Piyali Mandal

Epidemiology of candidemia in a tertiary care centre of north India: 5-year study.

Background:To determine the distribution of species of Candida and the risk factors associated with candidemia in Indian population for which we conducted a retrospective study for 5 years in a tertiary care centre of North India.Materials and Methods:Blood samples from 7,297 patients aged from 3 days to 85 years, suspected with candidemia, were collected and tested for Candida. The susceptibility patterns toward fluconazole for the year 2005 isolates were tested by micro-dilution assay as described in the CLSI (M27A-2 method).Results:Most of the episodes have been caused by species other than C. albicans. Non-albicans candidemia was 79%–80% in both female and male populations. The most frequent species isolated from 275 patients in 5 years (January 2001–December 2005) was C. tropicalis (35.3%), followed by C. albicans (21.5%), C. parapsilosis (20%), C. glabrata (17.5%), C. krusei (3.3%), C. haemulonii (1.5%), and C. guilliermondii (1%). C. parapsilosis was the predominant in the fifth year of the study (2004–2005). Dose-dependant susceptibility to fluconazole was observed in 5% (n = 3) of the strains. Antifungal resistance was found in 11.7% (n = 7), which includes only C. glabrata.Conclusion:These results were comparable to those derived from other regions of India. C. tropicalis has been reported as the predominant species involved in the cases of candidemia. But in 2005 it has moved toward C. parapsilosis. No true antifungal resistance is reported. Further epidemiological surveillance is needed.

Dual Infections with Pigmented and Albino Strains of Cryptococcus neoformans in Patients with or without Human Immunodeficiency Virus Infection in India

ABSTRACT Cryptococcus neoformans is an encapsulated yeast-like fungus of worldwide distribution. Melanin production is an important virulence factor of C. neoformans. We report the identification of distinct cryptococcal isolates with either pigmented or white colony phenotypes on l-dihydroxyphenylalanine agar plates in three patients who presented with meningitis to the All India Institute of Medical Sciences in India. Two of the patients were also infected with human immunodeficiency virus. Biochemical studies, India ink analysis, immunofluorescence with antibodies specific to capsular antigen, and serotyping confirmed that the melanotic and albino strains were C. neoformans serotypes A and D, respectively. Genotyping with M13 and [GACA]4 primers revealed that all the C. neoformans isolates were genetically different. The CNLAC1 gene associated with melanin production was identified in all the strains by PCR. Standard MIC testing revealed that the strains had similar susceptibilities to amphotericin B, but time-kill assays with the antifungal showed reduced susceptibility in melanin-producing strains. Infection studies with A/Jcr mice showed that the melanin-lacking yeast were less virulent than melanin-producing isolates. These findings indicate that these patients had dual infections with pigmented and albino strains of C. neoformans that were phenotypically and biologically different. Continued surveillance of primary isolates from patients with cryptococcosis by analyzing phenotypic differences and by molecular methods may reveal that mixed infections occur more commonly than is currently realized.

Current scenario of cryptococcosis and antifungal susceptibility pattern in India: a cause for reappraisal

This study analysed the spectrum, antifungal susceptibility pattern, clinical course and molecular epidemiology of cryptococcosis. Four hundred and thirty‐nine samples obtained from 378 meningitis patients were processed by standard procedures. Minimum inhibitory concentration (MIC) of fluconazole and amphotericin B for the isolates was tested by broth micro dilution and by E‐strip method. Molecular analysis by random amplified polymorphic DNA‐PCR of eight isolates was performed using M13 primer. Cryptococcosis was diagnosed in 35 patients [HIV‐1 seropositive (19) and apparently immunocompetent (16)]. Cryptococcus neoformans var. neoformans (serotype A and D) was the predominant isolate on phenotypic identification. Three C. neoformans var. gattii were isolated from HIV‐1 seropositive (2) and apparently immunocompetent (1) patients. MIC 90 for amphotericin B and fluconazole were 1 and 8 μg ml−1 respectively. On RAPD‐PCR, less diversity was seen among Indian isolates. AIDS remains the single most important risk factor for cryptococcosis. Rising MIC of the available induction and maintenance drugs is of grave concern. The DNA typing technique showed less diversity among Indian strains. Routine surveillance and application of molecular typing methods are crucial to know the baseline and existing pattern of cryptococcosis.

Differences in the cell wall architecture of melanin lacking and melanin producing Cryptococcus neoformans clinical isolates from India: an electron microscopic study

Cryptococcus neoformans e um importante fungo oportunista patogenico que causa infeccao no sistema nervoso central, e que pode levar o paciente a morte. Um dos principais fatores de virulencia do C. neoformans e a producao de melanina na parede celular. Utilizando microscopia eletronica de transmissao, nos estudamos as paredes celulares de tres pares de isolados obtidos de pacientes com dupla infeccao pelo fungo, onde um isolado melanizado e um albino foram isolados do liquor de cada paciente. A microscopia eletronica de transmissao revelou que as cepas albinas nao apresentavam a camada de melanina enquanto que uma camada de melanina estava associada com a parede celular de cepas melanoticas, constituindo aproximadamente 75% da area da parede celular. O tamanho da parede celular das celulas produtoras de melanina foi aproximadamente o dobro do tamanho da parede celular dos isolados albinos (p < 0,003). Neste estudo, a microscopia eletronica de transmissao revelou que as diferencas na estrutura dos isolados albinos sem melanina e dos isolados produtores de melanina estava associada a parede celular e a camada de melanina.

Factors Affecting Drug Use During Incarceration: A Cross-Sectional Study of Opioid-Dependent Persons from India

INTRODUCTION Substance abuse and criminality share a complex relationship. The rates of substance use among the prisoners, and that of criminal acts among substance users in community setting are high. Data from South Asian countries, including from India are inadequate. This study aimed to assess the pattern of criminal acts among opioid-dependent subjects and their substance use pattern in the month before, during and after imprisonment. METHODS Using a cross-sectional study design and purposive sampling, opioid-dependent subjects (n=101) attending two community drug treatment clinics who have had any contact with the law were assessed using a specifically-designed tool to record criminal acts and substance use before, during and after last imprisonment. RESULTS Most subjects (93%) had committed illegal acts in their lifetime. Physical assault was the most common illegal act, while 23% reported selling drugs and 9% reported committing serious crimes. About 95% were arrested and 92% had spent time in police lockups. About 29% were arrested for drugs possession or drug use, and 3% of injecting drug users arrested for carrying injection equipment. About 85% had been imprisoned at least once, of whom 88% used psychoactive substances in the 1-month period before their last imprisonment. Opioids were the most common substances used daily (68%), followed by cannabis (34%) and alcohol (22%). Ninety-seven percent reported the availability of substances in prisons, and 65% also used substances during their last imprisonment. Cannabis (35%) was the most common substances used in prison followed by opioids (19%). Seventy-six percent used substances soon after prison release, and 13% of opioid users experienced opioid overdose soon after prison release. Use of cannabis, injecting drugs, and opioid use before imprisonment were predictors of substance use in prison. CONCLUSION Opioid-dependent people have various contacts with the law, including imprisonment. Many users are dependent on substances during prison-entry, which is an important reason for their continued substance use in prisons. There is a need to provide substance abuse treatment across all stages of criminal justice system.

Is the DSM-5 position on dhat syndrome justified?

The DSM-5 lists dhat syndrome under the section ‘Glossary of cultural concepts of distress’. It describes dhat syndrome as ‘anxiety and distress about the loss of dhat in the absence of any identifiable physiological dysfunction.’ It further clarifies that ‘despite the name, it is not a discrete syndrome but rather a cultural explanation of distress’. This is a marked deviation from the DSM-IV-TR where the syndrome is described under the section ‘glossary of culture bound syndromes’ as a ‘folk diagnostic term used in India to refer to severe anxiety and hypochondriacal concerns associated with discharge of semen. . .’ It is also a deviation from the ICD-10 which had also given dhat syndrome a separate status under the section ‘neurotic disorders, other’ although it does mention that the syndrome is of uncertain etiology and nosologic status. So, has enough evidence accumulated in the last two decades to change our view on dhat syndrome in this manner? A Pubmed search using the search term ‘dhat syndrome’ yields a total of 44 results of which 38 were published after 1994. Of them, only 8 papers (Table 1) have discussed the issue of its nosological status in some detail. This includes only 3 original articles. We will briefly discuss whether these articles made a good case for the change in stance taken by DSM-5 or not. Mumford (1996) noted that men reporting dhat symptom had higher Hospital Anxiety and Depression Scale (HADS) depression score but not anxiety scores. Also, four out of six men who were diagnosed with depression or dysthymia endorsed the dhat symptom. Based on these findings, Mumford concluded that dhat syndrome was a culturally appropriate form of depression. However, this study had certain major flaws. A fundamental error was to enquire regarding dhat ‘symptom’ and not ‘syndrome’. This issue of dhat ‘symptom’ vs dhat ‘syndrome’ merits further discussion as this is a source of much confusion. Mere reporting of passage of dhat (without associated preoccupation or distress), in a patient presenting to the clinic for some other health condition, that too on being asked a leading question by a clinician, does not constitute dhat syndrome. It is usual for one to encounter in clinical practice a patient reporting occasional passage of dhat on being specifically asked by the clinician. But many such patients suggest that they are not concerned about it or have no problems that they believe are arising due to it. Considering all such patients to have dhat syndrome is obviously incorrect. An analogy to this is the presence of low mood alone without other associated symptoms of depression in a manner that is not persistent and

Psychological Barriers to Tobacco Cessation in Indian Buprenorphine-Naloxone Maintained Patients: A Pilot Study.

Context: The prevalence of smoking in opioid agonist treatment programmes remains high, leading to significant tobacco related health hazards and mortality. This is the first study from India addressing tobacco cessation and related barriers among recipients of buprenorphine-naloxone maintenance treatment. Aims: The purpose of the study was to investigate Indian buprenorphine-naloxone maintained patients’ willingness to quit tobacco use, to determine its possible association with demographic, agonist maintenance treatment, tobacco use related variables and personal health and risk perceptions related to health hazards associated with tobacco use. Settings and Design: The study was cross-sectional, observational. It was conducted in the out-patient department of a national level de-addiction centre in India. Materials and Methods: Fifty-five males on buprenorphine-naloxone treatment were assessed using Tobacco Use Characteristics, Fagerstrom Test for Nicotine Dependence (FTND and FTND-ST), Readiness to Change questionnaire (RCQ), Smokers Perceived Health Risk Evaluation (SPHERE), Importance of Intervention scale and a semi-structured questionnaire. Statistical Analysis: Descriptive statistics, Kruskal-Wallis Chi-square test, Spearman rank order correlation, paired-t test, ANOVA (STATA 9.2 statistical package). Results: Around 65.4% of the subjects were smokers, 9% were using smokeless tobacco only whereas 25.6% were using both. Mean duration of tobacco use was 20 ± 1.5 years. Only 20% had past quit attempts. Only 24% were in action phase of change. Personal health and risk perceptions were poor and only 61.62% considered intervention tobacco smoking cessation important. Conclusions: Higher severity of nicotine dependence, low perception of harm from tobacco warrant immediate attention and need for on-site treatment opportunity.

Profile of elderly women seeking treatment for substance use disorders at a tertiary care treatment center

Abstract Introduction: Elderly women comprise of a unique subpopulation of people who use drugs. However, literature on the profile of elderly women seeking treatment is scarce. Materials and methods: This retrospective chart review included 16 elderly (>60 years of age) women subjects seeking outpatient treatment at a tertiary care substance use treatment center located in North India. Information pertaining to their sociodemographics and substance use were extracted from available records. Results: The mean age of subjects was 63.63 ± 4.92 years (range 60–75 years). Most of the subjects were Hindu (14/16), married (13/16), illiterate (11/16), housewives (12/16), and coming from an urban background (11/16). Most common substances of abuse were tobacco (8/16) followed by opioids (05/16). Mean duration of opioid use was 3.20 ± 2.68. Only four patients reported comorbid psychiatric illness. None of the patients had sought treatment in the past. Conclusion: Elderly women substance users have a distinct profile. Interventions specifically targeted to them are required, especially in Indian settings.

Profile of women substance users seeking treatment at tertiary care treatment center in India: A retrospective chart review study

ABSTRACT Introduction: Among substance users, women represent a small, unique subpopulation. Studying their socio-demographic and substance-use profile helps us understand their concerns and formulate management strategies. Materials and Methods: In this retrospective chart review, all the available records of outpatient treatment seekers at National Drug Dependence Treatment Centre (NDDTC), All India Institute of Medical Sciences (AIIMS), Ghaziabad, from 1 January 2011 to 31 December 2015 were screened. Data from the women substance users were entered into a specially designed MS Excel format and analyzed. Results: In these 5 years, 217 women (mean age 36.75 ± 11.84 years) sought treatment. Majority were married (75.6%), housewife (53.5%), educated (59.4%), from an urban background (70.0%). Most common primary substance used was opioid (61.3%), including heroin (30.0%) and pentazocine (16.1%). About 20.3% reported injectable opioid use. The mean duration of opioid use was 5.44 ± 4.68 years. History of prior treatment seeking was reported by 4.6% and no prior significant abstinence attempts by 77.4%. Discussion and Conclusion: Majority of female treatment seekers, are young, married urban women and seek treatment for opioid use, particularly heroin (as opposed to pentazocine, suggested by previous studies). Prior treatment seeking and abstinence rates are low. Data indicates the need of specialized services for this population.

Natural disasters, armed conflict, and public health

n engl j med 370;8 nejm.org february 20, 2014 782 study completion dates, publication dates, and journal names could help to identify journals more likely to publish specific types of studies, to evaluate 10-year trends in studies funded by the National Heart, Lung, and Blood Institute (NHLBI), and to assess the effect of more recent developments in publishing, such as open access and electronic publication ahead of print. Adequately powered, well-funded clinical trials with relevant clinical end points will always be of interest to journal editors. However, smaller studies with surrogate end points have an important role to play and deserve timely publication as well. Identifying the most appropriate journals for these studies before submission may contribute to more opportune publication of NHLBI-funded studies.From the François-Xavier Bagnoud Center for Health and Human Rights, Harvard School of Public Health, Boston (J.L.); and the World Health Organization Collaborating Center for Research on the Epidemiology of Disasters, Institute of Health and Society, University of Louvain, Brussels (D.G.-S.). Address reprint requests to Dr. Leaning at the François-Xavier Bagnoud Center for Health and Human Rights, Harvard School of Public Health, 651 Huntington Ave., 7th Flr., Boston, MA 02115, or at jleaning@hsph.harvard.edu.