Testicular tissue cryopreservation: 8 years of experience from a coordinated network of academic centers.

STUDY QUESTION: Is it feasible to disseminate testicular tissue cryopreservation with a standardized protocol through a coordinated network of centers and provide centralized processing/freezing for centers that do not have those capabilities? SUMMARY ANSWER: Centralized processing and freezing of testicular tissue from multiple sites is feasible and accelerates recruitment, providing the statistical power to make inferences that may inform fertility preservation practice. WHAT IS KNOWN ALREADY: Several centers in the USA and abroad are preserving testicular biopsies for patients who cannot preserve sperm in anticipation that cell- or tissue-based therapies can be used in the future to generate sperm and offspring. STUDY DESIGN, SIZE, DURATION: Testicular tissue samples from 189 patients were cryopreserved between January 2011 and November 2018. Medical diagnosis, previous chemotherapy exposure, tissue weight, and presence of germ cells were recorded. PARTICIPANTS/MATERIALS, SETTING, METHODS: Human testicular tissue samples were obtained from patients undergoing treatments likely to cause infertility. Twenty five percent of the patient's tissue was donated to research and 75% was stored for patient's future use. The tissue was weighed, and research tissue was fixed for histological analysis with Periodic acid-Schiff hematoxylin staining and/or immunofluorescence staining for DEAD-box helicase 4, and/or undifferentiated embryonic cell transcription factor 1. MAIN RESULTS AND THE ROLE OF CHANCE: The average age of fertility preservation patients was 7.9 (SD = 5) years and ranged from 5 months to 34 years. The average amount of tissue collected was 411.3 (SD = 837.3) mg and ranged from 14.4 mg-6880.2 mg. Malignancies (n = 118) were the most common indication for testicular tissue freezing, followed by blood disorders (n = 45) and other conditions (n = 26). Thirty nine percent (n = 74) of patients had initiated their chemotherapy prior to undergoing testicular biopsy. Of the 189 patients recruited to date, 137 have been analyzed for the presence of germ cells and germ cells were confirmed in 132. LIMITATIONS, REASONS FOR CAUTION: This is a descriptive study of testicular tissues obtained from patients who were at risk of infertility. The function of spermatogonia in those biopsies could not be tested by transplantation due limited sample size. WIDER IMPLICATIONS OF THE FINDINGS: Patients and/or guardians are willing to pursue an experimental fertility preservation procedure when no alternatives are available. Our coordinated network of centers found that many patients request fertility preservation after initiating gonadotoxic therapies. This study demonstrates that undifferentiated stem and progenitor spermatogonia may be recovered from the testicular tissues of patients who are in the early stages of their treatment and have not yet received an ablative dose of therapy. The function of those spermatogonia was not tested. STUDY FUNDING/COMPETING INTEREST(S): Support for the research was from the Eunice Kennedy Shriver National Institute for Child Health and Human Development grants HD061289 and HD092084, the Scaife Foundation, the Richard King Mellon Foundation, the Departments of Ob/Gyn & Reproductive Sciences and Urology of the University of Pittsburgh Medical Center, United States-Israel Binational Science Foundation (BSF), and the Kahn Foundation. The authors declare that they do not have competing financial interests.

Circulating genotypes of Pneumocystis jirovecii and its clinical correlation in patients from a single tertiary center in India.

The present study was carried out with the objectives of genotyping Pneumocystis jirovecii at three distinct loci, to identify the single nucleotide polymorphisms (SNPs), and to study its clinical implications in patients with Pneumocystis pneumonia (PCP). Analysis of genetic diversity in P. jirovecii from immunocompromised patients was carried out by genotyping at three distinct loci encoding mitochondrial large subunit rRNA (mtLSU rRNA), cytochrome b (CYB), and superoxide dismutase (SOD) using polymerase chain reaction (PCR) assays followed by direct DNA sequencing. Of the 300 patients enrolled in the present study, 31 (10.33%) were positive for PCP by a specific mtLSU rRNA nested PCR assay, whereas only 15 P. jirovecii could be amplified at the other two loci (SOD and CYB). These positives were further subjected to sequence typing. Important genotypic combinations between four SNPs (mt85, SOD110, SOD215, and CYB838) and clinical outcomes could be observed in the present study, and mt85A, mt85T, and SOD110C/SOD215T were frequently associated with "negative follow-up". These SNPs were also noted to be relatively more prevalent amongst circulating genotypes in our study population. The present study is the first of its kind from the Indian subcontinent and demonstrated that potential SNPs of P. jirovecii may possibly be attributed to the clinical outcome of PCP episodes in terms of severity or fatality in different susceptible populations likely to develop PCP during their course of illness.

Antigen sequence typing of outer membrane protein (fetA) gene of Neisseria meningitidis serogroup A from Delhi & adjoining areas.

BACKGROUND & OBJECTIVES: Meningitis caused by Neisseria meningitidis is a fatal disease. Meningococcal meningitis is an endemic disease in Delhi and irregular pattern of outbreaks has been reported in India. All these outbreaks were associated with serogroup A. Detailed molecular characterization of N. meningitidis is required for the management of this fatal disease. In this study, we characterized antigenic diversity of surface exposed outer membrane protein (OMP) FetA antigen of N. meningitidis serogroup A isolates obtained from cases of invasive meningococcal meningitis in Delhi, India. METHODS: Eight isolates of N. meningitidis were collected from cerebrospinal fluid during October 2008 to May 2011 from occasional cases of meningococcal meningitis. Seven isolates were from outbreaks of meningococcal meningitis in 2005-2006 in Delhi and its adjoining areas. These were subjected to molecular typing of fetA gene, an outer membrane protein gene. RESULTS: All 15 N. meningitides isolates studied were serogroup A. This surface exposed porin is putatively under immune pressure. Hence as a part of molecular characterization, genotyping was carried out to find out the diversity in outer membrane protein (FetA) gene among the circulating isolates of N. meningitidis. All 15 isolates proved to be of the same existing allele type of FetA variable region (VR) when matched with global database. The allele found was F3-1 for all the isolates. INTERPRETATION & CONCLUSIONS: There was no diversity reported in the outer membrane protein FetA in the present study and hence this protein appeared to be a stable molecule. More studies on molecular characterization of FetA antigen are required from different serogroups circulating in different parts of the world.

Clostridium difficile infections in HIV-positive patients with diarrhoea.

BACKGROUND: Patients with HIV/AIDS are at a high risk of being infected with toxin-producing strains of Clostridium difficile (C. difficile) because of frequent hospitalization, exposure to antibiotics and antibiotic prophylaxis for opportunistic infections. There are little data from India on the prevalence of C. difficile infection in such patients. METHODS: We assessed the occurrence of C. difficile infections in HIV-positive patients with diarrhoea by looking for the presence of its toxin as well as by culturing. Enzyme immunoassay (EIA, Premier toxins A and B; Meridian Diagnostic Inc.) was used to detect toxin from 237 fresh stool samples collected from HIV-positive patients with diarrhoea. Culture was done on cycloserine-cefoxitin-fructose agar and brain- heart infusion agar. RESULTS: C. difficile was found in 12 of 237 (5.1%, 95% CI 2.64%-8.68%) HIV-positive patients with diarrhoea (9 patients were positive by EIA and 3 by culture). The presence of C. difficile in patients who had received antiretroviral therapy (7/66 [10.6%]) was significantly higher (p < 0.016) compared with those who had not (5/171 [3%]). Of the 12 patients positive for C. difficile, 7 were on antiretroviral therapy for a mean (SD) of 34.4 months with mean CD4+ count of 186 (98.81) cells/cmm and 5 patients were anti-retroviral-naïve with mean CD4+ count of 181 (68.7) cells/cmm. All the 12 patients were on antibiotics for previous 2 months and 4 of 12 had been hospitalized in the previous 30 days. CONCLUSION: C. difficile infections occurred more frequently in patients who had received antiretroviral therapy. Our study population had a lower frequency of C. difficile infections compared to previous studies.

Changes in cortical thickness in the frontal lobes in schizophrenia are a result of thinning of pyramidal cell layers.

Decreased cortical thickness and reduced activity as measured by fMRI in the grey matter of the subgenual cingulate cortex have been reported in schizophrenia and bipolar disorder, and cortical grey matter loss has been reliably reported in the frontal and temporal lobes in schizophrenia. The aim of this study was to examine the thickness of each of the six cortical layers in the subgenual cingulate cortex, five frontal lobe and four temporal lobe gyri. We examined two separate cohorts. Cohort 1 examines the subgenual cingulate cortex (SCC) in schizophrenia (n = 10), bipolar disorder (n = 15) and major depressive disorder (n = 20) against control subjects (n = 19). Cohort two examines frontal and temporal gyri in schizophrenia (n = 16), major depressive disorder (n = 6) against matched controls (n = 32). The cohorts were selected with identical clinical criteria, but underwent different tissue processing to contrast the effect of chemical treatment on tissue shrinkage. Measurements of layer I-VI thickness were taken from cresyl-violet- and haematoxylin-stained sections in cohort one and from cresyl-violet- and H&E-stained sections in cohort two. SCC cortical thickness decreased in male subjects with bipolar disorder (p = 0.048), and male schizophrenia cases showed a specific decrease in the absolute thickness of layer V (p = 0.003). Compared to controls, the relative thickness of layer V in the crown of the SCC decreased in schizophrenia (p < 0.001). A significant decrease in total cortical thickness was observed across the frontal lobe in schizophrenia (p < 0.0001), with specific pyramidal layer thinning in layers III (p = 0.0001) and V (p = 0.005). There was no effect of lateralization. No changes were noted in temporal lobe cortical thickness. This study demonstrates diminished pyramidal layer thickness resulting in decreased frontal lobe thickness in schizophrenia.

Serological & molecular approaches for diagnosis of leptospirosis in a tertiary care hospital in north India: a 10-year study.

BACKGROUND & OBJECTIVES: Leptospirosis, a spirochetal zoonosis, is underreported from the northern States of India. This study reports results of a 10-year retrospective sero-epidemiological survey of leptospirosis conducted in a tertiary care hospital in New Delhi, India. METHOD: A total of 1453 patients clinically suspected for leptospirosis were included and investigated initially by IgM ELISA. A proportion of these were subjected to culture, microscopic agglutination test (MAT) and polymerase chain reaction (PCR). RESULTS: Of the 1453 patients, 391 (26.90%) were positive serologically by IgM ELISA. Seropositive and seronegative patients revealed no significant difference in clinical features and laboratory parameters. Amongst the IgM seropositive cases, culture for leptospires was positive in 5 of 192 (2.6%), MAT in 50 of 138 (36.23%), PCR from blood and urine in 10 of 115 (8.7%) and 10 of 38 (26.31%) cases, respectively. In Leptospira spp. positive patients co-infections with viral hepatitis E, malaria and dengue fever were diagnosed in 27 cases. INTERPRETATION & CONCLUSIONS: The overall seropositivity for leptospirosis was 26.9 per cent in our study. A decreasing trend in seropositivity was observed in recent years. Co-infections with malaria, dengue, hepatitis A and E were also seen. Since leptospirosis is a treatable disease, correct and rapid diagnosis may help in effective management of patients.

Biomechanical Comparison of Krackow Repair and Percutaneous Achilles Repair System for Achilles Tendon Rupture Fixation: A Cadaveric and Finite Element Analysis Study.

Background: Open and percutaneous repair surgeries are widely used for the Achilles tendon rupture. However, prior biomechanic studies of these 2 approaches have mixed conclusions; therefore, we designed a cadaver and finite element (FE) model biomechanical study to compare the mechanical differences between the percutaneous Achilles repair system (PARS) and Krackow open repair under tensile load and rotation. Methods: Sixteen Achilles tendons were extracted from fresh-frozen cadaver ankles and the calcaneums were fixed in mortar. A force control dynamic tensile mechanical test was performed at 1 Hz with 30- and 100-N cyclic loads. Initial intact baseline testing was followed by an incision on all Achilles tendons, 4 cm from the calcaneus insertion, which were then repaired using the PARS (n = 8) or Krackow (n = 8) method. Recorded force-displacement values were used to calculate mechanical parameters, and statistical significance of differences was determined by unpaired (between repair techniques) and paired (intact vs repaired) t tests. Material properties of the Achilles tendon in the FE model were modified and a 10-Nm flexion was simulated for intact and surgical groups. Results: No differences were found between intact tendons assigned to PARS or Krackow repairs in Young's modulus (P = .582) and stiffness (P = .323). Pre- and postoperative Young's modulus was significantly decreased for both groups (Intact 230.60±100.76 MPa vs PARS 142.44±37.37 MPa, P < .012; Intact 207.46±81.12 MPa vs Krackow109.43±27.63 MPa, P < .002). Stiffness decreased significantly after surgery for both groups (Intact 25.33±10.89 N/mm vs PARS 6.51±1.68 N/mm, P < .003; Intact 20.30±8.65 N/mm vs Krackow 5.97±1.30 N/mm, P < .003). PARS ultimate tensile strength was significantly higher than the Krackow (PARS 280.29±47.32 N vs Krackow 196.97±54.28 N, P < .003) but not significantly different in the ultimate tensile strain. PARS had a significantly lower postoperative gap compared to Krackow (PARS 9.75±5.87 mm vs Krackow 25.19±7.72 mm, P < .001). FE analysis predicted an increased talocalcaneal contact pressure, maximum principal stress, and rotation in the Krackow vs PARS models, respectively. Conclusion: Biomechanical parameters observed in this study through mechanical testing and FE analysis favor the selection of PARS over the Krackow repair based on better strength, higher failure force, and lower gap generation.Clinical Relevance: The study has analyzed two Achilles tendon repair methods using cadaver and numerical estimation and may help clinicians gain insight into selection of tendon repair approaches to generate better clinical outcomes.

Scrub typhus in patients with acute febrile illness: a 5-year study from India.

BACKGROUND: Scrub typhus was once thought to be a disease of rural origin and was confined to specific pockets in South Asia. Early diagnosis and treatment is extremely important as it is associated with high mortality if left untreated. AIM: To delineate the clinical and molecular epidemiology of scrub typhus in patients presenting with acute febrile illness from various parts of India. METHODS: During the study period of 5 years (October 2013 to October 2018), a total of 1742 patients with acute febrile illness <15 days were enrolled after taking informed consent. Patients were diagnosed using IgM Enzyme-linked immunosorbent assay (ELISA) based on the pre-determined region specific cut offs. Patients with positive IgM ELISA were also subjected to IgM Immunofluorescence assay and nested polymerase chain reaction (PCR) assay. The demographic and relevant clinical details of the patients were documented and analyzed. RESULTS: A total of 210 (12.1%) patients were diagnosed with scrub typhus. Of these, nested PCR was positive in only 85 patients. Sequencing and phylogenetic analysis showed that the predominant circulating genotypes were Gilliam and Karp. On multivariate analysis, acute respiratory distress syndrome, myocarditis, encephalitis/encephalopathy, jaundice and splenomegaly were significantly more common in those patients who were diagnosed with scrub typhus. A total of 14 patients diagnosed with scrub typhus succumbed to the illness. CONCLUSION: Patients with fever, headache, pulmonary manifestations, CNS manifestations, myocarditis, transaminitis or thrombocytopenia presenting in the monsoon and post-monsoon season should be evaluated for scrub typhus irrespective of the geographical location in India.

Effects of salinomycin on cell-mediated immunity of broiler chickens against hydropericardium syndrome and Newcastle disease viruses.

The effects of salinomycin (SAL) on protective cell-mediated immune (CMI) responses of vaccinated and challenged broiler chicks against hydropericardium syndrome virus (HPSV) and Newcastle disease (NDV) were investigated while comparing 3 reference drugs [levamisole, cyclophosphamide (CYP), and cyclosporine (CYS)]. Peripheral lymphoproliferation, skin hypersensitivity reactions, and the ability of chicks to resist virulent HPSV and virulent NDV challenges were used to determine the effects of drugs on CMI responses in chicks. Salinomycin-medicated chicks showed significant (P < 0.05) stimulation of lymphoproliferation and nonsignificant (P > 0.05) stimulation of skin hypersensitivity reactions compared with untreated control chicks. However, skin thickness and lymphoproliferation of SAL-medicated chicks were significantly greater (P < 0.05) than those of CYP- and CYS-treated chicks. The greatest survival rate was recorded in SAL-medicated chicks compared with immune-suppressed (CYP- and CYS-treated) and untreated control chicks after virulent NDV and virulent HPSV challenges. Thus, it was concluded that SAL had beneficial effects on the CMI responses of broiler chicks against HPSV and NDV.

Dietary arginine stimulates humoral and cell-mediated immunity in chickens vaccinated and challenged against hydropericardium syndrome virus.

The effects of dietary supplement of arginine on protective humoral and cell-mediated immune responses of broiler chicks vaccinated and challenged against hydropericardium syndrome virus (HPSV) were investigated and compared with those of 2 reference drugs (cyclophosphamide and cyclosporine). Percentage ratios of lymphoid organs (bursa, spleen, and thymus) to BW, postvaccination and challenge serum antibody responses to HPSV, cutaneous basophil hypersensitivity reaction, peripheral lymphoproliferation, postchallenge detection of HPSV in the tissues of infected birds, and ability of chicks to resist virulent HPSV challenge were the parameters utilized to determine the effects of arginine on protective immune responses of chicks. A total of 600 chicks were used in this study. Arginine-supplemented chicks showed significant (P < 0.05) stimulation of lymphoproliferation and cutaneous basophil hypersensitivity reactions compared with untreated control chicks. Similarly, significantly higher body and lymphoid organ weights were (P < 0.05) recorded in arginine-supplemented chicks compared with untreated control chicks. The highest survival rate was recorded in arginine-supplemented HPS-vaccinated chicks compared with immune-suppressed (cyclophosphamide- and cyclosporine-treated and HPS-vaccinated chicks) and untreated unvaccinated control chicks after virulent HPSV challenges. Postchallenge tissue samples from arginine-supplemented and HPS-vaccinated chicks yielded negligible HPSV detections by virus isolation in cell culture or PCR method, or both, compared with untreated control chicks. Thus, it was concluded that dietary supplementation of arginine had beneficial effects on humoral and cell-mediated immune responses of broiler chicks against HPSV.

Laparoscopic Simulators : Are They Useful!

BACKGROUND: Laparoscopic surgery has changed the face of medical care forever. The benefits of laparoscopic open surgery have been demonstrated in virtually all major abdominal surgical procedures. Laparoscopy has introduced a new skill set that must be mastered and requires dedicated training. The teaching of laparoscopic operative skills in the clinical setting is constrained by the complexity of procedures, medicolegal and ethical concerns, fiscal and time limitations. This has created the need for formal training outside the operating room. Simulator-based training holds great promise in enhancing surgical education and providing a safe, cost-effective means for practicing techniques prior to their use in the operating room. METHODS: The surgical residents of two batches were recruited for the study. The residents were randomized to either a group that received training on a simulator or a controlled group that did not receive the training or to a group that received training twice. RESULT: The residents who received training on a simulator demonstrated better psychomotor skills in the operation theatre than those who did not. Training in simulator environment can contribute to the development of technical skills relevant to the performance of laparoscopic surgery in vivo. Training at regular intervals will benefit the residents in gaining significant improvement of their psychomotor skills. CONCLUSION: Laparoscopic trainer is a promising tool for training in laparoscopic surgery.

Utilization of Finite Element Analysis for Articular Cartilage Tissue Engineering.

Scaffold design plays an essential role in tissue engineering of articular cartilage by providing the appropriate mechanical and biological environment for chondrocytes to proliferate and function. Optimization of scaffold design to generate tissue-engineered cartilage has traditionally been conducted using in-vitro and in-vivo models. Recent advances in computational analysis allow us to significantly decrease the time and cost of scaffold optimization using finite element analysis (FEA). FEA is an in-silico analysis technique that allows for scaffold design optimization by predicting mechanical responses of cells and scaffolds under applied loads. Finite element analyses can potentially mimic the morphology of cartilage using mesh elements (tetrahedral, hexahedral), material properties (elastic, hyperelastic, poroelastic, composite), physiological loads by applying loading conditions (static, dynamic), and constitutive stress-strain equations (linear, porous-elastic, biphasic). Furthermore, FEA can be applied to the study of the effects of dynamic loading, material properties cell differentiation, cell activity, scaffold structure optimization, and interstitial fluid flow, in isolated or combined multi-scale models. This review covers recent studies and trends in the use of FEA for cartilage tissue engineering and scaffold design.

Emerging multidrug resistance isolates of hospital-acquired bacterial meningitis in a tertiary care centre in North India.

Purpose. Acute bacterial meningitis continues to be a potentially life threatening condition. Hospital-acquired meningitis is rapidly increasing and adding an immense burden to the health system due to the emergence of multidrug resistance isolates. The purpose of this study is to find the antibiotic susceptibility pattern of the bacteria detected from hospital- and community-acquired meningitis.Methodology. A total of 400 Cerebrospinal fluid (CSF) samples from the suspected meningitis cases were collected and processed for cell count, biochemical examination, Gram staining, latex agglutination and culture. Bacteria grown on blood, chocolate and Mac-conkey agar were identified by matrix-assisted laser desorption/ionization-time of flight. Antibiotic susceptibility tests were performed as per Clinical and Laboratory Standard Institute guidelines.Results. Of the isolates, most prevalent Gram negative organisms in hospital-acquired bacterial meningitis were Escherichia coli 13 (27.08 %), Acinetobacter baumannii 12 (25 %), Klebsiella pneumoniae 5 (10.42 %), Pseudomonas aeruginosa 4 (8.33 %) and Gram positive organisms were Staphylococcus aureus 4 (8.33 %), Enterococcus faecium 3 (6.25 %) and CONS 2 (4.16 %). Streptococcus pneumoniae 3 (6.25 %) was the predominant organism in community-acquired bacterial meningitis. All the Gram negative isolates were multidrug resistance. Only colistin and imipenem were effective antibiotics against them. Likewise Gram positive organisms were susceptible to most of the antibiotics tested. However, E. faecium was only susceptible to Vanco+Teicoplanin.Conclusion. In hospital-acquired bacterial meningitis, multidrug resistance Gram negative bacteria are a huge challenge for the treatment of patients. Hence, antimicrobial stewardship should be followed to counteract with the emerging multidrug resistance isolates.

Effects of polyether ionophores on the protective immune responses of broiler chickens against Angara disease and Newcastle disease viruses.

Immunization against Angara disease virus (ADV), a serotype 4 avian adenovirus, and Newcastle disease virus (NDV), an avian paramyxovirus serotype 1, is the mainstay of a broiler vaccination programme, while polyether ionophores usually form an essential component of a broiler medication programme in most parts of India and Pakistan. The role of polyether ionophores in the protective immune responses of broiler chickens vaccinated and challenged with ADV and NDV was investigated. A total of 1600 birds were divided into eight groups of 200 birds each. First four groups were vaccinated against NDV and ADV, while the remaining four served as unvaccinated controls. The first 3 groups of birds were administered salinomycin, monensin and cyclophosphamide (CYP), respectively. The last group served as an untreated control. The same treatment schedule was also followed for the next four unvaccinated groups. The post-vaccination and post-challenge serological responses to NDV and ADV, body and lymphoid organ weight gains, post-challenge survival rate and detection of NDV and ADV in the tissues of infected birds were evaluated. Birds administered salinomycin showed a significant stimulation of protective immune responses against both NDV and ADV as compared to the untreated and CYP-treated birds. Monensin also enhanced the protective immune responses against both viruses but the effect was not statistically significant. Thus, it is concluded that monensin and salinomycin augment the anti-NDV and anti-ADV immune responses in broiler chickens, which supports their use in poultry flocks.

Neonatal sepsis in rural India: timing, microbiology and antibiotic resistance in a population-based prospective study in the community setting.

OBJECTIVE: To examine the timing and microbiology of neonatal sepsis in a population-based surveillance in the Indian community setting. STUDY DESIGN: All live born infants in 223 villages of Odisha state were followed at home for 60 days. Suspect sepsis cases were referred to study hospitals for further evaluation including blood culture. RESULTS: Of 12 622 births, 842 were admitted with suspected sepsis of whom 95% were 4 to 60 days old. Culture-confirmed incidence of sepsis was 6.7/1000 births with 51% Gram negatives (Klebsiella predominating) and 26% Gram positives (mostly Staphylococcus aureus). A very high level of resistance to penicillin and ampicillin, moderate resistance to cephalosporins and extremely low resistance to Gentamicin and Amikacin was observed. CONCLUSION: The bacterial burden of sepsis in the Indian community is not high. Judicious choice of empiric antibiotics, antibiotic stewardship and alternate modalities should be considered for the management or prevention of neonatal sepsis in India.

Incidence and characterization of Clostridium perfringens isolated from antibiotic-associated diarrhoeal patients: a prospective study in an Indian hospital.

Clostridium perfringens has been reported as causing between 2-15% of all cases of antibiotic-associated diarrhoea (AAD), and may be diagnosed by detection of enterotoxin in faeces. A prospective study comprising 150 diarrhoeal patients and 100 non-diarrhoeal controls was undertaken to assess the incidence of C. perfringens-associated diarrhoea in an Indian hospital. Methods used included C. perfringens culture, reverse passive latex agglutination (RPLA) and enzyme-linked immunosorbent assay (ELISA) for detection of enterotoxin, and polymerase chain reaction (PCR) assay for the presence of enterotoxin gene. Attempts were made to type the isolates by multiplex PCR. Of the 150 diarrhoeal stool samples tested, 13 were culture positive. Of these, four were positive for C. perfringens enterotoxin by RPLA, two were positive by PCR and two were positive by RPLA and ELISA. Twenty-seven samples were positive for culture of C. perfringens in non-diarrhoeal controls but none were positive for enterotoxin either by RPLA or by PCR. The average incidence of C. perfringens AAD using these methods was 2.6%. Toxin typing showed that all the isolates belonged to type A. To conclude, the relatively low incidence of toxigenic C. perfringens suggests that enterotoxigenic C. perfringens is not a major cause of AAD in this population.

Damage Control Surgery for Abdominal Trauma.

Damage control is not a modern concept, but the application of this approach represents a new paradigm in surgery, borne out of a need to save patients with severe exsanguinating injuries. Definitive control and repair may be accomplished in the immediate post injury setting but the physiological derangement due to massive shock state resulting from the severe injury and the resuscitation that follows, often leads to a fully repaired but dead patient. The vicious triad of death in trauma, namely hypothermia, acidosis and coagulopathy should be tackled by initial abbreviated laparotomy, correction of physiological derangements and finally definitive repair of all injuries at second laparotomy. The concept needs a dedicated team effort with careful patient selection for achieving the optimal results.

Pathogenesis of Mycoplasma pneumoniae: An update.

Genus Mycoplasma, belonging to the class Mollicutes, encompasses unique lifeforms comprising of a small genome of 8,00,000 base pairs and the inability to produce a cell wall under any circumstances. Mycoplasma pneumoniae is the most common pathogenic species infecting humans. It is an atypical respiratory bacteria causing community acquired pneumonia (CAP) in children and adults of all ages. Although atypical pneumonia caused by M. pneumoniae can be managed in outpatient settings, complications affecting multiple organ systems can lead to hospitalization in vulnerable population. M. pneumoniae infection has also been associated with chronic lung disease and bronchial asthma. With the advent of molecular methods of diagnosis and genetic, immunological and ultrastructural assays that study infectious disease pathogenesis at subcellular level, newer virulence factors of M. pneumoniae have been recognized by researchers. Structure of the attachment organelle of the organism, that mediates the crucial initial step of cytadherence to respiratory tract epithelium through complex interaction between different adhesins and accessory adhesion proteins, has been decoded. Several subsequent virulence mechanisms like intracellular localization, direct cytotoxicity and activation of the inflammatory cascade through toll-like receptors (TLRs) leading to inflammatory cytokine mediated tissue injury, have also been demonstrated to play an essential role in pathogenesis. The most significant update in the knowledge of pathogenesis has been the discovery of Community-Acquired Respiratory Distress Syndrome toxin (CARDS toxin) of M. pneumoniae and its ability of adenosine diphosphate (ADP) ribosylation and inflammosome activation, thus initiating airway inflammation. Advances have also been made in terms of the different pathways behind the genesis of extrapulmonary complications. This article aims to comprehensively review the recent advances in the knowledge of pathogenesis of this organism, that had remained elusive during the era of serological diagnosis. Elucidation of virulence mechanisms of M. pneumoniae will help researchers to design effective vaccine candidates and newer therapeutic targets against this agent.

Tricky typhus ticks two: A report of two sisters from North India presenting with acute respiratory distress syndrome due to scrub typhus.

Scrub typhus is emerging as an important cause of acute febrile illness in Northern India. This is a report of two sisters presenting concurrently with acute respiratory distress syndrome. A diagnosis of scrub typhus was made in both the patients, and they were successfully treated with doxycycline.