Indian Journal of Medical Microbiology IAMM  | About us |  Subscription |  e-Alerts  | Feedback |  Login  
  Print this page Email this page   Small font sizeDefault font sizeIncrease font size
 Home | Ahead of Print | Current Issue | Archives | Search | Instructions  
Users Online: 185 Official Publication of Indian Association of Medical Microbiologists 
  ~   Site Statistics 
  ~   Addresses 
  ~   Search 
  ~   My Preferences 
  ~   Online Submission 


Export selected to
Reference Manager
Medlars Format
RefWorks Format
BibTex Format
  ~ Table of Contents - Current issue
April-June 2017
Volume 35 | Issue 2
Page Nos. 155-319

Online since Wednesday, July 5, 2017

Accessed 9,329 times.

PDF access policy
Full text access is free in HTML pages; however the journal allows PDF access only to users from INDIA and paid subscribers.

EPub access policy
Full text in EPub is free except for the current issue. Access to the latest issue is reserved only for the paid subscribers.
View as eBookView issue as eBook
Author Institution MappingAuthor Institution Mapping
Access StatisticsIssue statistics
Hide all abstracts  Show selected abstracts  Export selected to  Add to my list

Molecular monitoring of antimalarial drug resistance in India Highly accessed article p. 155
Susanta Kumar Ghosh
DOI:10.4103/ijmm.IJMM_15_548  PMID:28681800
[HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Current perspectives on biomedical waste management: Rules, conventions and treatment technologies Highly accessed article p. 157
Malini R Capoor, Kumar Tapas Bhowmik
DOI:10.4103/ijmm.IJMM_17_138  PMID:28681801
Unregulated biomedical waste management (BMWM) is a public health problem. This has posed a grave threat to not only human health and safety but also to the environment for the current and future generations. Safe and reliable methods for handling of biomedical waste (BMW) are of paramount importance. Effective BMWM is not only a legal necessity but also a social responsibility. This article reviews the current perspectives on BMWM and rules, conventions and the treatment technologies used worldwide. BMWM should ideally be the subject of a national strategy with dedicated infrastructure, cradle-to-grave legislation, competent regulatory authority and trained personnel. Improving the management of biomedical waste begins with waste minimisation. These standards, norms and rules on BMWM in a country regulate the disposal of various categories of BMW to ensure the safety of the health-care workers, patients, public and environment. Furthermore, developing models for the monitoring of hospital health-care waste practices and research into non-burn eco-friendly sustainable technologies, recycling and polyvinyl chloride-free devices will go in long way for safe carbon environment. Globally, greater research in BMWM is warranted to understand its growing field of public health importance.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Globally emerging hantaviruses: An overview Highly accessed article p. 165
Sara Chandy, Dilip Mathai
DOI:10.4103/ijmm.IJMM_16_429  PMID:28681802
Hantaviruses are known to cause haemorrhagic fever with renal syndrome in Eurasia and hantavirus cardiopulmonary syndrome in the Americas. They are globally emerging pathogens as newer serotypes are routinely being reported. This review discusses hantavirus biology, clinical features and pathogenesis of hantavirus disease, its diagnostics, distribution and mammalian hosts. Hantavirus research in India is also summarised.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Molecular biology of Group A Streptococcus and its implications in vaccine strategies p. 176
NK Brahmadathan
DOI:10.4103/ijmm.IJMM_17_16  PMID:28681803
Infections due to Streptococcus pyogenes and their complications are a problem of major concern in many countries, including India. Primary prophylaxis with benzathine penicillin is the key to control and prevent sequelae such as acute rheumatic fever and rheumatic heart disease (RF/RHD) or post-streptococcal glomerulonephritis (PSGN). Non-compliance to prophylaxis due to fear of injection and anaphylaxis is major issues in RF/RHD control in India and leads to continued high prevalence of infection and post-streptococcal sequelae. Differing reports on the efficacy of two weekly, three weekly or monthly injections raise questions on the actual dosages to be administered. Availability of more effective antibiotics with better dosages has replaced the use of penicillin; hence, companies are reluctant to manufacture penicillin preparations in India. It is in this context that a concept of a Group A streptococci vaccine is looked at and whether or not a globally designed vaccine will be useful in the Indian context. Modern molecular techniques and genomic analysis of S. pyogenes have identified many molecules as vaccine candidates among which the M-protein has attracted the most attention. High diversity of M (emm) types in endemic regions raises questions about the efficacy of such a vaccine. A recent 30-valent M-protein-based vaccine that elicits antibodies to homologous as well as non-vaccine M types looks promising. This review will discuss the genomics of S. pyogenes, the various candidate vaccine molecules and highlight their efficacy in the Indian context where control of post-streptococcal sequelae remains a challenge.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Statistical analysis of microbiological diagnostic tests p. 184
CP Baveja, Prabhav Aggarwal
DOI:10.4103/ijmm.IJMM_16_215  PMID:28681804
No study in medical science is complete without application of the statistical principles. Incorrect application of statistical tests causes incorrect interpretation of the study results obtained through hard work. Yet statistics remains one of the most neglected and loathed areas, probably due to the lack of understanding of the basic principles. In microbiology, rapid progress is being made in the field of diagnostic test, and a huge number of studies being conducted are related to the evaluation of these tests. Therefore, a good knowledge of statistical principles will aid a microbiologist to plan, conduct and interpret the result. The initial part of this review discusses the study designs, types of variables, principles of sampling, calculation of sample size, types of errors and power of the study. Subsequently, description of the performance characteristics of a diagnostic test, receiver operator characteristic curve and tests of significance are explained. Lack of a perfect gold standard test against which our test is being compared can hamper the study results; thus, it becomes essential to apply the remedial measures described here. Rapid computerisation has made statistical calculations much simpler, obviating the need for the routine researcher to rote learn the derivations and apply the complex formulae. Thus, greater focus has been laid on developing an understanding of principles. Finally, it should be kept in mind that a diagnostic test may show exemplary statistical results, yet it may not be useful in the routine laboratory or in the field; thus, its operational characteristics are as important as the statistical results.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Biomedical waste management guidelines 2016: What's done and what needs to be done Highly accessed article p. 194
Lipika Singhal, Arpandeep Kaur Tuli, Vikas Gautam
DOI:10.4103/ijmm.IJMM_17_105  PMID:28681805
The latest biomedical waste (BMW) management guidelines which have been introduced in 2016 are simplified and made easier so that they can be easily followed by various health agencies. The categories of BMW have been reduced from ten (in 1998) to four in the latest (2016) guidelines. Many changes have been made in these latest guidelines, which have been summarised in the article below. The segregation of hospital waste plays a very important role, so the waste has to be sorted out at the source of generation according to the category to which it belongs as given in the newer guidelines. Newer waste treatment facilities such as plasma pyrolysis, encapsulation, inertisation have been introduced, and we have to do away with older facilities such as incineration as toxic fumes (dioxins and furans) are produced which are harmful to both health and environment. We can even think of using these wastewater treatment plants to remove the antimicrobial resistance genes during the processing of the waste, which is being generated from the hospitals.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Departing from PowerPoint default mode: Applying Mayer's multimedia principles for enhanced learning of parasitology p. 199
Jyoti Mahantesh Nagmoti
DOI:10.4103/ijmm.IJMM_16_251  PMID:28681806
Purpose: PowerPoint (PPT) presentation has become an integral part of day-to-day teaching in medicine. Most often, PPT is used in its default mode which in fact, is known to cause boredom and ineffective learning. Research has shown improved short-term memory by applying multimedia principles for designing and delivering lectures. However, such evidence in medical education is scarce. Therefore, we attempted to evaluate the effect of multimedia principles on enhanced learning of parasitology. Methodology: Second-year medical students received a series of lectures, half of the lectures used traditionally designed PPT and the rest used slides designed by Mayer's multimedia principles. Students answered pre and post-tests at the end of each lecture (test-I) and an essay test after six months (test-II) which assessed their short and long term knowledge retention respectively. Students' feedback on quality and content of lectures were collected. Results: Statistically significant difference was found between post test scores of traditional and modified lectures (P = 0.019) indicating, improved short-term memory after modified lectures. Similarly, students scored better in test II on the contents learnt through modified lectures indicating, enhanced comprehension and improved long-term memory (P < 0.001). Many students appreciated learning through multimedia designed PPT and suggested for their continued use. Conclusions: It is time to depart from default PPT and adopt multimedia principles to enhance comprehension and improve short and long term knowledge retention. Further, medical educators may be trained and encouraged to apply multimedia principles for designing and delivering effective lectures.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Spectrum of diarrhoeagenic Escherichia coli in paediatric population suffering from diarrhoea and as commensals in healthy children p. 204
Taru Singh, Shukla Das, VG Ramachandran, Sajad Ahmad Dar, K Snehaa, Rumpa Saha, Dheeraj Shah
DOI:10.4103/ijmm.IJMM_16_21  PMID:28681807
Background: Diarrhoeagenic Escherichia coli (DEC) is associated with early death of children in developing countries and are being identified now as an important evolving pathogen. The objective of this study was to perform multiplex polymerase chain reaction (PCR) for simultaneous detection of six categories of DEC in two sets of PCR reactions using 11 virulent genes. Materials and Methods: During 1-year study period, forty isolates each from outpatient, inpatient and healthy groups were collected from children. E. coli was identified using conventional biochemical methods. DNA extraction was done using kit, and the extracted DNA was used as a template for multiplex PCR. Results: Virulent genes of DEC were detected in 106 (88.33%) samples. Overall, elt and est were detected in 8.33% and 30.83% of specimens; typical, atypical enteropathogenic E. coli and bfp were detected in 13.33%, 29.16% and 19.16% specimens; eagg was detected in 39.16% and east in 13.33% specimens and stx and hyla were isolated in 1.66% specimens each. While diffusely adherent E. coli and enteroinvasive E. coli genes were not isolated. Conclusion: Multiplex PCR is a rapid method for the simultaneous detection of 11 virulent genes of DEC at a time and it will provide a platform in understanding the diarrheal diseases in a more improved manner.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Genotypic characterisation of Mycobacterium tuberculosis isolates from tuberculous meningitis patients at a tertiary neurocare centre in Southern India p. 211
Akepati Chandramuki, Neelam Khanna, Elena Shashkina, Natalia Kurepina, Barun Mathema, Barry N Kreiswirth, Manjunatha M Venkataswamy
DOI:10.4103/ijmm.IJMM_16_166  PMID:28681808
Aims: Specific genotypes of Mycobacterium tuberculosis (MTB) have been reported to cause outbreaks of pulmonary tuberculosis (TB) in geographical areas that are endemic to TB. However, since there is little epidemiological evidence on the association of particular genotypes that cause tuberculous meningitis (TBM), we sought to investigate the association of specific MTB strains with infection of the central nervous system (CNS). Materials and Methods: We carried out a genetic characterisation of 89 MTB isolates from TBM patients at a Southern Indian tertiary neurocare centre and compared the genotypes with strains of pulmonary TB isolated from Indian immigrants in New York City. We applied the standard methods of genotyping of MTB, namely, IS6110-based restriction fragment length polymorphism and spoligotyping for strain identification, along with principal genetic grouping and single-nucleotide polymorphism cluster analysis. Results: The analysis revealed a high-level of diversity amongst the strain population. The genotypes of the isolates from TBM patients paralleled the pulmonary TB strain population recovered from the Indian immigrants in NYC. Conclusions: We conclude that there is no apparent association between genotypes of MTB and propensity to infect CNS tissue.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

An outbreak of Burkholderia cepacia complex in the paediatric unit of a tertiary care hospital p. 216
Swapna Mali, Lona Dash, Vikas Gautam, Jayanthi Shastri, Sunil Kumar
DOI:10.4103/ijmm.IJMM_16_258  PMID:28681809
Introduction: Burkholderia cepacia complex (Bcc) has emerged as a serious nosocomial pathogen worldwide especially in patients with indwelling catheters and cystic fibrosis. Bcc is a common contaminant of pharmaceutical products. We describe an outbreak of Bcc bacteraemia amongst children admitted in Paediatric Intensive Care Unit (PICU) and paediatric ward at a tertiary care hospital, Mumbai, in Western India. Materials and Methods: Blood culture samples from paediatric patients yielded growth of non-fermenting, oxidase positive, motile, Gram negative bacilli (NFGNB) (76/909) over a period of 8 months. Based on conventional biochemical tests and antimicrobial susceptibility testing, these isolates were provisionally identified as Bcc. The increased, repeated and continued isolation of Bcc alerted the possibility of an outbreak confined to PICU and paediatric ward. Active surveillance was undertaken to trace the source and contain the outbreak. Isolates were subjected to recA polymerase chain reaction (PCR) and Expanded multilocus sequence typing (EMLST). Results: Surveillance revealed the presence of Bcc on the upper surface of rubber stopper of sealed multidose amikacin vials. Isolates from blood culture and rubber stoppers were confirmed as Bcc by recA PCR. EMLST revealed that these isolates shared an identical novel sequence type 824 proving clonality. Timely interventions instituted led to control of the outbreak. Conclusion: This study highlights the importance of identification and molecular characterization of Bcc to establish its role in infection and outbreak.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Molecular characterisation and clinical correlates of rotavirus in children and adults in a tertiary care centre, Chennai, South India p. 221
Sribal Selvarajan, Sudhabharathi Reju, Premalatha Pushpanathan, Rajesh Arumugam, Ramachandran Padmanabhan, Sudhakar Muthiah Kothandaramanujam, Padma Srikanth, Gagandeep Kang
DOI:10.4103/ijmm.IJMM_16_51  PMID:28681810
Aims: This study was undertaken to determine the rate of detection of rotavirus causing diarrhoea among children and adults, identify the common genotypes circulating and determine clinical correlates. Settings and Design: This is a cross-sectional study in a tertiary care centre. Materials and Methods: Stool samples were collected from adults and children, transported on ice, aliquoted and stored at − 80°C. Rotavirus antigen detection enzyme-linked immunosorbent assay was performed on all samples. Representative samples were typed by conventional hemi-nested VP7 and VP4 reverse transcription-polymerase chain reaction. Statistical Analysis Used: Test of proportion, Student's t-test and Chi-square test were used for statistical analysis. Results: A total of 444 stool samples were collected and tested over 14 months. Among these, 116 were paediatric with a rate of positivity of 36.21% and 328 were adults with rate of positivity of 20.73%. Among children under 5 years (n = 90), the rate of positivity was 41.11%. Vesikari scale was used for clinical assessment. The mean ± standard deviation Vesikari score in rotavirus-infected children and rotavirus-uninfected children was 11.2 ± 3.2 and 8.9 ± 3.6, respectively, and the difference was statistically significant. Nineteen samples were genotyped in children < 5 years, 94.7% were of G1P[8] and 5.3% were of G9P[4] genotype. Genotyping of 14 adult samples, G1P[8](85.7%) was found as the predominant genotype, two samples (14.3%) were partially typed (G9PUT and G12PUT). Conclusions: The rate of positivity of rotavirus in children under 5 years was 41.11%. G1P[8] is the most common strain circulating across all age groups.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Increasing incidence of penicillin- and cefotaxime-resistant Streptococcus pneumoniae causing meningitis in India: Time for revision of treatment guidelines? p. 228
Valsan Philip Verghese, Balaji Veeraraghavan, Ranjith Jayaraman, Rosemol Varghese, Ayyanraj Neeravi, Yuvaraj Jayaraman, Kurien Thomas, Sanjay M Mehendale
DOI:10.4103/ijmm.IJMM_17_124  PMID:28681811
Purpose: Pneumococcal meningitis is a life-threatening infection, requiring prompt diagnosis and effective treatment. Penicillin resistance in pneumococcal infections is a concern. Here, we present the antibiotic susceptibility profile of pneumococcal meningeal isolates from January 2008 to August 2016 to elucidate treatment guidelines for pneumococcal meningitis. Materials and Methods: Invasive pneumococcal isolates from all age groups, were included in this study. Minimum inhibitory concentrations for the isolates were identified by agar dilution technique and VITEK System 2. Serotyping of isolates was done by co-agglutination technique. Results: Out of 830 invasive pneumococcal isolates, 167 (20.1%) isolates were from meningeal infections. Cumulative penicillin resistance in pneumococcal meningitis was 43.7% and cefotaxime non-susceptibility was 14.9%. Penicillin resistance amongst meningeal isolates in those younger than 5 years, 5–16 years of age and those aged 16 years and older was 59.7%, 50% and 27.3%, respectively, with non-susceptibility to cefotaxime in the same age groups being 18%, 22.2% and 10.4%. Penicillin resistance amongst pneumococcal meningeal isolates increased from 9.5% in 2008 to 42.8% in 2016, whereas cefotaxime non-susceptibility increased from 4.7% in 2008 to 28.5% in 2016. Serotypes 14, 19F, 6B, 6A, 23F, 9V and 5 were the most common serotypes causing meningitis, with the first five accounting for over 75% of resistant isolates. Conclusions: The present study reports increasing penicillin resistance and cefotaxime non-susceptibility to pneumococcal meningitis in our setting. This highlights the need for empiric therapy with third-generation cephalosporins and vancomycin for all patients with meningitis while awaiting results of culture and susceptibility testing.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Evaluation of serum galactomannan enzyme immunoassay at two different cut-offs for the diagnosis of invasive aspergillosis in patients with febrile neutropenia p. 237
Ritin Mohindra, Malini R Capoor, Shikha Puri, Hitesh Raheja, Dinesh K Gupta, B Gupta, Ranadip Chowdhury
DOI:10.4103/ijmm.IJMM_17_47  PMID:28681812
Background: Invasive aspergillosis (IA) is an increasingly common and fatal opportunistic fungal infection in patients with haematological diseases. Early diagnosis is difficult as mycological culture techniques have low sensitivity and the radiological tools have low specificity. Galactomannan enzyme immunoassay (GEI) detects galactomannan in the human serum with a reported sensitivity and specificity between 30% and 100%. Aims: The aim of this study was to analyse the role of GEI in diagnosis of IA in patients with febrile neutropenia and to evaluate the role of GEI in the diagnosis of IA as per the revised (2008) European Organization for Research and Treatment of Cancer–Mycoses Study Group (EORTC–MSG) criteria at two different optical density (OD) cut-offs of 0.5 and 1.0. Setting: This prospective study was conducted in Safdarjung Hospital, New Delhi, India. Methods: GEI testing was performed in adult patients of febrile neutropenia with evidence of IA. Results at two different OD indices (ODIs) of 0.5 and 1.0 were analysed. The evaluation of the diagnostic parameter, that is, GEI was measured in terms of sensitivity, specificity and positive and negative predictive value and was validated with the revised (2008) EORTC–MSG diagnostic criteria of IA. Results: One hundred and eleven patients had evidence of IA, of which 79 patients were GEI positive when cut-off ODI was 0.5, whereas with cut-off ODI 1.0, 55 patients were GEI positive. Conclusion: ODI of 1.0 should be considered as positive while in patients with OD between 0.5 and 1.0, repeat sampling from the patient is recommended.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Is there a need to revise the antibiotic concentration in Clinical and Laboratory Standards Institute-Recommended Oxacillin Screen Agar? p. 243
Niveditha Nagasundaram, Sujatha Sistla
DOI:10.4103/ijmm.IJMM_16_7  PMID:28681813
Introduction: In routine diagnostic microbiology laboratories, Clinical and Laboratory Standards Institute (CLSI) recommends the use of cefoxitin disc, in addition to oxacillin screen agar (OSA) of 6 μg/ml for the detection of methicillin-resistant Staphylococcus aureus (MRSA), whereas minimum inhibitory concentration values of oxacillin for S. aureus are ≤2 μg/ml (susceptible) and ≥4 μg/ml (resistant). Hence, the study was carried out to evaluate the ability of screen agar with lower concentrations of oxacillin to identify the isolates of MRSA and to compare this with cefoxitin disc diffusion (CDD). Materials and Methods: Six hundred and seventy-six isolates of S. aureus were screened for methicillin resistance by OSA with 2 μg/ml and 4 μg/ml and 6 μg/ml of oxacillin concentration as well as CDD. Polymerase chain reaction for mecA gene was carried out for all isolates which grew on OSA 2, 4 and 6 μg/ml regardless of their cefoxitin susceptibility. Latex agglutination test for penicillin-binding protein 2a was performed for the isolates which grew on OSA 2 and or 4 μg/ml but not on OSA 6 μg/ml. Results: Eight per cent of MRSA isolates was missed by using OSA 6 μg/ml, when compared with other methods. Sensitivities of OSA 2 μg/ml, OSA 6 μg/ml and CDD were found to be 100%, 92.5% and 97.5%, respectively, and specificities for the same were found to be 100%, 100% and 98%, respectively. As per FDA criteria, categorical agreement for OSA 2 μg/ml was found to be 100% in comparison with the reference broth microdilution method. No major and very major discrepancies were documented. Conclusion: Similar findings on a larger and more heterogeneous collection of isolates may indicate the need to revise the concentration of OSA to 2 μg/ml for the detection of MRSA.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Resurgence of diphtheria in rural areas of North Karnataka, India p. 247
Mahantesh V Parande, Subarna Roy, BG Mantur, Aisha M Parande, Rupali S Shinde
DOI:10.4103/ijmm.IJMM_17_48  PMID:28681814
Background: A diphtheria outbreak was identified from Vijayapura (formerly Bijapur) district in the South Indian state of Karnataka in 2011. There was a surge in the number of throat swab samples received under the Integrated Disease Surveillance Programme (IDSP) in North Karnataka since then. Objectives: A microbiological study was undertaken to generate information on the status of resurgence of the disease in the region. Materials and Methods: Throat swabs from 432 suspected cases of diphtheria during 2012–2015 were obtained from government hospitals and primary health centres of 8 districts in North Karnataka and were processed for the culture and identification of Corynebacterium diphtheriae. Polymerase chain reaction for the presence of toxin gene (toxA and toxB) was carried out on the isolates. Antibiotic sensitivity tests were performed on the isolates with a panel of 14 antibiotics. Results: Thirty-eight (8.79%) out of 432 samples yielded C. diphtheriae on culture. All isolates possessed the diphtheria toxin gene. Out of the 38 confirmed cases, whereas 21 (55.26%) were between 1 and 5 years of age, 14 (36.84%) were aged between 5 and 10 years. Male children were three times more than females in confirmed cases. No information was available on the immunisation status of the cases. Emergence of resistance to penicillin was found with minimum inhibitory concentration reaching up to 6.00 μg/ml. Conclusion and Discussion: Our study identified an upsurge in cases of diphtheria in North Karnataka, particularly in Vijayapura District, and to the best of our knowledge, reports the emergence of penicillin resistance for the first time in India. The study calls for enhanced surveillance for the disease, making antidiphtheritic serum available in key hospitals in the region and serves to provide a baseline for future assessment of the impact of the recently launched 'Mission Indradhanush' programme in strengthening Universal Immunisation Programme (UIP).
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Identification of the paradoxical effect of caspofungin and micafungin on Candida albicans growth in vitro using a growth curve methodology p. 252
Huang Zhouying, Li Chen, Wang Ruiqi, Liao Kang, Zeng Ji
DOI:10.4103/ijmm.IJMM_15_171  PMID:28681815
Background: The paradoxical effect of fungi, (which is a special phenomenon that certain Candida spp. might exhibit augmented growth in the presence of echinocandin at some concentration higher than the minimum inhibitory concentration) would be better illustrated through growth curves. Materials and Methods: We investigated the paradoxical effect of caspofungin and micafungin on the growth and cell viability of 38 clinical isolates of Candida albicans using a microbial sensitivity test and growth curve methodology. Results: When cells were incubated in the presence of antifungal agents for 48 h, the paradoxical effect was observed in 50% and 47.4% of the isolates incubated with caspofungin and micafungin, respectively. Growth curves indicated the occurrence of the paradoxical effect varied between different echinocandins. Moreover, increased turbidity in the sensitivity test did not correlate with increased fungal cell growth. For caspofungin, the paradoxical effect appeared earlier than in the microbial sensitivity test, while for micafungin, the effect observed in the microbial sensitivity test was not a true paradoxical effect. Conclusion: The growth curve methodology is more accurate for evaluating the occurrence of the paradoxical effect in comparison with the microbial sensitivity test.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Clinical and laboratory profile of dengue viral infections in and around Mangalore, India p. 256
Tina Damodar, Meena Dias, Reeta Mani, KA Shilpa, Ashwini Manoor Anand, V Ravi, Jutang Tiewsoh
DOI:10.4103/ijmm.IJMM_15_423  PMID:28681816
Background: Dengue (DEN) is being recognised as the world's major emerging tropical disease. Clinically, DEN may resemble other infections such as malaria, leptospirosis, and typhoid, and thus, laboratory investigations are required for definitive diagnosis. Secondary DEN infection, caused most often by dengue virus (DENV) serotypes 2 and 3, is known to present with severe disease manifestations. This study was undertaken to examine the clinical and laboratory profile of DEN viral infections and to determine the circulating serotypes in and around Mangalore, India. Materials and Methods: Serum samples from 285 clinically suspected cases of DEN in and around Mangalore between September 2013 and January 2014 were processed for detection of DEN IgM and IgG antibodies and nonstructural 1 (NS1) antigen using commercial ELISA kits. Detection of DEN viral RNA and serotyping was done by multiplex real-time reverse-transcriptase polymerase chain reaction (RT-PCR). The clinical and haematological profiles of the patients were analysed. Results: Serum samples from 83 (29%) patients were positive for DEN NS1 antigen and/or IgM antibodies. 33 (45%) out of 73 serum samples processed by multiplex real-time RT-PCR were positive for DEN viral RNA. DEN-1, -2 and -3 were the serotypes identified in this study. Fever was the most common presenting symptom followed by myalgia/arthralgia. Majority of the patients had thrombocytopaenia. Conclusion: Early detection of DEN can be achieved effectively using NS1 ELISA and IgM capture ELISA. Circulating DENV serotypes should be closely monitored for prevention of fatal outcomes in secondary infections.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

The evaluation of interferon lambda 4 rs368234815 as a predictor factor in treated patients with chronic hepatitis C genotype 1a infection p. 262
Shahram Jalilian, Seyed Mahmoud Latifi, Manoochehr Makvandi, Ali Teimoori, Azarakhsh Azaran, Mehdi Parsanahad, Gholamabas Kayedani
DOI:10.4103/ijmm.IJMM_16_309  PMID:28681817
Context: Host factors including single-nucleotide polymorphisms (SNPs) in or near interferon lambda (IFNL) gene are the important factors in predicting response to treatment of chronic hepatitis C (CHC). Aims: The aim of this study was to determine the frequency and association of IFNL4 rs368234815 with IFNL3 SNPs rs12979860, rs8099917 and other factors including cholesterol, alanine aminotransferase, fibrosis, viral load, age and body mass index in genotype 1a treated CHC patients, to achieve rapid virologic response (RVR) and sustained virologic response (SVR). Subjects and Methods: A total of 71 hepatitis C virus genotype 1a patients were enrolled from 2013 to 2015. The genotypes of rs12979860, rs8099917 were identified by polymerase chain reaction (PCR) and restriction fragment length polymorphism while the genotype rs368234815 detected by amplification-refractory mutation system-PCR. Results: The rate of RVR and SVR were 43/71 (60.6%) and 46/71 (64.8%), respectively. To achieve an SVR in patients with rs368234815, TT/TT genotype 20/24 (83.3%) was found to be higher than other SNPs. The correlation coefficient of rs368234815 was strongly associated with rs12979860 (r = 0.788, P < 0.001). Multivariate logistic regression showed that the cholesterol (odds ratio [OR]: 0.205, confidence interval [CI] 95%: 0.047–0.891, P = 0.035), age (OR: 0.160, CI 95%: 0.035–0.730, P = 0.018), baseline viral load (OR: 0.167, CI 95%: 0.032–879, P < 0.035) and IFNL4 (OR: 5.453, CI 95%: 1.015–29.293, P < 0.048) could be independent predictors of SVR. Conclusions: The results of these findings emphasise that factors such as age, cholesterol, baseline viral load and IFNL4 rs368234815 are better predictive factors and should be evaluated before CHC treatment.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Molecular identification and phenotypic characterisation of Sporothrix globosa from clinical cases of Eastern Assam, North-east India p. 269
Reema Nath, Pinky Lahon, Longmindar Timung
DOI:10.4103/ijmm.IJMM_16_264  PMID:28681818
Sporotrichosis is known to be endemic in the state of Assam, North-east India, which is situated in the Sub-Himalayan region. This disease is an acute or chronic infection caused by Sporothrix schenckii species complex which currently includes several species of clinical relevance such as Sporothrix brasiliensis, Sporothrix globosa, Sporothrix schenckii sensu stricto, Sporothrix albicans, Sporothrix mexicana, Sporothrix pallida and Sporothrix luriei. S. globosa is the prevalent species in India. Eight culture-positive patients were diagnosed from suspected consecutive cases of two lymphocutaneous and six fixed cutaneous forms over a period of 4 years in a clinical mycology laboratory of a tertiary care centre in Eastern Assam. Phenotypic speciation was inconclusive using the criteria of Marimon et al. because of atypical growth pattern shown by the isolates. Our isolates showed good growth at 37°C ranging from 6 to 27 mm; four of the isolates showed growth of 11–27 mm unlike S. globosa strains reported earlier. Molecular identification was done by sequencing both the internal transcribed spacer (ITS) region and the calmodulin (CAL) protein encoding gene (partial). All the isolates were identified as S. globosa. Molecular confirmation of species using ITS region and CAL protein encoding gene (partial) is necessary for isolates of S. globosa showing atypical biopatterns.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Genome sequence of an invasive strain of Streptococcus gordonii p. 274
Thangam Menon, V Naveen Kumar
DOI:10.4103/ijmm.IJMM_17_60  PMID:28681819
We report the genome sequence of IE35, a strain of Streptococcus gordonii isolated from the blood of a patient with prosthetic valve endocarditis. Whole-genome sequencing of S. gordonii IE35 strain by the combination of Illumina HiSeq2000 paired-end, Ion Torrent single-end sequencing and gap closing by Illumina NextSeq yielded a single, circular chromosome of 2,190,105 bp. It had 2106 predicted coding sequences, of which 2014 genes encoded proteins involved in various cellular processes and 66 genes coded for RNA. The predicted RNA genes were annotated up to pathway level and genes responsible for various metabolic processes and virulence were identified.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Changing epidemiology of coagulase-negative staphylococci in normal flora of skin p. 277
Vikas Gautam, Nandini Sethuraman, Ramanpreet Kaur, Suchet Sachdev, Neelam Marwaha, Pallab Ray
DOI:10.4103/ijmm.IJMM_16_282  PMID:28681820
Coagulase negative staphylococci (CoNS) have recently emerged as important pathogens causing nosocomial blood stream infections. To evaluate the prevalence of CoNS in cutaneous normal flora, skin swabs were collected from voluntary blood donors and processed for culture and identification using matrix assisted laser desorption ionisation-time of flight (MALDI-TOF). CoNS were isolated from 96% of blood donors, most commonly Staphylococcus hominis (86%), followed by Staphylococcus epidermidis (22%) and Staphylococcus haemolyticus (9%). There has been a shift in the prevalent species of CoNS in the community in India, from the earlier known S. epidermidis towards resistant species such as S. hominis and S. haemolyticus. Routine and rapid speciation of CoNS in clinical isolates with MALDI-TOF should be used effectively to manage these resistant species.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Risk factors and frequency of tuberculosis-associated immune reconstitution inflammatory syndrome among HIV/Tuberculosis co-infected patients in Southern India p. 279
Ramachandran Vignesh, Chinnambedu R Swathirajan, Sunil S Solomon, Esaki Muthu Shankar, Kailapuri G Murugavel
DOI:10.4103/ijmm.IJMM_16_163  PMID:28681821
Immune reconstitution inflammatory syndrome (IRIS) continues to be a complication in HIV/tuberculosis (TB) co-infected patients initiating highly active antiretroviral therapy (HAART). The aim of this study was to evaluate the risk factors associated with developing IRIS to identify a possible biomarker to predict or diagnose IRIS in patients initiating HAART. A total of 175 HIV/TB co-infected patients initiating HAART were followed up longitudinally during September 2010 to May 2013 attending a HIV care clinic in Chennai. Patients were followed up longitudinally after HAART initiation and baseline demographic, laboratory parameters and treatment characteristics between patients with IRIS events and those without IRIS events were compared. Chi-square or Fisher's exact test for categorical variables and a Wilcoxon rank-sum test for continuous variables were performed using SPSS, version 12.0 software. Patients with IRIS had a significantly lower median baseline CD4+ T-cell count (P = 0.0039). There were no differences in terms of sex, CD4 T-cell %, plasma viral load, time interval between initiating ATT and HAART between the IRIS and non-IRIS patients. Low CD4+ T-cell count (<100 cells/μL) could be used as a marker to screen and monitor patients initiating HAART.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Emergence of rmtC and rmtF 16S rRNA methyltransferase in clinical isolates of Pseudomonas aeruginosa p. 282
Lavanya Mohanam, Thangam Menon
DOI:10.4103/ijmm.IJMM_16_231  PMID:28681822
Occurrence of aminoglycoside (AG) resistance in clinical isolates of Pseudomonas aeruginosa is investigated in this study. Antimicrobial susceptibility test and minimum inhibitory concentration (MIC) for amikacin and gentamicin were performed followed by polymerase chain reaction amplifications of AG modifying enzyme genes (aac(6´)-I, aac(6´)-II, aac(3)-II/VI, ant(2´´)-I, aph(3´)-VI) and 16S methylases (rmtA-D, rmtF and armA). MIC50and MIC90were 64, 128 and > 256, >256 for amikacin and gentamicin, respectively. Four types of genes (aac(6´)-I, aac(3)-II/VI, ant(2´´)-I and aph(3´)-VI) were found in 53 (57.6%) isolates. ant(2´´)-I was the most predominant gene (28 isolates) followed by aac(6´)-I (23 isolates). Nineteen (20.6%) isolates were positive for 16S RMTases (rmtB, rmtC, rmtF and armA) and two isolates co-harboured rmtB + rmtC + rmtF.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Comparative analysis of syndromic case management and polymerase chain reaction based diagnostic assays for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis and genital mycoplasmas in patients of genitourinary discharge p. 286
Nazneen Arif, Sujeesh Sebastian, Neena Khanna, Seema Sood, Benu Dhawan
DOI:10.4103/ijmm.IJMM_17_4  PMID:28681823
To respond to the situation of high prevalence and need for effective treatment for sexually transmitted infections (STIs) in low-resource settings, syndromic diagnostic approach was recommended by the World Health Organization and was adopted by National AIDS Control Organization at the primary health centre level. A retrospective study was undertaken in symptomatic patients attending an STI clinic to validate the syndromic approach for genitourinary discharge syndrome. For aetiological diagnosis, culture and/or polymerase chain reaction was used. An infective aetiology could be established in only 20% (106 of 530) patients. The present data call for an early appraisal and review of the diagnostic policy by national authorities on syndromic case management.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Levels of circulating immune complexes containing Mycobacterium Tuberculosis-specific antigens in pulmonary tuberculosis and sarcoidosis patients p. 290
B Goyal, JA Sheikh, R Agarwal, I Verma
DOI:10.4103/0255-0857.209569  PMID:28681824
The present study was conducted to understand the aetiological link between tuberculosis (TB) and sarcoidosis. Sera from smear-positive TB subjects (n = 24), smear-negative TB subjects (n = 24), sarcoidosis patients (n = 24) and healthy controls (n = 24) were collected and circulating immune complexes were isolated. Sandwich ELISA was performed for detecting four highly specific mycobacterial regions of difference (RD) proteins (early secretory antigenic target 6 [ESAT6], 10 KDa culture filtrate protein [CFP10], 21 KDa CFP [CFP21] and mycobacterial protein from species TB [MPT 64]). Sensitivity and specificity was calculated, and receiver operating characteristic plots were plotted. Non-parametric Mann–Whitney U-test was used to calculate statistical significance. Seventy per cent of sarcoidosis patients showed the presence of immune complexes of mycobacterial RD proteins similar to that observed in the sera of smear-negative TB patients as opposed to antibody-based detection assay based on these RD proteins. Thus, immunoassays based on specific mycobacterial RD proteins also need to be developed and validated carefully to differentiate TB and sarcoidosis, a close mimic of smear-negative tuberculosis.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Co-circulation of all four dengue virus serotypes: First report from Odisha p. 293
Baijayantimala Mishra, Jyotirmayee Turuk, Subhra Jyoti Sahu, Atul Khajuria, Subrat Kumar, Anupam Dey, Ashok Kumar Praharaj
DOI:10.4103/ijmm.IJMM_15_536  PMID:28681825
The present report describes the detection of co-circulation of all the four dengue serotypes along with rarely detected dengue viruses (DENVs)-4 for the first time in Odisha. One hundred and forty-eight blood samples were tested for dengue NS1 antigen ELISA and IgM antibody (Ab), and twenty early samples were subjected for type-specific multiplex reverse transcription-polymerase chain reaction (RT-PCR). Twenty-three samples found positive for dengue NS1 and/or IgM Ab; five were positive by RT-PCR. DENV-4 was detected in one sample, DENV-2 in two and 2 were co-infected with DENV-1 and 3. Co-circulation of all four dengue serotypes in Eastern India emphasises the need of molecular monitoring of circulating DENV serotypes.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Prevalence of transfusion-transmitted viral pathogens among health-care workers and risk mitigation programme in a paediatric tertiary care hospital p. 296
Charu Nayyar, Rushika Saksena, Vikas Manchanda
DOI:10.4103/ijmm.IJMM_15_133  PMID:28681826
The health-care workers (HCWs) are at an occupational risk of exposure to blood-borne pathogens, mainly, HIV, hepatitis B virus (HBV) and hepatitis C virus. HBV is currently the only blood-borne virus for which a vaccine is available. All health-care institutions must encourage the HCWs to undergo screening for blood-borne pathogens.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Exploring the prescribing behaviours and the mind of antibiotic prescribers is critical for a successful antibiotic stewardship programme: Results of a survey from Eastern India p. 299
Nikhila Ravi, Anirban Laha, Lalawmpuia Hmar, Suddhasatwya Chatterjee, Jyotsna Goswami, Gaurav Goel, Kingshuk Dhar, Tanushree Ghosh, Soumyadip Chatterjee, Soumitra Shankar Datta, Sanjay Bhattacharya
DOI:10.4103/ijmm.IJMM_17_133  PMID:28681827
Quantitative and qualitative analysis were used to ascertain practices, perceptions and barriers about antibiotic stewardship program (ASP) in an oncology hospital in eastern India. In 2014 and 2017, 62% and 69.1% of the patients audited were found to be on anti infective medications respectively. Nearly 47% of patients in the study group (2014) who were on therapeutic antibiotics had an average cost of $46.48 per patient per day (inter-quartile range: $17.23–$94.76). Antibiotic related consultations from clinical microbiologists, was found to be in demand, and education of prescribers and policymakers was identified as critical to the success of ASP.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Development and evaluation of a loop-mediated isothermal amplification combined with au-nanoprobe assay for rapid detection of Mycobacterium tuberculosis p. 302
Thongchai Kaewphinit, Jutturong Ckumdee, Kosum Chansiri, Somchai Santiwatanakul
DOI:10.4103/ijmm.IJMM_15_333  PMID:28681828
Loop-mediated isothermal amplification (LAMP) has been proposed as an inexpensive and easy to perform assay for molecular diagnostics. We present a novel strategy for the detection of LAMP amplicons derived from Mycobacterium tuberculosis by the use of Au-nanoprobes. When applied to a total of 93 clinical specimens, the LAMP assay demonstrated sensitivity and specificity higher than that of polymerase chain reaction and culture. The Au-nanoprobe augmented LAMP test platform with its advantages of robust reagents and a simple colorimetric detection method can be adapted easily for the rapid detection of other infectious disease agents at a low cost.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Molecular characterisation of uropathogenic Escherichia coli isolates at a tertiary care hospital in South India p. 305
Arindam Chakraborty, Prabha Adhikari, Shalini Shenoy, Vishwas Saralaya
DOI:10.4103/ijmm.IJMM_14_291  PMID:28681829
Uropathogenic Escherichia coli (UPEC) express a multitude of virulence factors (VFs) to break the inertia of the mucosal barrier of the urinary tract. The aim of the present study was undertaken to characterised the UPEC strains and to correlate carriage of specific virulence markers with different phylogroups and also to correlate these findings with clinical outcome of patients. A total of 156 non-repeated, clinically significant UPEC isolates were studied. Virulent genes were determined by two set of multiplex polymerase chain reaction (PCR). Phylogenetic analysis was performed by triplex PCR methods. Antibiograms and patient's clinical outcomes were collected in a structured pro forma. Of the 156 patients infected by UPEC strains with significant bacterial counts the most common predisposing factors were diabetes (45.5%) followed by carcinoma (7%). On analysis of the VF genes of the isolates, a majority of strains (140; 90%) were possessing the fimH gene followed by iutA (98; 63%), papC (76; 49%), cnf1 (46; 29.5%), hlyA (45; 29%) and neuC (8; 5%), respectively. On phylogenetic analysis, 27 (17%) isolates were belong to phylogroup A, 16 (10%) strains to Group B1, 59 (38%) were from Group B2 and 54 (35%) were from Group D. High prevalence of antibiotic resistance was observed among the isolates. The incidence of papC, cnf1 and hlyA was significantly higher (P < 0.05) among the isolates from relapse patients. Our findings indicate that virulent as well as commensal strains are capable of causing urinary tract infection. Virulence genes as well as patients-related factors are equally responsible for the development of infections and also that virulence genes may help such isolates to persist even with appropriate chemotherapy and be responsible for recurrent infections.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Isolation of Salmonella typhi from high vaginal swab in a case of septic abortion p. 311
Pragnya Paramita Jena, Shalini Dewan Duggal, Avinash Kumar, Tanisha Bharara, Abha Sharma, Renu Gur
DOI:10.4103/ijmm.IJMM_16_180  PMID:28681830
Salmonella Typhi can be a significant cause of morbidity and mortality in pregnant females with adverse outcomes. Risk of infections increases manifold during pregnancy due to hormonal changes and immunological phenomena. S. Typhi has the ability to cross placenta (vertical transmission) resulting in miscarriage, stillbirth or premature labour. We report a case of a pregnant female who was admitted to emergency department with fever, missed abortion and hypovolaemic shock. Subsequently, S. Typhi was isolated from her high vaginal swab and blood cultures. Follow-up cultures were negative for S. Typhi, and the patient was discharged after 10 days. The possibility of salmonellosis should be considered if a pregnant woman residing in an endemic area presents with high-grade fever. Furthermore, it should be promptly treated to prevent foetal loss.
[ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Impact factor: An important parameter to decide the quality of publication p. 314
BS Nagoba, NM Suryawanshi
DOI:10.4103/0255-0857.209587  PMID:28681831
[HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Hepatitis B vaccination for healthcare workers p. 315
Sadia Khan, Anil Kumar
DOI:10.4103/ijmm.IJMM_16_177  PMID:28681832
[HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Oncogenic human papillomavirus types in a high risk population p. 316
Mahima Lall, Pankaj Kumar, Aashish Choudhary, Lalit Dar
DOI:10.4103/ijmm.IJMM_16_338  PMID:28681833
[HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Inconsistency in disk diffusion while testing carbapenems in Chryseobacterium spp. p. 317
Vivek Hada, Anuradha Sharma
DOI:10.4103/ijmm.IJMM_16_298  PMID:28681834
[HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Antibiotic susceptibility pattern of Burkholderia cepacia complex and Stenotrophomonas maltophilia: A 5-year analysis p. 318
Malavalli Venkatesh Bhavana, Sangeeta Joshi, Ranjeeta Adhikary, Hosdurg Bhaskar Beena
DOI:10.4103/ijmm.IJMM_16_236  PMID:28681835
[HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [PubMed]  [Sword Plugin for Repository]Beta

Erratum: Global eradication of measles: Are we poised? p. 319

[HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta

2004 - Indian Journal of Medical Microbiology
Published by Wolters Kluwer - Medknow

Online since April 2001, new site since 1st August '04