Effect of dietary manipulation and vaccination of turkey breeder hens on immunoglobulin levels of yolk, yolk sac and neonate poults.

Two hundred turkey breeder hens and 24 viable toms of 30-35 weeks age of small white variety were distributed into two treatment groups having four replicates of 25 hens and three toms in each treatment. First four replicates were offered a turkey breeder diet (Diet A) (Nutrient requirements of poultry, 1994, National Academic Press, Washington, DC) and the rest four replicates were maintained on a higher plane of nutrition (Diet B) for 8-week duration. After 6 weeks of experimental feeding, two replicates from each treatment groups were vaccinated with ND (R2 B) vaccine. Yolk sac of embryo from birds fed Diet B had a significantly higher (p < .05) IgG, IgM level and HI titre (log 2) than those fed Diet A. HI titre values of embryonic yolk sac from the vaccinated birds fed Diet B were significantly higher (p < .05) than that of the control groups. In addition, HI titre values were significantly higher (p < .05) in the day-old poults of the birds fed Diet B than that of those fed Diet A. There was significantly (p < .01) positive correlation between serum IgG and IgM of the breeder birds and day-old chicks. Similarly, there was significantly (p < .05) positive correlation between yolk IgG and IgM after 1-month experimental feeding and yolk sac IgG and IgM. Positive correlation (p < .05) also existed between yolk sac IgM and day-old chick serum IgM. Furthermore, the HI titres of breeder birds' serum at 14 days post-vaccination were positively correlated with their egg yolk after 10 and 15 days post-vaccination, yolk sac and day-old chicks. Thus, the study envisaged that a higher immunity in neonate poults from turkey breeders maintained on a higher plane of nutrition may be elicited as there was maternal transfer of antibodies from the serum of breeder birds to their offsprings through their yolk sac.

Assessment of water quality using multivariate statistical techniques in the coastal region of Visakhapatnam, India.

The present study was intended to develop a Water Quality Index (WQI) for the coastal water of Visakhapatnam, India from multiple measured water quality parameters using different multivariate statistical techniques. Cluster analysis was used to classify the data set into three major groups based on similar water quality characteristics. Discriminant analysis was used to generate a discriminant function for developing a WQI. Discriminant analysis gave the best result for analyzing the seasonal variation of water quality. It helped in data reduction and found the most discriminant parameters responsible for seasonal variation of water quality. Coastal water was classified into good, average, and poor quality considering WQI and the nutrient load. The predictive capacity of WQI was proved with random samples taken from coastal areas. High concentration of ammonia in surface water during winter was attributed to nitrogen fixation by the phytoplankton bloom which resulted due to East India Coastal Current. This study brings out the fact that water quality in the coastal region not only depends on the discharge from different pollution sources but also on the presence of different current patterns. It also illustrates the usefulness of WQI for analyzing the complex nutrient data for assessing the coastal water and identifying different pollution sources, considering reasons for seasonal variation of water quality.

Media scanning and verification system as a supplemental tool to disease outbreak detection & reporting at National Centre for Disease Control, Delhi.

Media scanning for unusual health events can efficiently supplement conventional communicable disease surveillance systems for early detection and response to outbreaks. There is a need to rapidly process and appropriately disseminate the media reports on unusual health events for timely action. Hence to address this need in India a Media Scanning & Verification Cell (MSVC) was established in July 2008 at the National Centre for Disease Control, Delhi. MSVC is supervised by Epidemiologists working in Central Surveillance Unit of IDSP. This unique system monitors Global and National Media sources such as National and Regional print media, news on internet, news wires and websites, news channels and news shared by partners like Global Public Health Intelligence Network (GPHIN), Canada, WHO and other International and national agencies. The information is shared to the districts affected and District Surveillance Officer (DSO) and his team is expected to investigate and revert through the internet about the correctness and action taken. A mean number of 4 Media Alert reports are generated each day. A total of 1685 alerts were reported in a period between July 2008 to December 2011. Of these 1241 (73.7%) were verified as real events and 183 (10.9%) were considered outbreaks by local health officials. Most events were captured through internet (57%) followed by the print media (24%). The most common disease events identified were food-borne and diarrhea (29.1%), dengue (10.68%), influenza & respiratory disease (8.1%) and malaria (7.4%). The sensitivity of MSVC to detect outbreaks was 14.8% with more than half of outbreaks detected before they were identified by the conventional surveillance system. It has proven to be a highly effective supplemental tool to official surveillance system in the detection of early warning signals and hence timely detection and management of public health threats in India.

Small interfering RNAs inhibit infectious bursal disease virus replication in Vero cells.

Small interfering RNA (siRNA) molecules are considered to be a promising antiviral therapeutics. This study was performed to analyze the application of siRNA against infectious bursal disease virus (IBDV) replication. Two siRNAs were designed to target common coding sequences of four IBDV proteins. Corresponding vectors were constructed to express anti-IBDV short hairpin RNAs (shRNA) that were tested for their antiviral effect in Vero cells. The results showed that expressed shRNA inhibited the virus replication to a significant extent (92%) as determined by the virus titration in cell culture. This outcome demonstrated the effectiveness of RNA interference (RNAi) based mechanism against the IBDV in vitro.

Development and in vitro characterization of a bivalent DNA containing HN and F genes of velogenic Newcastle disease virus.

Newcastle disease (ND) is highly contagious, economically important viral disease affecting most of avian species worldwide. Newcastle disease virus (NDV) has single stranded negative sense RNA genome which encodes for six structural and two non-structural proteins. Envelope glycoproteins i.e. hemagglutinin-neuraminidase (HN) and the fusion (F), elicit protective immune response. In this study, HN and F genes of velogenic (virulent) strain were amplified and cloned at multiple cloning sites A and B, respectively into pIRES bicistronic vector for use as bivalent DNA vaccine against ND. The recombinant plasmid was characterized for its orientation by restriction enzyme digestion and PCR. Expression of HN and F genes was assessed in transfected Vero cells at RNA level using RT-PCR in total RNA as well as protein level using IFAT, IPT and western blot using NDV specific antiserum. All these experiments confirmed that HN and F genes cloned in recombinant pIRES.nd.hn.f are functionally active. The recombinant construct is being evaluated as DNA vaccine against ND.

Foot and Mouth Disease (FMD) incidence in cattle and buffaloes and its associated farm-level economic costs in endemic India.

The study investigated the important epidemiological parameters and farm-level economic costs of FMD incidence in cattle and buffaloes during 2013-14 to 2015-16 in various states of India. Multistage random sampling procedure was adopted for the primary survey and data was collected through face-to-face personal interview from 18,609 cattle and buffalo rearing farm households from 123 districts across twelve states and one Union Territory. Besides epidemiological parameters, different farm-level direct and indirect loss associated with FMD was assessed at disaggregated level (states) by employing deterministic mathematical models. Highest number of affected villages and disease incidence was observed in non- FMD control programme (FMD-CP) implemented Madhya Pradesh and Assam states, respectively whereas negligible incidence was in FMD-CP implemented Punjab state. The disease incidence was high during 2013-14 and declined during 2014-15 and 2015-16, respectively implied severe incidence scenario (2013-14) succeeded by moderate (2014-15) and mild (2015-16) scenarios. The crossbred and high productive animals were severely affected than local breeds whereas on sexwise and agewise comparison revealed higher incidence in females and adult animals. During severe incidence scenario, milk loss/animal ranged from USD 6.87-47.44, 18.42-125.88, 16.33-91.43, and 27.17-123.62; mortality loss/animal ranged from USD 32.61-804.27, 30.76-577.7, 65.36-502.2, and 188.04-413.7; distress sale loss/animal ranged from USD 3.22-188.63, 64.34-519.3, 214.47-341.8, and 209.11-450.3; and opportunity cost of labour/animal from USD 5.49-54.29, 5.49-67.78; 7.95-31.37 and 9.83-72.38 in indigenous cattle, crossbred cattle, local and improved buffalo, respectively. The estimated draught power loss/animal varied from USD 39.46-142.94 with least being in Madhya Pradesh and highest in Assam states whereas the median treatment cost/animal was USD 9.18 and USD 27.07 in indigenous cattle and upgraded buffaloes, respectively. The total farm-level economic loss projected due to FMD in cattle and buffaloes in India was USD 3159 million (INR 221,110 million), USD 270 million (INR 18,910 million) and USD 152 million (INR 10,610 million), respectively during the severe, moderate and mild incidence scenarios at 2015-16 constant prices. The loss varied across the states, and in severe incidence scenario, the country might lose USD 3.2 billion/year and hence, the bi-annual vaccination schedule need to be strictly implemented in all the states. Besides timely vaccination coverage, managing unabated animal movement, educating and motivating the farmers to vaccinate their animals might reduce the incidence and consequential losses to various stakeholders in endemic states like India.

Textiloma, a rare pelvic tumor.

INTRODUCTION: Foreign bodies in the abdominal cavity are extremely rare findings. Their incidence is not known exactly because of under reporting of cases and they go unrecognized at times. CASE REPORT: We are presenting a case of retained surgical sponge removed 9 years after cesarean section. A 30-year-old female presented 9 years after cesarean section with menorrhagia and pain in abdomen. Ultrasonography revealed a pelvic mass and the patient was successfully managed by laparotomy and removal of the sponge. CONCLUSION: Iatrogenic foreign bodies are avoidable complications that need careful observation during surgery. Diagnosis needs high index of suspicion in patients with previous surgery.

Sensitivity of Anatase and Rutile Phases of TiO2 to ion irradiation: Examination of the applicability of Coulomb Explosion and Thermal Spike Models.

Sensitivity of the anatase and rutile phases of titanium dioxide to Swift Heavy Ion (SHI) irradiation was experimentally probed and compared with the predictions of the Coulomb explosion, analytical and inelastic thermal spike models of ion-matter interaction. Conforming to the predictions of all these models, our study indicated higher sensitivity of anatase to these ions than the rutile phase. A detailed examination however revealed that Coulomb explosion model cannot explain either the nature of variation of the interaction cross section of SHI with the energy deposited by these ions, Se to the target electrons, or the relative values of the threshold electronic energy loss, Seth of anatase and rutile. The analytical thermal spike (a-TS) model, using the available physicochemical data for this oxide, predicted that tracks cannot form either in anatase or in rutile by 297 MeV and 511 MeV Ni ions, while inelastic thermal spike (i-TS) model predicted formation of ion tracks by 297 MeV Ni ions and their absence with 511 MeV Ni ions in both anatase and rutile. Our observation agreed with the predictions of i-TS model albeit with a difference in the radius of the tracks. In addition, we observed halo of defect ridden crystalline region of much larger radius around the ion track. Interestingly, the radius of the halo scales with the velocity of the ions, which is opposite to the conventionally observed velocity effect.

Foot-and-mouth disease virus transmission dynamics and persistence in a herd of vaccinated dairy cattle in India.

Foot-and-mouth disease (FMD) is an important transboundary disease with substantial economic impacts. Although between-herd transmission of the disease has been well studied, studies focusing on within-herd transmission using farm-level outbreak data are rare. The aim of this study was to estimate parameters associated with within-herd transmission, host physiological factors and FMD virus (FMDV) persistence using data collected from an outbreak that occurred at a large, organized dairy farm in India. Of 1,836 regularly vaccinated, adult dairy cattle, 222 had clinical signs of FMD over a 39-day period. Assuming homogenous mixing, a frequency-dependent compartmental model of disease transmission was built. The transmission coefficient and basic reproductive number were estimated to be between 16.2-18.4 and 67-88, respectively. Non-pregnant animals were more likely to manifest clinical signs of FMD as compared to pregnant cattle. Based on oropharyngeal fluid (probang) sampling and FMDV-specific RT-PCR, four of 36 longitudinally sampled animals (14%) were persistently infected carriers 10.5 months post-outbreak. There was no statistical difference between subclinical and clinically infected animals in the duration of the carrier state. However, prevalence of NSP-ELISA antibodies differed significantly between subclinical and clinically infected animals 12 months after the outbreak with 83% seroprevalence amongst clinically infected cattle compared to 69% of subclinical animals. This study further elucidates within-herd FMD transmission dynamics during the acute-phase and characterizes duration of FMDV persistence and seroprevalence of FMD under natural conditions in an endemic setting.

Quantitative characteristics of the foot-and-mouth disease carrier state under natural conditions in India.

The goal of this study was to characterize the properties and duration of the foot-and-mouth disease (FMD) carrier state and associated serological responses subsequent to vaccination and naturally occurring infection at two farms in northern India. Despite previous vaccination of cattle in these herds, clinical signs of FMD occurred in October 2013 within a subset of animals at the farms containing juvenile-yearling heifers and steers (Farm A) and adult dairy cattle (Farm B). Subsequent to the outbreak, FMD virus (FMDV) asymptomatic carriers were identified in both herds by seroreactivity to FMDV non-structural proteins and detection of FMDV genomic RNA in oropharyngeal fluid. Carriers' seroreactivity and FMDV genome detection status were subsequently monitored monthly for 23 months. The mean extinction time of the carrier state was 13.1 ± 0.2 months, with extinction having occurred significantly faster amongst adult dairy cattle at Farm B compared to younger animals at Farm A. The rate of decrease in the proportion of carrier animals was calculated to be 0.07 per month. Seroprevalence against FMDV non-structural proteins decreased over the course of the study period, but was found to increase transiently following repeated vaccinations. These data provide novel insights into viral and host factors associated with the FMDV carrier state under natural conditions. The findings reported herein may be relevant to field veterinarians and governmental regulatory entities engaged in FMD response and control measures.

Determinants of the variability of aflatoxin-albumin adduct levels in Ghanaians.

Hepatocellular carcinoma (HCC) is a multifactorial disease with various host and environmental factors involved in its etiology. Of these, aflatoxin exposure has been established as an important risk factor in the development of HCC; the presence of aflatoxin-albumin (AA) adducts in the blood serves as a valuable biomarker of human exposure. In this study, the relationship between a variety of different HCC host factors and the incidence of AA adduct levels was examined in a Ghanaian population at high risk for HCC. These factors included age, gender, hepatitis virus B (HVB) and hepatitis C virus (HCV) status, and genetic polymorphisms in both microsomal epoxide hydrolase (mEH) and glutathione S-transferases (GSTs). Blood samples were analyzed for AA adducts and HBV and HCV status. GSTM1 and GSTT1 deletion polymorphisms and mEH exon 3 and exon 4 single-nucleotide polymorphisms (SNPs) were determined from urine samples. In univariate analysis, age, HBV and HVC status, and GSTT1 and mEH exon 3 genotypes were not associated with AA adduct levels. However, mean adduct levels were significantly higher in both females and individuals typed heterozygous for mEH exon 4 (vs. wild types). Stratification analysis also showed that gender along with mEH exon 4 genotype and HBV status had a significant effect on adduct levels. Both females typed HBsAg+ and males with mEH exon 4 heterozygote genotypes showed significantly higher adduct levels as compared to the HBsAg- and wild types, respectively. Understanding the relationships between these host factors and the variability in aflatoxin-adduct levels may help in identifying susceptible populations in developing countries and for targeting specific public health interventions for the prevention of aflatoxicoses in populations with HCC and chronic liver diseases.

Noninvasive identification of interindividual variation in xenobiotic-metabolizing enzymes: implications for cancer epidemiology and biomarker studies.

In this study, DNA extracted from frozen urine was used in the analysis of polymorphisms in genes coding for xenobiotic-metabolizing enzymes (XMEs). These included single-nucleotide polymorphisms (SNP) in microsomal epoxide hydrolase (mEH), that is, substitutions of tyrosine by histidine in codon 113 (Y113H) and histidine by arginine in codon 139 (H139R), and deletion polymorphisms in glutathione S-transferase (GST) M1 and T1 genes. The concentration of DNA extracted from urine of a Ghanaian population (n = 91) exposed to aflatoxins in their diet ranged from 82.5 to 573 ng/ml urine. Polymerase chain reaction (PCR) restriction fragment length polymorphism (RFLP) procedures were used for the characterization of mEH polymorphisms, whereas a multiplex PCR method was utilized to identify GST deletion polymorphisms. In total, 91% and 94% of 91 samples were genotyped for mEH exon 3 and exon 4 polymorphisms, respectively. In the multiplex analysis of GST polymorphisms, 94% and 91% of 91 individuals were genotyped for GSTM1 and GSTT1 polymorphisms, respectively. The polymorphisms in the mEH exon 4, GSTM1 and GSTT1, were not in Hardy-Weinberg equilibrium (HWE) except for mEH exon 3. Representative genotypes identified by PCR-RFLP were cloned and sequenced, then confirmed by comparison with reference sequences of human DNA published in the GenBank BLAST database. These results demonstrate that XMEs can be genotyped from urine with reliable accuracy and may be useful in cancer and molecular epidemiology studies.

Distribution of Plasmodium falciparum genotypes in clinically mild and severe malaria cases in Orissa, India.

A cross-sectional study was conducted in a malaria hyperendemic state of India to ascertain the distribution of Plasmodium falciparum genotypes in patients with mild (n=40) and severe (n=35) malaria. PCR and nested PCR were used to determine the glutamate-rich protein (GLURP), merozoite surface proteins 1 and 2 (MSP1 and MSP2) and knob-associated histidine-rich protein (KAHRP) for characterization of the parasite. The results indicate that (i) the 200bp allele of the MAD20 family of MSP1 and the 550bp allele of the 3D7 family of MSP2 show over-representation in severe malaria cases; (ii) the multiplicity of infection with respect to MSP2 alleles is significantly higher (P<0.001) in severe cases than in mild cases; and (iii) comparison with the findings of other studies leads to the conclusion that the distribution of P. falciparum genotypes between different clinical groups differs geographically.

Targeted cleavage of HIV-1 envelope gene by a DNA enzyme and inhibition of HIV-1 envelope-CD4 mediated cell fusion.

With the ultimate aim of developing an effective antiviral strategy against HIV-1, a mono-DNA enzyme possessing the 10-23 catalytic motif [Santoro and Joyce (1997) Proc. Natl. Acad. Sci. USA 94, 4264-4266] was synthesized against the HIV-1 envelope gene. We tested the in vitro cleavage efficiency of the 178 bp long truncated HIV-1 Env transcript by DNA enzyme 6339. Protein independent and Mg2+ dependent specific cleavage products were obtained. As soon as 5 min after mixing equimolar concentrations of DNA enzyme and substrate RNA, more than 50% cleavage was observed which increased steadily over a period of 4 h. Very little cleavage was obtained at 1 mM MgCl2 concentration which improved significantly when the concentration of MgCl2 was increased up to 20 mM. Specific inhibition of cell membrane fusion caused by the interaction of gp160 and CD4 in HeLa cells was observed when the above DNA enzyme was used. Thus, these chemically synthesized DNA enzymes could prove to be very useful for in vivo application.

Predominance of HIV type 1 subtype G among commercial sex workers from Kinshasa, Democratic Republic of Congo.

We have investigated the genetic diversity and potential mosaic genomes of HIV-1 during the early part of the HIV-1 epidemic among commercial sex workers (CSWs) in Kinshasa, Democratic Republic of Congo (formerly Zaire). Serologic analysis revealed that 27 (28.7%) of the 94 specimens were seropositive by both peptide and whole-virus lysate EIAs and that 24 were positive by molecular screening assays, using generic primers that can detect all known groups of HIV-1. Phylogenetic analyses of the gag(p24), C2V3, and gp41 regions of these 24 specimens showed that all were group M; none of them had any evidence of group O, N, or SIVcpz-like sequences. On the basis of env sequence analysis, the 24 group M specimens were classified as subtypes G (37.5%), A (21%), F1 (12.5%), CRF01_AE (8%), D (4%), and H (4%); 3 (12.5%) were unclassifiable (U). Similar analysis of the gag(p24) region revealed that the majority of infections were subtype A; however, one-third of the specimens were subtype G. Parallel analysis of gag(p24) and env regions revealed discordant subtypes in many specimens that may reflect possible dual and/or recombinant viruses. These data suggest a predominance of subtype G (both pure G and recombinant CRF02_AG) during the early part of the epidemic in Kinshasa. Infections with group N or SIVcpz-like viruses were not present among these CSWs in Kinshasa.

Nonprescription ibuprofen: side effect profile.

Single doses of nonprescription analgesics are commonly used to treat self-diagnosed conditions. To evaluate the safety of single doses of nonprescription-strength ibuprofen, we examined reported side effects from 15 double-blind, randomized, controlled trials we conducted of the drug to treat various common painful conditions (e.g., headache, sore throat). All studies included placebo and another nonprescription analgesic, acetaminophen. A total of 878 subjects received ibuprofen 200 or 400 mg, 849 acetaminophen 650 or 1000 mg, and 852 placebo. The overall frequency of side effects was comparable: ibuprofen 2.4%, acetaminophen 3.2%, and placebo 2.1%. The frequency of central nervous system symptoms was 0.8%, 2.1%, and 0.9%, respectively. Upper gastro-intestinal upset ranged from 0.8-0.9% of subjects in all groups. We conclude that single doses of nonprescription ibuprofen are well tolerated and demonstrate a side effect profile indistinguishable from that of acetaminophen and placebo.

Differential detection of Newcastle disease virus strains by degenerate primers based RT-PCR.

Degenerate primers based RT-PCR (previously described by [Avian Dis 26 (1997) 837]) has been used for the detection and differentiation of Newcastle disease (ND) viruses. Two sets of primers (A+B and A+C), with common forward primer and distinct reverse degenerate primers, designed from fusion protein gene encoding for cleavage site, could differentiate virulent and avirulent Newcastle disease viruses (NDV). Both sets of primers amplified "F" gene sequence of virulent (velogenic and mesogenic) viruses, whereas in avirulent strains, amplification was only with primer set A+C. Total 10 NDV isolates and two clinical samples including both known and unknown pathotypes, were checked. Based on amplification results 5 viruses were found to be virulent type and 6 as avirulent with one of the two clinical samples, earlier positive by RT-PCR using non-degenerate "F" gene specific primers was found negative in this study. The technique has been found to be a simple and quick for the detection and differentiation of virulent and avirulent NDV, which is important for control of the disease in the events of the outbreaks.

Genotoxicity of 'gudakhu', a tobacco preparation. I. In mice in vivo.

'Gudakhu' is a paste-like tobacco preparation used widely in Orissa and neighbouring states of India. During use it is rubbed over the teeth and gum with a finger tip. Besides tobacco, it contains molasses, lime, red soil and water. The genotoxic potential of acetone extract of gudakhu was evaluated in mice in vivo using the chromosome aberration assay, micronucleus test and SCE analysis following single as well as long-term repeated treatment. The animals received an aqueous suspension of the extract via the oral route. Gudakhu extract induced significantly high frequencies, compared to controls, of chromosome aberrations, micronuclei (MN) and SCEs. Single treatment with different doses clearly revealed a distinct dose-dependent increase of the effects in all the assays. Analysis of MN in regenerated hepatocytes also indicated a significant positive correlation between time-course of chronic treatment and frequencies of micronucleated cells. But incidences of chromosome aberrations, MN and SCEs in bone marrow cells following repeated treatment for different periods did not differ greatly from each other; and these repeated treatment data, particularly in the MNT in bone marrow cells and the SCE assay, also did not differ markedly from the respective single treatment data for the same dose. This was probably due to the proliferative nature of the bone marrow cells.

Induction of chromosome aberrations and micronuclei in pulmonary alveolar macrophages of rats following inhalation of mosquito coil smoke.

The genotoxic potential of inhalation of mosquito coil (MC) smoke was evaluated by using metaphase chromosome aberration and micronucleus assays in pulmonary alveolar macrophages (PAMs) of rats following short-term as well as long-term whole body intermittent exposure. For short-term exposure, the animals were exposed for 15 min/h, 8 h/day to smoke collected for 1, 5 or 10 min, and they were killed 16 or 24 h after the final exposure. For long-term exposure, they were exposed for 15 min/h, 8 h/day, 7 days/week to smoke collected for 10 min and then they were killed 24 h after the final exposure. Each time before exposure, fresh smoke was collected by burning a mosquito coil. Pulmonary lavage was collected, and conventional flame-drying preparation was done for metaphase chromosome analysis and micronuclei (MN) were analyzed from smear preparations. Significantly higher frequencies of chromosome aberrations, including as well as excluding gaps, and micronucleated PAMs in smoke-exposed animals, compared to controls, indicated genotoxic capacity of MC smoke. The increases significantly correlated with the "concentration" of the gas. Mitotic indices also showed a significant and concentration-dependent increase. The frequencies of chromosome aberrations and MN following 7-day exposure were very similar to those for 1-day exposure. This was probably due to the transient nature of PAMs. A post-exposure gap of 24 h, compared to the 16-h gap, yielded a higher incidence of both mitoses and chromosome aberrations.

Reduction of mechanical heart valve thrombosis through a clinical audit.

BACKGROUND AND AIM OF THE STUDY: Patients with mechanical heart valves implanted at four cardiothoracic centers were followed up in a hospital in Eastern India. Despite successful surgery and regular hospital visits, long-term survival was compromised by anticoagulation-related complications. METHODS: Systematic analysis revealed under-anticoagulation in most patients. Thrombosis risk in 80 patients on regular follow up from 1989 to 1997 was 8.68 per 100 patient years (pt-yr). The incidence of both thrombotic and bleeding complications was reported as less than two per 100 pt-yr, when prothrombin time was consistently in the range of INR 2.5 to 3.9. In targeting this low event rate, impediments to optimum anticoagulation in the local set-up were identified. International Normalized Ratio (INR) was introduced to report prothrombin time (PT). Patients and doctors were educated about drug and diet interactions with oral anticoagulants (OAC) and the early features of valve thrombosis. Treatment protocols were evolved. The impact of the remedial measures was studied in 81 patients (64 old, 17 new) over a total of 254 pt-yr of follow up, from 1998 to 2001. RESULTS: Thrombosis risk was reduced from 8.68 to 5.12 per 100 pt-yr, while non-fatal bleeding events increased from 0.28 to 1.96 per 100 pt-yr. Due to early recognition of occlusive prosthetic valve thrombosis and institution of fibrinolytic therapy, fatal events were reduced from 3.8 per 100 pt-yr to none for four consecutive years (statistically significant at 99% CI). CONCLUSION: The clinical audit proved to be a valuable tool for understanding the problems in health care delivery, and bringing about improvement.