apoptosis-mediated mechanisms. Furthermore, our data demonstrated that administration of NuBCP-9-SPIONs to mice bearing Ehrlich ascites tumors (EAT) was associated with loss of tumorigenicity and extensive apoptosis in tumor tissues. Taken together, these findings show that a non-CPP-tagged peptide can be successfully delivered to undruggable intracellular oncotargets using SPIONs.

Cellular interaction of folic acid conjugated superparamagnetic iron oxide nanoparticles and its use as contrast agent for targeted magnetic imaging of tumor cells.

The purpose of the study was to develop tumor specific, water dispersible superparamagnetic iron oxide nanoparticles (SPIONs) and evaluate their efficacy as a contrast agent in magnetic resonance imaging (MRI). We have developed SPIONs capped with citric acid/2-bromo-2-methylpropionic acid which are compact, water dispersible, biocompatible having narrow range of size dispersity (8-10 nm), and relatively high T2 relaxivity (R2 = 222L · mmol⁻¹ · sec⁻¹). The targeting efficacy of unconjugated and folic acid-conjugated SPIONs (FA-SPIONS) was evaluated in a folic acid receptor overexpressing and negative tumor cell lines. Folic acid receptor-positive cells incubated with FA-SPIONs showed much higher intracellular iron content without any cytotoxicity. Ultrastructurally, SPIONs were seen as clustered inside the various stages of endocytic pathways without damaging cellular organelles and possible mechanism for their entry is via receptor mediated endocytosis. In vitro MRI studies on tumor cells showed better T2-weighted images in FA-SPIONs. These findings indicate that FA-SPIONs possess high colloidal stability with excellent sensitivity of imaging and can be a useful MRI contrast agent for the detection of cancer.

Incidence of bacteremia at the time of ICU admission and its impact on outcome.

CONTEXT: Blood culture is routinely taken at the time of admission to the intensive care unit (ICU) for patients suspected to have infection. We undertook this study to determine the incidence of bacteremia at the time of ICU admission and to assess its impact on the outcome. METHODS: Retrospective cohort study from all the admissions in ICU, in whom blood cultures sent at the time of admission were analyzed. Data regarding patient demographics, probable source of infection, previous antibiotic use and ICU course was recorded. Severity of illness on admission was assessed by acute physiology and chronic health evaluation II score. STATISTICAL ANALYSIS: Qualitative data were analyzed using Chi-square or Fisher Exact test and quantitative data were analyzed using Student's t-test. Primary outcome measure was ICU mortality. RESULTS: Of 567 patients, 42% patients were on antibiotics. Sixty-four percent of the patients were direct ICU admission from casualty, 10.76% were from wards and 6.17% from other ICUs, and 19.05% were transfers from other hospitals. Blood cultures were positive in 10.6% patients. Mortality was significantly higher in patients with positive blood cultures (45% vs. 13.6%; P=0.000). On univariate analysis, only previous antibiotic use was statistically associated with higher mortality (P=0.011). Bacteremic patients who were already on antibiotics had a significantly higher mortality (OR 12.9, 95% CI: 1.6-100). CONCLUSIONS: Blood cultures may be positive in only minority of the patients with suspected infection admitted to ICU. Nevertheless, the prognosis of those patients with positive blood culture is worse, especially if culture is positive in spite of the patient being on antibiotics.