RARE MALIGNANT FEMALE ADNEXAL TUMOR OF WOLFFIAN ORIGIN (FATWO) WITH MULTIPLE RELAPSES AND CHEMOTHERAPY REGIMENS.

CONTEXT: Female adnexal tumors of probable Wolffian origin (FATWO) represent very rare borderline ovarian tumors with low malignant potential. Only 15 cases of malignant FATWO are described in the current literature, among which, only 5 are reported as being recurrent. OBJECTIVE: Due to the rare presentation of the recurrence of the malignant FATWO and the few cases reported in the scientific database, there are no clear therapy recommendations. This paper should help practitioners to choose the best therapy approach. DESIGN: This paper presents the 6th case of malignant recurrent FATWO and will compare all the cases available in the literature. SUBJECTS AND METHODS: We present a review of the literature comparing the therapeutic approaches and outcomes of all the five cases of recurrent malignant FATWOs. Also, we introduce the case of a stage III Wolffian origin adnexal tumor with multiple recurrences appeared after 6 years of disease free interval. RESULTS: Our case presents the longest survival reported in the literature and underwent most surgical procedures of the recurrences and more than 4 lines of chemotherapy regimens. CONCLUSIONS: This paper shows possible therapeutic approaches to be used as example by the practitioners according to the drug availability in their centers.

Evaluation of safety and immunogenicity of a live attenuated tetravalent (G1-G4) Bovine-Human Reassortant Rotavirus vaccine (BRV-TV) in healthy Indian adults and infants.

BACKGROUND: Rotavirus infections, prevalent in human populations worldwide are mostly caused by Group A viruses. Live attenuated rotavirus vaccines are highly effective in preventing severe rotavirus gastroenteritis. However, the cost of these vaccines and local availability can be a barrier for widespread adoption in public health programs in developing countries where infants suffer a heavy burden of rotavirus related morbidity and mortality. A phase I/II study was carried out with the long term aim to produce a locally licensed vaccine which is equally safe and immunogenic as compared to available licensed vaccines. METHODS: This study was conducted in two cohorts. In the first cohort, 20 healthy adults were administered a single dose of the rotavirus vaccine (highest antigen concentration planned for infants) or placebo and were followed up for 10 days for safety. Following demonstration of safety in adult volunteers, 100 healthy infants were recruited (cohort 2) and randomly divided into five equal study groups. They were administered three doses of either the investigational rotavirus vaccine (BRV-TV) at one of the three antigen concentrations or Rotateq or Placebo at 6-8, 10-12 and 14-16 weeks of age. All infants were followed up for safety till 28 days after the third dose. Immune response to the vaccine, in terms of seroresponse and geometric mean concentrations, was compared across the five study groups. RESULTS: Increase in anti-rotavirus serum IgA antibodies from baseline, demonstrated higher immune response for all the three antigen concentrations of BRV-TV vaccine and RotaTeq in comparison with the placebo. Sero-response rates for placebo, BRV-TV dose-levels 10(5.0) FFU, 10(5.8) FFU, 10(6.4) FFU, and Rotateq at 28 days post third dose were 11.1%, 27.8%, 41.2%, 83.3%, and 63.2% respectively using the four-fold or more criteria. The BRV-TV vaccine arm corresponding to the highest antigen concentration of 10(6.4) FFU had a higher sero-response rate compared to the active comparator arm (RotaTeq), 28 days post each vaccine dose. The safety profile was comparable across the treatment groups. CONCLUSIONS: Overall, the results showed that all three doses of BRV-TV vaccine were safe, well tolerated and displayed good immunogenicity (dose-response) in healthy Indian infants.

Diarrhoea-related knowledge and practice of physicians in urban slums of Kolkata, India.

Diarrhoeal management practices are unsatisfactory in India especially in the slum areas. Dearth of information regarding physicians' diarrhoea-related knowledge and practice in India necessitated this cross-sectional study of allopathic practitioners in the slums of Kolkata, to assess the distribution and interrelationship between physicians' characteristics, knowledge and practice regarding diarrhoea. A total of 264 randomly selected consenting practitioners were interviewed using a field-tested questionnaire. Nineteen percent had good overall knowledge, 49% and 80% prescribed antibiotics to diarrhoea and cholera patients, respectively, and 55% advised stool examination for every case. Qualified and Government physicians had better knowledge regarding diarrhoea [MBBS: odds ratio (OR) 5·96, P < 0·001; postgraduates: OR 9·33, P < 0·001; Government physicians: OR 11·49, P < 0·0001] and were less likely to prescribe antibiotics for all diarrhoea cases (MBBS: OR 0·30, P = 0·002; postgraduates: OR 0·20, P < 0·001; Government physicians OR 0·24, P < 0·029). Better knowledge was associated with a lower likelihood of prescribing antibiotics for diarrhoea (OR 0·72, P < 0·001), cholera (OR 0·78, P = 0·027) and investigative procedure (OR 0·85, P = 0·028). In the slums of Kolkata, diarrhoea-related knowledge and practice were poor with the exception of qualified physicians, hence an improvement in the knowledge of pharmacists and unqualified practitioners is necessary for the overall improvement of diarrhoeal management in these slums.

Evaluation of a rapid dipstick test for identifying cholera cases during the outbreak.

BACKGROUND & OBJECTIVES: Intermittent cholera outbreaks are major problem in many of the states of India. It is essential to identify cholera at the earliest for timely mobilization of public health responses and to abort the outbreaks. The present study was a part of a diarrhoeal outbreak investigation in Secunderabad, India, during May 2009 where the usefulness of Crystal VC rapid dipstick kit was assessed for detecting the aetiologic agent of the outbreak. METHODS: Stool specimens were collected from 15 hospitalized patients with acute watery diarrhoea and analyzed for detection of cholera vibrios using Crystal VC rapid dipstick kit and the usefulness of the kit was determined by comparative analysis of the same set of specimens using both microbiological and real-time PCR (RT-PCR) based assays. RESULTS: Detection of Vibrio cholerae O1 from 10 of 15 specimens was recorded using dipstick assay. Microbiological methods detected V. cholerae O1 positivity among 11 specimens. However, RT-PCR based assay showed all 15 specimens positive for the presence of V. cholerae O1. In addition, the same assay showed that the pathogen load in the dipstick as well as RT-PCR positive specimens ranged from 10 6 colony forming units (cfu)/ml or more. INTERPRETATION & CONCLUSIONS: Crystal VC kit had the potential to identify cholera cases in 10 min in field conditions without having good laboratory support. Therefore, dipstick kit may be considered as cholera detecting tool in diarrhoeal outbreak investigations. Specimens from clinically typical cholera cases, if negative by dipstick, should be reanalyzed by culture based methods.

Costs of illness due to endemic cholera.

Economic analyses of cholera immunization programmes require estimates of the costs of cholera. The Diseases of the Most Impoverished programme measured the public, provider, and patient costs of culture-confirmed cholera in four study sites with endemic cholera using a combination of hospital- and community-based studies. Families with culture-proven cases were surveyed at home 7 and 14 days after confirmation of illness. Public costs were measured at local health facilities using a micro-costing methodology. Hospital-based studies found that the costs of severe cholera were US$32 and US$47 in Matlab and Beira. Community-based studies in North Jakarta and Kolkata found that cholera cases cost between US$28 and US$206, depending on hospitalization. Patients' cost of illness as a percentage of average monthly income were 21% and 65% for hospitalized cases in Kolkata and North Jakarta, respectively. This burden on families is not captured by studies that adopt a provider perspective.

Factors associated with HIV infection among Indian women.

There is still a paucity of research on the sociodemographic and other underlying factors associated with HIV transmission among women in India. This study was designed to investigate such factors in sexually experienced Indian women. We used data from the National Family Health Survey 3 (NFHS-3), which tested 52,853 women for HIV, including 27,556 husband and wife pairs. Significant risk factors for all women and married women only were: aged 26-35 years (adjusted odds ratios [AORs] = 3.65 and 2.53, respectively), being poor (AORs = 1.57 and 1.79), having had a genital sore in the last 12 months (AORs = 3.16 and 3.01) and having more than one sexual partner (AORs = 5.95 and 5.15). For husband and wife pairs, suffering sexual violence (AOR = 2.63), husband having other wife/wives (AOR = 3.40) and husband's education being secondary level or higher (AOR = 0.43) were significant. Intervention strategies in India should target young married (aged 25-35 years) and formerly married urban women who are poor, as well as those who have suffered sexual violence from their husbands, and/or are (or whose husbands are) multi-partnered. Empowerment of women is fundamental to HIV/AIDS prevention in India.

Influence of relative humidity in Vibrio cholerae infection: a time series model.

BACKGROUND & OBJECTIVES: Spread of cholera in West Bengal is known to be related to its ecosystem which favours Vibrio cholerae. Incidence of cholera has not been correlated with temperature, relative humidity and rainfall, which may act as favourable factors. The aim of this study was to investigate the relational impact of climate changes on cholera. METHODS: Monthly V. cholerae infection data for of the past 13 years (1996-2008), average relative humidity (RH), temperature and rainfall in Kolkata were considered for the time series analysis of Seasonal Auto-Regressive Integrated Moving Average (SARIMA) model to investigate relational impact of climatic association of V. cholerae infection and General Linear Model (GLM) for point estimation. RESULTS: The SARIMA (1,0,0)(0,1,1) model revealed that monthly average RH was consistently linear related to V. cholerae infection during monsoon season as well as temperature and rainfall were non-stationary, AR(1), SMA(1) and SI(1) (P<0.001) were highly significant with seasonal difference. The GLM has identified that consistent (<10%) range of RH (86.78 ± 4.13, CV=5.0, P <0.001) with moderate to highest (>7 cm) rainfall (10.1 ± 5.1, CV=50.1, P <0.001) and wide (>5-10ºC) range of temperature (29.00 ± 1.64, CV=5.6, P <0.001) collectively acted as an ideal climatic condition for V. cholerae infection. Increase of RH to 21 per cent influenced an unusual V. cholerae infection in December 2008 compared to previous years. INTERPRETATION & CONCLUSIONS: V. cholerae infection was associated higher RH (>80%) with 29°C temperature with intermittent average (10 cm) rainfall. This model also identified periodicity and seasonal patterns of cholera in Kolkata. Heavy rainfall indirectly influenced the V. cholerae infection, whereas no correlation was found with high temperature.

Role of probiotic in preventing acute diarrhoea in children: a community-based, randomized, double-blind placebo-controlled field trial in an urban slum.

Acute diarrhoea remains a major public health challenge in developing countries. We examined the role of a probiotic in the prevention of acute diarrhoea to discover if there was an effect directed towards a specific aetiology. A double-blind, randomized, controlled field trial involving 3758 children aged 1-5 years was conducted in an urban slum community in Kolkata, India. Participants were given either a probiotic drink containing Lactobacillus casei strain Shirota or a nutrient drink daily for 12 weeks. They were followed up for another 12 weeks. The primary outcome of this study was the occurrence of first episodes of diarrhoea. We assessed this during 12 weeks of intake of study agent and also for 12 weeks of follow-up. There were 608 subjects with diarrhoea in the probiotic group and 674 subjects in the nutrient group during the study period of 24 weeks. The level of protective efficacy for the probiotic was 14% (95% confidence interval 4-23, P<0·01 in adjusted model). The reduced occurrence of acute diarrhoea in the probiotic group compared to nutrient group was not associated with any specific aetiology. No adverse event was observed in children of either probiotic or nutrient groups. The study suggests that daily intake of a probiotic drink can play a role in prevention of acute diarrhoea in young children in a community setting of a developing country.

Cholera in India: an analysis of reports, 1997-2006.

OBJECTIVE: To more accurately define the annual incidence of cholera in India, believed to be higher than reported to the World Health Organization (WHO). METHODS: We searched the biomedical literature to extract data on the cases of cholera reported in India from 1997 to 2006 and compared the numbers found to those reported annually to WHO over the same period. The latter were obtained from WHO's annual summaries of reported cholera cases and National health profile 2006, published by India's Central Bureau of Health Intelligence. FINDINGS: Of India's 35 states or union territories, 21 reported cholera cases during at least one year between 1997 and 2006. The state of West Bengal reported cases during all 10 years, while the state of Maharashtra and the union territory of Delhi reported cases during nine, and Orissa during seven. There were 68 outbreaks in 18 states, and 222 038 cases were detected overall. This figure is about six times higher than the number reported to WHO (37 783) over the same period. The states of Orissa, West Bengal, Andaman and Nicobar Islands, Assam and Chhattisgarh accounted for 91% of all outbreak-related cases. CONCLUSION: The reporting of cholera cases in India is incomplete and the methods used to keep statistics on cholera incidence are inadequate. Although the data are sparse and heterogeneous, cholera notification in India is highly deficient.

Arterial hypertension - prevalence of risk factors and morbide associations that increase cardiovascular risk.

Hypertension represents a serious problem in Romania, as there are over 3 million hypertensive people in our country. There is a high incidence of deaths caused by hypertension.WE PERFORMED AN ANALYTICAL PROSPECTIVE STUDY THAT AIMS TO DETERMINE: prevalence of arterial hypertension in a population from Cluj county, distribution on age and gender, arterial hypertension severity, association of hypertension with other cardiovascular risk factors. Our study included 2266 patients, age 14 years old up to over 90 years old, both masculine and feminine gender, known with hypertension and new-diagnosed ones. Each subject was submitted to an interview based on a questionnaire. Diagnosis of arterial hypertension was established according to ESH criteria that consider as hypertension: values over 140/90 mmHg. Out of all subjects submitted to the study 647 (29.74%) were diagnosed with arterial hypertension and, from these, 102 (15.13%) were new-diagnosed patients.We found out a predominance of arterial hypertension at the age of 51-60 and over 60, an increased involvement of feminine sex; an association of hypertension with other major cardiovascular risk factors: obesity, diabetes, dislypidemia.Arterial hypertension represents an important health problem in Romania due to an increased prevalence, major impact on morbidity and mortality by cardiovascular and cerebro-vascular disease. These facts accentuate the necessity of an early diagnosis, of making people aware of the severity of the disease and it's impact on their lifestyle.

A community-based, comparative evaluation of direct agglutination and rK39 strip tests in the early detection of subclinical Leishmania donovani infection.

In the Indian state of Bihar, the sensitivities and specificities of direct agglutination tests (DAT) and rK39 test strips for the detection of Leishmania donovani infection in humans were explored and found to be generally good (92%-100%). When 172 asymptomatic individuals [16 'case-contacts' who lived in the same households as past or current, confirmed cases of visceral leishmaniasis (VL) and 156 other subjects from neighbouring households] were tested, the same 36 (21%) individuals, including all 16 'case-contacts', were found seropositive using each type of test. When followed-up after 3 months, 18 of the individuals who had been found seropositive in the baseline survey remained seropositive, and eight (44%) of these had developed symptomatic VL, with amastigotes in their splenic aspirates. Seven (44%) of the 16 'case-contacts' but only one (5%) of the other 20 subjects found seropositive at baseline went on to develop VL within 3 months. Although the strip test appeared slightly better than DAT for predicting the development of VL in the 172 subjects, either type of test may be very useful for the early detection of asymptomatic L. donovani infection and thus the identification of those at relatively high risk of developing VL.

Molecular epidemiology of human picobirnaviruses among children of a slum community in Kolkata, India.

Picobirnaviruses are a group of unclassified, non-enveloped, small spherical viruses, 35-41 nm in diameter without any apparent surface morphology. They have characteristic bisegmented double stranded RNA genome of two types namely large profile (2.3-2.6 kbp for the larger and 1.5-1.9 kbp for the smaller segment, respectively) or small profile (1.75 and 1.55 kbp for segments 1 and 2, respectively). Human picobirnaviruses (n=12 positives; 2/56 diarrhoeic children and 10/607 non-diarrhoeic children) with large (n=11) or small (n=1) genome pattern were observed in faecal specimens of children from a slum community by silver stained PAGE gels. Faecal specimen from four asymptomatic cases (P597_02_IND, K135_02_IND, A373_03_IND, A356_03_IND) and one diarrhoeic case (K135_03_IND) had genogroup I picobirnaviruses (1-CHN-97 like) showing amplicons within the 201 bp region, with primers PicoB25-PicoB43, targeting the conserved domain of RNA-dependent RNA polymerase (RdRp) gene. It was interesting to note that only the PBV strain P597_02_IND from Kolkata with large genome was closely related to a reported strain (similarity with 2-GA-91 from USA was 87% at the nucleotide level and 90% at the amino acid level). Sequence analysis showed three conserved amino acid domains as well as a highly conserved D-S-D motif, characteristic of RNA-dependent RNA polymerase gene of bisegmented, double stranded RNA viruses. Sequence data of the picobirnavirus A356_03_IND indicated strong heterogeneity with all other picobirnavirus strains sequenced till date. After nearly a decade a genogroup II picobirnavirus strain (R227_03_IND) was isolated from a diarrhoea case in the community, with small genome profile and amplified with specific primers PicoB23-PicoB24; but the sequence data showed that it was divergent from the hitherto reported prototype strain 4-GA-91 of genogroup II human picobirnaviruses.

Visceral leishmaniasis (kala-azar)--the Bihar (India) perspective.

From a hospital-based surveillance carried out in Rajendra Memorial Research Institute of Medical Sciences, Patna, Bihar, India, the socio-economic, demographic and treatment response information of 737 patients admitted with visceral leishmaniasis (VL) during January 2001-December 2003, were analysed. The disease was two times higher in males than in females because of several factors including clothing pattern, sleeping habits and occupation. In Bihar, the second poorest state in India, poverty plays a major role in perpetuation of the disease, contributing to malnutrition, illiteracy (60%), and poor housing (82%). Further, presences of peri-domestic animal shelters around houses (63%) and vegetations (77%) facilitate breeding of sand fly vector. Clinical and laboratory characteristics were similar in the age groups <12 years and >12 years. The increasing unresponsiveness of VL patients to conventional anti-leishmanial drugs, e.g. sodium antimony gluconate (SAG) and pentamidine, has definitely posed a major therapeutic challenge in combating the disease. Amphotericin B, though costly, is highly effective. Miltefosine is a highly promising new oral drug for VL.

The burden of cholera in the slums of Kolkata, India: data from a prospective, community based study.

AIMS: To conduct a prospective, community based study in an impoverished urban site in Kolkata (formerly Calcutta) in order to measure the burden of cholera, describe its epidemiology, and search for potential risk factors that could be addressed by public health strategies. METHODS: The study population was enumerated at the beginning and end of the study period. Surveillance through five field outposts and two referral hospitals for acute, watery, non-bloody diarrhoea was conducted from 1 May 2003 to 30 April 2004. Data and a stool sample for culture of Vibrio cholerae were collected from each patient. Treatment was provided in accordance with national guidelines. RESULTS: From 62 329 individuals under surveillance, 3284 diarrhoea episodes were detected, of which 3276 (99%) had a stool sample collected and 126 (4%) were culture confirmed cholera. Nineteen (15%) were children less than 2 years of age, 29 (23%) had severe dehydration, and 48 (38%) were hospitalised. Risk factors for cholera included a household member with cholera during the period of surveillance, young age, and lower educational level. CONCLUSIONS: There was a substantial burden of cholera in Kolkata with risk factors not easily amenable to intervention. Young children bear the brunt not only of diarrhoeal diseases in general, but of cholera as well. Mass vaccination could be a potentially useful tool to prevent and control seasonal cholera in this community.

Periodic deworming with albendazole and its impact on growth status and diarrhoeal incidence among children in an urban slum of India.

This study was undertaken to measure the impact of periodic deworming with albendazole on growth status and incidence of diarrhoea in children aged 2-5 years in an urban setting in India and to assess the feasibility of local health workers implementing the procedures involved. This was a double-blind, placebo-controlled, randomized, community-based intervention trial with 702 children randomly allocated to receive either albendazole or placebo. The two study groups received two doses of albendazole (400 mg) or placebo six months apart. Mean weight increased significantly in the albendazole group compared to the control group at three months, six months and nine months following treatment (P<0.01, P<0.01 and P<0.001 respectively). The albendazole group also experienced fewer episodes of diarrhoea than their control counterparts (relative risk 1.3, 95% CI 1.07-1.53) with a 28% reduction. The health workers administered the correct dosage satisfactorily and there were no adverse effects. Thus, periodic mass deworming with albendazole would seem to be a safe and effective method that could be adopted at the community level or as an integral part of school health services and could be expected to improve growth and reduce the incidence of diarrhoea in children.

Impact of zinc supplementation on diarrhoeal morbidity in rural children of West Bengal, India.

AIM: To determine the role of zinc supplementation in reducing diarrhoeal morbidity in children. METHODS: A randomized, double-blind, community-based intervention study was conducted in 280 rural children aged between 6 and 41 mo. Children were randomly allocated into three groups. One group received a daily dose of 10 mg zinc for 5 d wk(-1), another group received 50 mg zinc once weekly and the remaining group received placebo. Zinc was supplemented for 16 wk from November 1999. Diarrhoeal episodes were detected by weekly surveillance during the supplementation period. RESULTS: Eighty diarrhoeal episodes were detected among 59 children in all 3 groups. The groups were compared with each other at baseline and as regard to the outcome variable (incidence of diarrhoea). The proportion of children suffering from diarrhoea during the period was significantly lower in the zinc-supplemented groups (15.8% in daily and 16.5% in weekly group) than in the placebo group (30.8%). The incidence of diarrhoea in the daily and weekly zinc-supplemented groups was 0.68 and 0.69 episodes child(-1) y(-1), and that in the placebo group was 1.67 episodes child(-1) y(-1) (relative risk 0.41, 95% confidence interval 0.24-0.71). Diarrhoeal incidence of < 4 d duration was found to occur significantly less often in the supplemented groups. There was no difference in diarrhoeal incidence between the daily and weekly zinc-supplemented children. There were no detected adverse reactions in any of the supplemented groups. CONCLUSION: The study indicates that zinc supplementation is effective in reducing diarrhoeal morbidity when administered either daily or in a weekly schedule.

A localised outbreak of Vibrio cholerae O139 in Kolkata, West Bengal.

BACKGROUND & OBJECTIVES: An explosive outbreak of diarrhoeal disease which occurred in the Baishnabghata, Patuli area of Kolkata Municipal Corporation during September 28 to October 12, 2000, was investigated by a team from the National Institute of Cholera and Enteric Diseases, Kolkata, to identify the causative agent and determine the antimicrobial susceptibility pattern. METHODS: Clinical and epidemiological data were collected from domiciliary cases and also from patients attending two medical camps that had been set up for the purpose. Stool and water samples were collected for isolation of diarrhoeagenic pathogens. RESULTS: A total of 710 cases of diarrhoea occurred with an attack rate of 7.1 per cent; majority were adults. All 6 faecal samples and 2 water samples collected, were positive for Vibrio cholerae O139. The strains were uniformly (100%) susceptible to the commonly used drugs for cholera such as tetracycline, norfloxacin, ciprofloxacin, co-trimoxazole and nalidixic acid but resistant (100%) to furazolidone and ampicillin. INTERPRETATION & CONCLUSION: This is the first localised outbreak of V. cholerae O139 in Kolkata since the devastating epidemic in 1992. Extensive chlorination of all water sources resulted in a dramatic decline of the outbreak. The appearance of resistance in V. cholerae O139 to furazolidone is a matter of great concern since this drug is used for the treatment of cholera in children and pregnant women.