A randomized controlled trial of an Internet-based cognitive-behavioural skills package for carers of people with anorexia nervosa.

BACKGROUND: Anorexia nervosa (AN) poses a major burden on families. Carers (e.g. parents or partners) of people with AN are often highly distressed and may inadvertently respond in ways that can contribute to the maintenance of the disorder, e.g. through high levels of over-involvement and criticism [also known as expressed emotion (EE)]. This study aimed to evaluate the efficacy of a novel web-based systemic cognitive-behavioural (CBT) intervention for carers of people with AN, designed to reduce carer distress and teach skills in how to offer effective support. METHOD: Carers of people with AN (n=64) were randomly allocated to either the web-intervention, overcoming anorexia online, with limited clinician supportive guidance (by email or phone), or to ad-hoc usual support from the UK patient and carer organization Beat. Carer outcomes were assessed at post-treatment (4 months) and follow-up (6 months). RESULTS: Compared with the control intervention, web-based treatment significantly reduced carers' anxiety and depression (primary outcome) at post-treatment, with a similar trend in carers' EE. Other secondary outcomes did not favour the online intervention. Gains were maintained at follow-up. CONCLUSIONS: This is the first ever study to use an online CBT program to successfully reduce carer distress and improve carers' ability to support the person with AN.

Pneumocystis jirovecii dihydropteroate synthase (DHPS) genotypes in non-HIV-immunocompromised patients: a tertiary care reference health centre study.

Studies on Pneumocystis jirovecii dihydropteroate synthase (DHPS) genotypes among non-HIV immunocompromised patients from developing countries are rare. In the present prospective investigation, 24 (11.8%) cases were found to be positive for Pneumocystis jirovecii out of 203 non-HIV patients with a clinical suspicion of Pneumocystis pneumonia (PCP). Dihydropteroate synthase (DHPS) genotype 1 (Thr55+Pro57) was noted in 95.8% P. jirovecii isolates in the present study in contrast to only 4.1% of patients with DHPS genotype 4 (Thr55Ala + Pro57Ser).

Quality assurance of annual HIV sentinel surveillance 2006: experience of regional institute, central zone.

National AIDS Control Organisation (NACO) identified five regional institutes (RIs) to monitor and supervise the 2006 round of annual HIV sentinel surveillance. The task mandated was quality control of both epidemiological data collection and HIV testing. The team at RI consisted of epidemiologist and microbiologist. We describe here the process of quality control and the quality of surveillance in the states of Uttar Pradesh, Uttarakhand, Bihar, Jharkand, and Delhi. The supervisors visited almost 90% of the sentinel sites. Performance of vast majority of the sentinel sites (92%) was satisfactory. The testing laboratories were found to be adhering to standard operating procedures. Concordance rate of test results between testing laboratory and the designated reference laboratory was high. Overall, the quality of sentinel surveillance was good. The lacunae found during the visit have been enumerated along with the recommendations for future surveillance round.

Prevalence of ovine cystic echinococcosis in Kashmir Valley, North India.

A total of 1455 local and non-local (originating from other Indian states), slaughtered or spontaneously dead, sheep in various areas of Kashmir Valley were investigated for the presence of cystic echinococcosis over a period of one year. The overall prevalence was 7.97% with higher prevalence in local (14.3%) than in non-local sheep (6.06%). The prevalence of infection, total number of cysts recovered and mean intensity of infection were higher in lungs as 66.2%, 506 & 5.1% respectively, followed by liver (28.5%, 169, 3.9%) and spleen (5.3%, 9, 1.13%). Either single (71.55%) or multiple (28.45%) organ involvements were observed. 66.6% of cysts were of small size, 19.29% medium, 7.01% large and 7.01% calcified. The fertility of cysts was noted to be 65.7% whereas 34.2% were infertile which included 27.1% sterile and 7.01% calcified cysts. The viability percentage of protoscolices from all the fertile cysts was 74.2%. The number of cysts recovered was higher in sheep with body condition score- emaciated, thin and average, and lower in, fat and obesed. The study showed that the local sheep were more vulnerable to contract cystic echinococcosis than non-local sheep which is further aggravated by poor body condition.

Dengue fever with papilledema: a case of dengue-3 virus infection in central nervous system.

BACKGROUND AND OBJECTIVES: Neurological manifestations of dengue fever are rarely reported during acute illness and clinical presentation commonly observed is of acute encephalitis or one of the post-infectious immune mediated manifestations. We describe a case of dengue fever having mild encephalopathy and papilledema at presentation. CASE REPORT: Twenty-year-old female presented with fever, headache and vomiting. On examination she did not have classical signs of dengue fever and was found to have bilateral papilledema on fundus examination. Detailed work-up did not reveal any other cause of papilledema. Diagnosis of dengue fever was established by blood IgM antibody test on day 7 of illness. Retrospective analysis of CSF (drawn on day 5 of illness) by RT-PCR assay showed a characteristic band of dengue-3 virus. Papilledema was transient and subsided following symptomatic treatment. The patient recovered from acute illness and follow-up was unremarkable. CONCLUSION: Especially in dengue endemic areas, in the patients having acute febrile illness with subtle signs and symptoms suggestive of CNS involvement, dengue virus infection should also be ruled out early in the clinical course.

Dengue vaccines: challenges, development, current status and prospects.

Infection with dengue virus (DENV) is the most rapidly spreading mosquito-borne viral disease in the world. The clinical spectrum of dengue, caused by any of the four serotypes of DENV, ranges from mild self-limiting dengue fever to severe dengue, in the form dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). Increased rates of hospitalization due to severe dengue, during outbreaks, result in massive economic losses and strained health services. In the absence of specific antiviral therapy, control of transmission of DENV by vector management is the sole method available for decreasing dengue-associated morbidity. Since vector control strategies alone have not been able to satisfactorily achieve reduction in viral transmission, the implementation of a safe, efficacious and cost-effective dengue vaccine as a supplementary measure is a high public health priority. However, the unique and complex immunopathology of dengue has complicated vaccine development. Dengue vaccines have also been challenged by critical issues like lack of animal models for the disease and absence of suitable markers of protective immunity. Although no licensed dengue vaccine is yet available, several vaccine candidates are under phases of development, including live attenuated virus vaccines, live chimeric virus vaccines, inactivated virus vaccines, subunit vaccines, DNA vaccines and viral-vectored vaccines. Although some vaccine candidates have progressed from animal trials to phase II and III in humans, a number of issues regarding implementation of dengue vaccine in countries like India still need to be addressed. Despite the current limitations, collaborative effects of regulatory bodies like World Health Organization with vaccine manufacturers and policy makers, to facilitate vaccine development and standardize field trials can make a safe and efficacious dengue vaccine a reality in near future.

Comparison of conventional, immunological and molecular techniques for the diagnosis of symptomatic congenital human cytomegalovirus infection in neonates and infants.

PURPOSE: Human cytomegalovirus (HCMV) is the commonest pathogen causing congenital infection globally. The diagnosis of congenital infection is based either on viral isolation (in cell culture) or demonstration of HCMV DNA from the urine. Saliva is also being used as an alternative sample to urine for the same. The objective of this study was to compare the following assays-polymerase chain reaction (PCR) from urine, saliva and blood, serology (anti-HCMV IgM) and antigen detection (HCMV pp65 antigenaemia) for the diagnosis of congenital HCMV infection. MATERIALS AND METHODS: Urine and blood samples were collected from 31 infants (median age: 13 weeks) with suspected HCMV infection. For 18 infants, additional saliva samples were collected and all the above assays were compared. RESULTS: PCR for HCMV DNA from urine and anti-HCMV IgM were performed for all 31 infants. Of these, 22 (70.9%) were positive for both assays. In 18 (of the 22) infants positive by both assays, PCR for HCMV DNA from saliva was positive in all 18 (100%), PCR from blood in 7/18 (38.8%) and HCMV pp65 antigenaemia only in 1/18 (5.5%) of the infants. CONCLUSION: Detection of HCMV DNA in urine combined with anti-HCMV IgM are suitable assays to diagnose HCMV infection in infants. Both PCR from the blood and HCMV pp65 antigenaemia lack sensitivity in infants. Salivary PCR combines convenience with high sensitivity and can substitute PCR from urine, especially in the outpatient and field settings. To the best of our knowledge, this is the first study from India to evaluate salivary PCR for the diagnosis of congenital HCMV infection.

Predominace of a novel Mycobacterium tuberculosis genotype in the Delhi region of India.

Using IS 6110 -restriction fragment length polymorphism (RFLP) and spoligotyping, genetic variations of 83 Mycobacterium tuberculosis strains isolated from tuberculosis patients from two wards in a hospital in Delhi and a rural chest clinic near Delhi were analysed. The vast majority of the isolates (75%) were closely related and this novel genogroup was designated the 'Delhi type'. Both drug-sensitive and drug-resistant strains were found among strains of this genogroup. A minority of the strains harboured a single IS 6110 copy and only one strain belonged to the Beijing genotype, a genotype that is predominant in other parts of Asia. A comparison of the RFLP and spoligotype with existing data suggests that the predominance of Delhi genogroup is geographically limited to the Indian subcontinent and perhaps to specific regions in India. Despite the high prevalence of the M. tuberculosis strains of the Delhi type, the strains could easily be discriminated due to polymorphisms in the IS 6110 patterns. Future studies may disclose the genetic characteristics of strains belonging to the Delhi genotype, analogous to the recently observed virulence among the Beijing genogroup.

Rapid detection of respiratory viruses by centrifugation enhanced cultures from children with acute lower respiratory tract infections.

BACKGROUND: Acute respiratory tract infection (ARI) is the major cause of morbidity and mortality in young children in developing countries. Information on viral aetiology in ARI in India is very limited. OBJECTIVE: The aim of the study was to define the role of viruses in acute lower respiratory tract infections (ALRTI) in children in India using centrifugation enhanced cultures followed by indirect immunofluorescence (IIF). STUDY DESIGN: Nasopharyngeal aspirates (NPAs) were collected from children from September 1995 to April 1997, attending paediatric clinic of All India Institute of Medical Sciences (AIIMS) with symptoms of ALRTI. Virus isolation was done by centrifugation enhanced cultures using HEp-2, LLC-MK2 and MDCK cells. The viruses were identified at 24-48 h post inoculation by IIF staining using monoclonal antibodies to respiratory syncytial virus (RSV), parainfluenza virus (PIV), influenza virus and adenovirus. RESULTS: Of 200 NPA samples, 89 (44.5%) were positive for one or more viral pathogens. RSV was detected in 34 (17%) of all ALRTI cases followed by influenza viruses in 29 (14.5%), PIVs in 23 (11.5%) and adenoviruses in three (1.5%). In 79 children with bronchiolitis, RSV was most frequently isolated (25%) pathogen, while in bronchopneumonia cases (101) the most common viral pathogen was influenza virus (17%). In eight cases (4%) of ALRTI dual infections were detected. In 100 NPA specimens IIF staining on direct cell smears was carried out and viruses were detected in only 17%. RSV and influenza virus infection peaked from September to December, where as PIV infections were more frequent from January to April. CONCLUSION: Respiratory viruses accounted for 44.5% of cases of ALRTI in India and the results of viral aetiology could be given in 24-48 h using centrifugation enhanced cultures. RSV was the most common viral agent associated with ALRTI in children under 5 years of age with greater association with bronchiolitis.

Myocardial dysfunction in children with dengue haemorrhagic fever.

BACKGROUND: Dengue fever/dengue haemorrhagic fever/dengue shock syndrome is a serious health problem in tropical countries. Intravascular fluid depletion due to capillary leak is presumed to be the cause of hypotension in dengue haemorrhagic fever. The treatment guidelines of the World Health Organization lay stress primarily on monitoring and fluid replacement therapy. During the 1996 epidemic in New Delhi, we observed problems in fluid management of such children and prospectively looked for myocardial dysfunction as an additional factor for hypotension. METHODS: Fifty-four children (< 12 years old) admitted to the All India Institute of Medical Sciences, New Delhi after 15 October 1996 with various grades of the disease, who were fit to be shifted to the echocardiography laboratory, were examined clinically and subjected to a detailed M-mode, 2-dimensional and colour doppler echocardiography. Ejection fractions (Teichholz/Modified Simpson's) and shortening fractions were calculated. RESULTS: Ejection fraction by modified Simpson's rule was reduced (< 50%) in 9/54 (16.7%) children; 2 of these had significant reductions (< 35%). These 9 children belonged to all stages of clinical severity. Three of these 9 children who had a repeat echocardiogram within 2 months of the illness had improved ejection fractions. CONCLUSION: The role of myocardial dysfunction remains to be defined as there was no correlation with clinical severity. Myocardial functions need to be assessed in patients with this disease, especially those who have persistent hypotension in spite of adequate hydration.

Diagnosis of pulmonary tuberculosis by polymerase chain reaction for MPB64 gene: an evaluation in a blind study.

Polymerase chain reaction (PCR) has been found to be a sensitive and rapid method to confirm a clinical diagnosis of tuberculosis. We evaluated PCR for M. tuberculosis complex specific MPB64 gene for the diagnosis of pulmonary tuberculosis, in a double blind study. One hundred and eighty-two clinical samples (sputum, bronchioalveolar lavage and pleural fluid) from patients with a clinical diagnosis of pulmonary tuberculosis and 72 samples from patients with non-tubercular pulmonary lesions and normal healthy individuals were included. The samples were coded and clinical details were concealed from the laboratory, where conventional diagnostic methods and PCR were carried out independent of each other. On decoding and analysing the data, PCR was positive in 59% of single sputum samples from clinically diagnosed pulmonary tuberculosis, while M. tuberculosis could be grown in 18% of the samples. PCR could identify M. tuberculosis in 81.8% of the culture positive sputum samples. PCR was also positive in 71.4% of bronchioalveolar lavage (BAL) fluid and 60.7% pleural fluid samples from clinically suspected cases, which were mostly culture negative. On comparison with response to treatment, PCR was positive in 79.5% of patients who improved on anti-tuberculosis treatment, with a positive predictive value of 92%. PCR for MPB64 gene provides a useful alternative for the diagnosis of pulmonary tuberculosis from sputum and paucibacillary samples like BAL and pleural fluid in which conventional methods show low sensitivity, especially in areas from which strains show a low copy number of other PCR targets like the IS 6110 insertion sequence.

Dengue virus infection during post-epidemic period in Delhi, India.

Dengue fever (DF) and dengue hemorrhagic fever (DHF) are major public health problems in India. During the period following an epidemic, a study was carried out using virological and serological tests for confirmation of suspected cases of dengue virus infection in fever cases presenting to the All India Institute of Medical Sciences. Serum samples of suspected DF/DHF cases were processed from January to December 1997. In 37 samples from patients with fever of less than 5-day duration, received on ice, virus isolation was attempted in C6/36 clone of Aedes albopictus cell line, followed by indirect fluorescent antibody staining with monoclonal antibodies to dengue viruses 1 to 4. One hundred and forty-three serum samples from patients with more than 5 days fever were tested for dengue specific IgM antibody by either MAC-ELISA or a rapid immunochromatographic assay. Dengue virus type 1 was demonstrated by culture in 8 (21.6%) of 37 serum samples and IgM antibody could be detected in 42 (29.4%) of the 143 serum samples by the serological methods. The peak of dengue virus infection was seen from September to November 1997.

Multidrug resistant Salmonella typhi in Delhi.

In 1990, we isolated 158 strains of Salmonella typhi from blood cultures of patients suffering from typhoid fever. Seventy nine (50%) of these isolates were found to be simultaneously resistant to chloramphenicol, ampicillin and cotrimoxazole. These strains were also resistant to streptomycin and tetracycline, but sensitive to gentamicin, amikacin and cephalexin. The minimum inhibitory concentrations of chloramphenicol and trimethoprim for a representative number of these strains were found to be greater than 1024 micrograms/ml and greater than 128 micrograms/ml respectively. Majority of the multidrug resistant (MDR) strains tested against cefotaxime (23/23), ciprofloxacin (38/38) and amoxycillin plus clavulanic acid (23/24) were sensitive to these drugs.

Levels of CD4 and CD8 among the inhabitants of Manipur, India.

Data on mean reference CD4 and CD8% is in general lacking in India. Manipur in the North-East India has high prevalence of HIV infection among the injecting drug users. This study was carried out to establish mean reference CD4 and CD8 cell count in normal and HIV infected individuals in our population, for use in interpretation of these prognostic markers in HIV infected persons. Whole blood sample was collected in EDTA from 14 normal and 23 HIV infected individuals. Fluorescence staining was carried out with FITC conjugated anti-CD4 and CD8 antibodies (Becton Dickinson) directly on whole blood, followed by single step lysis using commercial lysing solution (Optilyse C, Immunotec). The samples were analyzed by two-colour flow cytometry on Coulter Elite cytometer. It was observed that the mean CD4 and CD8 positive cells in normal healthy individuals were 36% (absolute 848/cumm) and 21% (absolute 427/cumm) respectively. The mean CD4% was significantly decreased in HIV infected individuals with a mean value of 13.4% (absolute 246/cumm), while the mean CD8% was significantly increased to 39.2% (absolute 660/cumm) in HIV infected individuals. A lower CD4+ cell count was also observed as compared to the western population among the normal healthy individuals. The mean CD4 and CD8 positive cells in normal healthy adult population were found to be 36% and 21% respectively, and 13.4% and 39.2% in HIV infected individuals respectively. These values should be considered when interpreting CD4 and CD8 counts in HIV infected individuals in this part of the country.

Prevalence of HIV Drug Resistance Mutations in HIV Type 1 Isolates in Antiretroviral Therapy Naïve Population from Northern India.

Objective. The increased use of antiretroviral therapy (ART) has reduced the morbidity and mortality associated with HIV, adversely leading to the emergence of HIV drug resistance (HIVDR). In this study we aim to evaluate the prevalence of HIVDR mutations in ART-naive HIV-1 infected patients from northern India. Design. Analysis was performed using Viroseq genotyping system based on sequencing of entire protease and two-thirds of the Reverse Transcriptase (RT) region of pol gene. Results. Seventy three chronic HIV-1 infected ART naïve patients eligible for first line ART were enrolled from April 2006 to August 2008. In 68 patients DNA was successfully amplified and sequencing was done. 97% of HIV-1 strains belonged to subtype C, and one each to subtype A1 and subtype B. The overall prevalence of primary DRMs was 2.9% [2/68, 95% confidence interval (CI), 0.3%-10.2%]. One patient had a major RT mutation M184V, known to confer resistance to lamivudine, and another had a major protease inhibitor (PI) mutation D30N that imparts resistance to nelfinavir. Conclusion. Our study shows that primary HIVDR mutations have a prevalence of 2.9% among ART-naive chronic HIV-1 infected individuals.

Role of CSF serology in follow-up of subacute sclerosing panencephalitis patients on treatment.

Subacute sclerosing panencephalitis (SSPE) is a progressive inflammatory disease of the central nervous system with poor prognosis and high mortality. No effective treatment has a proven role; oral isoprinosine and intrathecal administration of alpha-interferon may prolong survival. We report an unusual case of adult onset SSPE patient on treatment with significant clinical improvement, even in the absence of conversion to seronegativity in either CSF or serum, on follow-up serological examination.

Classification of rotavirus into G and P types with specimens from children with acute diarrhea in New Delhi, India.

Sixty rotavirus-positive stool specimens from children with diarrhea were classified into G and P genotypes. G typing was done by PCR and then by hybridization with G type-specific (G1 to G4) oligonucleotide probes, whereas nested PCR was performed for P typing. Thirty-nine samples could be classified into both G and P types, of which P8G1 and P4G2 (33% each) genotypes were predominant. The P6 genotype was detected in four children with diarrhea.