Escherichia coli (E.coli) Think beyond your Laboratory? I wish to express I am one of the fortunate ones in 1980 to get a assistance from ICMR to do my Dissertation work at National Institute of Chorea and Enteric diseases ( ICMR ) at Calcutta, I thesis topic was child hood diarrhea diseases The imagination of Microbiology is entirely different in a research organization and medical college , I had few facilities in Andhra Medical College Vizag the encouragement of My guide Dr B Raja Rao was immense that I should learn a quality Microbiology. There are dedicated laboratories on every aspect of E.coli at NICED Calcutta and little work includes EPEC and Entero adherent E.coli apart from other pathogen which includes common pathogen Shigella apart from Rota virus. Although Escherichia coli can be an innocuous resident of the gastrointestinal tract, it also has the pathogenic capacity to cause significant diarrheal and extra intestinal diseases. Pathogenic variants of E. coli (pathovars or pathotypes) cause much morbidity and mortality worldwide. Consequently, pathogenic E. coli is widely studied in humans, animals, food, and the environment. The most difficult problem to understand E.coli it is a common and prominent commensal and at the same time can turn to be a pathogenic, In most of the routine diagnostic bacteriology laboratories we discard them as commensals as we have no high titre serum to identify the EPEC we isolate in infantile diarrhea cases, While there are many common features that these pathotypes employ to colonize the intestinal mucosa and cause disease, the course, onset, and complications vary significantly. Outbreaks are common in developed and developing countries, and they sometimes have fatal consequences. Many of these pathotypes are a major public health concern as they have low infectious doses and are transmitted through ubiquitous mediums, including food and water. The seriousness of pathogenic E. coli is exemplified by dedicated national and international surveillance programs that monitor and track outbreaks; I had help from Dr.Dey who helped to type the EPEC proved many cases of Infantile diarrheal disease in our laboratory as commensals without resources, at least 15 to 20% proved to be EPEC testing with high titer sera from Burros welcome , The epidemiology of EPEC infection has shifted since these strains were first identified in the 1940s and 1950s. Initially, EPEC was an important cause of infantile diarrhea in the developed world, but over the years it became much more prevalent in developing countries. The prevalence of EPEC infection varies between epidemiological studies based on differences in study populations, age distributions, and methods used for detection and diagnosis In addition, geographic region and socioeconomic class may also contribute to the epidemiology of EPEC-induced diarrheal disease, The diversity of E. coli strains is remarkable, ranging from harmless inhabitants of the gastrointestinal tract to diverse pathogens capable of causing intestinal or extra intestinal diseases. While some clinical outcomes are more severe than others, E. coli still remains a major public health concern. It is clear that pathogenic E. coli continues to evolve, as exemplified by the EAEC and hybrid strain that caused a large outbreak throughout Europe in 2011. This also points to the ease of transmissibility of pathogenic E. coli; the low infectious doses of many of the pathotypes and the potential to disseminate among a variety of sources are extraordinary. Food, water, companion pets, animals, and other people are all potential points of contamination and transmission. I wish many young Microbiologists should think beyond what they are doing, Todays concern is using Antibiotics for trivial and self-limited conditions of diarrheal diseases which have made simple commensal into an aggressive back biter. The true menace continues to be treating aggressively all the E.coli isolated in many privately run and under unscientific Microbiologists , If the younger generation Microbiologists wish to understand kindly read the article as below what E.coli means? I WISH THE YOUNGER OF MICROBIOLOGISTS THINK BEYOND WHAT THEY ARE DOING IN LIMITED CIRCUMSTANCES .
Ref Recent Advances in Understanding Enteric Pathogenic Escherichia coli Matthew A. Croxen etal Clinical Microbiology Reviews
Dr.T.V.Rao MD Professor of Microbiology Freelance writer

INTENSIVE CARE UNITS AND INFECTIONS 
Growing Concern to Health Care Role of Diagnostic Microbiology 
Dr.T.V.Rao MD Every literate knows that the Intensive care units are fraught with threat to life with Infections, Many esquire what are my success to come out, and many esquire what are my chances to survive, Many are not willing to get admitted to ICU as their wish, I was always telling that ICU care and success is great boon to many hospitals for improving the reputation, However the Infections in ICU has a great beginning else were as patients enter from different areas when the matters become critical , While this infection is not introduced into the patient in the intensive care unit—and those infected during surgery do, of course, come into the ICU following the procedure. Once there, they enter the care of the ICU nurses and physician, Of course, more pertinent to the ICU clinician is the central-line associated bloodstream infections, or CLABSIs, which,, cost health care institutions. MICROBES CANNOT BE AVOIDED - Microbes are the oldest inhabitants to universe before the man so we cannot be avoided and we have to live with them and control their propagation and spread in the areas the where the critical patients live, This is a significant healthcare challenge, and so far not much has been offered in the way of guidance for dealing with the issue, Some of the hospital pathogens live both in the humans and in very expensive pieces of medical equipment that are hard to clean, Recently, the superbug CRE (carbapenem-resistant Enterobacteriaceae) has received considerable press coverage in healthcare and mainstream news outlets alike, as occurrences of these antibiotic-resistant bacteria have been found in several hospitals across the world and India, Great ripples are created when NDM was reported from patients treated in India, After linking the CRE outbreak in Chicago to ERCP scopes, the Centers for Disease Control and Prevention issued a warning about the risks of spreading infections among patients who undergo the procedure. The problem, investigators found, is that biological material can collect in the "elevator" mechanisms that control tiny devices that extend from the tip of the duodenoscope, .Most hospitals that do these procedures are not even looking for this problem, or they may not be aware, and that's got to change,
CARBAPENEM RESISTANCE - A GREAT CHALLENGE - The Carbapenem class of antibiotics are the most aggressive and potent treatment available, and are administered as a last resort for infections of this kind. Unfortunately, it has been discovered that Enterobacteriaceae produce Carbapenemase, an enzyme that destroys the Carbapenem molecule, rendering the antibiotic ineffective. The risk of this new ‘superbug’ reaching pandemic proportions, and of rapidly increasing cases of mortality, is significant, so it is no surprise that the issue of CPE remains high on the agenda for infection prevention and control professionals. Unfortunately, the nature and associated costs of antibiotic research and development means that a drug-based solution to CPE is unlikely any time soon, meaning that the best approach to preventing a CPE outbreak is to improve hygiene through more effective decontamination in healthcare settings, which can significantly reduce the chances of the infection spreading.
CHANGING ROLE OF DIAGNOSTIC MICROBIOLOGY We have a greater role to do in surveillance, documenting auditing and forecasting on the matters related to Intensive care units, It is time that all Hospitals maintain a register and document the growing problem with SUPERBUGS
Ref CDC Resources,
Dr.T.V.Rao MD 

GROWING NEED FOR CLINICAL MICROBIOLOGY SERVICES 
Dr.T.V.Rao MD In a Country like India and many developing countries the role of a good clinical Microbiology services are undermined with lack of communication between the seniors , technicians and the clinical services, however the clinical microbiology will certainly play a great role in taking decisions at least in the serious and critically ill patients however no care is taken in the beginning to depended on diagnostic microbiology and people approach the laboratory when it is too late get the effective services, However the antibiotics are free for all nothing changes, In part perhaps because the diagnostic activities of microbiologists are pursued separately, in hospital and commercial labs,
GOOD MICROBIOLOGY STARTS WITH MICROSCOPY AND READING A CULTURE PLATE - Many of my teachers told us that good Microbiology starts with simple observations of Microscopy, it is important to gather as much information as possible from microscopic examinations of Gram stains. an experienced person can often tell a-hemolytic strep from b-hemolytic ones by just looking at them in a smear. A true experience develops when they correlate the Microscopy with growth on culture plate Here, basic microbiology knowledge often enters the picture. Though “reading” the plates may sound simple, it surely is not. Every set of plates presents a different challenge about what to do next with each bacterial colony and it takes considerable experience to get it right.We have to choose among many paths, such as picking a colony for biochemical tests, making a smear for a Gram stain, carrying out antibiotic sensitivity tests, and so on.If one can separate a pathogen from commensals and identify the drug resistance is the best work one can do and even all the postgraduates should be proficient to get a post graduate degree awarded I was curious about how the people in the lab felt about the possible impacts of future changes. All the signs point to continuing technological developments geared toward increasing the speed of diagnosis but likely displacing laboratory personnel in the process. Which however not possible as long we practice a good clinical microbiology as it matters to care the patients in real time service, GROWING NEED FOR CLINICAL MICROBIOLOGY - Today Clinical microbiologists uncover new and important pathogens, perform the role of sentinels to alert of possible upcoming epidemics, provide statistical and clinical information regarding the pathogens currently on the scene, and spur demands on research to create novel diagnostic tools.
There is a growing disappointments in Medical Microbiologists in India due to lack of work culture and in coordination both intra departmental interdepartmental issues I wish to state using Antibiotics without a competent diagnostic services is a blind trail /treatments in an era where is entry of many Super bugs which needs proper identification documentation and sensible Antibiograms,
TIME TO THINK ABOUT CHANGING NEED FOR CLINICAL MICROBIOLOGY
Ref The Excitement of Clinical Microbiology by Elio American society for Microbiology
Dr.T.V.Rao MD

ERRORS IN DIAGNOSIS OF SYPHILIS WITH RAPID PLASMA REAGIN TEST ( RPR )
A post graduate question in Medical Microbiology
Today we almost stopped doing the VDRL test, and the next proposition continues to do with RPR test, if you work with laboratory we get at least 1 in 10 tests may be liable of difference of opinion and error prone , a true problem when we do in Pregnant women who are liable to give false positive results defeating the purpose of doing as lone test to screen for syphilis
Sources of Error
Error can be introduced into test results because of factors such as contamination of rubber bulbs False-positive biological reactions have been reported with cardiolipin type of antigens in the following conditions:
Lupus erythematosus • Rheumatic fever • Vaccinia and viral pneumonia • Pneumococcal pneumonia Pneumococcal pneumonia • Infectious mononucleosis • Infectious hepatitis • Leprosy • Malaria • Rheumatoid arthritis • Pregnancy • Aging individuals
False-negative reactions can result from the following:
Poor technique • Ineffective reagents • Improper rotation A gain, if mechanical rotation is below or above the 95- to 110 –rpm acceptable range, the clumping of the antigen tends to be less intense in procedures with undiluted specimen; thus, some minimal reactions may be missed. In quantitative tests, rotation above 110 rpm tends to produce a decrease in titre, apply approximately one dilution lower.Interpretations to limit errors
A diagnosis of syphilis cannot be made based on a single reactive result without clinical signs and symptoms or history
Testing for Neurosyphilis
The RPR cards should not be used for testing CSF. Little reliance should be placed on cord blood serologic testing testing for syphilis
RPR a useful Prognostic test - It can also be used to check the progress of treatment for active syphilis. After a course of effective antibiotic therapy, your doctor would expect to see the number of antibodies drop, and an RPR test could confirm this.
Today many laboratories are doing both RPR and TPHA tests as routine tests moving away from RPR as lone test with possibilities of Missing the diagnosis with false negatives, and conforming the false positives .

Ref -SOURCES OF ERROR IN SEROLOGIC AND IMMUNOLOGIC LAB from web resources
Dr.T.V.Rao MD

Specimen Management and Rejection criteria in Diagnostic Microbiology - 
Dr.T.V.Rao MD 
A postgraduate question in Medical Microbiology / Accreditation standards in Laboratory Medicine The much of the success of the Microbiology depends on sample collection criteria, the dependability of the test truly depends on How - Why- Who collected matters, a blind processing will be unproductive and compromises the quality of the laboratory, I wish we have few hospitals truly bothers things go on and leads to many conflicts between clinicians and microbiologists, Many times the clinicians insist that Laboratory personnel should collect the specimens, however it is prime responsibility of the Phlebotomist s in blood cultures, and clinical staff who handle the patients in the patient care areas,
WHY WE NEED ACCOUNTABILITY
Rejection criteria are designed to prevent inaccurate data and to ensure the safety of patients and laboratory personnel.
Microbiology samples that do not meet the required sample and test request requirements will be rejected.
Reasons for sample rejection can include the following
Improperly labelled sample
Unlabelled sample
Incomplete information on the sample
Incomplete information on the requisition
Sub-optimal sample
i.e. leaking urine and/or stool containers, insufficient quantity, inappropriate sample for test request
Duplicate microbiology samples received on the same day
i.e. multiple stool, sputa samples
Sample delayed in transit
Routine Microbiology The most common reasons to reject a specimen are due to the addition of a preservative (such as formalin or alcohol) . • Sputum/Bronchial —Specimens which are poor quality (i.e. saliva) as indicated by gram stain (oral flora, rare polys, presence of epithelial cells). —Limit one (1) per day, not to exceed three (3) per week. • Urine Culture —First morning specimen is preferred, but random specimen will be processed. —Limit one (1) per day not to exceed three (3) per week. —Specimen received after 2 hours of collection if not refrigerated or after 24 hours, if refrigerated. • Urinalysis —Contaminated specimens-i.e., paper, feces. —Specimens submitted in improper container. —Specimen received after 2 hours of collection if not refrigerated or after 8 hours if refrigerated.
Say No to Foleys catheter culturing - Results of Foley catheter tip cultures have not been shown to correlate with the presence of urinary tract infections, therefore, requests for culture of these specimens should be rejected. Person responsible for collection will be notified and requested to send a urine specimen instead. • Feces —Specimen submitted in improper container. Stool specimens sent in a liquid other than saline, formalin, • Other Body Fluids as CSF Pleural ,pericardial amniotic fluids joint aspirates — are rare and vital specimens and best to be performed in spite of limitations in the laboratory and not forget No specimen will be rejected without consulting with Technical Specialist or Pathologist. • Blood Cultures —No more than 4 blood culture sets will be drawn in 24 hours. No more than 3 blood culture sets for each subsequent and separate febrile illness.
Transport Temperature - Specimens left at room temperature will become overgrown with normal bacterial flora. Bacteria can multiply at room temperature particularly in urine samples. Therefore it is very important to have the specimens sent to the laboratory straight away or refrigerated in the specimen collection points. (Exceptions include blood culture bottles, CSF and genitourinary samples for gonococcal culture - these should not be refrigerated be transported to the laboratory as soon as possible)
Mycobacterial Studies (Mycobacteriology )• Poor quality specimen (i.e. saliva). • Specimens <10 br="" mls="">Important - specimens received by the laboratory are not discarded until the physician ordering the test or responsible nursing unit is notified.
Ref and to read more at Pathology Handbook Walsall Healthcare NHS
Dr.T.V.Rao MD

GIFT THE WORLD WITH POSITIVE THOUGHTS
Dr.T.V.Rao MD - We live with many friends and less known acquaintances today much buzz is on money fortune and materialism, Many losing the realities of the life as at matters, With passing of time and growing challenges there cannot be good idea than living with positive people and better books how people sustained their lives with positive thinking and I see highly qualified start their day with negative ideas, and destroy the system and makes many lives miserable, never forget many less fortunate peoples lives are affected by the negative thinkers on the higher position, However inking, and talking to positive people it may not fetch any fortunes but we can walk with challenges, Unfortunately whatever we do is a matter of criticism and negative thinking destroy the human relations I wanted to really dig into positive thinking as a habit and see what science has to say about it. I found some really interesting research on how positive thinking can improve our health and happiness, as well as some great advice to cultivate a habit of being positive.Negativity doesn’t work as we cannot draw the money with no balance account same to effect the negative thinkers Our subconscious brain can’t handle it, The other thing about negativity is that our brains can not process negative words, As we pass with life everyone is influenced by the negative thoughts and negative people however little of medication makes a great difference t, Research is beginning to reveal that positive thinking is about much more than just being happy or displaying an upbeat attitude. Positive thoughts can actually create real value in your life and help you build skills that last much longer than a smile.
Positive thinking will help the life to higher goals or we are left in a narrow well of ignorance,

Dr.T.V.Rao MD

IMPACT OF TEACHERS IN THE TECHNOLOGICAL ERA 
Dr.T.V.Rao MD With advances in technology and impact of Multimedia there are people support the need for better teachers on the other side of the coin many say we can get away with many teachers, it continues to be a debate without conclusions. However, many say we need good teachers, and I just wish to say the teachers are indispensable as our own parents who brought us with great love and care which a technology cannot do, today many policies are designed to promote teacher quality. Research using student scores on standardized tests confirms the common perception that some teachers are more effective than others and reveals that being taught by an effective teacher has important consequences for student achievement .Students still love the teachers with innovative mind with contribution of better thoughts when we discuss their future, The modern world is going to assess the teacher performance as it matters, Many great teachers emphasized the kindness of the teachers matters most than mere qualifications titles, and Technology we use in the classroom, Being kind matters. Learning is enhanced when teachers demonstrate a variety of behaviors associated with kindness: interpersonal warmth, care, empathy, support, safety, and intellectual encouragement. Research suggests that these behaviors increase a learner’s creativity, critical, autonomy, and satisfaction; and result in better student attendance and grades. However, the student and teacher relationships are critical and sensitive when we work with young and commercialized education with changing human values, Consensus among educational researchers can be rare, yet here there is little dispute: positive teacher-student relations are integral to young people’s learning.
Major research proved the technology cannot be compared with a competent teachers,
TECHNOLOGY CANNOT REPLACE THE TEACHERS BUT WHO DO NOT USE WILL BE REPLACED
 HOWEVER, THE MOST LOVED TEACHERS WERE SIMPLE HUMBLE AND WELL LEARNED REST ARE???
Dr.T.V.Rao MD @ To be a better teacher

WHAT MAKES US THE BETTER ACHIEVERS 
Dr.T.V.Rao MD 
 “There is only one thing that makes a dream impossible to achieve: the fear of failure.”
― Paulo Coelho, The Alchemist It was a great day when a teacher was parting from students for Good, It was a time that a students asked a question to the Teacher what makes us better achievers, The teacher thought it was the best question asked by any student in his career, and realized that every student we teach are interested to be better achievers in Real time career, than the few things we try to impress on the subjects we teach the teacher said in a humble manner, yes it was a right question by students to a sensible teacher he said
Be fearless and sincere as better achievers are those people who have an unwavering commitment to happiness and success, .. A true achiever is passionate about learning. The excitement of not knowing fuels their curiosity and motives them to take their new ideas to the next level. Today people with little knowledge act to be excellent the teacher says in reality no body becomes perfect in life, but our mission to achieve is, be a student all through life. There is no room for ego or complacency in the lives of master achievers. They are always open to learning and never assume they know it all because that would limit their creativity and leave no room for more success.
In conclusion try read a great book of Time ALCHEMIST Paulo Coelho the successful have learned that success is a process, not an event. They expect to have good and bad days, experiences, deals and failures.
Dr.T.V.Rao MD @ Better achiever

What is a Ring Vaccination for EBOLA
A postgraduate question for MD Community Medicine / Medicine and Microbiology 
Ring vaccination: The vaccination of all susceptible individuals in a prescribed area around an outbreak of an infectious disease. Ring vaccination controls an outbreak by vaccinating and monitoring a ring of people around each infected individual. The idea is to form a buffer of immune individuals to prevent the spread of the disease.
Ring vaccination was used to control smallpox until the last naturally occurring case in 1977. When an infection was diagnosed, all people who were or may have been exposed were identified and vaccinated. Then, a second "ring" of people who may have been exposed to the first ring were also identified and vaccinated. Ring vaccination has been used successfully as a disease-control strategy under other circumstances, The ring is not necessarily a contiguous geographic area but captures a social network of individuals and locations that may include dwellings or workplaces further afield, where the index patient spent time while symptomatic, or the households of individuals who had contact with the patient during illness or after his or her death. RING VACCINATION FOR EBOLA There are ongoing trials by WHO in many geographic areas affected by spread of Ebola,The first study shows that rVSV-ZEBOV vaccine has high efficacy during outbreaks, that a ring-vaccination strategy has value, and that it's feasible to conduct an efficacy study amidst an epidemic. An editorial observes the need to assess the durability of immunity; attenuation of the VSV-based vaccines might reduce adverse events. The investigators in the second study observe that antibodies in the African population were considerably less durable than in Chinese participants in the phase 1 trial.
Current research on Ring Vaccination strategies in deadly communicable diseases, to contain the spread of the infection when the safety is limited with existing studies or the safety is not established
Read more at
Ref Ebola Vaccine Efficacious in Ring-Vaccination Trial in Guinea
Mary E. Wilson, MD reviewing Henao-Restrepo AM et al. Lancet 2016 Dec 22. Geisbert TW. Lancet 2016 Dec 22. Zhu F-C et al. Lancet 2016 Dec 22. Grobusch MP and Goorhuis A. Lancet 2016 Dec 22.
Dr.T.V.Rao MD Medical Reporter on Afro Asian resources

ESSENTIAL CRITERIA IN DIAGNOSIS OF URINARY TRACT INFECTIONS - With many years of experience in reporting the Urinary tract infections with culturing, I still feel we have not perfected in many matters, and getting optimal conclusions are difficult and opinions vary in the individuals when reporting. The reasons being not inadequacies in Laboratory testing as we find three or more species of bacteria in a urine specimen, it usually indicates contamination at the time of collection and interpretation are fraught with error. Well said and not done cleaning of the Genital area carries a real priority because urine is so easily contaminated with commensal flora, specimens for culture of bacterial urinary tract pathogens should be collected with attention to minimizing contamination from the perineal and superficial mucosal microbiota. Although some literature suggests that traditional skin cleansing in preparation for the collection of midstream or “clean catch” specimens is not of benefit, many laboratories find that such specimens obtained without skin cleansing routinely contain mixed flora and if not stored properly and transported within one hour to the laboratory, yield high numbers of one or more potential pathogens on culture. Interpretation of such cultures is difficult, so skin cleansing is still recommended. We have to educate the concerned physicians, not ask the laboratory to report “everything that grows” without first consulting with the laboratory and providing documentation for interpretive criteria for culture that is not in the laboratory procedure manual. This is the grave error of many private laboratories without a qualified supervision report many commensals and contaminates as potential pathogens and testing with Antibiotic sensitivity pattern. The differentiation of cystitis and pyelonephritis requires clinical information and physical findings as well as laboratory information, and from the laboratory perspective the spectrum of pathogens is similar for the two syndromes. Culturing only urines that have tested positive for pyuria, either with a dipstick test for leukocyte esterase or other indicators of PMNs may increase the likelihood of a positive culture, but occasionally samples yielding positive screening tests yield negative culture results and vice versa, and undue dependency by physicians on Dip stick method should be understood. The Gram stain is not the appropriate method to detect PMNs in urine but it can be ordered as an option for detection of high numbers of gram-negative rods when a patient is suspected of suffering from urosepsis. The use of urine transport media in vacuum-fill tubes or refrigeration immediately after collection may decrease the proliferation of small numbers of contaminating organisms and increase the numbers of interpret-able results. Straight or “in-and-out” catheterization of a properly prepared patient usually provides a less contaminated specimen Specimens from urinary catheters in place for more than a few hours frequently contain colonizing flora due to rapid bio-film formation on the catheter surface, which may not represent infection. Culture from indwelling catheters is therefore strongly discouraged, but if required, the specimen should be taken from the sampling port of a newly inserted device. We should insist that the Clinicians should indicate whether they are sending a catheterised specimen Cultures of Foley catheter tips are of no clinical value and will be rejected. Even we find resistance when we reject these specimens from even the senior practitioners Collection of specimens from urinary diversions such as ileal loops is also discouraged because of the propensity of these locations to be chronically colonized Laboratories routinely provide antimicrobial susceptibility tests on potential pathogens in significant numbers .Specimens obtained by more invasive means, such as cystoscopy or suprapubic aspirations should be clearly indicated, to the laboratory, Identification of a single potential pathogen in numbers as low as 200 cfu/mL may be significant, such as in acute urethral syndrome, but requests for culture results reports of <10 000="" actually="" additional="" an="" appropriate="" as="" bacterial="" be="" br="" can="" candida="" cfu="" conducted="" confirmation.="" coordinated="" cultures="" do="" even="" for="" from="" have="" high="" in="" indicate="" infection="" infrequent="" interpretation="" is="" laboratory="" may="" ml="" must="" not="" of="" pathogens.="" patients="" rarely="" recovery="" reprocessed.="" should="" so="" spp="" standardized="" systemic="" tests="" that="" the="" thus="" urine="" usually="" uti="" volume="" which="" who="" with="" yeast="" yielding="">Changing Trends on Detection of AFB from urine – The current peer reviewed information indicates Recovery of Mycobacterium tuberculosis is best accomplished with first-voided morning specimens of >20 mL, and requires a specific request to the laboratory so that appropriate processing and media are employed. The collection of 24 hours urine is totally abandoned in future testing for AFB detection. Never forget that genital cleaning with disinfect is essential to reduce the contamination with the Saprophytic Acid Fast bacilli as M.smegmatis.

How to collect a urine from a young child or infant a question has few best solutions however the method described below has scientific success
A recent paper from Madrid proposes a method to produce a flow of urine on demand in infants. And I can report that our own unit has found it to be quite effective for both neonates, infants and some older babies.
Procedure:
It takes a minimum of two people to perform this procedure. However, it is better with three, one dedicated to making the catch.
Encourage oral fluid intake.
25 minutes following this feed, the baby/infants genitals are cleaned thoroughly with warm soapy water and dried with sterile gauze.
Sterile container is prepared to collect specimen.
Baby is held under the armpits (just above the bed) with legs dangling (the parents can easily assist with this).
The nurse then starts bladder stimulation which consists of gentle tapping in the supra pubic area at a rate of 100 taps per minute for 30 seconds.
Next, the lumbar para vertebral zone (think the small of the lower back) is massaged in a light circular motion for 30 seconds.
Step 5 and six are repeated until urine is released.
Stand clear & catch the mid-stream.

Ref and Abstracts from A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases:2013 Recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM)Ellen Jo Baron,et al
Dr.T.V.Rao MD Professor of Microbiology. Freelance writer

HOW TO LIVE AND PROGRESS WITH LIFE? 
 Dr.T.V.Rao MD No day goes without challenges, and simply how we cope up matters, the people who made progress are never tired with the process of life, I always try to read a little of men and women who made the best with their own choices, In the recent time the most famous book many read is Alchemist Coelho’s most popular novel read by many one thing we find we do find every day is a challenge and never to be disappointed, the HERO a little boy never thinks to turn back before be wins what he wanted, Anyhow no one wins the game of life, along unless some real ones with us, this is how many of us get isolated when we have strong convictions, Ultimately everyone has to turn to faith of his choice for some religious beliefs , positive thinking and many their own convictions, Many great achievers learn to live different, and never believed to be a sheep in a flock and live as Shepard to lead the flock, Don’t be afraid to be different “You are someone who is different, but who wants to be the same as everyone else.. And that, in my view, is a serious illness. Financial setbacks and unknown factors make you realize what really you are, God chose you to be different. Why are you disappointing God with this kind of attitude?” Wake and listen to your heart, the God wants you to be different, listen to your heart “Tell your heart that the fear of suffering is worse than the suffering itself. And that no heart has ever suffered when it goes in search of its dreams, because every second of the search is a second’s encounter with God and with eternity.” —The Alchemist. Always imagine we are born to progress in life, the Teachers are to be role models as we occupy high chairs to change the society it is just possible with a little thought “There is only one way to learn. It’s through action.”, Even you missed in the past start today with good actions
Ref The Alchemist by Paulo Coelho. 
Dr.T.V.Rao MD 

MAKING BEST USE OF OUR LIVES 
Dr.T.V.Rao MD Every day when we wake up in the morning, a great feeling that we are back to our role and next feeling a another Gift from God to contribute something useful to the world, all through life we cannot live with profession and mechanical responsibilities and certainly a Time will come everyone is oneself, and free to think beyond the responsibilities of the employed life, From here we can go further crossing into higher spiritual realms to experience regions of Light, love, and bliss far beyond any we can know in this world. The aim of that journey is to realize our true self as soul and realize the creative power, gifted by unknown force and many call as God and other names in a variety of languages. I was reading a text when we are truly disturbed live in silence for few minutes, it certainly searches our true inner sense of our living One day I was walking with many challenges to fulfill in the next few days, with Dr Borappa a Senior surgeon of our Hospital in Karnataka , we had a simple chat, discussing the unexpected challenges, he said the best book to Understand lives is Mahabharata, we are all one of the characters in the great epic, the problem with humans is everyone thinks as a Hero and Heroine, but not otherwise, and if you wish to live in peace imagine to be a simple character and never imagine that you can do everything as a Hero or imagine to be a failed characters, as Arjuna thought in early chapters in Bhagavad Gita and balancing life with challenges is the best choice, without great expectations, in reality no body truly wins or any one lose totally, it all just restiveness we live, however
Our Purpose: remain constant in despite many challenges
Find information about ‘living your best life’ and find happiness and contentment while managing the stress that can come with living with diabetes.
Build your motivation to better manage your health and emerging challenges.
Setting and working towards meaningful goals to improve an area of your life.
Life with disease is not easy, but it gets better when we look at the positive side of life with the realities
Getting into a positive routine or groove, instead of a negative rut, will help you become more effective. Why is the subway the most energy efficient means of transportation?
KEEP MOVING WITH POSITIVE SENSE LIFE IS VERY SIMPLE GAME TO PLAY
Dr.T.V.Rao MD

SUGGESTED REGULATIONS IN MEDICAL EDUCATION 
1 All Medical colleges will be accountable in running the Medical Colleges, as per the regulations formulated by MCI subject to approval by regulatory authority
 2 Digital Biometry is mandatory to run the Medical Institutions and the matters related to attendance is the prime responsibility of the Deans and respective Principles of the Institutio
3 All cadres of the Teaching staff have same regulations in attendance, the discriminatory attitude of the college managements will be viewed seriously subject for actions as formulated, Principals will monitor the staff presence in the working hours prescribed by Medical council of India 
4 The eligibility criteria of the students to appear for university examination depends not alone on attendance and academic performance of students but also on Teachers attendance and performance as certified by the Principals or competent authority submitted to the respective universities.
5 The clinical training and documentation of Real time training should recorded by CCTV’s respective Medical superintendents will coordinate the matters and considered in future increase of seats for MBBS admissions and post graduate approval
6 The students can approach the respective universities in matter of conflicts of Interest and discriminatory attitude of the Administration as in detention and disciplinary matters
6 Draft already circulated on maintenance establishment equipment and staff role in laboratory services await final preparation after the representations of stakeholders.
7 Teacher promotions are subject to attendance performance and publication of scientific papers in accredited journals except in e-journals,
8 All grievances of students and staff are subject to existing rules and regulation

ANTIBIOTIC STEWARDSHIP TO REGULATE MISUSE OF ANTIBIOTICS 
Dr.T.V.Rao MD 
 A topic of Academic interest to Medical and Microbiology postgraduates The last 50 years have witnessed the golden age of antibiotic discovery and their widespread use in hospital and community settings. Regarded as very effective, safe and relatively inexpensive, antibiotics have saved millions of lives. However, this has led to their misuse through use without a prescription and overuse for self-limiting infections, universally, the health care providers are increasingly recognizing the importance of AMSP in HCI as a major contributor to sustaining usefulness of AMA in the treatment of infections
The need for Antibiotic Stewardship is growing It has appeared and is growing fast. Today so much resources are invested on educating the professionals and the society on matters related to Antibiotics misuse and creation of SUPERBUGS AND MDR STRAINS, still the awareness to catch up however it all depends on the cooperation of competent Clinical Microbiologists and wise clinicians, wish the teaching hospitals should take the initiative, to BRING the matters in order, and certainly utter chaos in times of crisis as happening in patients with sepsis LONG term care with many advances in medical profession. The aim of the Antimicrobial Stewardship Initiative is to improve the safe and appropriate use of antimicrobial s, reduce patient harm and decrease the incidence of antimicrobial resistance Criterion: Antimicrobial Stewardship
Safe and appropriate antimicrobial prescribing is a strategic goal of the clinical governance system.
Have an antimicrobial stewardship program in place
Provide clinicians prescribing antimicrobial access to current endorsed Therapeutic Guidelines on antimicrobial usage
Undertake monitoring of antimicrobial usage and resistance
Act to improve the effectiveness of antimicrobial stewardship
Stewardship increases coverage of empirical antimicrobial treatment while reducing the use of antimicrobial s in general, and broad spectrum antimicrobial s. As a result, Stewardship creates savings in terms of bed-days and lives, and reduces the spread of antimicrobial resistance
WHAT MICROBIOLOGISTS SHOULD TO
Another approach is to identify and communicate to prescribes specific situations where antibiotics should be withheld and guidance in relation to the duration of antibiotic use, which is often an area of misuse.
The importance of communicating, sharing and learning from data is also important.
Face-to-face meetings with prescribers, where there is an opportunity for reflection about their prescribing practices, or attending multidisciplinary teams, web-ex conferences, etc. are all important in promoting learning about prudent prescribing.
WHAT INDIA NEEDS - Regular education, easy availability of guidelines and audit of AMA prescription practices and their feedback are essential. Major stakeholders, physicians and surgeons must be involved in and even be leaders in all aspects of AMSP, guidelines and audits. Continuous research is warranted in all aspects of AMSP to obtain the best Programme for local needs. However all the Microbiologists should adopt to document the Antibiograms with credited software with maximum parameters it is the WHONET IT PROVIDES BEST OPTIONS AND THE MICROBIOLOGISTS SHOULD CONTRIBUTE FOR AUDITING THE ANTIBIOGRAMS THE FACTS ON ANTIBIOTIC RESISTANCE IN THE RESPECTIVE HOSPITALS
MANY MEDICAL COLLEGES IN INDIA HAVE STARTED INITIATION TO COLLABORATE WITH INTERNATIONAL ORGANIZATION HOPE WE ALL CAN DO GET WITH GREAT COOPERATION OF CLINICIANS
Ref Growing challenges of Antibiotic Resistance and stewardship application on world wide web
Dr.T.V.Rao MD Freelance Clinical Microbiologist
Resource person to WHONET.org USA

WHY MEDICAL STUDENTS ARE SWITCHING INTERNET TIME TO RETHINK ON MEDICAL EDUCATION 
Dr.T.V.Rao MD – A new trend setting all over the world, the Medical students are empowered professionals, realize that they cannot survive without the better skills, which are poorly transmitted in their professionals Institutes this is just not a matter of developing countries even the developed countries face the challenges, with lack and shortage of dedicated professionals as it matter the difference is in statistics, students halfway through their medical education considered the most important learning activities for their professional development to be connected with the Roles of Medical Expert, Scholar, and Communicator in real time but find few to empower them, In a established organization they find matters are all that not well, many seniors and professors say find you ways to learn as we have many obligations to fulfil as senior teachers, Competence-based medical education has been well implemented globally, and it’s not implemented in India and many developing countries it goes as didactic way, and most upcoming institutes have no idea to conduct any classes on integrated teaching leading to split system to learn the matters, with no practical skills, What really happening is Students are prone to struggle with learning in clinical environments, especially when transitioning from preclinical to clinical medical education. Students may have a hard time understanding what they can expect and what is expected of them, resulting in high levels of uncertainty. In a clinical context that is not primarily designed for teaching and learning, students are no longer told what exactly to learn, and are expected to take control of their own learning. Being expected to engage in so-called self-regulated learning (SRL) poses a large challenge to undergraduate medical students, and not forget even our post graduates, 
WHAT HAPPENS WHEN WE HAVE NO EFFECTIVE SYSTEM TO EDUCATE E THE UNDERGRADUATES – With the mushrooming of Medical and Dental colleges, to control the system, has become out of bounds as many teachers are either outdated or very inexperienced, students decide to learn on their own, with the proliferation of internet broad and smartphones, few studies proved many students try to sit in the back benches start browsing the smartphones on what the teachers are teaching, losing concentration on both ways, PEOPLE SWITCHING TO INTERNET FOR LEARNING - Examples of modern technology in medical education E-learning and webcasting are examples of educational strategies that have become commonplace in many medical institutions. More recently, interest has moved towards the use of mobile technologies to improve learning. Podcasts and podcasts’, audio and video files respectively, can be downloaded to portable computer devices such as an MP3 player. They are being increasingly used for lectures. Some of their many advantages include portability, facilitation of learning “on the go,” and encouragement of self-directed learning. Selective replay to consolidate weaknesses can also be useful.
CORRECTING THE SYSTEM IS CERTAINLY DIFFICULT HOWEVER MANY DEVELOPING COUNTRIES WORKING ON MODERLS TO RETHINK ON OUR DETERIORATING MEDICAL EDUCATION It has been peer reviewed - Simulation based medical education allows the learner to use a variety of resources that aim to mimic real life situations. Simulation includes simplistic procedural models that have been used for many years to assist individuals in task specific clinical skills
I wish certainly to rethink on deteriorating medical education and certainly new technologies are true boon if we truly assess the system, and students to be certainly regulated on newer methods of learning 
 Ref Medical students’ experiences of their own professional development during three clinical terms: a prospective follow-up study Susanne Kalé BMC Medical Education BMC Medical Education series – open, inclusive and trusted 201717:47
Ref Effective teaching skills—how to become a better medical educator Authors: Shvaita Ralhan, Paul Bhogal, Gauraang Bhatnagar, Jane Young, Matt Green Publication date: 08 Feb 2012 BMJ Careers 
Dr.T.V. Rao MD Freelance Reporter

WHY WE NEED FRIENDS -? 
Great question to many do we really need freinds, with the mechanical life and technological lera we have less time to spare, to talk and more we are communicating as business professional in real life, friends are important. So important, in fact, that it’s been proven that friendship can extend life expectancy and lower chances of heart disease. Friendship helps us survive. Part of why that is has to do with what happens in our brains when we interact with other humans:
 WE CAN OVERCOME DISEASE - Friends can keep you alive longer.Various studies have pointed out the correlation between strong social connections and overall longevity. A 2006 study on nurses diagnosed with breast cancer found that those who were deemed “socially isolated” had a higher mortality risk. .Even Freud would say that we are formed psychologically by our friends and relatives, and in the same way we mold others. Many depressions and suicides are associated with loneliness Those who do not have the opportunities for self-expression withdraw to themselves and become more and more selfish and self-enclosed. This selfish nature disrupts interpersonal relationships. As they withdraw to themselves more and more, their egocentricity increases, and that makes them more and more antisocial and unpopular.
Both Science and Religion teaches the value of friends cannot be compared with emerging isolation with technology
Resource WHO IS OUR TRUE FRIEND The Need of Friends Swami Adiswarananda Sri Ramakrishna mutt
Dr.T.V.Rao MD

DOES THE MANIPULATION SUCCEED ? Today we live with manipulating people and distorted professionals only gains matter and the rest is thrown to wind, it is true many attain a temporary success, how long truly matters, We have no way except to put with bosses colleagues Doctors, Doctorates, PhD’s and even our own professionals administering the system and talk more morals and lured with shortcuts, cutting all morals , Most our Engineering degrees are doubtful value, and not employable and Medicine is going the same path, the society’s trust on Doctors dismissing, even with many degrees, It is true there is no shortcut to anywhere worth going, ultimately one day system boomerangs. . The true philosophy of our journey begins when we are born. The destination is death. So, the journey is far superior to the destination. Don’t sell yourself lured to shorts! Make your journey worthwhile every single day, because the distance we each get to travel is a mystery. Meditate on this every day: “I will do the work.” As Einstein once said, “Genius is 1% talent and 99% effort.” You must run to be a runner. You must write to be a writer, be a researcher to sustain as talented person, the very little people working under you know the work you are doing, we find nurse knows more of the Doctor than the patients, and technician in our department knows what really you are however you must actively attend to your relationships with hard work and integrity it’s about putting in the required time and effort. You must set goals and fulfill your commitments, even when no one would notice but you, and know in your heart why doing so matters. However, you attain any position with short cuts, the matters of success are short lived shortcuts usually lead to disappointments rather than quicker success.
WHAT ALL SAID THERE IS NO SHORT CUT TO SUCCESS REST ARE OUR CHOICES
Dr.T.V.Rao MD

THINK BEYOND A PETRI DISH ? 
Dr.T.V.Rao MD All our competence of the Diagnostic Microbiology is many times limited to a Petri dish as we have limited facilities, and see many struggles and in fights in the departments are limited to a few expressions on Petri dish , certainly it is all not true as anything which grows on petri dish may not all useful has many inputs some good and many uncontrolled factors , Never to forget majority of specimens we get in laboratories may be infected with Bacteria, parasitic fungal and viral etiology , which is not imagined many times, today many see the request and discard the specimens without futures thinking , and always tell the friends in the department keep the specimen in the cold temperature at least till the requested report is dispatched, when we are confused with the results arising out of limited testing’s in the laboratory, this continues to my vison THINK BEYOND A PETRI DISH and many times we do not fully understand the true diagnostic value of a clinical specimen, I have seen people start showing their egos without knowing many realities of the specimens we get in the laboratories, I wish it is time TO expand our thinking beyond our limited knowledge, and grow better in career , Still for any wise in the word INFECTION is ill understood word as manifestations of infections are very wide, and manifestations of an infection depend on many factors, including the site of acquisition or entry of the microorganism; organ or system tropisms of the microorganism; microbial virulence; the age, sex, and immunologic status of the patient; underlying diseases or conditions; and the presence of implanted prosthetic devices or materials. Think about a simple urine culture it is in reality more difficult and complex when we see the realities one dose of Antibiotic certainly alter the cfu units, it just means no dictum's to be depended, absolutely, No specimen has any value without true clinical inputs as requested by the Microbiologists staff of a clinical microbiology laboratory should be qualified to advise the physician as well as process specimens. The physician should supply salient information about the patient, such as age and sex, tentative diagnosis or details of the clinical syndrome, date of onset, significant exposures, prior antibiotic therapy, immunologic status, and underlying conditions. It is truly awful many physicians fish the diagnosis from ill understood Science of Microbiology. For a student started his career in diagnostic Microbiology, the microbiology specimen is a product of many facts Physicians and Microbiologists must also consider that the composition of microbial species on the skin and mucous membranes may be altered by disease, administration of antibiotics, endotracheal or gastric intubation, and the hospital environment. For example, potentially pathogenic bacteria can often be cultured from the pharynx of seriously ill, debilitated patients in the intensive care unit, but may not cause infection, the clinical Microbiologists should certainly KNOW when delivering the reports from Intestine and Critical care units, the recent studies enlighten patients after few days of admission to hospitals will be colonized with MDR strains yet not invading, and unwise reports of us without rationalism make the physicians to use last generation of antibiotics to date and certainly unwise treatment are counterproductive. The clinical microbiologists should be proactive to participate in decisions regarding the micro-biologic diagnostic studies to be performed, the type and timing of specimens to be collected, and the conditions for their transportation and storage he clinical microbiology laboratory, whenever appropriate, should provide an interpretation, I feel certainly growing beyond a Petri dish is the true need of the Hour?
MICROBES ARE LIKE OUR FRIENDS HOWEVER STILL WE HAVE NOT PERFECTED TO KNOW USEFUL FROM DANGEROUS ONES
Ref Principles of Diagnosis John A. Washington. Medical Microbiology. 4th edition John A. Washington.
Dr.T.V.Rao MD Freelance reporter on Infectious diseases as it matters

SPUTUM CULTURING - CLINICAL UTILITY OF LABORATORY REPORTS
Dr.T.V.Rao MD A frequent specimen in our diagnostic laboratories is Sputum for Microscopy and culturing, we all have experienced many specimens sent as sputum are not sputum just saliva, nobody bothers to instruct the patients to send the better specimens, repeated instructions make no difference, many casually report and get rid of the matters, However to improve the matters Care must be taken in the sample collection process to ensure that the sample is from the lower airways and not from the upper respiratory tract. Sputum samples may be expectorated or induced I spoke on many occasion the greater failure of Microbiology lies with poor collection of specimens, clinicians too are not serious or wait for the reports, all the good efforts of microbiology go to files but not for utility. I always wonder so much human resource is wasted on many matters, from collecting the samples to processing with valuable media and chemicals, and at the end unfollowed results
 HOW WE PROCESS THE SAMPLES Typically, the first step in the routine analysis of a sputum sample is a Gram stain to identify the general type of bacteria that may be present. The sample is then placed on or in appropriate nutrient media and incubated. The media encourages the growth of bacteria that are present, allowing for further testing and identification. Never to forget the sputum is never sterile we have lot of flora which live with harmony of respiratory mucous membranes. That means that when a person has a bacterial respiratory infection, there will typically be harmless bacteria that are normally present in the mouth, throat, etc. as well as disease-causing (pathogenic) bacteria present. A trained laboratorian differentiates normal flora from pathogenic bacteria and identifies the various types of bacteria present in the culture. Identification is a step-by-step process that may involve several biochemical, immunological, and/or molecular tests and observations of the organism's growth characteristics. some fastidious organisms clearly seen on Gram stain may be overgrown by indigenous respiratory flora on solid media (e.g., Streptococcus pneumoniae). Many inexperienced microbiologists assume everything one sees or cultured can be interpreted as pathogen flow the misinformation to clinicians a true happening today with mushrooming of Microbiology laboratories without basic competence.
 NEVER TO FORGET - Useful sputum culture results rely heavily on good sample collection. If examination of a Gram stain of the sample reveals that it contains a significant number of normal cells that line the mouth (squamous epithelial cells), then the sample is not generally considered adequate for culture and a re-collection of the sample may be required. If the sample contains most white blood cells / pus cells that indicate a body's response to an infection, then it is an adequate sample for culturing. (Refer 13 Edition Mackey McCartney Microbiology text Book)
SPUTUM CULTURING -Routine media used for the isolation and identification of respiratory pathogens include blood agar, chocolate agar, and MacConkey agar. Blood agar supports the growth of Gram positive cocci and most Gram-negative rods, and is especially useful for evaluation of the colony morphology and hemolysis of streptococci. Chocolate agar permits recovery of Haemophilus influenza. MacConkey agar is selective for Gram negative bacteria and allows further classification into lactose positive or negative organisms, based upon their ability to ferment lactose.
HOW WE COMMONLY REPORT - that a few colonies of a respiratory pathogen (e.g. Streptococcus pneumoniae, Haemophilus influenza, Moraxella catarrhalis) nestling among a mass of mixed upper respiratory tract flora is unlikely to be significant, but I am not aware of any literature that supports such an assertion. Clinicians don’t hang or bother around waiting for the patient to firstly produce a sputum sample, and then wait another 2 or 3 days whilst the microbiology laboratory processes it. They treat the patient empirically, according to guidelines that are hopefully formulated by laboratory data or with their own clinical experience outlining the expected pathogens and antibiograms in the local area. Only on rare occasions does a sputum culture result change patient management. So, we will continue to grapple with the vagaries of sputum culture, but I suspect it will be around for many years yet.
WE SHOULD THINK BEYOND THE CULTURE PLATE - For example, depending upon the clinical findings, additional tests for agents such as Mycoplasma pneumoniae, Bordetella pertussis, Legionella species, Aspergillus species, Typical Mycobacterium, atypical mycobacteria, respiratory syncytial virus, adenovirus, parainfluenza virus, influenza virus, and rhinovirus may be indicated. Which are more common causes in respiratory infections in the era where we have many immunosuppressed patients and misuse of antibiotics certainly give fallacious culture reports and sputum is no exception, Entire flora of the Respiratory system with doses of Antibiotics loses the value of bacterial culturing
IT IS TRUE HAPPENING THAT THE CLINICIAN EXHAUST ALL THE NEW GENERATION OF ANTIBIOTICS BEFORE OUR REPORTS REACH THE CLINICIANS?
Ref 1 Thresholds” May 8, 2017The Art of Microbiology sensitivity, specificity, sputum Michael @ Microbiology matters
2 Recent advances on culturing the clinical specimens from Web resources
Dr.T.V.Rao MD Freelance reporter on Clinical Microbiology in patient care

Surgical site infections and Role of Clinical Microbiologists
Dr.T.V.Rao MD 
 A post graduate question to Health care practitioners in a European University ?
Question – Describe on Epidemiology of Surgical site infections and Importance of surveillance? Every surgery done in a Hospital has accountability to patient safety and prevention of infection Majority of times the infections may occur after the discharge of the patients, to define Surgical site infections (SSIs) are defined as infections occurring up to 30 days after surgery (or up to one year after surgery in patients receiving implants) and affecting either the incision or deep tissue at the operation site. Despite improvements in prevention, SSIs remain a significant clinical problem as they are associated with substantial mortality and morbidity and impose severe demands on healthcare resources.it is just not the infection there is a changing responsibility of the Hospitals and surgeons who perform and may lead to legal challenges and compensatory claims, The causative pathogens depend on the type of surgery; the most commonly isolated organisms are Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus spp. and Escherichia coli. Numerous patient-related and procedure-related factors influence the risk of SSI, and hence prevention requires a 'bundle' approach, with systematic attention to multiple risk factors, to reduce the risk of bacterial contamination and improve the patient's defenses. The Centers for Disease Control and Prevention guidelines for the prevention of SSIs emphasize the importance of good patient preparation, aseptic practice, and attention to surgical technique; antimicrobial prophylaxis is also indicated in specific circumstances, Surgical site infections (SSI) account for 14% to 17% of all hospital-acquired infections and 38% of nosocomial infections in surgical patients. SSI remain a substantial cause of morbidity and death, possibly because of the larger numbers of elderly surgical patients or those with a variety of chronic and uncompromising conditions, and emergence of antibiotic-resistant microorganisms.
NEED TO IMPROVE THE OPERATION THEATER SAFETY - A safe and salubrious operating theater is an environment in which all sources of pollution and any micro environmental alterations are kept strictly under control. This can be achieved only through careful planning, maintenance and periodic checks, as well as proper ongoing training for staff. Indeed, an operating theater is an extraordinarily complex system in which numerous risk factors are present, including not only the features of the structure and its fixtures, but also the management and behavior of healthcare workers. (Refer to my literature on sterilization of Operation theaters on GOOGLE Search,)
Parthenogenesis of surgical site infection
The development of an SSI depends on contamination of the wound site at the end of a surgical procedure and specifically relates to the pathogenicity and inoculum of microorganism’s present, balanced against the host’s immune response Staphylococcus aureus is the microorganism most commonly cultured from SSIs. When a viscus, such as the large bowel, is opened, tissues are likely to be contaminated by a whole range of organisms. In this environment, normally non-pathogenic organisms such as Staphylococcus epidermidis (coagulase-negative staphylococcus) may also cause an SSI. Operations on sites that are normally sterile (‘clean’) thus have relatively low rates of SSI (generally less than 2%), whereas after operations in ‘contaminated’ or ‘dirty’ sites, rates may exceed 10%.7
Surveillance for surgical site infection - As to date in India there are no mandatory guiltiness or regulation to control surgical site infection we dependent mainly with CDC WHO and NIH guidelines
WHY MATTERS GO WRONG
In many cases of suspected infection: necessary cultures were not obtained, The antibiotic administration was not initiated or delayed, The choice of antibiotic was not appropriate
Surveillance of SSI provides data that can both inform and influence practice to minimize the risk of SSI, as well as communicate more clearly the risks of infection to patients. Surveillance was first recognized as an important tool in reducing rates of infection in the 1980s. The Study on the Efficacy of Nosocomial l Infection Control (SENIC) showed that surveillance and infection control programs that included the collection, analysis and feedback of data on infection rates to surgeons were associated with significant reductions in rates of SSI.. Surveillance focused on detecting SSI during the inpatient stay is thus likely to underestimate the true rate of SSI, a problem that is exacerbated by the increasing trend towards shorter lengths of postoperative hospital stay and day surgery. Therefore, systems that enable cases of SSI to be identified after discharge from hospital enhance the value of surveillance. However, there are several practical difficulties in reliably identifying SSI in community settings and methods that systematically and accurately identify SSI are required if valid comparisons of rates are to be made.
We certainly need the greater cooperation of clinical Practitioners and committed Microbiologists to reduce the morbidity and mortality in our hospital
Ref 1 Surgical site infections: epidemiology, microbiology and prevention. Owens CD, Stoessel K. J Hosp Infect. 2008 Nov;70 Pub Med
2 Surgical site infection Clinical Guideline October 2008 Funded to produce guidelines for the NHS by NICE RCOG Published by the Royal College of Obstetricians and Gynecologists.
3 CDC guidelines of Control of Surgical Site Infections
Dr.T.V.Rao MD Clinical Microbiologist On line reporter on Infectious Diseases

WHY WE NEED WORK CULTURE IN THE LABORATORY
Laboratory the Heart of the Hospital -
Dr.T.V.Rao MD I was really fascinated when I read the Novel Final Diagnosis Arthur Hailey in 70s it has great impact on me and many other friends who have become laboratory specialists, A laboratory has great role to decide the future of any disease, many in abroad in Africa run under British culture great committed people with limited resources , never forget the African and British people are truly committed than many of our own friends, I I wished that I should specialize in a part of Laboratory Medicine and lucky became a Medical Microbiologist However I lived much of my life in conflict with lack of commitment by many qualified leave the matters to technicians with my 30 years as a Microbiologist I truly disappointed what will be future of Diagnostic Medicine in our Hospitals now we are entering into era of no return with many Private Medical Colleges least care the diagnostic aspect , and many professors just live for MCI purpose leaving the matters to the least qualified and interested juniors even many MDs in responsible position do anything with diagnostic work and only supervisors almost Microbiology is dying in many teaching Hospitals and many qualified come to spend time rather than contributing anything good, However I met one committed Microbiologist in Kerala at Trivandrum Dr Mebel Lagori Former Professor of Microbiology in 1994 who has imposed the night duty system in Trivandrum Medical College in 90s may be with much opposition ? I leant some thing good from she said unless we work and committed to the laboratory we will be no longer cared by anyone the Hospital or teaching hospital, Never forget in reality we will be a liability to the Medical Profession
I was searching what is wrong with our work culture I had a interesting article in WWW
Michael Hengartner, says I clearly communicate my philosophy regarding how my lab should run,” says PI Michael Hengartner, dean of the faculty of science, at the University of Zurich, in Switzerland. “I do not necessarily proselytize, but I do bring it up regularly, particularly when one of my lab members seems to be ignoring my philosophy. I take great pains to make sure that during any recruiting of new lab members, they are informed (or shall I say “warned”) of our lab philosophy. I also make sure that current lab members get an opportunity to meet with prospective new lab members, and I make sure to consider their feedback, since a single ‘dominant negative’ person can kill the good atmosphere of a lab.” this is truly killing many laboratories in our country, If have any interest and play the politics to ruin the system, to cover up their ignorance and lack of commitment to the profession
 Today many Hospitals are losing the faith in their hospital laboratories in spite of many qualified people with postgraduate qualifications, if they are conscious and wish to stay as professors and consultants experts, follow the advice as laboratory are based on science and not personal dogmas opinion and fancies please read
Regardless of location, funds, resources, personality, and all the other variables that go into making up a lab culture, however, “In science, if you don’t work hard, it is unlikely you are going to be successful,” Doetsch says. “Putting in the hours and the ability to overcome setbacks and failures is a great equalizer in research. I tell my students that if they excel in hard work and can ‘roll with the punches’ they will be successful not only in science but in many other situations in life.”
I truly believe philosophy of As Gandhi said, “Be the change you want to see in the world” I am happy many will be committed to work laboratory always belong to qualified with MD to improve the matters,
I wish many to read the following article to stay in the profession with respect and dignity
It is TIME we should start learning the work cultures or many laboratories will be dangerous to the system we work
I always say if we do not do laboratory work we will be no better than a specimen in a museum

Lab Is Where the Heart Is? Trials and Tribulations of Lab Culture By Emma Hitt
The Science his special feature is brought to you by the Science/AAAS Custom Publishing Office
Compiled by Dr.T.V.Rao MD Professor of Microbiology

SUPERBUGS – HOW THEY INFLUENCE CLINICAL CARE ?
Dr.T.V.Rao MD
The last true revolution in infection control occurred in 1867 when British surgeon Joseph Lister began using carbolic acid as an antiseptic, significantly reducing mortality rates from infection by 30 percent within a decade. There is now a genuine threat of humanity returning to an era where mortality due to common infections is rife. Now many are aware that our Antibiotic pipe line has become narrow and little is flowing out, as few firms are interested to develop new Antibiotics as they lose efficacy due to irrational use of Antibiotics. One patient out of every 20 admitted to hospital contracts a nosocomial infection, (an infection the patient did not have when they entered the facility), and with 1.8 million people per year acquiring an infection during their hospital stays (USA). More than 99,000 Americans die annually — that’s 270 deaths every day. The elderly and immunocompromised patients are particularly at risk. If this was the incidence imagine how many are dying in a country like India, it is not death of a person many resistant strains are spread in the Hospital environment keeping very one guessing who will be infected and die with the consequences. While the threats have grown more sophisticated, the methods of controlling and preventing these life-threatening infections have not.
Current HAI prevention practices include: • Isolating infected patients.
• Requiring staff to wash their hands after each patient examination.
• Wearing protective gowns, masks, gloves and other equipment.
• Cleaning rooms with harsh chemicals such as hydrogen peroxide.
There is now a genuine threat of humanity returning to an era where mortality due to common infections is rife,"
While microbes typically developed resistance to drugs in hospitals and healthcare facilities, a concerning trend was the increased number of people acquiring antibiotic-resistant infections in their communities. Many organisms, known as superbugs, were now resistant to multiple drugs. Drug-resistant microbes also entered the country with travelers, and no single country can be blamed for the events as it is a Global concern need health care efforts to reduce the incidence
The most common life threatening infection types are respiratory tract infections such as pneumonia and infections of the bloodstream. These are often caused by Klebsiella pneumoniae and E. coli bacteria, both of which have shown an ability to develop resistance to some of the most powerful antibiotics. Among many reported healthcare-associated infections, surgical site infections and urinary tract infections are also common. Many of the infections are also found to be drug-resistant microbes or popularly called "superbugs", as per our observations, Many facts will be enlightened when we analyse the patients who are staying in the hospitals for various reasons for more than 2 weeks, and on Antibiotics, as they are important group of patients who are likely to be put on several antibiotics, and most likely harbour the drug resistant bacteria, which need more evaluations and health care awareness to reduce to spread to other patients, This will be a a primary step in the prevention of local spread of Multi drug and Pan resistant strains in our Hospital . This may lead also a path to know it is mere Antibiotics alone contribute to morbidity and mortality and we wish to increase the frequency of Hand washing in these areas, as simple measures have great impact on human safety. NEVER FORGET SUPERBUGS ARE MAN MADE SO THE SOLUTIONS ARE IN OUR REACH. In the developing countries, the real threat lies with careless and unwarranted used of Antibiotics, just think before prescribing an Antibiotic?
 The great challenge to diagnose and control depends on the effective Diagnostic Microbiology and greater cooperation between the Microbiologists and practicing physicians
Yet we do not have auditing system to SUPERBUGS AND CERTAINLY NEED OF THE HOUR TO IMPROVE THE QUALITY CARE IN CRITICAL CARE PATIENTS
 LITTLE BEST WE CAN DO IS HAND WASHING 

CURRENT RECOMMENDATIONS OF RNTC PROGRAM IN INDIA IN PULMONARY TUBERCULOSIS
A Post Graduate question in COMMUNITY MEDICINE – AND MICROBIOLOGY 
 Question - Describe the RNTC program in India its limitations and what are current recommendations?
It was a gold standard yesteryears, and the RNTC and DOTS were dependent on sputum smear examination by ZN methods and Florescent methods, Sputum microscopy for acid-fast bacilli (AFB) is the most appropriate method for case-finding in a tuberculosis (TB) control Programme. It is usually carried out by general technicians, often after minimal training. Quality control of their results therefore seems indispensable Several studies have shown that three serial sputum smear examination is ideal for diagnosis of pulmonary tuberculosis cases. AFB testing may be used to detect several different types of acid-fast bacilli, but it is most commonly used to identify an active tuberculosis (TB) infection caused by the most medically important AFB, Mycobacterium tuberculosis. Much of the RNTC program assumes the AFB are Mycobacterium proving it be sensitive but not specific in diagnosis of Tuberculosis
HOW THE SMEARS DONE - An AFB smear is used as a rapid test to detect mycobacteria that may be causing an infection such as tuberculosis. The sample is spread thinly onto a glass slide, treated with a special stain, and examined under a microscope for "acid-fast" bacteria. This is a relatively quick way to determine if an infection may be due to one of the mycobacteria, such as M. tuberculosis. AFB smears can provide presumptive results within a few hours and are valuable in helping to make decisions about treatment while culture results are pending. However, this rapid test is less sensitive than culture to diagnosis a mycobacterial infection.
The objectives of RNTPCP were to achieve at least 85% cure rate among the new smear-positive cases initiated on treatment and thereafter a case detection rate of at least 70% of such cases. The major addition of RNTCP was the establishment of a sub-district supervisory unit known as TB Unit, with RNTCP supervisor and decentralization of diagnostic and treatment services with treatment given under the support of DOT provider (DP).
Advantages:
Microscopy of sputum smears is simple and inexpensive, quickly detecting infectious cases of pulmonary TB; Sputum specimens from patients with pulmonary TB – especially those with cavitary disease – often contain sufficiently large numbers of acid-fast bacilli to be readily detected by microscopy.
Disadvantages: Direct smear microscopy is relatively insensitive as at least 5,000 bacilli per milliliter of sputum are required for direct microscopy to be positive.
Smear sensitivity is further reduced in patients with extra-pulmonary TB, those with HIV-co-infection, and those with disease due to non tuberculous mycobacteria (NTM).
The modalities of the National programs are changing as simple examination for AFB detection becoming obsolete for a variety of reasons as few
Limitations: Microscopy for acid-fast bacilli (AFB) cannot distinguish
Mycobacterium tuberculosis from NTM,
Viable from non-viable organisms,
Drug-susceptible from drug-resistant strains.
CHANGING ROLE OF RNTPCP 2016- 2017
Diagnostic algorithm of pulmonary TB has been completely changed from the previous guidelines
All presumptive TB will undergo sputum smear examination (spot–early morning or spot–spot). If the first sputum is positive and not at risk for DRTB, it is categorized as micro biologically confirmed TB
Smear-positive and presumptive multi-drug resistance TB (MDR TB): A Cartridge-Based Nucleic Acid Amplification Test (CBNAAT) will be performed to rule out Rifampicin resistance and categorized as micro biologically confirmed drug-sensitive TB or RIF-resistant TB
If the first smear is negative and chest X-ray (CXR) is suggestive of TB, 2nd sample will be subjected to smear and CBNAAT simultaneously
Based on the CBNAAT result, patients will be categorized as micro biologically confirmed drug-sensitive TB or RIF-resistant TB
A RIF indeterminate result will get an additional CBNAAT to get a valid result and in case of indeterminate on second occasion, the specimen will be sent to the Intermediate Reference Laboratory (IRL) or Culture and Drug Sensitivity Test (C and DST) Center for Line Probe Assay (LPA) or Liquid Culture and Drug Sensitivity Test (LC and DST)
Whenever facilities are available, effort should be made to obtain DST results of all drugs
If both the sputum smear and CXR are negative, the patient should be referred to a pulmonologist
All key population (PLHIV, children, EPTB, etc.) will preferentially get a CBNAAT
All diagnostic health care facilities should have TB lab that are quality assured by competent authority.
Ref Advantage, Disadvantage and limitations of Microscopy to detect Acid Fast Bacilli (AFB)No ratings yet. DECEMBER 6, 2013 BY TANKESHWAR ACHARYAIN BACTERIOLOGY · Microbes online
Post graduates should refer the following article in detail
2 Recent changes in technical and operational guidelines for tuberculosis control Programme in India - 2016: A paradigm shift in tuberculosis control Arunabha D Chaudhuri JACP EDITORIAL Department of Pulmonary Medicine, R.G. Kar Medical College, Kolkata, West Bengal, India [cited 2017 May 6];5:1-9
3 Revised National Tuberculosis Control Programme National Strategic Plan for Tuberculosis Control 2012–2017
Program is created for the benefit of Postgraduates in Medicine and Diagnostic services
Dr.T.V.Rao MD created as on line resource for developing countries, and PANAFRICAN RESOURCES

LEARNING MICROBIOLOGY /MEDICINE THROUGH SOCIAL MEDIA – AND ONLINE RESOURCES 
Dr.T.V.Rao MD We have many medical colleges, offering the medical students the learning through didactic teaching less of practical training and interactive symposiums, However the world is changing for better learning. In a recent survey in well-established medical school in Europe the students log into the next topic coming up for teaching and discussions on WWW Google and get acquitted with matters, faster and it proved that they are more updated with Online resources than their teachers, now the Social media wish to catch the young just not gossiping but with Real Time resources in medicine and science Social media such as Facebook, Twitter, Google Plus, and Flickr, as well as open social practices such as blogging, s are being used in learning for the purpose of convenient communication with other students and potentially with others outside the class such as students of the same topic and subject experts., Many social media, as commercial endeavors, are attractive in that their features often surpass those of internal fire walled environments now it is truly happening in many of our mushrooming medical colleges, and students mug up theory and few Teachers are interested to transfer the skill based training, I have taken to the ideas why not train the many young in the world in Microbiology and Infectious diseases with little atavism, I have integrated Twitter and Facebook into the teaching of my Activism and publish in the Information Age module. Many students have reported that it helps them make the links between theory and breaking news stories and social activity simultaneously and never get bored with the serious learning in Microbiology, I have curated these links, which I use to direct the class to additional resources throughout the learning. Do you wish to help students discover and discuss the very latest in issues? Encourage them to use Twitter/ Facebook. Soon we will be connected with progressing science and Medicine The fact that these media are generally open to the world implies a need to carefully consider the risks of openness as well as need for ongoing communication with students to address their concerns and deal with issues in the use of social media as they arise. These risks are counter-balanced by the benefits of open discussion and academic debate in authentic online environments. Today even in India > 50% log to online to current aspects for learning verify the matters and to be a able communicator in seminars,
I have compiled a list of blogs and online resources that focus on microbiology with WWW SlideShare and or have a reasonable number of posts about medical microbiology made the matters very simple as many own a smartphone and internet connectivity , just have application Slide Share on your smart phone and access to more than 600 posts in files on most of the undergraduate MBBS program and many for the Post graduates in Medical Microbiology, Today I am happy many teachers use my posts for teaching and many students too access the knowledge, It is time that we can make things better and you can read topics 24x7 x 365, Never to forget the role of Medical teachers is changing we have to make the students to learn better fundamental in what we teach and rest becomes the choice of students to current updates and many seniors may object or averse to internet and we have to accept today's reality lies in online learning.
YOUR SMARTPHONE IS NEXT BEST TEACHER
 VISIT ME AT RAO’S MICROBIOLOGY ON FACEBOOK, @doctorrao at TWITTER WWW slideshare .com and WWW medmicrobes.com
Dr.T.V.Rao MD