Detection of vancomycin variable enterococci (VVE) among clinical isolates of Enterococcus faecium collected across India-first report from the subcontinent

PurposeEmergence of vancomycin variable enterococci (VVE) poses a challenge to empiric vancomycin therapy. Vancomycin-variable enterococci (VVE) are vanA-positive, yet phenotypically vancomycin-susceptible enterococci that can switch to a vancomycin-resistant phenotype when exposed to vancomycin. The aim of the present study was to determine the prevalence of VVE in India.MethodsIsolates of phenotypically vancomycin susceptible Enterococcus faecium from 20 tertiary care hospitals across India were collected and tested for the presence of vanA, vanR, vanS, vanB and vanC genes by conventional PCR using previously published primers. Isolates positive for vanA gene were considered as VVE.ResultsThe prevalence of VVE was 1.5% (5/340). Only one VVE isolate was positive for vanR and vanS, and all the isolates were negative for vanB and vanC.ConclusionsAlthough the prevalence is low, our finding emphasizes the importance of routinely screening for van genes in enterococci that are phenotypically susceptible. Silenced vanA able to escape detection and revert to resistance during vancomycin therapy represents a new challenge in clinical settings.     

The role of T regulatory cell-associated markers in monitoring tuberculosis treatment completion and failure

Monitoring tuberculosis (TB) treatment success is crucial for clinical decision-making. The only available tool in this regard is sputum microscopy, but it has demerits. Moreover, in case of smear negatives and extrapulmonary TB, an efficient tool is still sought for. Therefore, we evaluated T regulatory cell (Treg)-associated markers (CD25, CD39, and FoxP3) and cellular subsets in monitoring treatment success in treatment-completed groups. Expression profile of various markers and subsets were compared real time among treatment-naive pulmonary TB patients (TN-PTB), followed-up treatment-completed (TC-fu) cohort, and a not followed-up (TC-nfu) cohort. Peripheral blood mononuclear cells from various groups were incubated overnight and were stained with antibodies for specific markers and studied by flow cytometry. In both the treatment-completed groups, a decline in frequencies of CD25⁺ marker and CD4⁺CD25⁺, CD4⁺CD25⁺FoxP3, CD4⁺CD25⁺CD39⁺ Treg was observed with clearance of infection, indicating their potential in monitoring treatment success. However, in the case of treatment failure patient (Tfp), a drastic increase in frequency of CD4⁺CD25⁺FoxP3⁺ Treg subset was found, indicating its usefulness in predicting treatment failure. Although the investigation unveils markers useful in predicting treatment success or failure, the findings from this study needs to be validated in a larger cohort.     

The international migration of dentists: directions for research and policy

In 2010, the World Health Organization Global Code of Practice for International Recruitment of Health Personnel (the WHO Code) was adopted by the 193 Member States of the WHO. The WHO Code is a tool for global diplomacy, providing a policy framework to address the challenges involved in managing dentist migration, as well as improving the retention of dental personnel in source countries. The WHO Code recognizes the importance of migrant dentist data to support migration polices; minimum data on the inflows, outflows and stock of dentists are vital. Data on reasons for dentist migration, job satisfaction, cultural adaptation issues, geographic distribution and practice patterns in the destination country are important for any policy analysis on dentist migration. Key challenges in the implementation of the WHO Code include the necessity to coordinate with multiple stakeholders and the lack of integrated data on dentist migration and the lack of shared understanding of the interrelatedness of workforce migration, needs and planning. The profession of dentistry also requires coordination with a number of private and nongovernmental organizations. Many migrant dentist source countries, in African and the South‐Asian WHO Regions, are in the early stages of building capacity in dentist migration data collection and research systems. Due to these shortcomings, it is prudent that developed countries take the initiative to pursue further research into the migration issue and respond to this global challenge.     

Localization of VP28 on the baculovirus envelope and its immunogenicity against white spot syndrome virus in Penaeus monodon

White spot syndrome virus (WSSV) is a large dsDNA virus responsible for white spot disease in shrimp and other crustaceans. VP28 is one of the major envelope proteins of WSSV and plays a crucial role in viral infection. In an effort to develop a vaccine against WSSV, we have constructed a recombinant baculovirus with an immediate early promoter 1 which expresses VP28 at an early stage of infection in insect cells. Baculovirus expressed rVP28 was able to maintain its structural and antigenic conformity as indicated by immunofluorescence assay and western blot analysis. Interestingly, our results with confocal microscopy revealed that rVP28 was able to localize on the plasma membrane of insect cells infected with recombinant baculovirus. In addition, we demonstrated with transmission electron microscopy that baculovirus successfully acquired rVP28 from the insect cell membrane via the budding process. Using this baculovirus displaying VP28 as a vaccine against WSSV, we observed a significantly higher survival rate of 86.3% and 73.5% of WSSV-infected shrimp at 3 and 15 days post vaccination respectively. Quantitative real-time PCR also indicated that the WSSV viral load in vaccinated shrimp was significantly reduced at 7 days post challenge. Furthermore, our RT-PCR and immunohistochemistry results demonstrated that the recombinant baculovirus was able to express VP28 in vivo in shrimp tissues. This study will be of considerable significance in elucidating the morphogenesis of WSSV and will pave the way for new generation vaccines against WSSV.     

Timing of surgery for hip fractures: A systematic review of 52 published studies involving 291,413 patients

In order to define the optimum timing of surgery for a hip fracture, we performed a systematic review of published evidence. Data was extracted by two independent reviewers and the methodology of each study was assessed. Fifty-two studies involving 291,413 patients were identified. Outcomes measured were mortality, post-operative complications, length of hospital stay and percentage of patients discharged home.We found no randomised trials. For the 25 studies involving 282,470 participants that undertook adjustment for confounding factors, early surgery was associated with a reduced hospital stay. These studies produced conflicting results regarding mortality and morbidity being increased or unaffected by delaying surgery. None of these studies reported any adverse outcomes for early surgery. Those studies with more careful methodology were less likely to report a beneficial effect of early surgery, particularly in relation to mortality.In conclusion early surgery (within 48 h of admission) after a hip fracture reduces hospital stay and may also reduce complications and mortality.     

Drug interaction presenting as acute abdomen

Warfarin is the most common oral anticoagulant prescribed around the world. Adverse drug interactions with warfarin are a huge problem especially in the elderly and in patients who take multiple medications. Most adverse drug interactions involve concomitantly prescribed oral or intravenous medications. Occasionally, topical or mucosally absorbed drugs can interact, leading to fluctuations in warfarin levels with adverse consequences. In this case report, we describe a case of intestinal intramural hematoma, a rare but known consequence of a supra therapeutic international normalized ratio (INR). The supra therapeutic INR was a consequence of mucosally absorbed miconazole, prescribed for vaginal candidiasis. We wish to highlight this rare and potentially fatal drug interaction, along with the need for frequent INR monitoring when new drugs are added or removed in patients taking warfarin.