Knowledge and practice of clinical ethics among healthcare providers in a government hospital, Chennai.

The growing public concern about the ethical conduct of healthcare professionals highlights the need to incorporate clinical ethics in medical education. This study examined the knowledge and practice of clinical ethics among healthcare providers in a government hospital in Chennai. A sample of 51 treating physicians and 58 other non-physician service providers from the hospital answered a self-administered, semi-structured questionnaire on their knowledge of and adherence to ethical principles, and the problems they faced related to healthcare ethics. More than 30% did not give a definition of healthcare ethics, and 40% did not name a single ethical principle. 51% stated that they witnessed ethical problems in their settings and named patient dissatisfaction, gender bias by provider, and not maintaining confidentiality. The responses of healthcare providers to various ethical scenarios are reported.

A Pathway Idea for Model Building.

Models, mathematical or stochastic, which move from one functional form to another through pathway parameters, so that in between stages can be captured, are examined in this article. Models which move from generalized type-1 beta family to type-2 beta family, to generalized gamma family to generalized Mittag-Leffler family to Lévy distributions are examined here. It is known that one can likely find an approximate model for the data at hand whether the data are coming from biological, physical, engineering, social sciences or other areas. Different families of functions are connected through the pathway parameters and hence one will find a suitable member from within one of the families or in between stages of two families. Graphs are provided to show the movement of the different models showing thicker tails, thinner tails, right tail cut off etc.

Loop-mediated isothermal amplification assay for the diagnosis of retinitis caused by herpes simplex virus-1.

A loop-mediated isothermal amplification (LAMP) assay was developed for the detection of herpes simplex virus 1 (HSV-1). The specificity of the assay was tested using DNA extracted from HSV-1-infected rabbit corneal epithelium cultures, HSV-2 grown on Vero cell line, cytomegalovirus (CMV) (AD-169), varicella zoster virus (VZV) (Oka-vaccine), adenovirus, Aspergillus flavus and Staphylococcus aureus. The specificity of LAMP was confirmed by bidirectional sequencing of the amplicons. The sensitivity of the LAMP assay was tested using different concentrations of HSV-1 DNA. To evaluate the application of the LAMP assay in clinical diagnosis, we tested vitreous samples from 20 patients with suspected viral retinitis using LAMP and real-time PCR for HSV-1. The LAMP primers amplified only HSV-1 DNA; no LAMP products were detected with the DNAs of HSV-2, CMV, VZV, adenovirus A. flavus and S. aureus. The sequences of the positive HSV-1 LAMP products perfectly (99-100%) matched the HSV-1 sequences deposited in the GenBank database. LAMP is as sensitive as real-time PCR, with the lowest detection limit being 10 copies/µL of HSV-1 DNA. Of the 20 patients with suspected viral retinitis, four tested positive for HSV-1 using real- time PCR and LAMP. A 100% concordance was observed across the two methods. The LAMP assay is a rapid, highly specific and sensitive method for the diagnosis of retinitis caused by HSV-1.

Pseudomembranous colitis in a pregnant woman.

Pseudomembranous colitis in association with pregnancy has not been well described in English literature. Recent studies show a drastic increase in the incidence and severity of Pseudomembranous colitis in pregnant women, who were once thought to be at low risk. We report here a case of Pseudomembranous colitis in a young healthy immunocompetent pregnant lady. An early suspicion of this entity with the characteristic appearance of pseudomembranes on colonoscopy and histology confirmed the diagnosis enabling prompt treatment and complete recovery without any serious consequences.

Stenotrophomonas maltophilia endogenous endophthalmitis: clinical presentation, sensitivity spectrum and management.

Stenotrophomonas maltophilia is gaining importance as a community-acquired pathogen, after becoming firmly established as a nosocomial pathogen. Here we report a case of endogenous endophthalmitis due to S. maltophilia. Antibiotic-susceptibility testing of the isolate was performed by the Kirby-Bauer disc diffusion method. The organism was resistant to aminoglycosides, imipenem, ticarcillin and cotrimoxazole and was sensitive to ceftazidime and chloramphenicol. The patient was successfully treated with a sensitivity-based intravitreal antibiotic regimen.

Dot-immunobinding assay.

Dot-immunobinding assay (Dot-Iba) is a simple and highly reproducible immunodiagnostic method. Antibody or antigen is dotted directly onto nitrocellulose membrane (NCM) discs. The diagnostic material to be checked can be incubated on this disc. Presence of antigen-antibody complex in NCM discs can be directly demonstrated with enzyme-conjugated antiglobulins and substrate. Development of a purple-pink colored, insoluble substrate product in the NCM will be considered a positive result in the assay. This assay allows the processing of multiple specimens at a time and the entire operational procedures require only 4-6 h. Dot-Iba is rapid, and the technical steps involved in the assay are much simpler than in the other immunoassays such as enzyme-linked immunosorbant assay in detecting circulating antigen and antibody in clinical samples. The Dot-Iba showed an overall sensitivity of 60% for tuberculous meningitis diagnosis and no false positive results were encountered. Hence, this assay is highly specific for the diagnosis of paucibacillary diseases such as extrapulmonary tuberculosis. Dot-Iba is best suited to laboratories in developing world where there are constraints in laboratory resources.

Psycho-social impact and quality of life of people living with HIV/AIDS in South India.

This study examines psycho-social impact of HIV and quality of life of 646 HIV-infected persons from a major government sexually transmitted disease (STD) clinic in South India. In this cross-sectional study, data was collected using interview schedule and scales. Nearly 70% had problems in parenting their children after acquiring the infection. Most (88%) of the respondents reported of seeking help from their family members, relatives or close friends at the time of their illness. Among the four categories of stigma, most of them (96%) reported perceived stigma whereas actual stigma was mentioned by only 33%. All four categories of stigma were experienced on a higher proportion by females than males (p<0.05). Each type of stigma was significantly associated with each domain of quality of life of the respondents (p<0.005). Respondents who reported of actual stigma (33%) had significantly good quality of life in their physical domain (49%), psychological domain (48%) and environmental domain (44%). Multivariate analysis showed that gender and marital status had significant association with quality of life. The findings of the study underscore the need for enabling environment through "human force" to uplift their social status and to have a better quality of life.

Appropriateness and execution challenges of three formal size estimation methods for high-risk populations in India.

OBJECTIVES: To describe formal, external to programme methods for size estimation of high-risk populations and compare execution challenges and validity of results. DESIGN: A cross-sectional HIV risk behavioural and biological survey was implemented among 24, 10 and five female sex workers, high-risk men who have sex with men and injecting drug user survey groups, respectively. Size estimates were calculated using three formal methods: capture-recapture, the multiplier method and the reverse tracking method (RTM), a new method. METHODS: Estimates were compared with each other and programme data. RESULTS: In general, when appropriately executed, formal methods produced smaller estimates to programme data, although the RTM tended to be closer to programme estimates. CONCLUSIONS: Capture-recapture requires some knowledge of site location. It can be used as a community mobilization measure at the initiation of a programme. The multiplier method presumes the existence of high quality external data and requires care in selecting the appropriate multiplier. All size estimation methods require careful planning and a full understanding of population dynamics and limitations of data. Before selecting a size estimation method, one must be aware of the strengths, weaknesses and applicability of each method. Use of size estimation methods in large-scale programmes should be considered carefully with adequate importance given to planning and implementation.

Characterization of idiopathic macular telangiectasia type 2 by fundus fluorescein angiography in Indian population.

PURPOSE: To characterize the variations in fundus fluorescein angiography (FFA) features in idiopathic macular telangiectasia (IMT) type 2. METHODS: Retrospective observational study. The authors included all the patients with IMT type 2 who underwent FFA during the period from January 2004 to December 2005. The main outcome measures were subretinal neovascularization and number and distance of telangiectasia from the center of the foveal avascular zone. RESULTS: The mean age of 21 patients included in the study was 53.0+/-7.7 years. There were 11 women and 10 men. Six of the 21 patients had a history of diabetes mellitus. Subretinal neovascularization (SRN) was observed in 10 (23.8%) eyes. Subretinal plaque of pigment hyperplasia in the macula was found in 7 (21.9%) eyes, and crystalline yellowish deposits on the retinal surface were seen in 19 (59.4%) eyes. Only one eye had visible retinal telangiectasia. Most had more than 10 telangiectatic lesions in the macular area and the temporal macula was most commonly involved. The mean distance from the center of the foveal avascular zone (FAZ) up to which telangiectasia could be observed was 1340+/-400 microm. The maximum distance from the FAZ at which telangiectasia was identified was 2530 microm. CONCLUSIONS: In IMT type 2, telangiectasia may be seen farther from the parafoveal area.

Perception of HIV testing among attendees at an STD clinic in India.

This study reports perception of STD clinic attendees of Government General hospital, Chennai, India towards free HIV testing. All STD clinic attendees who were eligible for the study (511), from January to April 2001 formed the study subjects. In all, 362 (71%) subjects responded to the question on perception of risk in getting HIV/AIDS. Among them 36% perceived that they were at risk of getting infected with HIV. There was a significant difference (P=0.01) between the genders, as more males perceived risk of getting HIV than females and, with the increase in number of sexual partners in a lifetime there was an increasing trend (p<0.0001) in the perception of risk. There were 244 (55%) subjects willing for HIV testing. A significant difference between the genders (p<0.0001) was observed, as more females were willing to accept free HIV testing than males. When adjusting the effect of co-variates such as gender, age, marital status and perception of risk in getting HIV, persons having two or more sexual partners in their life time were four times more willing to be HIV tested than persons with one sexual partner (OR=4; p=0.001). The findings in this study will help optimize HIV testing in at risk patient populations in India.

Pancreatic mucinous cystadenoma.

We report here the case of a 75-year-old lady who presented to us with a 4-month history of abdominal symptoms. The computed tomography scan revealed a cystic lesion in the tail of the pancreas. Distal pancreatectomy was done and biopsy showed a benign mucinous neoplasm. Because this is potentially malignant it is vital to diagnose it before it becomes malignant; identification of this entity remains a diagnostic and therapeutic challenge.

Serum tumour necrosis factor-alpha and soluble tumour necrosis factor receptors levels in patients with Guillain-Barre syndrome.

OBJECTIVES: To estimate the serum concentrations of Tumour Necrosis Factor alpha (TNF-alpha) and soluble TNF receptors (s TNF-RI and TNF-RII) in patients with Guillain-Barre syndrome (GBS), before and after treatment. MATERIAL AND METHODS: The serum TNF-alpha and the soluble TNF receptors concentrations were measured by a sandwich enzyme-linked immunosorbent assay (ELISA) in 47 patients with GBS before and after the treatment - IVI therapy (n=26); Plasma Exchange (n=21). RESULTS: At the time of admission, the serum TNF-alpha concentrations were elevated (32.5-182.5 pg/ml) in 41/47 GBS patients (87.2%). Following the treatment (IVIG or PE), there was a significant decrease in the serum TNF-alpha concentrations (8.5-58.5 pg/ml) in these 41 GBS patients. The soluble TNF receptors, particularly sTNF-RII concentrations were significantly increased in GBS patients treated by IVIG therapy. CONCLUSIONS: The results of this indicated that (a) Elevated serum concentrations of TNF-alpha showed a positive correlation with the disease severity in patients with GBS. (b) The decrease in the serum TNF-alpha and increase in the serum soluble TNF receptors, particularly sTNF-RII showed a positive correlation with the neurological recovery in GBB patients following treatment.

Circulating tumour necrosis factor alpha & soluble TNF receptors in patients with Guillain-Barre syndrome.

BACKGROUND & OBJECTIVES: Tumour necrosis factor-alpha (TNF-alpha) is regarded as one of the immune factors that can induce demyelination of peripheral nerves in patients with Guillian-Barre syndrome (GBS). This present study was undertaken to find out the role of TNF-alpha and soluble TNF receptors in the pathogenesis of GBS; and to study the effect of intravenous immunoglobulin (ivIg) therapy on the serum TNF-alpha and soluble TNF receptors in patients with GBS. METHODS: Thirty six patients with GBS in progressive stages of motor weakness were included in this study. The serum TNF-alpha and soluble TNF receptors (TNF-RI, TNF-RII) were measured in the serum samples of these patients before and after ivIg therapy by a sandwich ELISA. RESULTS: Of the 36 patients with GBS, 26 (72.2%) showed elevated serum TNF-alpha levels prior to ivIg therapy. Following a complete course of ivIg therapy there was a progressive decrease in the serum TNF-alpha concentrations in these 26 patients. On the other hand, the soluble TNF receptors, particularly TNF-RII showed an increase in the serum of GBS patients following ivIg therapy. INTERPRETATION & CONCLUSION: The results indicate that ivIg reduces the serum TNF-alpha concentrations in the GBS patients having elevated levels prior to ivIg therapy. Elevated serum levels of soluble TNF receptors following ivIg therapy may play a protective role by inhibiting the demyelinating effect of TNF-alpha in the peripheral nerves of patients with GBS.

Detection of heat stable mycobacterial antigen in cerebrospinal fluid by Dot-Immunobinding assay.

BACKGROUND: Isolation of Mycobacterium tuberculosis in cerebrospinal fluid (CSF) specimen in patients with tuberculous meningitis (TBM) is infrequent and carries low sensitivity. Thus development of an alternative laboratory diagnostic test is essential for the early diagnosis and treatment of TBM. OBJECTIVE: A simple, rapid Dot immunobinding assay (Dot-Iba), for the laboratory diagnosis of TBM is devised. This method minimizes the risk of handling infectious material in the laboratory. METHOD: The Dot-Iba was standardized with heat-inactivated M tuberculosis antigen (PPD). The heat-inactivated CSF from TBM and non-TBM patients was similarly assayed and it can detect antigen upto 1ng/ml in CSF. RESULT: A positive result was obtained in all the five culture positive patients with TBM and in 20/25 probable TBM. A negative result was obtained in 38/40 CSF from disease control group. The overall sensitivity and specificity of Dot-Iba was 83.3% and 95% respectively. CONCLUSION: Dot-Iba can be used as an adjunct for the laboratory diagnosis of TBM, particularly in culture negative TBM patients and also in those clinical situations where no laboratory tests are available to distinguish between TBM and partially treated pyogenic meningitis.

Intravenous immunoglobulin reduces serum tumor necrosis factor alpha in patients with Guillain-Barre syndrome.

BACKGROUND: Tumor necrosis factor a TNF-alpha has a possible role in the pathogenesis of the Guillain-Barre syndrome (GBS). AIMS: To study the effect of intravenous immunoglobulin (IVIg) on serum TNF-alpha concentrations in patients with GBS. MATERIAL AND METHODS: The effect of IVIg on TNF-alpha was evaluated in 36 patients with GBS. Serum TNF-alpha concentration was measured by enzyme-linked immunosorbent assay (ELISA). The sera of 22 (61%) patients with GBS showed elevated concentrations of TNF-alpha (35-182 pg/ml) and these sera were individually incubated in vitro with IVIg (0.25 mg/ml) at 37 degrees C for 24 hours. RESULTS: The serum TNF-alpha concentrations in the 22 GBS patients with elevated levels showed a steady decline (60.34-19.78 pg/ml) following incubation with IVIg. These 22 patients also received IVIg therapy, and serum TNF-alpha concentrations showed a significant decline (65.5-9.75 pg/ml) at the end of the therapy. At the time of discharge from the hospital, there was a positive correlation between neurological recovery and decline in TNF-alpha concentrations in these 22 GBS patients. CONCLUSIONS: The results of this study indicate that elevated levels of TNF-alpha occur in a proportion of patients with GBS and in these patients elevated serum TNF-alpha levels decline with IVIg therapy.

Immunocytochemical method for early laboratory diagnosis of tuberculous meningitis.

A simple immunocytochemical method was standardized for the direct demonstration of mycobacterial antigen in cerebrospinal fluid (CSF) specimens of patients with tuberculous meningitis (TBM). CSF-cytospin smears were prepared from 22 patients with a clinical diagnosis of TBM and also from an equal number of patients with nontuberculous neurological diseases (disease control). Immunocytological demonstration of mycobacterial antigens in the cytoplasm of monocytoid cells was attempted, by using rabbit immunoglobulin G to Mycobacterium tuberculosis as the primary antibody. Of the 22 CSF-cytospin smears from TBM patients, 16 showed positive immunostaining, while all of the CSF-cytospin smears from the disease control showed negative immunostaining for mycobacterial antigen. The technical aspects of this immunocytological method for the demonstration of mycobacterial antigens are simple, rapid, and reproducible, as well as specific, and therefore can be applied for the early diagnosis of TBM, particularly in patients in whom bacteriological methods did not demonstrate the presence of M. tuberculosis in the CSF.

A comparative evaluation of dot immunobinding assay (Dot-Iba) and polymerase chain reaction (PCR) for the laboratory diagnosis of tuberculous meningitis.

The results of a Dot immunobinding assay (Dot Iba) for the detection of mycobacterial antigen in the cerebrospinal fluid (CSF) of 45 patients with tuberculous meningitis (TBM) were compared with the results of a polymerase chain reaction (PCR) for the detection of Mycobacterium tuberculosis. In eight patients with culture proven TBM, Dot-Iba gave positive results, while PCR yielded positive results only in six patients. The overall sensitivities of Dot-Iba and PCR in 37 patients with culture negative (probable) TBM were 75.67% and 40.5% respectively. Dot-Iba, in contrast to PCR is a rapid and relatively easier method. More importantly, Dot-Iba is suitable for the routine application for the laboratory diagnosis of TBM and therefore best suited to laboratories in the developing world.

Diagnostic utility of polymerase chain reaction and immunohistochemical techniques for the laboratory diagnosis of intracranial tuberculoma.

In an attempt to establish a tuberculous etiology, polymerase chain reaction (PCR) and immunohistochemical (IHC) methods were undertaken in formalin-fixed paraffin sections of ten surgical specimens of intracranial tuberculoma. The control group included an equal number of intracranial fungal granuloma. Both PCR and IHC methods did not yield false-positive results in fungal granuloma. PCR was found to be less sensitive (60%) than IHC method (80%) in this study. IHC method definitely possesses several operational advantages over PCR and is more suited to laboratories in developing countries for establishing a tuberculous etiology particularly in those patients in whom the conventional bacteriological methods did not confirm the diagnosis of tuberculoma.

A newer approach for the laboratory diagnosis of tuberculous meningitis.

In this prospective study, a simple method was standardized for measuring circulating mycobacterial antigen in the cerebrospinal fluid (CSF) for the laboratory diagnosis of tuberculous meningitis (TBM). The heat-inactivated CSF specimens from tuberculous and non-tuberculous patients were subjected to sodium dodecyl sulfate (SDS) - polyacrylamide gel electrophoresis (PAGE) (SDS-PAGE) and they were subsequently transferred onto nitrocellulose membrane (NCM) Using a rabbit polyvalent antibody to M tuberculosis, a heat stable 82 kDa mycobacterial antigen was demonstrated in the CSFs of patients with TBM. This antigen was conspicuous by its absence in the CSFs of non-tuberculous subjects. Due to inactivation of CSF specimens, there is a minimal risk of handling of infectious material in the laboratory. Besides, this newer approach is simple, inexpensive and can be readily applied in any routine clinical laboratory and it is particularly suited to developing countries.