Unusual presentation of Plasmodium vivax: a neglected human malaria parasite

Severe and complicated malaria is usually caused by Plasmodium falciparum malaria (PF) but it has been increasingly observed that Plasmodium vivax malaria (PV), which was otherwise considered to be benign malaria, with a low case-fatality ratio, can also occasionally result in severe disease as with PF malaria. There is an urgent need to re-examine the clinical spectrum and burden of PV so that adequate control measures can be implemented against this emerging but neglected disease. We report a case of severe PV malaria with multi-organ dysfunction. Patients exhibited acute kidney injury, severe anemia/thrombocytopenia, jaundice, hypoglycemia, hyponatremia, and pulmonary edema. Peripheral blood microscopy by trained and expert pathologist and rapid diagnostic test showed the presence of PV and absence of PF. The patient recovered completely with anti-malarial drugs, supportive measures, and hemodialysis.Recent microrheologic research that analyzed malaria severity in PV clearly demonstrated enhanced aggregation, erythrocyte clumping, and reduced deformability affecting microcirculation. Our case report highlights the fact that PV malaria is benign by name but not always by nature. PV can lead to unusual and potentially life-threatening complications. Further large-scale multi-centric studies are needed to define this less known entity.     

Placental histologic criteria for diagnosis of cord accident: sensitivity and specificity

ABSTRACT "Cord accident" (compromised umbilical blood flow) as a cause of stillbirth is underreported, mainly due to a lack of diagnostic criteria. Based on fetal vascular pathology in the placenta, we have previously established histologic criteria for the diagnosis of cord accident. In the current study, we set out to test the sensitivity and specificity of these criteria by reviewing an independent set of stillbirth cases. Placental slides from 26 cases (in which cord accident was deemed the cause of death) and 62 controls (in which the cause of death was anything other than cord accident) were reviewed. The following histologic changes were noted: (1) dilated fetal vessels, (2) thrombosis in fetal vessels, and (3) avascular or near-avascular chorionic villi. "Minimal" criteria were defined as the presence of dilated and thrombosed fetal vessels, while the additional presence of focal or regional avascular or near-avascular villi satisfied the complete criteria. Of the 62 stillbirth controls with cause of death other than cord accident, 13 (21%) met the minimal criteria (specificity 79%) and only 4 (6%) met the complete criteria for cord accident (specificity 94%). In contrast, of the 26 cases with a cause of death related to cord accident, 16 met the minimal criteria (sensitivity 62%) and 12 met the complete criteria (sensitivity 46%). These histologic criteria identify cases of cord accident as a cause of stillbirth with very high specificity. This study confirms the utility of these criteria for diagnosis of cord accident and further stresses placental examination in evaluation of stillbirths.     

Effect of vaginal speculum lubrication on cervical cytology and discomfort during smear examination

AIM: To evaluate the role of lubricant gel in the cytology of a Pap smear and whether it results in an improvement in the discomfort experienced by women while undergoing Pap smear screening. METHODS: A total of 151 women were analyzed in the study. After screening for inclusion criteria, a Pap smear was taken with no lubricant in all the women and the discomfort experienced was rated on a visual analogue scale. The women underwent a second Pap smear on the next visit using a lubricant gel and were again rated on a visual analogue scale for the discomfort felt. The pathologist was blinded to the fact of whether the lubricating gel was used. RESULTS: The number of unsatisfactory smears in the no gel group was 3 vs 5 in the gel group, P < 0.05. However, a significant difference (P = 0.00) was observed in the visual analogue pain score in both groups, suggesting that application of lubricant gel over the speculum improves the pain experienced by women. CONCLUSION: Using a small amount of lubricant over the speculum does not impair cervical cytology but significantly improves the discomfort experienced by women while undergoing a Pap smear.     

Microbiologic effectiveness of boiling and safe water storage in South Sulawesi, Indonesia

In Indonesia, where diarrhea remains a major cause of mortality among children <5 years, the government promotes boiling of drinking water. We assessed the impact of boiling on water quality in South Sulawesi. We surveyed randomly selected households with at least one child <5 years old in two rural districts and tested source and stored water samples for Escherichia coli contamination. Among 242 households, 96% of source and 51% of stored water samples yielded E. coli. Unboiled water samples, obtained from 15% of households, were more likely to yield E. coli than boiled samples [prevalence ratios (PR) = 2.0, 95% confidence interval (CI) 1.7–2.5]. Water stored in wide-mouthed (PR = 1.4, 95% CI = 1.1–1.8) or uncovered (PR = 1.8, 95% CI = 1.3–2.4) containers, or observed to be touched by the respondent's hands (PR = 1.6, 95% CI = 1.3–2.1) was more likely to yield E. coli. A multivariable model showed that households that did not boil water were more likely to have contaminated stored water than households that did boil water (PR = 1.9, 95% CI = 1.5–2.3). Although this study demonstrated the effectiveness of boiling in reducing contamination, overall impact on water quality was suboptimal. Future studies are needed to identify factors behind the success of boiling water in Indonesia to inform efforts to scale up other effective water treatment practices.     

Impact of proton pump inhibitors on efficacy of clopidogrel: Review of evidence

Clopidogrel is a prodrug which requires cytochrome P450 2C19 (CYP 2C19) enzyme for its conversion to an active thiol metabolite. Proton pump inhibitors (PPIs) inhibits enzyme CYP 2C19 interfering with the conversion of clopidogrel into its active metabolite. Studies document the possible interaction of clopidogrel and PPIs leading to a decrease in the antiplatelet efficacy of clopidogrel. A PubMed/MEDLINE database literature search was carried out and the bibliographies of found articles were checked for other relevant literature. Most retrospective cohort studies and studies using platelet markers found a significant association between PPI use especially omeprazole and decreased efficacy of clopidogrel while few comparative trials using clinical outcomes found no association between the same. Pantoprazole was not associated with the decrease in the antiplatelet efficacy of clopidogrel. Patients on dual antiplatelet therapy and/or with a history of gastrointestinal bleed will require gastroprotection in the form of PPIs. In such cases, pantoprazole should be the preferred PPI. Rabeprazole can be used as an alternative.     

Residual symptoms in depressed outpatients who respond by 50% but do not remit to antidepressant medication

Little is known about the quantity or quality of residual depressive symptoms in patients with major depressive disorder (MDD) who have responded but not remitted with antidepressant treatment. This report describes the residual symptom domains and individual depressive symptoms in a large representative sample of outpatients with nonpsychotic MDD who responded without remitting after up to 12 weeks of citalopram treatment in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. Response was defined as 50% or greater reduction in baseline 16-item Quick Inventory of Depressive Symptomatology--Self-Report (QIDS-SR??) by treatment exit, and remission as a final QIDS-SR?? of less than 6. Residual symptom domains and individual symptoms were based on the QIDS-SR?? and classified as either persisting from baseline or emerging during treatment. Most responders who did not remit endorsed approximately 5 residual symptom domains and 6 to 7 residual depressive symptoms. The most common domains were insomnia (94.6%), sad mood (70.8%), and decreased concentration (69.6%). The most common individual symptoms were midnocturnal insomnia (79.0%), sad mood (70.8%), and decreased concentration/decision making (69.6%). The most common treatment-emergent symptoms were midnocturnal insomnia (51.4%) and decreased general interest (40.0%). The most common persistent symptoms were midnocturnal insomnia (81.6%), sad mood (70.8%), and decreased concentration/decision making (70.6%). Suicidal ideation was the least common treatment-emergent symptom (0.7%) and the least common persistent residual symptom (17.1%). These findings suggest that depressed outpatients who respond by 50% without remitting to citalopram treatment have a broad range of residual symptoms. Individualized treatments are warranted to specifically address each patient's residual depressive symptoms.     

Effect of lead on human erythrocytes: an in vitro study

The present study was an attempt to investigate toxic effects of lead on red blood corpuscle (RBC) under in vitro conditions. Venous blood samples from adult, healthy, well-nourished male donors falling in age group of 25-30 years were collected in EDTA vials for preparation of RBC suspension. These donors were the residents of an area of Bhuj, where soil was not contaminated with lead and also concentration of lead was below detectable limit in blood and drinking water. RBC suspension was treated with (0.0625 to 0.625 ppm) of Pb(NO3) for 4 h at 37 degrees C. The results revealed that addition of lead salt causes concentration-dependent increase in the rate of hemolysis, thus, proving Pb(NO3) as cytotoxic agent even at very low concentration.