Annals of International Medical and Dental Research

1-2

Authors: Varshney R

Have you ever heard of Horizontal Gene Transfer (HGT)? In essence, the idea is that genes and DNA can be transferred between species in the same environment.[1] It is well known process for the evolution for unicellular organisms like bacteria in resistance to antibiotics;[2] nematode worms who have acquired genes from microorganisms and plants; some beetles that gained bacterial genes to produce enzymes for digesting coffee berries and the genome of wasps was found to contain not just DNA from their own species, but also from microbes that live in their guts. Now a days, the idea that HGT occurs in more complex animals, such as humans, rather than them solely gaining genes directly from ancestors, has been a serious matter of debate and discussion.[3] If confirmed, this finding would significantly impact theories about the underlying mechanisms of evolution. Traditionally, it was believed that genes were inherited solely from parents, but the process of DNA evolution could prove far more complex than once believed. Most, if not all, animals may have evolved in part due to this transfer of foreign genes, researchers believe. Well known author Crisp et al[4] from the University of Cambridge, UK, said: "This is the first study to show how widely horizontal gene transfer (HGT) occurs in animals, including humans, giving rise to tens or hundreds of active 'foreign' genes. Surprisingly, far from being a rare occurrence, it appears that HGT has contributed to the evolution of many, perhaps all, animals and that the process is ongoing, meaning that we may need to re-evaluate how we think about evolution." The researchers studied the genomes of 12 species of Drosophila or fruit fly, four species of nematode worm, and 10 species of primate, including humans. They calculated how well each of their genes aligns to similar genes in other species to estimate how likely they were to be foreign in origin. By comparing with other groups of species, they were able to estimate how long ago the genes were likely to have been acquired.[4] It was a matter of surprise that a number of genes, including the ABO blood group gene, were confirmed as having been acquired by vertebrates through HGT. The majority of the other genes were related to enzymes involved in metabolism. In humans, 17 previously-reported genes acquired from HGT were confirmed, and 128 additional foreign genes were identified in the human genome that has not previously been reported.[4] Some of those genes were involved in lipid metabolism, including the breakdown of fatty acids and the formation of glycolipids.[4] Others were involved in immune responses, including the inflammatory response, immune cell signalling, and antimicrobial responses, while further gene categories include amino-acid metabolism, protein modification and antioxidant activities.[4] The team were able to identify the likely class of organisms the transferred genes came from. Bacteria and Protists, another class of microorganisms, were the most common donors in all species studied.[4] They also identified HGT from viruses, which was responsible for up to 50 more foreign genes in primates.[4] Some genes were identified as having originated from fungi.[4] This explains why some previous studies, which only focused on bacteria as the source of HGT, originally rejected the idea that these genes were 'foreign' in origin. The majority of HGT in primates was found to be ancient, occurring sometime between the common ancestor of Chordata and the common ancestor of the primates. The authors say that their analysis probably underestimates the true extent of HGT in animals and that direct HGT between complex multicellular organisms is also plausible, and already known in some host-parasite relationships.[4] The study also has potential impacts on genome sequencing more generally. Genome projects frequently remove bacterial sequences from results on the assumption that they are contamination. While screening for contamination is necessary, the potential for bacterial sequences being a genuine part of an animal's genome originating from HGT should not be ignored, say the authors.

9-12

Authors: Das B, Palaria U, Sinha AK, Kumar S, Pandey S

Background: Dexmedetomidine is a centrally acting alpha-2 adrenoceptor agonist. In this study, we compared dexmedetomidine to fentanyl in attenuating sympathetic response to laryngoscopy and tracheal intubation. Methods: Eighty ASA grade I-II patients requiring tracheal intubation were included in this prospective study and were randomly assigned to the dexmedetomidine (Group D) and fentanyl group (Group F) (40 patients in each group). Both the drugs were given at 1 µg/kg dose prior to laryngoscopy. We assessed heart rate, blood pressures and complications (bradycardia, hypotension and sedation). Results: The two groups were comparable in demographic parameters. The baseline mean heart rate (P=0.94) was not significantly different between Group F and Group D. Increase in heart rate after laryngoscopy and intubation was significantly lower in Group D compared to Group F (P=0.039). Mean heart rate remained lower at one minute after intubation in Group D but it was not statistically significant (94.64 s vs 86.28 sec). The difference in mean heart rate between two groups was comparable at three, five, ten and fifteen minutes after intubation. The baseline Mean arterial pressure was comparable between the groups (P=0.83) and remained similar throughout 15 minutes after intubation. Group D showed significant hypotension compared to Group F (P=0.03), whereas there was no significant bradycardia between these groups (P=0.19). Mean sedation score is higher in Group D compared to Group F. Conclusion: At 1 µg/kg dose, both dexmedetomidine and fentanyl cause partial attenuation of sympathetic response to laryngoscopy and intubation but dexmedetomidine blunts this response more effectively than fentanyl.

18-20

Authors: Verma N, Kalpana, Verma A

Background: Gokshuradi Yog used from for strengthening and functioning of genitourinary tract. The study aims to study the role of this Ayurvedic medicine along with antibiotic in early response to treatment of urinary tract infection in children. Methods: This study was conducted on 52 children (32 girls and 20 boys). They had symptomatic and culture proven urinary tract infection. They were randomly allotted the treatment group and control group. Patents in control were given the antibiotics for seven days and were evaluated every alternate day for symptomatic relief. Similarly the patients in treatment group were started the antibiotics along with preparation of ‘Gokshuradi Yog’ for seven days and were evaluated every alternate days. Repeat culture was performed on seventh day of treatment and the final result was evaluated. Results: The most common organism grown on culture was Escherichia coli in 39 patients (22 girls and 17 boys). Of the 28 children in treatment group 26 were asymptomatic in 2 days however they continued to be on therapy for seven days. Two patients were symptomatic even after four days, one of whom was culture positive even after 7 days of treatment and was put on intravenous antibiotics. Six out of 24 patients in control group were asymptomatic in two days; the 18 remaining patients were symptomatic even till day seven of treatment out of which two patients were culture positive. Conclusion: Patients when treated with ‘Gokshuradi Yog’ along with the antibiotics brings early symptomatic relief in children suffering from culture proven UTI.

25-8

Authors: Bhandari G, Mitra S, Shahi KS, Chand G, Tyagi A.

Background: The aim of study is to compare I-gel and Air-Q supraglottic airways in terms of - success rate of device insertion, number of attempts taken, haemodynamic parameters before and after device insertion, incidence of trauma and postoperative sore throat, dysphagia. Methods: This randomised single blind study was conducted on 90 patients of age 18-60 years, undergoing elective surgery requiring general anaesthesia. Patients were randomly allocated in two groups Group I: I-gel (n= 45), Group II: Air-Q (n=45). After preoxygenation, induction and muscle relaxation appropriate size I-gel or Air-Q was inserted and all parameters were noted by an independent observer. For statistical analysis, Student t-test was employed to compare the means and Chi-square test was used for categorical variables. Complications were compared using Fisher’s exact test. Results: The demographic profile of patients in both groups was similar. In all patients supraglottic airway device was inserted within 3 attempts. Mean insertion time in first attempt for I-gel (25.85 ±1.7 sec) was found to be significantly lower than Air-Q (26.73±1.51 sec) [P=0.0128]. Conclusion: We conclude that I-gel is easier and safer than AirQ when ventilation through LMA is intended during surgery.

34-6

Authors: Ali AM, Sinha SP, Sharma SC.

Varicose veins have troubled mankind for thousands of years, and their various treatments and complications have been documented from the times of Hippocrates. Although thrombophlebitis is a relatively common condition in the superficial veins of the upper or lower limbs, it usually follows some intravenous intervention or trauma. Thrombosis followed by thrombophlebitis in varicose veins has seldom been reported in literature but the occurrence of spontaneous thrombosis in only the above knee perforator veins of the lower limb has been seldom mentioned. We report the case of a patient with long standing varicose veins of the left lower limb presenting with spontaneous thrombosis of only the above knee perforators and our subsequent management.

39-40

Authors: Sharma M, Kaundal P, Sharma P, Chaudhary R.

Post electric burn sigmoid perforation is a rare but dreadful complication. It can lead to increased chances of mortality/morbidity if any delay is made during diagnosis or active management. We report a case of electric current burn on left hand, forearm, arm and shoulder with erforation of sigmoid colon with successful management by primary closure.

44-6.

Authors: Moinuddin A

Dear Editor, AIDS (Acquired Immune deficiency syndrome) is an infectious disease caused by a retrovirus called HIV (Human Immuno deficiency Virus) which attacks CD4 cells resulting in suppressed immune response.[1] HIV EPIDEMIOLOGY IN INDIA The statistical data in WHO epidemiological fact sheet on HIV/AIDS was available from 1990 onwards and the overall trend showed a steep rise from 1990 to 2001 followed by a slow decline. The total number of adults (15+) and children living with HIV decreased from 2 700 000 (2001) to 2 400 000 (2007) of which 39% are females and 3.5% are children. The prevalence % (15-49) dropped from 0.45 to 0.34 during the same period though an increase of 0.2% was observed among young people (15-24) from 2005-07.[2] If we monitor adult prevalence % (15-49) more specifically within the states (2006), Andhra Pradesh being the only state carrying a burden of more than 0.69% whilst rest of them shared a rate between 0.08% to 0.69% exempting Uttar Pradesh (less than 0.08%).[3] Some of the preventive indicators such as Prevention of mother to child transmission (PMTCT) supported the current declining trend as the number of pregnant women receiving ART have increased from 4289 (2004) to 8816 (2007). Similarly in 2007 donated blood unit screening was also 100%.[2] The NACO annual report highlighted an increase of men having sex with men (MSM) and injecting drug users although sex continues to be the main mode of transmission. It continue its program NACP III (2006-2011) primarily preventing new infection amongst high risk group as well as offering care and support to PHLA (People living with HIV/AIDS). It aims to work in collaboration with Non Government Organisations (NGO), Community based Organisations (CBO), Tribal Strategy and Implementation Plan etc targeting rural populations.[4] HIV EPIDEMIOLOGY IN SCOTLAND According to Health Protection Scotland (HPS) there are 5718 HIV positive cases in Scotland (2008) out of which 4154 (73%) are males and 1564 (27%) are females. It was estimated that 38% of the total cases acquired infection abroad especially Africa whereas almost one third (2017) thought to be unaware of their AIDS status.[5] In 2008 Scotland 412 new cases were reported and Greater Glasgow and Clyde (141) along with Lothian (120) shared 63% of total Scotland’s HIV/AIDS burden.[6] The HIV/AIDS diagnosis, AIDS deaths and CD4 monitoring run in close proximity and parallel to each other during 1992-1996 and remain low as well. But since the introduction of combination HAART (Highly Active Antiretroviral Therapy) in 1996 the whole trend changed. The AIDS deaths declined thereafter whilst the diagnosis and CD4 monitoring showed a momentous rise. The diagnosis is usually made at GUM (genitor-urinary medicine) clinics and STISS (Sexually transmitted infection surveillance systems). There is an increase of 71% amongst people undergoing HIV tests from 2004-2008. [6- 8] The risk groups continue to be men having sex with men (MSM) and heterosexual non drug users as compared to injecting drug users (IDU) although prevalence % of MSM dropped from 4.4 (2007) to 3.1 (2008) and IDU increased slightly from 0.3% to 0.5% yet the overall scenario remains pretty much the same.[6-8] DESCRIPTION AND CRITICAL APPRAISAL OF HIV SURVEILLANCE SYSTEM IN INDIA National AIDS Control Organisation (NACO) is a division of Government of India’s Health Ministry which works for prevention and cure of HIV/AIDS when it was detected in India (1986).[9] It started NACP (National AIDS Control Program) since 1992 which is now in its third phase (NACP-III) and did most of its surveillance via HIV sentinel surveillance system (HSS) though it has also included other surveillance systems such as Behavioural Sentinel Surveillance (BSS) and PPCTC (Preventing Mother to Child Transmission) as well.[10] In general HSS is responsible for monitoring level, trend and spread of HIV/AIDS throughout the country along with the enlightenment of risk factors. We will use the CDC's Framework for Program Evaluation in Public Health[11] to describe HSS as it forms the core of NACP Letter to Editor Annals of International Medical and Dental Research, Vol (1), Issue (1) Page 45 strategies and policies for combating HIV/AIDS epidemic. As per Task ‘A’[11] which requires engagement of stakeholders for evaluation is partly described in the form of health professionals (practitioners, nurses and allied health staff) but data providers, and representatives of organisations are missing.[12] Although their involvement is inevitable it’s perhaps their description which is missing from the surveillance report. The first part of Task ‘B’[11] dealt with the public health importance of the event under surveillance. The indices of frequency i.e. prevalence, mortality rates etc are disseminated as ‘HIV Fact Sheet’ separately[14] and severity measures of quality of life, years of healthy life etc are completely absent. Also it’s not emphasised that they are responsible for making HIV/AIDS an important public health issue. The second part is perhaps the most important one concentrating on the purpose and operationalization of surveillance system. The objectives seem quite convincing aiming to monitor disease prevalence over a period of time and in various geographic locations. The planned use and the citation of legal authority for data collection is vaguely written but the place where data evaluation is done in the organisation is skipped quite clearly.[13] Though it is said to be working in integration with PPCTC, BSS and ANC surveillance systems yet there isn’t any hint of defining the extent and methodology of this collaboration. Flow charts are drawn throughout elaborating issues such as organisation and implementation of HSS in general, informed consent, HIV testing strategy, flow of data, quality assurance etc.[13] Moving on to the components of the HSS, population under surveillance would be the data collected from people visiting ANC (Ante Natal Care) and STD (Sexually Transmitted Diseases) sites although high risk groups for HIV/AIDS in India are female sex workers (FSW) and injecting drug users (IDU) and this has been given less emphasis making results a bit dubious.[12, 14] Data collection is carried out every year but the exact period of time required is not mentioned.[13] It is collected in the form of blood samples of 5ml each from ANC and STD sentinel sites under the strategy of unlinked anonymous testing (UAT) with informed consent. The inclusion criteria for ANC sites would be the women (15-49 years) attending clinic for the first time and consecutive first time visitors are recruited to get a sample size of 400. For STD sites all new STI cases are included with a sample size of 150.[13] The methodology involved in collection of blood, its storage and transportation is quite clear but data informatics i.e. formatting, coding and backup is not precisely described Patient privacy and data confidentiality is maintained throughout by the personnel taking all necessary steps for protocol adherence, collecting minimal socio-demographic information and using a unique code for linking data form to lab results.[13] Also not much is said about the government policies on data release although information is disseminated in the form of technical report and fact sheet on a regular basis. Resources: The third part is all about resource description and no clear guidelines are provided here about the financial and other maintenance sources but there is a word about human resource engaged at certain levels of the system.[12, 13] Task ‘C’ concentrates on the evaluation design and as stated earlier the purpose and the intended use of the surveillance system is quite definite.[13] The problem might be the execution of designed strategy fairly consistently at all places. Task ‘D’ uses different criterion to describe the overall performance of the surveillance system. It is useful in the sphere of its working but appropriate coverage is by far the biggest challenge keeping in mind the vast country size. The second part evaluates HSS in terms of each system attribute. Simplicity: It works on the principle of simplicity as its data collection follows case ascertainment definition with the involvement of only few organisations and used methodology is quite straightforward. Moreover there is no special laboratory requirement for testing samples or multiple levels of reporting as well.[13] Flexibility: It is somewhat flexible as it integrates with the Behavioural Sentinel Surveillance (BSS) in its third phase i.e. NACP-III which is one of the flexibility criteria of CDC evaluation framework.[10] Data Quality: HSS relies on the site in charge for completeness of all forms and do periodic checks at HIV laboratories by External Quality Assurance Scheme (EQAS) to ensure data quality [13] but still missing statistics are found at some places in disseminated reports.[14] Acceptability: The expanding agenda of the HSS manifests its acceptability to some extent but its inability to respond to a variety of recommendations owing to economic costs Sensitivity: There are question marks over HSS sensitivity as the HIV prevalence Letter to Editor Annals of International Medical and Dental Research, Vol (1), Issue (1) Page 46 decreased from 0.45 (2001) to 0.36 (2007) [2] and there isn’t any description about sensitivity anywhere in the surveillance report. Predictive value positive: The use of DBS (Dried blood Spot) method of sample collection and then treating with either ELISA or Western blot is 100% and 93% sensitive and its cost effective as well especially when transportation is required from remote areas.[3] This might hint the existence of few false negative cases but predictive value positive again like sensitivity is nowhere discussed in HSS. Representativeness: HSS seems to fulfil representativeness criteria as its reports shows the population characteristics, geographical distribution taking into account factors such as age and socioeconomic status. But are the sample sizes of 400 and 250 used at ANC and STD sites respectively large enough.