ARTIFICIAL INTELLIGENCE IN MEDICINE – HOW GOOGLE CHANGING EDUCATION
Dr.T.V.Rao MD The world has changed with little feature phones, lead to smartphones, never ending technology and the world is moving to intelligent phones with artificial intelligence, It just means that you get anything on Online for learning and teaching or executing the plan, I was fascinated to read on Google Pixel mobile to be launched with artificial intelligence, Artificial intelligence (AI) is intelligence exhibited by machines. In computer science, an ideal "intelligent" machine is a flexible rational agent that perceives its environment and takes actions that maximize its chance of success at some goal. Colloquially, the term "artificial intelligence" is applied when a machine mimics "cognitive" functions that humans associate with other human minds, such as "learning" and "problem solving. For example, optical character recognition is no longer perceived as an exemplar of "artificial intelligence" having become a routine technology. Capabilities currently classified as AI include successfully understanding human speech, competing at a high level in strategic game systems, self-driving cars, and interpreting complex data. I already use the Artificial intelligence from Google store with downloaded application of ALLO, Empowered with Google Assistant , it is just refined research to our needs with a background of your, search History, and your needs, never forget the search design depends upon how to search the matters, When I I ask with voice command what is New in Medicine or whatever you want, it answers better than many, you get a nice ideas on what is happening you get the real Time answer, If you are Microbiologist ask what is the best solutions to treat the patient with Multidrug resistant tuberculosis , or How to deal with MDR Tuberculosis in a developing country We are going to use much faster technology in a few fraction of second you get more intelligent answers with the new innovative intelligent phone, , Today every smartphones can use Google Assistant . Never forget certainly it many prove threat to the Teachers many doubts of the students can be dealt with a voice command, and Google answers all the matters, faster. I wish all the Students and teachers to use GOOGLE ALLO is, a smart messaging app that helps you say more and do more., Get answers. Get the latest info on everything from news, weather, traffic, sports, or your upcoming flights status. Artificial intelligence techniques have the potential to be applied in almost every field of medicine. There is need for further clinical trials which are appropriately designed before these emergent techniques find application in the real clinical setting.
Ask the Assistant to send you daily updates on the information you care about, it helps the postgraduates and researchers to get updated, B E CAUTIOUS IT WORKS AND SEARCHES INFORMATION AS PER YOUR PSYCHOLOGY AND WAY YOU SEARCH WITH LITTLE BASIC INTELLIGENCE WITHOUT DISTORTING THE FACTS
TODAY TOPIC OF ARTIFICIAL INTELLIGENCE IS INCLUDED IN MEDICAL EDUCATION WORKSHOPS EVEN IN DEVELOPING COUNTRIES
TRY ASKING QUESTIONS TO GOOGLE ASSISTANT ?
Ref – Wikipedia and Google on Artificial Intelligence
Dr.T.V.Rao MD @ Artificial intelligence 2017

WE ARE NEVER OLD TO LEARN BETTER THINGS IN LIFE ? The world is progressing faster than what we know, imagine to me and we are outdated soon or later in a system we work, remember our own teachers we remember the great teachers, who had a greater knowledge, and committed to the profession than gossipers and lived by status and power, Knowledge is considered as the state of knowing facts and information acquired with the help of experience and reading books. Evolution of civilization over the years is due to increase in the knowledge base of the human’s A teacher who is sincere to his profession is respected for the knowledge he possesses, the more knowledgeable you are, the more advantage you have over the other people. The better you are equipped to manage yourself and others, the easier your journey of life. More than anything, knowledge must be put to good use. Someone once remarked that while ignorance was the curse of God, knowledge was the important power of wings which carried one to heaven. The power of knowledge lends him such distinction, Knowledge in wrong direction is much harmful than the actions of illiterate man We need to learn the art of life. We must master the techniques of adjusting and accommodating with the changes in our surroundings, as we are surrounded by people who live to meddle in everything, and many life situations. Wish to survive we must move well with the people and persuade them effectively to get things done in our favor. A fascinating fact about knowledge is that despite being shared with others, it grows unlike the wealth and fortunes we possess, Modern knowledge can only be acquired through education as it plays a very important role in enhancing the professional life of the individuals, many learned believe they wish to be the greater learners than the authoritarian teachers?
A great quote to remember by ― Roy T. Bennett, The Light in the Heart
“Let the improvement of yourself keep you so busy that you have no time to criticize others.”
Dr.T.V.Rao MD

ERRORS IN THROAT SWAB COLLECTION , CULTURING AND REPORTING IN PEDIATRIC PATIENTS
Dr.T.V.Rao MD We do receive many specimens in Microbiology departments from young children, and infants, The errors start from collecting the throat, many times the throat is not reached and swabs are collected in erratic ways and laboratories too report the errors, the reasons being very few staff are trained in the meticulous ways in collecting the pediatric specimens, However in developed countries have many trained child caring nurses however we certainly have to work in a compromised conditions in technical and clinical competency in collecting specimens , Coming to analysis much of the reports express either a sterile culture report and many irrelevant microbes are reported from many uncontrolled laboratories, today we see few of the results reporting Moraxella, Pneumococcus, Diphtheroids may be mistaken to be Diphtheria bacillus, however we should do a special stain at least a Albert's stain and culturing the swabs on selective media for Diphtheria, the minimal expectations in throat swab culture from a pediatrician in routine practice is Group A Streptococcal infection as when present with raised ASO levels, and ill-defined arthritis suspected to be Rheumatic fever, However in many developing countries look out about Diphtheria Infection involving throat presenting with pseudo membrane, or fever with toxicity and tachycardia For example, the presence of group A streptococcus bacteria (Streptococcus pyogenes) in throat is a key sign that child may have strep throat. Many cases of sore throat are caused by Virus but mistaken to be bacterial,
TECHNIQUE Of Collecting A THROAT SWAB
The child undergoing the specimen collection for throat culture is asked to tilt his or her head back and open his or her mouth. However, in infants the mother or care taker to be instructed, The health professional will press the tongue down with a tongue depressor and examine the mouth and throat. A clean swab will be rubbed over the back of the throat, around the tonsils, and over any red areas or sores to collect a sample.
Using a sterile cotton swab, touch the infected area with the swab with several strokes to collect any pathogenic or bacteria for a microbiologist to analyze.
Be careful not to touch the tongue, uvula, or lips due to possible contamination.
This should not be a painful procedure but expect your patient to gag since you will touch the back of her throat. At least few people working in the department to be trained
Prepare the swab for transportation to the laboratory for analysis. Always label the sample with patient name, date of birth, and patient ID and not forgetting the clinical details, and possible Antibiotic administration,
ALTERNATIVE APPROACHES -The sample may also be collected using a throat washout. For this test, the patient will gargle a small amount of salt water and then spit the fluid into a clean cup. This method gives a larger sample than a throat swab and may make the culture more reliable. However, it is not possible in infants and non-cooperative groups
CULTURING METHODS and RESULTS - The most portion of a specimen was identified, inoculated onto agar plates by swab and streaked for isolation of colonies. Media inoculated were 5% sheep blood agar, chocolate agar, MacConkey agar, mannitol-salt agar, all from plates were incubated at 35 degrees centigrade for a minimum of 72 hours, and observed for growth of pathogens specified by the SOP available in the laboratory , including Staphylococcus aureus, beta-hemolytic streptococci, Streptococcus pneumonia, Streptococcus milleri group, Haemophilus influenza, Moraxella catarrhalis, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Achromobacter species, Acinetobacter species, Burkholderia species and yeast
It is essential to pick only CLINICALLY essential to be picked for identification and reported as Group A streptococcus. This bacterium can cause strep throat, scarlet fever, and rheumatic fever. A throat culture is more accurate than the rapid strep test. The rapid strep test can give false-negative results even when strep bacteria are present. When the results of a rapid strep test are negative, many doctors recommend doing a throat culture to make sure that strep throat is not present.
Candida albicans. This fungus causes thrush an infection of the mouth and tongue and sometimes of the throat. Bottle fed infants will have much colonization of Candida, the matters left to the pediatrician’s discrimination to treat or not to treat
Neisseria meningitis. This bacterium can cause meningitis. Can be present as colonizer of the throat in times of Epidemics with N meningitides
Obtaining a “standard” culture may lead to identification of a organism, but may be subject to differences in competitive growth patterns in vitro versus in vivo.
NOTE - THROAT SWAB IS MOST ERROR PRONE AT COLLECTION AND REPORTING THE CLINICALLY RELEVANT RESULTS
I wish the new generation of Microbiologists to read 13th edition of Macy Diagnostic Microbiology for optimal reporting on Syndrome based approaches
Formulated by Dr.T.V.Rao MD for Online resources on Improving health care in Developing countries ‘

MICROBIAL SURVEILLANCE IN HEALTH CARE - CHANGING TRENDS WITH EMERGING SUPERBUGS -Infection continues to be a great threat, less perceived even by the Medical personal, even the developed countries estimate many die and become morbid as consequences of infections, the world needs better approaches to control the infections, In addition to improving safety, the approach could significantly improve productivity and reduce health care costs, Technologies advanced, highly competent doctors and nurses care than in the past however Today’s ICU is likely less safe and productive than it was 30 years ago. It is packed with more devices and alarms, and none communicate in scientific day, False alarm rates are extremely high in critical care, Because the number of changes that may benefit the health care system is vast, strategies that focus scarce resources on the promotion of changes with the largest positive impact are essential. The surveillance of health care areas without understanding the implications is much harmful than no surveillance, today internet has become source of information and misinformation too, many Infection control group think /believe in aggressive surveillance, forgetting how much it costs in surveillance culture media swabs and human man power and creating and collecting documents is end of the matters, ultimately nothing will change , Because the number of changes that may benefit the health care system is vast, strategies that focus scarce resources on the promotion of changes with the largest positive impact are essential. Getting back to literature well perceived and peer reviewed, there is no better action like human behavior in health care areas and HAND HYGIENE. Today most important matter in critical care areas is CARING TO PREVENT THE INFECTIONS WITH SUPERBUGS AS The world faces the grave outcomes with Carbapenem-resistant Enterobacteriaceae (CRE) major isolates being Klebsiella species (KRE), MRSA VRE Prevention of nosocomial transmission of KPC has surfaced as an emerging priority. Infections caused by KPC-producing bacteria have resulted in substantial morbidity and mortality because of limited treatment options, and they present significant therapeutic and infection control challenges in health care settings.
As matters stand majority of the Hospitals follow their own dictum every information literature formulated with authors experience, making surveillance REPORTS remain to hospital records and Microbiologists should at least audit the results, to educate on infection trends, PREVAILING TRENDS ON MDR strains and SUPERBUGS in the organization we work, and implications and growing affluence and corporate culture we are spending much on unsafe chemicals rather than investing safe hospital practices, and surveillance is a necessity without follow up or action plans costs huge resources, It is happening that there are few departments who collect the Microbiology surveillance reports, even of critical care areas and Operation theaters ,
THE WORLD IS CHANGING THE PATIENTS AWARENESS IS INCREASING TODAY MANY WISHES TO BE TREATED AT BIO HAZARD SAFE HOSPITALS
References and to learn more at Advances in the Prevention and Control of HAIs Prepared by IMPAQ International, LLC Columbia, MD AHRQ Publication No. 14-0003June 2014 Dr.T.V.Rao MD @ Hospital surveillance matters
Dr.T.V.Rao MD

NEWER METHODS IN DIAGNOSIS OF LYMPH NODE TUBERCULOSIS - UTILITY OF Xpert MTB/RIF 
Dr.T.V.Rao MD 
A topic for Post graduates in Microbiology, Pathology and Medicine Lymph nodes are one of the preferred sites for Infection with tuberculosis many surgeons expressed at least 1 or 2 patients present with lymphadenopathy ( majority Cervical regions ) Not to b forget the tuberculosis continues to be most important cause of cervical lymph nodes enlargement , and it is a dictum the surgeons wish to investigate for tuberculosis, The traditional methods of FNAC for cytology and biopsy of lymph nodes for detection of AF,B most pathologists express the suggestion on histopathological examinations, For histology/cytology in case of “Probable TB”, a specimen was positive if the presence of caseation necrosis and epithelioid granulomas was reported. stood the test of time since the onset of AIDS many pathology departments are testing for identification of Acid fast bacilli , the microbiology departments do get for Microscopy culturing, the procedure is undermined by many technical difficulties and lack of dedicated staff, and lacking proper decontamination procedures made many cultures being contaminated with careless processing lacking supervising by Medical Microbiologists, and we have lost the a very valuable specimens, and frequent reporting contamination by Microbiologists many clinicians stop sending the specimen in Microbiology departments, I have to say my frank opinion in a service of 3 decades I have seen 2 to 3 technicians mind their work sincerity and decontamination was the greatest step and neutralization of decontaminating agents was to bring down the ph. If taken care results are excellent, and the growth was demonstrable on LJ medium rapid growers and atypical bacteria are still difficult to identify by Biochemical methods are difficult and kills the valuable time of technical staff Certainly the above said procedures are getting obsolete.
Current trends WHO RECOMMENDATIONS - The WHO has evaluated the matters of the past and traditional methods and made the new protocols
WHO has issued policy recommendations for the use of Xpert MTB/RIF in the diagnosis of extra pulmonary TB and rifampicin resistance detection
• Xpert MTB/RIF should be used in preference to conventional microscopy and culture as the initial diagnostic test in testing cerebrospinal fluid specimens from patients presumed to have TB meningitis (strong recommendation given the urgency of rapid diagnosis, very low quality of evidence);
• Xpert MTB/RIF may be used as a replacement test for usual practice (including conventional microscopy, culture, and/or histopathology) for testing of specific on-respiratory specimens (lymph nodes and other tissues) from patients presumed to have extra pulmonary TB (conditional recommendation, very low quality of evidence).
The World Health Organization (WHO) has endorsed the Xpert MTB/RIF assay as a replacement for sputum smear microscopy. For the diagnosis of patients presumed to have extra pulmonary TB, Xpert MTB/RIF may be used as a replacement test for usual practice (including conventional microscopy, culture, and/or histology) for testing of specific non-respiratory specimens (lymph nodes and other tissues)
This multi functional diagnostic platform is an automated, closed system that performs real-time PCR and can be used by operators with minimal technical expertise, enabling for the diagnosis of TB and simultaneous assessment of RIF resistance to be completed within 2 h
Preparation of Lymph nodes and other tissues (for Xpert MTB/RIF only) is propriety needs the dedicated man power to handle the matter and in biosafe environments if is advisable to send the specimen to the dedicated laboratories with committed manpower and biosafety consideration.
It truly helps the pathologists, microbiologists and physicians as the possibility of tuberculosis is ruled out and can consider the other possibilities for lymphadenopathy , not forgetting malignancies
yet the clinical acumen of physicians remains a necessity for the wise use of any new diagnostic test. Careful application of these new diagnostic tools should improve clinicians' ability to deliver timely, cost-effective care to patients with suspected EPT throughout the world, an approach that future studies should systematically evaluate.
Caution - These recommendations do not apply to stool, urine or blood, given the lack of data on the utility of Xpert MTB/RIF on these specimens
NOTE- Unresolved issues continue with diagnosis of Atypical mycobacterium many reference laboratories still use the traditional methods supported with.use of Xpert MTB/RIF
Reference and Adopted Form Standard Operating Procedure (SOP)Specimen processing of CSF, lymph nodes and other tissues for Xpert MTB/RIF and WHO Resources
T V Rao MD Freelance Reporter on Infectious diseases formulated online teaching portals on Infectious diseases

Limitation of Diagnostic Microbiology Departments What Clinicians Should Know?
Dr.T.V.Rao MD
Majority of the Diagnostic Microbiology laboratories are utilized for Diagnosis of Bacterial, Fungal and Virus Infections, which have rapid solutions if promptly treated. The word Infection still confuses many Clinicians and Microbiologists, and they send the specimens to laboratories for immediate solutions. The malady of Microbiology starts with few qualified nurses to collect specimens, every specimen makes the difference in bacterial flora and contamination continues to hamper the quality of services. Blood collection for blood cultures remain the grey area and major loss of specimen value. The doctors and nurses fail to give proper instructions to the patient. I am certain very few laboratories get an ideal sample, rejecting the sample creates conflict between a clinician and laboratory personal. Everyone at the end of the day accepts all the specimens and processed as we practice a path of least resistance. A microorganism is judged as sensitive or resistant according to the diameter of the zone of inhibition of from purified isolate from cultural growth, which is then correlated statistically with the minimal inhibitory concentration (MIC). The degree of correlation depends on both the antibiotic and the species tested; between 71% and 90% of the results of disc diffusion were consistent with the Minimum inhibitory concentration, which is not done routinely in majority of the laboratories as at it costlier and processing of specimen will increases to more than 10 times. The expected error distribution cannot be reliably predicted by regression analysis. Especially those bacteria which are classified as having intermediate sensitivity in their inhibition zones, based on their MIC values, have, in fact, intermediate sensitivity in less than 50% of the cases. It is also necessary to use methods which take the biological and methodological variations of daily routine into account. In critical cases such as life-threatening infections or apparent failure of the patient to respond to antibiotic therapy, the MICs of selected agents should be determined. The tests are performed under standardized conditions so that the results are reproducible. The test results should be used to guide antibiotic choice. When a microorganism is isolated from a patient, the microbiology laboratory will often perform susceptibility testing. There is often confusion about what these results mean and how it can be used by the clinician to guide the treatment of the patient. The results of antimicrobial susceptibility testing should be combined with clinical information and experience when selecting the most appropriate antibiotic for your patient. We and Many in the Developing world receive the requests without any proper clinical information about the patients, many do not write whether he is on any Antibiotic treatment. I request all the Clinicians to remember the patients specimens are vital samples and not subjects for blind studies. We Microbiologists report as, the "susceptible" category implies that isolates are inhibited by the usually achievable concentrations of antimicrobial agent when the recommended dosage is used for the site of infection.' (CLSI definition) Our reports are based on peer reviewed major studies please do note that this definition says nothing about the chances of clinical success; in fact predicting clinical outcome based on susceptibility testing and the use of drugs shown to be in the susceptible category is very imprecise. This imprecision is due to the effect of host responses, site of infection, toxin production by bacteria that is independent of antimicrobial susceptibility, the presence of bio films as in catheterized patients, drug pharmacodynamics and other factors. The clinicians should note when reported as resistant it means, the "resistant” isolates are not inhibited by the usually achievable concentrations of the agent with normal dosage schedules, and/or that demonstrate zone diameters that fall in the range where specific microbial resistance mechanisms (e.g. beta-lactamases) are likely, and clinical efficacy of the agent against the isolate has not been reliably shown in treatment studies.' (CLSI definition). However, with the exception of urinary bladder infections and some mycobacterial infections, most clinicians avoid the use of a "resistant" category drug to treat infection. Many clinicians demand Zone sizes of sensitivity and resistance to different antibiotics, they wish to choose the antibiotic showing higher size of inhibition for an effective consideration. All clinicians should be familiar, bigger zone do not mean they are choosing the right choice of Antibiotic; ( example if I give a zone of Nitrofurantoin 30mm and Cephalosporin as 23 mm which are we choosing in a serious patient with established infection) They have to think which among many classes of antibiotic suits to his present clinical condition. Many clinicians do believe laboratories giving a Zone sizes are doing a great service however they are doing a great harm to your patient and in fact they are not following the basic principles in Diagnostic Microbiology. Factors affecting the reliability of in vitro testing systems include the limitations in interpreting MIC data, because in vitro test conditions cannot duplicate the host environment. In vitro testing systems do not consider the pharmacokinetics of the antimicrobial agent or the post antibiotic effect, whereby microbial growth is suppressed even when the antibiotic concentration falls below the MIC. Many clinicians expect some positive results from Microbiology reports please do remember humans contain 10 times more normal flora than our cells together in the body If we start testing antibiotic sensitivity for all normal isolates, the wards and hospital will be flooded with resistant strain the future of Hospitals will be in jeopardy. We all should be familiar, majority of the patients coming to a teaching hospitals are treated for several days as output patients by private practitioner, many prescribe without rationalism the antibiotics influenced by commercial interests. Majority have already used several antibiotics including the third generation cephalosporins. We have no existing facilities to neutralize the antibiotic in the blood or in any specimen and economically not feasible to process the sample as in in developed countries. Many pathogens like chlamydia, mycoplasmas and tuberculosis need defined conditions to process and culture as they are harmful to laboratory workers. They can be processed only in upgraded diagnostic and reference laboratories. It is important to understand the limitations of antimicrobial susceptibility testing. It should be recognized that resistance patterns will change and guidelines will be subject to periodic revision. The interpretation of an antimicrobial susceptibility test result on a laboratory report must never be taken in isolation. It is important that all factors are taken into account and that it should be remembered that there is no substitute for sound clinical judgment. The expectation of clinicians from Microbiologists is a mismatch in majority of the Laboratories in developing countries, as we have no Antibiotic policy and few hospitals invest for the changing needs, lack of trained technicians and apathy among the many Microbiologists. Conflicts widens with time between clinicians and microbiologists if proper investment are not done and committed Microbiologists take over the Profession,
CRITICAL CARE NEEDS BEST OF THE SERVICES OF MICROBIOLOGY
tvraomd

Laboratory Automation in Diagnostic Microbiology:
Dr T.V.Rao. MD
Infectious diseases are now the world's biggest killer of children, young and aged, however effective diagnosis and treatment SAVE many in the world. In recent years, conventional methods of culturing for bacterial infections are found to be slow and the physicians lose vital time to take effective decisions, depending only traditional methods, which were more than many decades old, delays in effective decision in treating patients, are now being replaced by automated methods for identification and culturing, of bacterial and fungal pathogens. On average routine diagnostics can take anywhere from 48-72 hours. This delay can result in incorrect empirical antibiotic therapy, prevents early targeted therapy and can promote nosocomial infections and generate Multidrug resistant bacterial pathogens. Why has it taken until only recently for the microbiology laboratory to move towards total laboratory automation? Frankly change is hard and due to the complexity of testing, cost, and the need for the human factors, needing training of work force The historical perspective has been that, automating microbiology was too much of a challenge to undertake. However, times are changing and there is a quiet revolution afoot in microbiology. With progress of time Automation is replacing the many traditional methods owing to reduced time for culture and ease of laboratory work using machines and helping in higher isolation rate than conventional methods. Automation is not new as Automation has steadily spread throughout the clinical chemistry and clinical hematology areas of diagnostic laboratories, clinical microbiology laboratories have not been upgraded in the same pace, as microbiology is too complex to automate. In comparison to chemistry and hematology, microbiology specimens are much more complex and need better understanding as much of human surfaces and mucosal membranes are associated with normal flora. The great challenge still remain which is a true pathogen or just a normal Human flora, The newer developments in automation wish to address the challenges and cut short in turnaround time for prompt decisions for practice of evidence based medicine. WHAT DELAY IN MICROBIOLOGY REPORTS MEAN IN PATIENT CARE ?
Microbiological delays in isolation identification and antibiotic sensitivity testing will lead to empirical over treatment or inappropriate antibiotic use, a true concern to medical profession with emergence of Multi drug resistant bacterial and fungal pathogens, The increase in resistance can lead to increased acuity of patient presentation, which increases the length of stay and costs of health care, and Automation enables workflow optimization, removing unnecessary delays and better utilizing the skills of trained lab professionals ADVANCES IN PATIENT CARE NEED BETTER FASTER MICROBIOLOGY REPORTS - Many clinical specialties invested much in critical and multi specialty care and most complex procedures are done , driven by a variety of factors, we believe that the level and degree of automation in clinical microbiology laboratories are poised for dramatic change the modern laboratories equipped with newer equipment bringing in automation to the advantages of the timely decision making in critical and advanced care of the patients. The key drivers for growth of the clinical microbiology market are availability of automation, outbreaks caused by novel organisms (Swine flu virus, Ebola virus), the growing menace of antimicrobial drug resistance, the need for performing research to understand re-emerging pathogens, and identifying drugs to combat them. These factors have led to increased public-private partnerships and better funding to conduct research to develop kits for specific pathogen
TRENDS OF CHANGE IN DIAGNOSTIC MICROBIOLOGY - However, systems are emerging for the clinical microbiology laboratory with the potential to automate almost all areas of testing, including inoculation of primary culture plates, detection of growth on culture media, identification of microorganisms, susceptibility testing, and extraction and detection of nucleic acids in clinical samples. As a result, the workflow in the microbiology laboratory is changing at a rapid pace and microbiologists have the challenge of selecting the most appropriate, clinically useful, and cost-effective automation for their laboratories.
NEWER AUTOMATION IN MICROBIOLOGY BACTEC blood culture system - Since the mid-1970s there has been many advances in blood culture practices and technology; these advances have been based largely on well-designed controlled clinical evaluations of blood culture systems and media. Thus, a sound scientific basis for the fundamental principles of blood culturing now exists Instrumented blood culture systems. Until recently, the BACTEC instrumented systems were the only products commercially available in the United States; these systems were initially equipped with radiometric instruments and media, followed in the mid-1980s by the non-radiometric instruments and media. Both systems (as well as in the newer BACTEC and BacT/Alert continuous-monitoring devices) are based on the utilization of carbohydrate substrates in the culture media and subsequent production of CO2 by growing microorganisms, for the radiometric system, the instrument detects 14C02 in the bottle head space, and for the non radiometric system, CO2 is detected by infrared spectrophotometry.
MATTERS INFLUENCING THE NEED FOR AUTOMATION IN MICROBIOLOGY
increasing testing volumes
improved health care/access
Ageing population
Emerging diseases / HIV AIDS produced great challenges to Medical profession Many opportunistic emerging and reemerging infections entering the immunosuppressed patients need testing innovations, certainly created necessity for many innovations in rapid, automated and molecular methods
Infection control demands growing challenges resulting from detection and identification of multidrug-resistant microorganisms
The trend toward increasingly shorter lengths of stay for hospital inpatients has led to increased demand for more rapid turnaround times for infectious disease assays thereby improving patient care The(24/7) with microbiology laboratories support is becoming much more common, and automation that can shorten turnaround time is being viewed more favorably, and certainly greater need of the future
AUTOMATION – IN SEPTIC AND LIFE THREATING CONDITONS – it is utmost priority to save many with critical condition as happens in septic condition, blood culturing is the top priority and culturing the specimens of CSF, ventilator associated pneumonia and surgical site infections as every hour of delay account to faster death and higher morbidity and increasing costs in treating with empirical treatment, and necessities the Automation.
NEWER AUTOMATION METHODS -Although continuous-monitoring blood culture systems, automated microbial identification, and automated antimicrobial susceptibility testing systems are widely utilized in microbiology laboratories, microbiology specimen
BACTEC blood culture system supported with VITEK® 2:
VITEK® 2: Healthcare Optimizing Collection to Care
The VITEK® 2 system has everything the healthcare laboratories need for fast, accurate microbial identification, and antibiotic susceptibility testing.
The innovative VITEK® 2 microbial identification system includes an expanded identification database, the most automated platform available, rapid results, improved confidence, with minimal training time.
The VITEK® 2 system next-generation platform provides greater automation while increasing safety and eliminating repetitive manual operations. The rapid response time means results can be provided more quickly than with manual microbial identification techniques.
Total laboratory automation systems currently are available to handle specimens, streak plates, incubate, and digitally image cultures. “That’s one of the great things about microbiology at the moment, THE WORLD OF AUTOMATION IS PROGRESSING WITH
Automated urine analyzers
• Plate streakers
• Blood cultures
• Automated ID
• Automated susceptibility testing
• Automated molecular platforms. Gene Xpert
MALDI-TOF
Recently the availability of new technologies such as identification by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF), the utilization of liquid-based transport devices and laboratory consolidation have triggered the development of automated solutions designed for microbiology. MALDI/TOF spectra are used for the identification of micro-organisms such as bacteria or fungi. A portion of a colony of the microbe in question is placed onto the sample target and overlaid with matrix. The mass spectra generated are analyzed by dedicated software and compared with stored profiles. Species diagnosis by this procedure is much faster, more accurate and cheaper than other procedures based on immunological or biochemical tests. MALDI/TOF is becoming a standard method for species identification in medical microbiological laboratories. The technology has been readily imbibed by microbiologists who have reported usage of MALDI-TOF MS for several purposes like, microbial identification and strain typing, epidemiological studies, detection of biological warfare agents, detection of water- and food-borne pathogens, detection of antibiotic resistance and detection of blood and urinary tract pathogens etc. The first automated modules to be launched on the market were automated specimen processors. The first generations were developed more than 20 years ago, but only third-generation instruments allowing high-throughput and accurate inoculation were successfully introduced into routine diagnostic laboratories. Many working with MALDI-TOF MS experience it has become a valuable tool for a microbiological laboratory, which might potentially replace molecular identification techniques in near future.
SYNDROME BASED APPROACH IN DIAGNOSIS OF INFECTIOUS DISEASES – Till recently our approach to infectious disease with identification of individual microbial infections, as we are aware a patient can get infected in many ways with many unknown pathogens, to fulfill the desired goal multiple testing are needed, needing many resources and much with the help of the technological staff spending many working hours, and yet the results are difficult to analyze which is true of the identification the problem can be solved with newer methods and Film Array® a emerging technology
The Film Array® Blood Culture Identification (BCID) Panel tests for a comprehensive set of 24 gram positive, gram negative and yeast pathogens and 3 antibiotic resistance genes associated with bloodstream infections. The BCID Panel detects and identifies the most common causes of bloodstream infections. Quickly identifying the cause of sepsis may help clinicians more rapidly and appropriately manage septic patient therapy. Rapid identification of bloodstream pathogens may help reduce the time to appropriate antimicrobial therapy and positively impact patient survival. The FilmArray® Respiratory Panel detects 20 viral and bacterial pathogens known to cause respiratory tract infections. Test results are automatically reported in about an hour. The FilmArray® Trend is a cloud based epidemiology network that exports de-identified results from participating sites across the United States. Data displayed here aggregate results from hundreds of thousands of tests and the graphs are updated daily. Known quality control tests are removed prior to display. There are more than 20 sites contributing data to the FilmArray Trend, about half of the sites are in the East, 20% are in the Midwest and West and 10% are in the South. A manuscript describing the FilmArray Trend project is in preparation
BAR CODING THE LABORATORY SPECIMENS - Accurate identification of patients, their specimens and laboratory test results linked to them is essential in all healthcare settings for providing effective, safe, timely, efficient, equitable and patient-centered healthcare Bar coding is effective for reducing patient specimen and laboratory testing identification errors in diverse hospital settings and is recommended as an evidence-based “best practice.” The overall strength of evidence rating is high and the effect size rating is substantial. Unpublished studies made an important contribution comprising almost half of the body of evidence.
TELE BACTERIOLOGY
Telebacteriology is the use of digital imaging and file storage for on-screen reading and decision making. The laboratory has access to a library of digitally recorded images that can be electronically shared between consultants located at different sites; they may also be used as an educational tool. Thus, diagnostic laboratories can create ‘reading rooms,’ which may offer a comfortable working environment for the reading of the digitalized images. However, such an organization requires a separation of the reading and the downstream applications (i.e. subculture, ID, AST), which should be performed by different technicians for optimized laboratory workflows.
MAN, VERSUS MACHINE- Despite many arguments and counter arguments, no machine can replace a human in the microbiology laboratory. A long-standing mantra is that humans are generally considered capable of performing tasks faster than machines and that machines cannot think. The perception that machines cannot exercise the critical decision-making skills required to process microbiology specimens has persisted. Specifically, human observation of organism growth on agar plates is still considered essential by many. While machines are programmable, humans are more flexible. However, with progress of technological advances, we are entering an age of monumental change for clinical microbiology laboratories. While a precise assessment of the full impact of these changes is in its infancy, there is no doubt in our minds that the benefits of automation on laboratory efficiency and indirectly on clinical care will be profound, Automation in clinical microbiology will also have some impact on patient care by improving trace ability, reproducible, and quality and certainly reduce the morbidity and mortality, Finally, while quality of the diagnostic results was mainly based on the experience and expertise of the microbiology staff in the past, in the course of automation it will much more depend on the method or apparatus used, It is certain that next generation of Doctors dependent on Automation as everybody needs faster delivery of laboratory results helping the evidence based Medicine a true reality
References –
1 Automation in Clinical Microbiology Paul P. Bourbeaua and Nathan A. Ledeboerb, J. Clin. Microbiol. June 2013 vol. 51 no. 6 1658-1665
2 Automation and the Future of Microbiology Laboratories Labs Weigh Upfront Investment Against Faster Throughput Author: Julie Kirkwood // Date: MAR.1.2017 // Source: Clinical Laboratory News AACC
3 Laboratory automations in clinical bacteriology: what system to choose? Croxatto A1, Prod'hom G1, Faverjon F2, Rochais Y3, Greub G4. Clin Microbiol Infect. 2016 Mar;22(3):217-35
4 Automation in the Clinical Microbiology Laboratory Carey-Ann D. Burnham, W. Michael Dunne, Gilbert Greub, Susan M. Novak, Robin Patel Published November 2013 CLINICAL CHEMISTRY
5 Seng, P.; Drancourt, M.; Gouriet, F.; La Scola, B.; Fournier, P. E.; Rolain, J. M.; Raoult, D. (2009). "Ongoing revolution in bacteriology: routine identification of bacteria by matrix-assisted laser desorption ionization time-of-flight mass spectrometry". Clinical Infectious Diseases. 49 (4): 552–3. PMID 19583519
Dr.T.V.Rao MD
Email; doctortvrao@gmail.com
Formulated for web resources in Infectious diseases

EMPOWERING NURSING PROFESSIONALS IN ICU CARE
INFECTION MATTERS MOST
Dr.T.V.Rao MD Intensive care units are just not another area to care patients, but certainly everybody admitted are certainly suffering with an ailment of organ involvement and much of the seriously injured are put in intensive care units, the great and continuous visitor to these patients are microbes around the bed, environment the patient lodged, and on hands of those who care for them, however the nursing staff continue to be great care taker, the western world and developed countries have recognized nurses are champions of infection control and certainly recognized the nursing staff as most important persons to care the best to save many lives, however the role of Nursing is not well recognized in many regions of the developing countries and suffers higher number of patients die and morbid for longer times, The infection control field now has its own three-word maxim: vigilance, vigilance, vigilance it just means how much we are vigilant to implement, watch and take better decisions and follow basic principles of HAND WASHING
HOW THE PATIENTS DIFFER FROM OTHER PATIENTS IN HOSPITALS
And ICU patients, more than the general population of patients , may already be compromised by several elements:
Disease processes
Trauma
Interruption of normal defense mechanisms (by mechanical ventilation, etc.)
Malnutrition due to the inability to eat and needs the help to be fed.
The inability to ambulate and lesser mobility liable for bed sores which unpredictable outcomes
PATENTS IN ICU ARE PREDISPOSED FOR INFECTIONS - the difference between infection control in ICUs vs. the wards is one of degree. "Patients in the ICU are severely ill and often bed-ridden," "They also tend to have many invasive devices such as Foley catheters to measure output, central lines for fluids and monitoring, arterial lines to measure pressures, endotracheal tubes for assisted ventilation, etc., that patients in other parts of the hospital don't have. The presence of an invasive device automatically increases the risk of infection because it provides a ready means of entry by bacteria into a normally clean space CARING MOST CRITICALLY ILL WITH IMMUNE SUPPRESSION
The segment of potentially immune compromised patients. "Oncology is much the same as the ICU setting, except that the patients tend to have fewer invasive devices (they rarely have Foley's; they are rarely intubated unless critically ill; all have central lines of some sort. "However, many oncology patients have altered neutrophil counts, which directly impacts the body's ability to fight off infection. Oncology patients are particularly prone to infection with opportunistic organisms, or organisms that are ubiquitous in the environment but cause problems in severely immuno compromised patients, like Aspergillus, other molds and fungi and certain viruses like cytomegalovirus, herpes virus, etc. This is one reason stem cell/bone marrow transplant units have special ventilation systems (all the rooms are at positive pressure, so the air flows from the room into the hall). This is specifically designed to keep airborne pathogens out of the patient rooms."
Hand washing - ICU patients' severe illnesses and injuries necessitate much more hands-on care than in normal wards, although these patients can be particularly susceptible to infections, hand hygiene guidelines remain the same everywhere there are more situations requiring good hand hygiene on the part of HCWs with either soap/water or alcohol based product. I believe some researchers have found that the busier staff are, the more likely they are to not wash their hands when they should, which again increases the potential for person-to-person transmission." "The use of alcohol-based waterless products can improve adherence with hand hygiene practices due to ease of use and less time required for effective disinfection."
." Next who manages these devices and major matters in control of infections IT IS JUST NON- OTHER THAN OUR NURSING STAFF, THE QUESTIONS REAMIN ARE WE TRAINING THEM TO BE THE REAL EXPERTS IN DEALING THE MATTERS
Ref Infection Control in the ICU: The Final Frontier By Kathy Dix
The CDC has numerous recommendations for preventing hospital-acquired infections. A complete list is available at www.cdc.gov.
Dr.T.V.Rao MD
Can be reached at doctortvrao@hotmail.com
WhatsApp +91828169524

MISSED DIAGNOSIS OF CRYPTOCOCCUS NEOFORMANS – It was a uncommon infection in the past From its humble beginnings as a single case report in 1895 to its worldwide explosion of disease with a million cases per year as the HIV epidemic peaked (Park et al., 2009), Cryptococcus has achieved a major place in clinical mycology. We are all much trained that if on has HIV/AIDS are linked with cryptococcal meningitis, I always wished that all specimens of CSF should along with Gram stain and culturing should never forget to an India ink preparation. The diagnosis of cryptococcosis, after 100 years of experience, is relatively facile with multiple methods and improved diagnostic strategies however it certainly need a qualified microbiologists patience and competence we can do better, as happened a 24 years young person’s CSF ( HIV negative by Rapid dot method ) a CSF specimen was sent to the Microbiology Laboratory with a persistent head ache qualified in post-graduation too do not care much and matters are left to technicians a sterile culture report sent after, for bacteriological work up, as the case of treated as Viral meningitis with antiviral drugs and lower doses of steroid patient becomes top moribund and a MRI was done and Radio logical opinion suggests possible cryptococcal Meningitis ? need Microbiology reviews and I happened to see the slide at emergency hour and happen to observe the CSF flooded with many capsulated with India ink preparation as it is one and only we can do in the critical hour, and patient dies after 3 days after aggressive anti fungal therapy with Ketoconazole , has some legal and litigation into this case, and we are helpless on many matters, and as many specimens are totally not evaluated as it is a dedicated workup and expensive, It is unfortunate still we may be missing many cases of Cryptococcus with lack of laboratory facilities . certainly need better methods as the techniques include direct examination of the fungus in body fluids with India ink examination, histopathology of infected tissue with specific stains to identify capsule (mucicarmine and alcian blue) or presence of melanin (Fontana-Masson), serology from body fluids and culture of fluids and/or tissues, Certainly we miss with India ink preparation the sensitivity is poorer than many other emerging tests as Polysaccharide antigen testing has two other important principles. First, a baseline high titer of polysaccharide antigen in serum or CSF carries prognostic significance, in that a high titer (>1:1024) is associated with a large burden of yeasts and a high viable quantitative yeast count in CSF is a predictor of death during systemic anti fungal therapy (Jarvis et al., 2014)
Not forgetting cryptococcosis is in a state of evolution, from the organism, to the host, to the guidelines for diagnosis and treatment. We know a lot but still not enough! The sugar-coated yeast still sickens and we need better technologies and dedicated diagnostic microbiology to manage it better. As many patients treated assuming as bacterial infection and many die and Cryptococcus are missed as we too primitive in approaches to diagnosis
Not to forget any patient After organ transplantation heavy doses of corticosteroid therapy are potential medications to treat rheumatoid arthritis, or other medications that weaken the immune system. and there are many surprises that without any established predisposing conditions can infected with Cryptococcal infections in any organ of the body
Photo courtesy CDC 1 and 2
Ref Cryptococcosis diagnosis and treatment: What do we know now Author John R. Perfecta Fungal Genetics and Biology Science Direct
Formulated by Dr.T.V.Rao MD

HAZARDOUS CHEMICALS IN THE NURSING CARE – REASONS TO STOP FUMIGATION IN HEALTH CARE ?
Question to Post graduate education in Nursing European union There was much communications and knowledge spread on the Universal precautions to prevent infections from HIV / HBV/ HCV in the past 2 decades after the onset of AIDS pandemic, it paid the good results, There is growing concern on the excessive use of chemical disinfectants in the health care areas can be of risk to human life and Nurses are at greater risk than anyone who continuously present in the health care environments The bad news is that if you work in healthcare, you are exposed to hazardous chemicals, Among the hazardous chemicals still used widely in hospitals are cleaning products, disinfectants, sterilant, and floor care products that contain toxic active ingredients, such as ammonia, chlorine, phosphates, alkylphenol ethoxylates, volatile organic compounds, formaldehyde, phenolic compounds, propellants, and petroleum solvents. In specific areas of the hospital, workers can be exposed to glutaraldehyde, ethylene oxide, formaldehyde, para formaldehyde, methyl methacrylate, Freon, peracetic acid, or waste anesthetic gases. Pesticides, rodenticides, and fungicides are also used in hospitals. Unfortunately, many chemicals which are banned in developed countries are dumped with commercial interests, in developing countries, today much of our hospitals use chemical disinfectants not caring much of cleanliness and hygiene
FORMALDEHYDE - Formaldehyde inactivates microorganisms by alkylating the amino acid and sulfhydryl groups of proteins and ring nitrogen atoms of purine bases.
Occupational Safety and Health Administration OSHA indicated Formaldehyde as potential carcinogen and limits an 8-hour time- weighted average exposure concentration of 0.75ppm. Still many hospitals use the fumigation as a habit without much scientific discussion of hazards It is surprising that many people are unaware of the longstanding scientific evidence on the carcinogenicity of formaldehyde. However, this had been detailed in five National Toxicology Program Reports on Carcinogens from 1981 to 2004. These classified formaldehyde as “reasonably anticipated to be a human carcinogen,” based on limited evidence of carcinogenicity in humans, and sufficient evidence in experimental animals. This evidence was confirmed in a series of reports by the prestigious International Agency for Research on Cancer (IARC). Its 2006 and 2010 reports explicitly warn that formaldehyde is “a known cause of leukemia in experimental animals — and nasal cancer” in humans.“Strong” evidence of the nasal cancer risk was also cited in the May 2010 President’s Cancer Panel report, “Environmental Cancer Risk: What Can We Do Now?” Nevertheless, and despite this explicit evidence, a September 2010 Government Accountability Office report attempted to trivialize the cancer risks of formaldehyde on the alleged grounds that exposure levels are low or “non-detectable.”
Fumigation is obsolete in many developed nations in view of toxic nature of Formalin. Too frequent use and inhalation is hazardous. Several new safe chemicals are emerging but constrains of economy limit the use and several hours of closure of operation theaters can be curtailed as with Fumigation. Aldehydes are potentially carcinogenic and it is therefore recommended that other agents such as hydrogen peroxide, hydrogen peroxide with silver nitrate, peracitic acid and other chemical compounds of formaldehyde should be used in place of the currently prevalent practice of using formaldehyde,
Many developing counties to regulate the hazardous chemicals with mandatory laws and needs more research and documentation of health hazards on the health caring staff. Reference- Unrecognized Dangers of Formaldehyde Samuel S. Epstein Cancer prevention expert, Prof. emeritus at U. of IL School of Public Health, Chicago
Answered by Dr.T V.Rao MD for online resources

TEACHING PROFESSIONALISM AND ETHICS TO MEDICAL STUDENTS- WHAT THE MEDICAL STUDENTS THINK? I happens to be Student of ANDHRA Loyola College Vijayawada in1964 to 1965 for my course in PUC before my Medical Under graduation – and it was Fridays the first lecture was a Moral class, mainly based on Christian teachings, truly the lectures were good but many times we never followed as we are too young to follow the good advises, The great spirit for many was Father Gordon a American his actions and discipline was a great spirit to progress in life, not to forget that Andhra Loyal college has produced most trusted medical profession in society and certainly USA, in the last 5 decades India has grown boundless with the conflicts in morality, ethics and economic matters, Every Medical Teacher carries the mission to make every Medical student a productive individual to make the human suffering reduced and curing the ailment and above all as Doctors hold a position of power and responsibility that demands trust when carrying out professional duties. While doctors are often rated by the public as the ‘most trusted profession’ in the past, no longer today as there is a mismatch between the expectations to live better and cured of the ailments and current advances in Medicine and the faster eroding of human ethics and need for more money, India hugely grown in Medical profession with hundreds of Medical colleges and research Institutes, as medical students they are placed in a somewhat unique position. Unlike many other disciplines of study, they are scrutinized even before entry to university through extensive entrance tests, as NEET Many academic ethical surveys prove many students feel many teachers advise more on discipline than they follow, and they are compelled to follow whatever they think as a dictum, we as students know what our teachers are up in life, we see many teachers hardly do anything both in teaching and publishing fake papers attaining fake PhD degrees or even MD or MS occupying higher chairs to improve their own careers,
WE LIVE IN CHANGING TIMES - As many students say teachers too are confused with conflicts and selfish interests individual most untrusty control us, However, many MERITORIOUS say we learned professionalism from very good of our teacher’s BEHAVIOR TO US AND ENCOURAGING TO THE LEAST PERFORMING STUDENTS, it just means honesty and integrity are core values of professionalism that we must all embody Many students expressed because of demand and supply many teachers and doctors, living with immorality than by professionalism so much rot in the system and express Teachers too need moral classes as happening in Developed countries MANY STUDENTS OPPOSE THE MORAL AND ETHICAL CLASSES AND THEY WISH TO HAVE COMPETENT AND MORAL BEHAVIOR IN TEACHERS?
Dr.T.V.Rao MD @ What students think on Moral classes in medical education

MICROBIOLOGICAL DIAGNOSIS OF URINARY CATHETER ASSOCIATED INFECTIONS- A topic of growing importance to both treating physicians and microbiologists, as we all know a catheter is a foreign substance can lead to changing dynamics of urinary bladder and urethra, A specimen for urine culture should be obtained before initiation of antibiotic therapy, because of the wide spectrum of potential infecting organisms and the increased likelihood of antimicrobial resistance is priority that the treating physician should write in requests that the reasons for cauterization and how long the catheter in place, and blind processing of the urine and reporting is counterproductive, as we teach our students as the signs and symptoms are different from a non-catheterized patients, Symptoms of catheter-related urinary tract infection (UTI) generally are nonspecific; most patients present with fever and leukocytes. Significant pyuria is generally represented by more than 50 white blood cells (WBCs) per high-power field (HPF). Colony counts on a urine culture range from 100-10,000/mL. If we read the culture plate from these patients much to our surprise the growth is poly microbial flora certainly we will miss many individual bacteria if we compromise inoculating many specimens on a single plate as many have resource crunch not to forget a full plate is an optimal area to identify the isolates with clarity, The 2009 Infectious Diseases Society of America (IDSA) guidelines define catheter-related UTI in patients whose urinary (urethral, supra pubic, or condom) catheter has been removed within the previous 48 hours by the presence of symptoms or signs compatible with UTI with no other identified source of infection along with 1000 or more colony-forming units (CFU)/mL of 1 or more bacterial species. Repeated poly microbial isolation should warrant for aseptic collection of the urine by trained paramedical staff this is true problem many do not care to send a specimen worth processing leading to prescription of antibiotic which are not warranted, and we will be treating all contamination as true infection
NEED FOR REPEATED CULTURING - If cauterization can be discontinued, the culture can be obtained in a voided midstream urine specimen A better understanding needed. If an indwelling catheter has been in place for longer than 2 weeks at the onset of the UTI and is still indicated, as happening with paralytic patients who have no control and many surgical interventions it should be replaced, and the urine culture should be obtained from the freshly placed catheter.
CAUTIs are one of the most common hospital-related infections. Therefore, many healthcare organizations place great emphasis on prevention. Catheter care in prevention of Hospital associated catheter infections
Healthcare providers clean their hands by washing them with soap and water or using an alcohol-based hand rub before and after touching catheter.
If you do not see your providers clean their hands, please ask them to do so.
NOT TO FORGET DIAGNOSING AND TREATING CATHETER ASSOCIATED INFECTIONS A GREAT CHALLENGE IN SPITE MANY ADVANCES IN PATIENT CARE
Ref Catheter-Related Urinary Tract Infection (UTI) Updated: Sep 08, 2017 Author: John L Brusch, MD, FACP;1 Chief Editor: Michael Stuart Bronze, MD
2 FAQs (frequently asked questions) “Catheter-Associated Urinary Tract Infection” IDSA AND CDC
Formulated by Dr.T.V.Rao MD for Infectious disease resource on worldwide web

TUBERCULIN SKIN TESTING IN HEALTH CARE WORKERS
Dr.T.V.Rao MD It was interesting to listen to Dr Chug MD one of the living legend in Microbiology on tuberculosis at Care Hospital Hyderabad, his work proves that the Health care workers at least a few of them succumb to tuberculosis and even the incidence rate of tuberculosis is higher in family members, Yet we have not mandatory recommendation how we care our Health care professionals, with progress of time many Doctors practicing in clinical care too get infected, however much under reported to health records fearing losing the confidence of the public and patients
UTILITY OF TUBERCILIN SKIN TESTING - We have certainly underutilized to Skin testing for tuberculosis at our Hospitals. Skin testing in Tuberculosis is one of the oldest testing method to evaluated for the infection with tuberculosis A tuberculin skin test (also called a Mantoux tuberculin test) is done to see if one is being exposed to tuberculosis (TB). The TB antigens used in a tuberculin skin test are called purified protein derivative (PPD). A measured amount of PPD (5 units to 10 units) and is injected with tuberculin syringe under the epidermal layer of skin on your forearm. Periodic testing of health care workers is recommended as part of a TB Infection Control Plan, and may be required by state regulations. and hospital policies This is a good test for finding a TB infection. It is often used when symptoms, screening, or testing, such as a chest X-ray, show that a person may have TB. a strong tuberculin test certainly supports the presence of tuberculous bacilli and its reactivity with immune repose
TESTING TO NEEDED AS FOLLOWING PROTOCLS
There are two types of testing for TB in health care workers.
Initial baseline testing upon hire: Two-step testing with a TB skin test
Annual or serial screening: determined by state regulations or risk assessment outcomes.
Baseline Testing: Two-Step Test
Two-step testing with the Mantoux tuberculin skin test (TST) should be used for baseline or initial testing. Some people with latent TB infection have a negative reaction when tested years after being infected. The first TST may stimulate or boost a reaction. Positive reactions to subsequent TSTs could be misinterpreted as a recent infection. And people to be watched for active infection with tuberculosis in future
Step 1
Administer first TST following proper protocol
Review result
Positive — consider TB infected, no second TST needed; evaluate for TB disease.
Negative — a second TST is needed. Retest in 1–3 weeks after first TST result is read.
Document result
Step 2
Administer second TST 1-3 weeks after first test
Review results
Positive — consider TB infected and evaluate for TB disease.
Negative — consider person not infected.
Document result
Improper Tuberculin skin testing -Administer the TB skin test following proper protocol In many hospitals the matter of testing Tuberculin is left to student nurses and untrained staff, never to forget the best results will be possible only with injecting the material as intradermal injection going deeper will lose the validity of test as the material is deposited in the fatty layer, and certainly the test will be negative in actively infected people, Injecting tuberculin is a skill the professionals should practice to perfection
TURNING FROM NEGATIVE TO POSITVE HAS A SUPPORTING VALUE IN DIAGNOSIS IN CASES PULONARY AND ETRA PULMONARY TUBERCULOIS
Review result — a change from a prior negative test result to a positive test result is evidence of recent TB infection
Document the Results in proper fashion
TODAY MANY HOSPITALS ARE ASKING FOR STATUS OF HBV AND HIV WHEN TAKING UP EMPLOYMENT WITH OR WITHOUT REASON
EVALUATION ON TUBERCULOSIS CARRIES MUCH IMPORTANCE AS TB IS TOTALLY CURABLE DISEASE Ref - Testing Health Care Workers Tuberculosis CDC
Formulated by Dr.T.V.Rao. MD for Medical and paramedical professionals in Euro vision to Health

LEARNING IS A GREAT INVESTMENT? When we talk about investing the common man’s idea is investing in wealth, and fortune, however with time you will realize only sustainable investment without much fluctuation is investing in knowledge and learning better things in life, At every stage of our lives as said – by Dan Gilbert, we make decisions that will profoundly influence the lives of the people we’re going to become, then when we become those people, we’re not always thrilled with the decisions we made.” –, never forget our desire to learn to better of the matters and skills never go waste, If I remained as a Graduate I would not have made as I have become a postgraduate, one effective way to trick yourself into stronger learning habits, and better exercise habits, is to think of you now and your future self as the same person. Everyone has problem non-free from the circumstances, we live with people the aim is only the money and power to survive and many find this the cause of much organizational failures, the world is changing fast with much growing intelligence and artificial intelligence and a simple machine or robot can take over our job, Today the world is too small with internet making us to be heard by many, or even when we have something to tell, or even a good story of our lives, Grow personal and professional networks. Learning provides a comfortable space to meet new people and makes for a great icebreaker, giving you a common topic to talk about. Depending on what learning opportunity you choose to invest in, the potential to establish both friendship and professional connections are abundant, You don’t have to attend a lectures, there are great podcasts teaching you best of what you are supposed to teach, or strive for an excellence, to be a better survivor you have to be top on many matters, Are you a Doctor? never mind nurses are best watching how good you are in practical skills are you a teacher the students know well of us, never mind accept the truth of yourself learning is only short cut await you and everyone , people around laugh if you are talking same things what you are doing yesterday The practice of teaching and learning has experienced tremendous growth in terms of methodology and engagement. There are countless ways to acquire the knowledge you seek, it’s simply a matter of which method is the most fun for you.
ONE IS NEVER OLD TO LEARN NEW ?

Dr.T.V.Rao MD

HOW NEET HAS BECOME A REALITY – FACTS BEHIND NEET Times of India ran an article that the market for black money on medical colleges is to the tune of Rs. 12,000 cr. The article further states that ‘Of the 422 medical colleges in India, 224 are private, accounting for 53% of MBBS seats. Many of these colleges are running with little or no facilities, no patients and fake faculty. The going price for an MBBS seat could range from Rs. 1 crore in colleges in Bangalore to Rs 25-35 lakh in some in UP. Seats in MD in radiology and dermatology cost up to Rs 3 crore.’ The article points that the PG seat are been offered at Rs. 3.0 cr., for radiology, ortho and dermatology streams. In fact, of the total value of ‘Seat Sale’ is about Rs. 9000 cr., just from the MBBS stream. Add to those statistics, most of the private colleges with management quota and NRI quota have a seat sale to the extent of 60% of total seats. This is quite alarming and incomprehensible.” “The medical education sector is sickening and everyone is hurt” or “The noble profession and its education is tarnished “The important point that has come is that NEET is applicable to private educational institutes”. This is the biggest Game Changers. This has such far reaching ramifications, that it will change the way Medical Institutions operate in this country; as explained in the ensuing section. The blame must be shared by the medical fraternity as well, which is mainly behind promoting the practice of paid seats in private colleges. After all they need to secure the investments made by them in their clinics and nursing homes by pushing their kids into medicine even if they are not competent, NEET will curb the malpractices and corruption in medical seat allocation. Medical institution which should be quality based has become business market with huge capitation fees and rampant corruption. It is generally owned and managed by politicians and businessmen without any medical background. Government should also try to make this course low cost as much possible. However many senior professionals with stature think it will make many colleges suffer the impact with financial crisis, and certainly affect the newly started colleges as many old one made their own buck and established, Some colleges will go bankrupt WE FIND MANY SELLERS AND FEW TO BUY AS NO BODY WILL BUY A SICK HORSE AND will certainly have great impact on students’ parents, and society, It was suggested medical colleges should take some senior professionals skilled clinicians who are retired with academic mind to help the Institutes facing financial crunch, However there is great support for NEET as many middle class families with intention of making their children doctors it is possible now with NEET
Far reaching problem lies with shortage of senior dedicated teachers and the on going problem of Ghost teachers, and teachers fit only for MCI inspections spoiling the work culture in the Medical colleges
A great suggestion was rich parents can donate for development of the Institute ?
The matter of Medical education under the control of Judiciary and Supreme court and all judgments from lower courts are subject of overruling by higher courts
Resource TOI
tvraomd

LABORATORY ERRORS - IMPLICATIONS ON CLINICAL CARE
Dr.T.V.Rao MD
Post graduate topic for discussion in Laboratory Medicine and Critical Care Medicine in Afro Asian web resources
DEFINING LABORATORY ERROR – as Dictionary by FARLEX
Any error made by the personnel in a clinical laboratory in performing a test, interpreting data, or reporting or recording the results. Laboratory error must always be considered a possible explanation for findings that are at variance with the composite clinical condition of the patient or are widely divergent from previous laboratory tests. The general procedure is to repeat the test when an abnormal result is found.
Although tens of thousands of people around the world suffer harm, many times disabling, and even die because of unsafe acts in health care, in the past the Clinicians were taking much responsibility and matters of omission and commission was lying with treating physicians we as laboratory personal had little infrastructure and resources to do many investigations, with progress of clinical care, the treating physicians must dependent on laboratory investigations taking critical decisions. Since many decades western medicine identified that laboratories are source of scientific information and made a great impact on the developed countries, Laboratory medicine is a substantial part of health care systems. It is essential for many decision-making tasks by doctors, nurses and other health professionals, and is related to prevention, diagnosis, treatment, management of illnesses and patients' rehabilitation. WHAT IS A LABORATORY ERROR IN CLINICAL CARE - Error is the difference between the true result (or accepted true result) and the measured result? If the error in an analysis is large, serious consequences may result. A patient may undergo expensive and even dangerous medical treatment based on an incorrect laboratory result may implement costly and incorrect modifications to process because of an analytical error. To initiate the Mattress, the science is a progressing a true reality, it just means the matters are never perfect and so also the laboratory which are based on scientific fundamentals, however we do so many investigations in the laboratories some are good, many imprecise and few certainly wrong to the circumstances we work,
Matter need a better understanding in every laboratory
wrong sample collected
sample mislabeled or unlabeled
sample stored inappropriately before testing
sample transported inappropriately
reagents or test kits damaged by improper storage-examination errors What matters to many in the health care, As Laboratory data are extensively used in medical practice; consequently, laboratory errors have a tremendous impact on patient safety. Therefore, programs designed to identify and reduce laboratory errors, as well as, setting specific strategies are required to minimize these errors and improve patient safety,
WHAT BEST WE CAN DO - The laboratory should:
employ an active process for occurrence management and take a positive approach.
try to detect problems early, and take immediate remedial and corrective action.
seek opportunities to identify potential error, thus preventing its occurrence.
keep good records of all problems, investigations, and actions taken.
I we do not focus on errors many litigation and career repercussions happens
Laboratory error is an occurrence or an event that has a negative impact on Laboratory, which includes personnel, product, equipment, or the environment. And interpersonal litigation in the Hospitals we work
UNSUPERVISED LABORATORIES ARE TRUE THREAT IN PATIENT CARE
References – 1Changing trends in laboratory medicine and human care training manual in health care
2 Errors in clinical laboratories or errors in laboratory medicine? Plebani M Clin Chem Lab Med. 2006; Pub Med
Dr.T.V.Rao. MD

Gonorrhea has affected humans for centuries and remains common sexually transmitted Infection Worldwide, an estimated 106.1 million cases occur annually, Gonorrhea disproportionately affects racial, ethnic, and sexual minorities. Untreated gonococcal infection can lead to pelvic inflammatory disease, ectopic pregnancy, and infertility in women and can facilitate transmission of human immunodeficiency virus. Childhood blindness still affects infants born to mothers infected with gonorrhea, particularly in resource-limited countries. In India like many in underdeveloped countries infected with sexually transmitted infection, primary consult the less qualified and many illiterate people approach to quacks, who experiment with least effective and sub optimal doses of the best options and making the bacteria venerable to drug resistance. We have few laboratories which try culturing for Gonorrheal infections, to any one’s surprise few patients attend a teaching hospital before exhausting the available new generation of antibiotics, many who chosen the topic of Gonorrhea find very difficult to isolate on the available media leave the topic as the growth of the organism is certainly difficult and a matter of happening Gonorrhea has progressively developed resistance to the antibiotic drugs prescribed to treat it. The emergence of cephalosporin-resistant gonorrhea would significantly complicate our ability to treat gonorrhea successfully, since we have few antibiotic options left that are simple, well-studied, and highly effective. It is critical to continuously monitor antibiotic resistance in Neisseria gonorrhea and encourage research and development of new treatment regimens. Cephalosporins continue to be newer options in treating emerging drug resistant strain in Gonorrhea. Trends in Declining Effectiveness cephalosporins, considering the proportion of samples with elevated “minimum inhibitory concentrations” (MICs) of Cefixime and ceftriaxone, recent analyses indicate that higher concentrations of cephalosporins are increasingly needed to stop the bacteria’s growth in laboratory tests. An MIC is the lowest concentration of antibiotics needed to stop the bacteria’s growth in the laboratory. The most significant change in the new guidelines is that CDC no longer recommends Cefixime as an effective oral treatment for gonorrhea, leaving only inject able ceftriaxone to be used in combination with one of two oral antibiotics, either azithromycin or doxycycline. Ceftriaxone is more potent against gonorrhea than Cefixime, and when paired with the additional oral antibiotic, might slow the emergence of drug resistance by ensuring that gonococcal infections are quickly cured and not allowed to spread. The newer research proves that that we are in need of regimes if the trends raise with resistance to ceftriaxone. Two new antibiotic regimens using existing drugs – inject able gentamicin in combination with oral azithromycin and oral Gemifloxacin in combination with oral azithromycin – successfully treated gonorrhea infections in a clinical trial. The trial was conducted by the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH). The study was conducted to identify new treatment options in the face of growing antibiotic resistance. CDC still recommends only one first-line treatment regimen: inject able ceftriaxone, in combination with one of two other oral antibiotics, either azithromycin or doxycycline. This regimen remains highly effective in treating gonorrhea and causes limited side effects. However, providers may consider using the regimens studied in this trial as alternative options when ceftriaxone cannot be used, such as in the case of a severe allergy. CDC is taking the findings of this trial into consideration for inclusion in future treatment guidelines. In the developing countries many are venerable to Gonorrhoea in view of lack of sex education and social support related to STD, it remains critical for people to take steps to protect themselves from gonorrhea infection. The surest way to prevent infection is not having sex. For those who are sexually active, consistent and correct condom use and limiting the number of sex partners can help reduce the risk of infection. (As per CDC guidelines)
MOLECULAR METHODS IN DIAGNOSIS - NAH, nucleic acid amplification test (NAAT) and multiplex PCR. Results are available in <24 above="" addition="" also="" and="" be="" br="" can="" endocervical="" even="" females.="" for="" h.="" having="" heterosexual="" in="" include="" males="" may="" men="" msm="" naat.="" or="" oropharyngeal="" rectal="" sex="" specimens="" swab="" swabs="" the="" to="" urethral="" urine="" used.="" used="" vaginal="" with="">The sensitivity of NAAT (95%), is superior to culture, especially for rectal and pharyngeal swabs, but specificity is less. Only NAAT for urethral swab is presently Food and Drug Administration (FDA), USA approved. And culture is the only method for antimicrobial susceptibility with many challenges in the resource poor laboratories.
WHAT WHO RECOMMENDS - Development of new drugs
The R&D pipeline for gonorrhoea is relatively empty, with only 3 new candidate drugs in various stages of clinical development: solithromycin, for which a phase III trial has recently been completed; zoliflodacin, which has completed a phase II trial; and gepotidacin, which has also completed a phase II trial.
The development of new antibiotics is not very attractive for commercial pharmaceutical companies. Treatments are taken only for short periods of time (unlike medicines for chronic diseases) and they become less effective as resistance develops, meaning that the supply of new drugs constantly needs to be replenished.
References -! Antibiotic-resistant gonorrhoea on the rise, new drugs needed 7 JULY 2017 | GENEVA
2- Molecular methods in the laboratory diagnosis of sexually transmitted infections Sumathi Muralidhar Indian J Sex Transm Dis. 2015 Jan-Jun; 36(1):
3 Current resources from CDC on Sexually transmitted infections
Updated Article by Dr.T.V.Rao MD

MICROBIOLOGICAL DIAGNOSIS OF CATHETER ASSOCIATED INFECTIONS-
A question to postgraduates in Pathology /Laboratory medicine in European union We receive few intravascular catheters for evaluation of infections from many critical care patients, every catheter we insert has some risk of systemic infection with involvement of blood stream with all percutaneous catheters are associated with risk of (skin) exit site infection and subsequent migration of that infection along the extraluminal catheter surface to the bloodstream. . Bacterial or fungal contamination of a catheter hub can also lead to intraluminal infection of the catheter and extension of that infection to the bloodstream.
MICROBIOLOGY MATTERS - The leading causes of CRBSI in descending order of frequency are staphylococci (both Staphylococcus aureus and the coagulase-negative staphylococci), enterococci, aerobic Gram-negative bacilli and yeast. When aerobic Gram-negative bacilli are assessed as a group, their frequency follows that of the staphylococci
Quantitative culture of the distal (5 cm) tip of central venous and arterial catheters should be performed when they are removed for suspected infection. The tip of the introducer should be sent for culture when a pulmonary artery line is removed. For patients with short-term central venous catheters without severe sepsis or shock, in whom the index of suspicion for catheter-related infection is moderate or less, the catheter may be exchanged over a guide wire for a new catheter allowing culture of the tip of the removed catheter without immediately sacrificing the site of insertion (The clinicians or phlebotomist s would do the matters with asepsis )
ESATBLISHED AND REVIWED STANDARS - positive culture with the same microorganism of either:
quantitative CVC culture ≥ 103 CFU/ml or semi-quantitative CVC culture > 15 CFU; quantitative blood culture ratio CVC blood sample/peripheral blood sample > ;differential delay of positivity of blood cultures: CVC blood sample culture positive two hours or more before peripheral blood culture (blood samples drawn at the same time);positive culture with the same microorganism from pus from insertion site. NEED FOR BLOOD CULTRUING At least 2 blood cultures should be obtained when catheter infection is suspected. When the tip of a catheter is sent for culture, the 2 blood cultures may be obtained by peripheral venipuncture. Alternatively, or when culture of the tip of the catheter is not performed, blood culture should be obtained by peripheral venipuncture and at least blood culture should be obtained from a lumen of the catheter. A recent study has found that for multilumen catheters, drawing multiple catheter blood cultures, one from each lumen of the catheter suspected of infection, in addition to blood culture obtained by peripheral venipuncture will enhance detection of catheter infection.
Currently, most hospital microbiology laboratories use automated systems for detecting growth in incubating blood cultures
A diagnosis of CRBSI is achieved by any of the following 3 criteria:
same organism recovered from percutaneous blood culture and from quantitative (>15 colony-forming units) culture of the catheter tip; same organism recovered from a percutaneous and a catheter lumen blood culture, with growth detected 2 hours sooner (ie, 2 hours less incubation) in the latter; same organism recovered from a quantitative percutaneous and a catheter lumen blood culture, with 3-fold greater colony count in the latter
Some hospitals report multiple cases of Catheter associated infection when the matters on aseptic precautions are neglect or under performed, the correction needs the understanding of pathophysiology and need proper caring technical and clinical staff WITH DEDICATED HAND WASH AND PROPER GLOVING WITH USE OF EFFECTIVE ANTISEPTIC AGENTS
All the critical care units should develop their own Standard operating procedures on the matters with effective training for all the staff and reviewed CME’s on matters
ARTICLE FOR REOSURCE AND BETTER UNDERSTANING LEARN FROM FULL TEXT
1 Intravascular Catheter-Related Bloodstream Infection Harshal Shah, Neurohospitalist. 2013 Jul; 3(3): 144–151. NCBI
2 Catheter-Related Infection ARTICLES - WIKI
Formulated for European on-line education on infectious diseases
Dr.T.V.Rao MD

MPLEMENTATION OF NEET - EMERGING CHALLENGES - Our Medical education is one of the most complicated system, In the past Government thought they cannot invest much in medical education and allowed many medical dental and nursing colleges, In the last two decades there is abrupt rise of Medical institutions, The government thought all is well as everyone has their own share, the Medical Council of India as a regulatory authority made rules, mended the rules made many rich through MCI inspectors I have seen many act as custodians of law and impossible regulations and made their buck to share with high ups with accepting all the lacunae in the system, The strict regulations made the corruption bigger, many preferred to initiate colleges in rural areas, where there are few people living lead to shortage of beds and turned to be a failed clinical learning, Many colleges have few patients for the University examination, However many private colleges improved and doing fine when the greediness was little and invested much in development of infrastructure and facilities to attract the poor people admitted, who alone allowed the students to examine and learn better of clinical medicine
Many Medical colleges heading to crisis
1 With growing costs it is certainly not possible to pay even the agreed salaries, leave developing infrastructure, the parents demanding least fees even in private medical colleges, it will certainly to lead to closure of some medical colleges recently initiated for profit purpose 
2 Difficult to bring in accountability of the senior teachers, and retired teachers many enjoyed unlimited leave, higher salaries, just coming 2 or 3 day, long weekends and only interested to be the Principals, vice principals and HOD’s it makes them to rule the system as they liked, It is certainly difficult to implement the Biometry many threaten the system, and then how to run the system a great question to many upcoming medical colleges, 
3 With ranking of NEET as criteria for admission a common students attained much rights, to question the system and many administrations and represent the matters to the higher authorities to fight for their rights 
4 Certainly there will much unrest from Nursing, technical, paramedical staff, for higher salaries comparing with few teachers and clinicians enjoying the boot without contributing anything, as we see many senior professors hardly interested to do anything as they are wanted by the Medical council of India as a mandatory requirements,
5 Laboratory medicine is in poor shape, least money is invested as laboratories are no more cheap to run, and buying the machines is too expensive to invest unless it can produce the returns, above all many Microbiology Pathology and Biochemistry professors run the laboratories with many remote controls and power and not even contribute a little, to improve the system most of the time happy to glued to chairs, leaving to technicians, and even the juniors try to imitate the bosses, as everyone has a reason to avoid work as management's never bothered to correct the system except the financial concerns, If you want to run the system with responsibility soon you are opposed by many it is unfortunate many professors think their presence is divine , rest to known to all who work in the system.
6 Power Brokers - Many colleges have a middle men even our teachers act high with the support of the management's loot / break the system and harass the innocent and sincere as the managements cannot handle the administration, With implementation NEET we moved from one extreme to another with lack of much money hitting the system
TIME to WATCH NEET WHAT NEXT ?
TRULY MONEY IS NEED OF THE HOUR WHO PAYS TO RUN THE PRIVATE MEDICAL COLLEGES ?
Dr.T.V.Rao MD