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author:("sunday, Shyam")
1.  Does Screen Size Matter for Smartphones? Utilitarian and Hedonic Effects of Screen Size on Smartphone Adoption 
Abstract
This study explores the psychological effects of screen size on smartphone adoption by proposing an extended Technology Acceptance Model (TAM) that integrates an empirical comparison between large and small screens with perceived control, affective quality, and the original TAM constructs. A structural equation modeling analysis was conducted on data collected from a between-subjects experiment (N=130) in which users performed a web-based task on a smartphone with either a large (5.3 inches) or a small (3.7 inches) screen. Results show that a large screen, compared to a small screen, is likely to lead to higher smartphone adoption by simultaneously promoting both the utilitarian and hedonic qualities of smartphones, which in turn positively influence perceived ease of use of—and attitude toward—the device respectively. Implications and directions for future research are discussed.
doi:10.1089/cyber.2013.0492
PMCID: PMC4080862  PMID: 24694112
2.  Asymptomatic Leishmania Infection: A New Challenge for Leishmania Control 
Visceral leishmaniasis is a serious parasitic disease, causing high morbidity and mortality in the developing world. This article highlights the crucial knowledge gaps as well as the obstacles in research on asymptomatic leishmanial infection.
Visceral leishmaniasis (VL) is a serious parasitic disease, causing high morbidity and mortality in the developing world. The pathogenesis of VL is complex, and the clinical presentation ranges from asymptomatic infection to severe and fatal disease. Despite a wealth of research on the full-blown “clinical VL” syndrome, asymptomatic leishmania infections remain poorly understood. Asymptomatic infection could present a major challenge for control programs if its infectiousness is confirmed. In this viewpoint, we highlight the crucial knowledge gaps as well as the obstacles in research on asymptomatic leishmanial infection. Research in this area is essential for the development of more-effective VL control strategies.
doi:10.1093/cid/ciu102
PMCID: PMC4001287  PMID: 24585564
visceral leishmaniasis; asymptomatic infection; immunity
5.  Whole blood Assay and Visceral Leishmaniasis: Challenges and Promises 
Immunobiology  2014;219(4):323-328.
For years, the ability to study immune responses in patients with active visceral leishmaniasis (VL) has been hampered by the absence of detectable antigen-specific Th1 responses using cells from peripheral blood mononuclear cells (PBMCs). Employing whole blood assay (WBA), we recently reported that whole blood cells of active VL patients maintain the capacity to secrete significant levels of antigen driven IFN-γ and IL-10. Furthermore, WBA that uses soluble leishmania antigen (SLA) have advantages over the leishmanin skin test (LST), in terms of higher specificity and better correlation with surrogate markers of exposures to L. donovani. These findings open the door to a series of immunological and epidemiological studies not previously possible for VL. In the present review, we discuss current status, future perspectives as well as obstacles in the research on WBA. Research in this area is essential for development of potential immunological and epidemiological tools for VL.
doi:10.1016/j.imbio.2014.01.005
PMCID: PMC3951560  PMID: 24571797
Whole blood assay; Visceral leishmaniasis; SLA; IGRA; LST
6.  Identifying vaccine targets for anti-leishmanial vaccine development 
Expert review of vaccines  2014;13(4):489-505.
Leishmaniasis is a neglected tropical disease spread by an arthropod vector. It remains a significant health problem with an incidence of 0.2–0.4 million VL and 0.7–1.2 million CL cases each year. There are limitations associated with the current therapeutic regimens for leishmaniasis and the fact that after recovery from infection the host becomes immune to subsequent infection therefore, these factors forces the feasibility of a vaccine for leishmaniasis. Publication of the genome sequence of Leishmania has paved a new way to understand the pathogenesis and host immunological status therefore providing a deep insight in the field of vaccine research. This review is an effort to study the antigenic targets in Leishmania to develop anti-leishmanial vaccine.
doi:10.1586/14760584.2014.894467
PMCID: PMC4040457  PMID: 24606556
Leishmania; arthropod; vaccine; pathogenesis
7.  Heterogeneity of Leishmania donovani Parasites Complicates Diagnosis of Visceral Leishmaniasis: Comparison of Different Serological Tests in Three Endemic Regions 
PLoS ONE  2015;10(3):e0116408.
Diagnostic tests for visceral leishmaniasis that are based on antigens of a single Leishmania strain can have low diagnostic performance in regions where heterologous parasites predominate. The aim of this study was to investigate and compare the performance of five serological tests, based on different Leishmania antigens, in three endemic countries for visceral leishmaniasis. A total number of 231 sera of symptomatic and asymptomatic cases and controls from three endemic regions of visceral leishmaniasis in East Sudan, North India and South France were evaluated by following serological tests: rKLO8- and rK39 ELISA, DAT (ITMA-DAT) and two rapid tests of rK39 (IT LEISH) and rKE16 (Signal-KA). Overall, rKLO8- and rK39 ELISA were most sensitive in immunocompetent patients from all endemic regions (96–100%) and the sensitivity was reduced to 81.8% in HIV co-infected patients from France. Sera of patients from India demonstrated significantly higher antibody responses to rKLO8 and rK39 compared with sera from Sudan (p<0.0001) and France (p<0.0037). Further, some Indian and Sudanese patients reacted better with rKLO8 than rK39. Sensitivity of DAT (ITMA-DAT) was high in Sudan (94%) and India (92.3%) but low in France being 88.5% and 54.5% for VL and VL/HIV patients, respectively. In contrast, rapid tests displayed high sensitivity only in patients from India (96.2%) but not Sudan (64–88%) and France (73.1–88.5% and 63.6–81.8% in VL and VL/HIV patients, respectively). While the sensitivity varied, all tests showed high specificity in Sudan (96.7–100%) and India (96.6%).Heterogeneity of Leishmania parasites which is common in many endemic regions complicates the diagnosis of visceral leishmaniasis. Therefore, tests based on homologous Leishmania antigens are required for particular endemic regions to detect cases which are difficult to be diagnosed with currently available tests.
doi:10.1371/journal.pone.0116408
PMCID: PMC4348478  PMID: 25734336
8.  Arsenic Exposure and Outcomes of Antimonial Treatment in Visceral Leishmaniasis Patients in Bihar, India: A Retrospective Cohort Study 
PLoS Neglected Tropical Diseases  2015;9(3):e0003518.
Background
In the late twentieth century, emergence of high rates of treatment failure with antimonial compounds (SSG) for visceral leishmaniasis (VL) caused a public health crisis in Bihar, India. We hypothesize that exposure to arsenic through drinking contaminated groundwater may be associated with SSG treatment failure due to the development of antimony-resistant parasites.
Methods
A retrospective cohort design was employed, as antimony treatment is no longer in routine use. The study was performed on patients treated with SSG between 2006 and 2010. Outcomes of treatment were assessed through a field questionnaire and treatment failure used as a proxy for parasite resistance. Arsenic exposure was quantified through analysis of 5 water samples from within and surrounding the patient’s home. A logistic regression model was used to evaluate the association between arsenic exposure and treatment failure. In a secondary analysis survival curves and Cox regression models were applied to assess the risk of mortality in VL patients exposed to arsenic.
Results
One hundred and ten VL patients treated with SSG were analysed. The failure rate with SSG was 59%. Patients with high mean local arsenic level had a non-statistically significant higher risk of treatment failure (OR = 1.78, 95% CI: 0.7–4.6, p = 0.23) than patients using wells with arsenic concentration <10 μg/L. Twenty one patients died in our cohort, 16 directly as a result of VL. Arsenic levels ≥ 10 μg/L increased the risk of all-cause (HR 3.27; 95% CI: 1.4–8.1) and VL related (HR 2.65; 95% CI: 0.96–7.65) deaths. This was time dependent: 3 months post VL symptom development, elevated risks of all-cause mortality (HR 8.56; 95% CI: 2.5–29.1) and of VL related mortality (HR 9.27; 95% CI: 1.8–49.0) were detected.
Discussion/Conclusion
This study indicates a trend towards increased treatment failure in arsenic exposed patients. The limitations of the retrospective study design may have masked a strong association between arsenic exposure and selection for antimonial resistance in the field. The unanticipated strong correlation between arsenic exposure and VL mortality warrants further investigation.
Author Summary
The parasitic disease visceral leishmaniasis (VL) causes a significant burden of illness and death in India. The main drug used to treat VL, which is based on the chemical element antimony, stopped working well in about half of all patients in the late twentieth century. We hypothesised that arsenic exposure of the Indian population, through contaminated groundwater, was contributing to treatment failure with antimony based drugs. Arsenic and antimony are similar chemical elements and exposure of the parasite to arsenic within the liver of arsenic-exposed patients could allow the parasite to become resistant to treatment with antimony. Using a field-based questionnaire study we retrospectively evaluated whether arsenic exposure was linked to antimonial treatment failure in a cohort of 110 antimonial treated patients. No significant association was found, although this may be because the number of patients in the study was low as antimony use was officially discontinued in 2005 due to high rates of treatment failure. However, arsenic exposure was found to increase risk of mortality from VL particularly if death occurred more than 3 months after the symptoms of VL developed. More research into the relationship between arsenic exposure and mortality in VL is warranted.
doi:10.1371/journal.pntd.0003518
PMCID: PMC4346263  PMID: 25730310
9.  CD8 T Cell Exhaustion in Human Visceral Leishmaniasis 
The Journal of Infectious Diseases  2013;209(2):290-299.
Little is known about CD8 T cells in human visceral leishmaniasis (VL) and it is unclear if these cells have a protective, pathological and/or suppressive function. In experimental VL CD8 T cells have been shown to contribute to parasite control and play an important role in vaccine-generated immunity. To better understand the role of CD8 T cells in human VL, we examined molecules associated with anergy and cytotoxic T lymphocytes (CTL) in peripheral blood mononuclear cells (PBMC) and splenic aspirates (SA), and in CD8 cells derived from these tissues. Gene and surface marker expression suggest that splenic CD8 cell predominantly display an anergic phenotype, whereas CD8-PBMC have features of both anergic cells and CTLs. CD8 cells contribute to the baseline IFNγ levels in whole blood (WB) and SA cultures, but not to the Leishmania induced IFNγ release that is revealed using WB cultures. Blockade of CTLA-4 or PD1 had no effect on IFNγ production or parasite survival in SA cultures. Following cure, CD8 T cells contribute to the Leishmania induced IFNγ production observed in Leishmania stimulated cell cultures. We suggest CD8 T cells are driven to anergy/exhaustion in human VL, which affect their ability to contribute to protective immune responses.
doi:10.1093/infdis/jit401
PMCID: PMC3873784  PMID: 23922369
Visceral leishmaniasis; CD8 T cell; IL-10; PD1; CTLA-4; spleen; PBMC
10.  Efficacy and Safety of Miltefosine in Treatment of Post-Kala-Azar Dermal Leishmaniasis 
The Scientific World Journal  2015;2015:414378.
Background. Long regimens for the treatment of post-kala-azar dermal leishmaniasis (PKDL) result in noncompliance. A safe, effective, and acceptable regimen for the treatment of PKDL is still to be developed. Miltefosine has been found to be effective in the treatment of Visceral Leishmaniasis (VL). Hence, its efficacy was tested in patients of PKDL. Methods. In this exploratory study, 33 patients with PKDL aged 10 years and above were administered miltefosine (50 mg for those weighing <25 kg or 100 mg in divided doses for those ≥25 kg and 2.5 mg per kg for children) for 12 weeks and followed up for one year to find out the efficacy. Results. Out of 33 patients, 3 patients withdrew consent. Treatment was stopped due to adverse effect in 1 patient. 28 (96.6%) got cured with complete disappearance of lesion while 1 patient (3.4%) failed treatment by protocol analysis. Conclusion. Miltefosine was found to be effective and safe in the treatment of PKDL.
doi:10.1155/2015/414378
PMCID: PMC4313722  PMID: 25685839
11.  Microsurgical management of aneurysms of the superior cerebellar artery - lessons learnt: An experience of 14 consecutive cases and review of the literature 
Objective:
This is a retrospective study from January 2002 to December 2012 analyzing the results of microsurgical clipping for aneurysms arising from the superior cerebellar artery (SCA).
Materials and Methods:
All patients with SCA were evaluated with computerized tomography angiography and/or digital subtraction angiography (DSA) prior to surgery. All patients in our series underwent microsurgical clipping and postoperative DSA to assess the extent of aneurysm occlusion. The Glasgow outcome scale (GOS) and the modified Rankin's scale (mRS) were used to grade their postoperative neurological status at discharge and 6 months, respectively.
Results:
Fourteen patients had SCA aneurysms (ruptured-9, unruptured-5). There were 10 females and 4 males with the mean age of 47.2 years (median - 46 years, range = 24–66 years). Subarachnoid hemorrhage (SAH) was seen in 11 patients. The mean duration of symptoms was 2.5 days (range = 1–7 days). The WFNS score at presentation was as follows: Grade 1 in 10 cases, II in 2 cases, III in 1 case and IV in 1 case. In the 9 cases with ruptured SCA aneurysm, average size of the ruptured aneurysms was 7.3 mm (range = 2.5–27 mm, median = 4.9 mm). The subtemporal approach was used in the first 7 cases. The extradural temporopolar (EDTP) approach was used in the last 5 cases. Complications include vasospasm (n = 6), third nerve palsy (n = 5) and hydrocephalus (n = 3). Two patients died following surgery. At mean follow-up 33.8 months (median - 25 months, range = 19–96 months), no patient had a rebleed. At discharge 9 (64%), had a GOS of 4 or 5 and 3 (21%) had a GOS of 3. At 6 months follow-up, 10/14 (71%) patients had mRS of 0–2, and 2 (14%) had mRS of 5.
Conclusions:
Aneurysms of the SCA are uncommon and tend to rupture even when the aneurysm size is small (<7 mm). They commonly present with SAH. The EDTP approach avoids complication caused by temporal lobe retraction and injury to the vein of Labbe.
doi:10.4103/1793-5482.151513
PMCID: PMC4352632  PMID: 25767580
Accessory superior cerebellar artery; aneurysm; extradural temporopolar approach; subarachnoid hemorrhage; superior cerebellar artery
12.  The overexpression of genes of thiol metabolism contribute to drug resistance in clinical isolates of visceral leishmaniasis (kala azar) in India 
Parasites & Vectors  2014;7:596.
Background
Visceral leishmaniasis (VL), also called Kala Azar (KA) or black fever in India, claims around 20,000 lives every year. Chemotherapy remains one of the most important tools in the control of VL. Current chemotherapy for Kala Azar in India relies on a rather limited arsenal of drugs including sodium antimony gluconate and amphotericin B in addition to the very expensive drug miltefosine. Pentavalent antimonials have been used for more than half a century in the therapy of leishmaniasis as it is relatively safe and inexpensive, however, the spread of resistance to this drug is forcing clinicians in India to abandon this treatment. Consequently, improvement of antimonial chemotherapy has become a major challenging area of study by leishmaniacs worldwide. The alarming emergence of resistance to the commonly used antleishmanial drug, sodium antimony gluconate, in India, has led us to elucidate the resistance mechanism(s) in clinical isolates. Studies on laboratory mutants have shown that resistance to antimonials is highly dependent on thiol levels. The parasite evades cytotoxic effects of antimonial therapy by enhanced efflux of drug upon conjugation with thiols, through overexpressed membrane proteins belonging to the superfamily of ABC transporters.
Methods
We have carried out functional studies to determine the activity of the efflux pumps in antimonial resistant clinical isolates collected from disease endemic areas in India and also carried out molecular characterization of thiol levels in these parasites.
Results
Overexpression of the gene coding for γ glutamylcysteine synthetase was observed in these resistant clinical isolates thereby establishing that thiols represent the key determinants of antimonial resistance. The SbIII/thiol conjugates can be sequestered by ABC transporter multidrug resistance protein A (MRPA) into intracellular organelles or can be directly pumped out by an uncharacterized transporter.
Conclusions
Our studies investigating antimonial resistance in different L. donovani clinical isolates suggest that over functioning of MRP plays a role in generation of antimony resistance phenotype in some L. donovani clinical isolates.
doi:10.1186/s13071-014-0596-1
PMCID: PMC4280036  PMID: 25515494
Leishmania donovani; Drug resistance; Drug efflux; Thiols; Clinical isolates
13.  Quantitative PCR in Epidemiology for Early Detection of Visceral Leishmaniasis Cases in India 
Introduction
Studies employing serological, DTH or conventional PCR techniques suggest a vast proportion of Leishmania infected individuals living in regions endemic for Visceral Leishmaniasis (VL) remain asymptomatic. This study was designed to assess whether quantitative PCR (qPCR) can be used for detection of asymptomatic or early Leishmania donovani infection and as a predictor of progression to symptomatic disease.
Methods
The study included 1469 healthy individuals living in endemic region (EHC) including both serology-positive and -negative subjects. TaqMan based qPCR assay was done on peripheral blood of each subject using kDNA specific primers and probes.
Results
A large proportion of EHC 511/1469 (34.78%) showed qPCR positivity and 56 (3.81% of 1469 subjects) had more than 1 calculated parasite genome/ml of blood. However, the number of individuals with parasite load above 5 genomes/ml was only 20 (1.36% of 1469). There was poor agreement between serological testing and qPCR (k = 0.1303), and 42.89% and 31.83% EHC were qPCR positive in seropositive and seronegative groups, respectively. Ten subjects had developed to symptomatic VL after 12 month of their follow up examination, of which eight were initially positive according to qPCR and among these, five had high parasite load.
Discussion
Thus, qPCR can help us to detect significant early parasitaemia, thereby assisting us in recognition of potential progressors to clinical disease. This test could facilitate early intervention, decreased morbidity and mortality, and possibly interruption of disease transmission.
Author Summary
Anthroponotic VL caused by Leishmania donovani in the Indian subcontinent accounts for 70% of the world burden of VL. Among the estimated 100,000 cases of VL acquired annually in India, 90% occur in the state of Bihar. Leishmania infection can result in either symptomatic or asymptomatic infection. L. donovani infection can also manifest as post-kala azar dermal leishmaniasis, a chronic cutaneous form thought to provide the reservoir for anthroponotic transmission of VL in regions endemic for this parasite species. We hypothesized that, in areas endemic for L. donovani, asymptomatic infections might also play a crucial role in disease transmission. This study describes use of quantitative PCR (qPCR) to determine the infection status in individuals living in an endemic region of India. We hypothesized that parasite load estimation by qPCR of peripheral blood cells among healthy individuals living in the endemic region might reveal the true frequency of infections through direct evidence of parasitemia. We reasoned this test would detect both asymptomatic non-progressors as well as asymptomatic individuals who will progress to fully symptomatic VL. Serologic testing by ELISA or DAT showed poor agreement with molecular detection of parasite DNA by qPCR, suggesting the tests differentiate between infection and immune response. Amongst ten healthy individuals who progressed to VL, only six were serologically positive whereas eight were initially qPCR positive, among whom five had high parasite loads in their blood. Thus, deployment of qPCR technique to estimate the presence and level of parasitemia in healthy individuals from Leishmania endemic regions may contribute to early case detection, thereby reducing morbidity and mortality. Consistent with the goals of the VL control and elimination program, this early intervention approach could help interrupt disease transmission.
doi:10.1371/journal.pntd.0003366
PMCID: PMC4263468  PMID: 25503103
14.  Characterization of the Proliferating Cell Nuclear Antigen of Leishmania donovani Clinical Isolates and Its Association with Antimony Resistance 
Previously, through a proteomic analysis, proliferating cell nuclear antigen (PCNA) was found to be overexpressed in the sodium antimony gluconate (SAG)-resistant clinical isolate compared to that in the SAG-sensitive clinical isolate of Leishmania donovani. The present study was designed to explore the potential role of the PCNA protein in SAG resistance in L. donovani. For this purpose, the protein was cloned, overexpressed, purified, and modeled. Western blot (WB) and real-time PCR (RT-PCR) analyses confirmed that PCNA was overexpressed by ≥3-fold in the log phase, stationary phase, and peanut agglutinin isolated procyclic and metacyclic stages of the promastigote form and by ∼5-fold in the amastigote form of the SAG-resistant isolate compared to that in the SAG-sensitive isolate. L. donovani PCNA (LdPCNA) was overexpressed as a green fluorescent protein (GFP) fusion protein in a SAG-sensitive clinical isolate of L. donovani, and modulation of the sensitivities of the transfectants to pentavalent antimonial (SbV) and trivalent antimonial (SbIII) drugs was assessed in vitro against promastigotes and intracellular (J774A.1 cell line) amastigotes, respectively. Overexpression of LdPCNA in the SAG-sensitive isolate resulted in an increase in the 50% inhibitory concentrations (IC50) of SbV (from 41.2 ± 0.6 μg/ml to 66.5 ± 3.9 μg/ml) and SbIII (from 24.0 ± 0.3 μg/ml to 43.4 ± 1.8 μg/ml). Moreover, PCNA-overexpressing promastigote transfectants exhibited less DNA fragmentation compared to that of wild-type SAG-sensitive parasites upon SbIII treatment. In addition, SAG-induced nitric oxide (NO) production was found to be significantly inhibited in the macrophages infected with the transfectants compared with that in wild-type SAG-sensitive parasites. Consequently, we infer that LdPCNA has a significant role in SAG resistance in L. donovani clinical isolates, which warrants detailed investigations regarding its mechanism.
doi:10.1128/AAC.01847-13
PMCID: PMC4068424  PMID: 24614385
15.  Elucidation of Cellular Mechanisms Involved in Experimental Paromomycin Resistance in Leishmania donovani 
Leishmania donovani is the causative agent of the potentially fatal disease visceral leishmaniasis (VL). Chemotherapeutic options available to treat VL are limited and often face parasite resistance, inconsistent efficacy, and toxic side effects. Paromomycin (PMM) was recently introduced to treat VL as a monotherapy and in combination therapy. It is vital to understand the mechanisms of PMM resistance to safeguard the drug. In the present study, we utilized experimentally generated PMM-resistant L. donovani to elucidate the mechanisms of resistance and parasite biology. We found increased membrane fluidity accompanied by decreased intracellular drug accumulation in the PMM-resistant parasites. There were marked increases in gene expression of ATP-binding cassette (ABC) transporters (MDR1 and MRPA) and protein phosphatase 2A that evince increased drug efflux. Further, evaluation of parasite tolerance toward host leishmanicidal mechanisms revealed PMM-resistant parasites as being more tolerant to nitrosative stress at the promastigote and amastigote stages. The PMM-resistant parasites also predicted a better survival capacity, as indicated by resistance to complement-mediated lysis and increased stimulation of host interleukin-10 (IL-10) expression. The susceptibilities of PMM-resistant isolates to other antileishmanial agents (sodium antimony gluconate and miltefosine) remained unchanged. The data implicated the roles of altered membrane fluidity, decreased drug accumulation, increased expression of ABC transporters, and greater tolerance of parasites to host defense mechanisms in conferring PMM resistance in Leishmania.
doi:10.1128/AAC.01574-13
PMCID: PMC3993210  PMID: 24550335
16.  IgG1 as a Potential Biomarker of Post-chemotherapeutic Relapse in Visceral Leishmaniasis, and Adaptation to a Rapid Diagnostic Test 
Background
Visceral leishmaniasis (VL), caused by protozoa of the Leishmania donovani complex, is a widespread parasitic disease of great public health importance; without effective chemotherapy symptomatic VL is usually fatal. Distinction of asymptomatic carriage from progressive disease and the prediction of relapse following treatment are hampered by the lack of prognostic biomarkers for use at point of care.
Methodology/Principal Findings
All IgG subclass and IgG isotype antibody levels were determined using unpaired serum samples from Indian and Sudanese patients with differing clinical status of VL, which included pre-treatment active VL, post-treatment cured, post-treatment relapsed, and post kala-azar dermal leishmaniasis (PKDL), as well as seropositive (DAT and/or rK39) endemic healthy controls (EHCs) and seronegative EHCs. L. donovani antigen-specific IgG1 levels were significantly elevated in relapsed versus cured VL patients (p<0.0001). Using paired Indian VL sera, consistent with the known IgG1 half-life, IgG1 levels had not decreased significantly at day 30 after the start of treatment (p = 0.8304), but were dramatically decreased by 6 months compared to day 0 (p = 0.0032) or day 15 (p<0.0001) after start of treatment. Similarly, Sudanese sera taken soon after treatment did not show a significant change in the IgG1 levels (p = 0.3939). Two prototype lateral flow immunochromatographic rapid diagnostic tests (RDTs) were developed to detect IgG1 levels following VL treatment: more than 80% of the relapsed VL patients were IgG1 positive; at least 80% of the cured VL patients were IgG1 negative (p<0.0001).
Conclusions/Significance
Six months after treatment of active VL, elevated levels of specific IgG1 were associated with treatment failure and relapse, whereas no IgG1 or low levels were detected in cured VL patients. A lateral flow RDT was successfully developed to detect anti-Leishmania IgG1 as a potential biomarker of post-chemotherapeutic relapse.
Author Summary
Visceral leishmaniasis (VL) is a systemic disease with highest prevalence in South Asia, East Africa, and Brazil. VL is caused by protozoan (unicellular) parasites of the Leishmania donovani complex, transmitted to humans when an infected sandfly takes a bloodmeal. Within the human host, the parasites replicate within cells, particularly of bone marrow and spleen. Without effective treatment, symptomatic VL is usually fatal. As outlined in a recent World Health Organisation report, the development of new diagnostic tools to test for successful cure after chemotherapy is a research priority. In this work we investigated the association of clinical status of VL patients (active pre-treatment, and those deemed cured or relapsed post-treatment) with subclasses of the IgG antibody response made to L. donovani infection. We show that high levels of subclass IgG1 are found in pre-treatment and relapsed patients, but are very much lower in patients deemed to be cured. We further show that the decrease in IgG1 is detectable in patients 6 months after successful treatment, and that this detection method can be adapted to a rapid diagnostic test format requiring minimal technical expertise. Thus we believe that IgG1 levels are potentially a biomarker of post-chemotherapeutic monitoring.
doi:10.1371/journal.pntd.0003273
PMCID: PMC4207679  PMID: 25340782
17.  Association of Interleukin-18 Gene Polymorphism with Susceptibility to Visceral Leishmaniasis in Endemic Area of Bihar, an Indian Population 
The Scientific World Journal  2014;2014:852104.
Interleukin-18 (IL-18) is a cytokine that mediates Th1 response by inducing interferon-gamma (IFN-γ) production in T cells and natural killer cells. Genetic polymorphisms in the IL-18 gene have been found to be associated with its expression in cancer, tuberculosis, HBV infection, and various other diseases. Lower plasma level of IL-18 in visceral leishmaniasis (VL) patients might be associated with polymorphisms in the regulating or coding region of the gene. Three single nucleotide polymorphisms (SNPs), rs1946519 (−656 G/T) and rs187238 (−137 G/C) in the promoter region and rs549908 (+105 A/C) in the codon region, were genotyped in 204 parasitological confirmed VL patients and 267 controls with no past history of VL. For each locus, polymerase chain reaction (PCR) followed by restriction digestion was performed. IL-18 expression in peripheral blood mononuclear cells (PBMC) collected from VL patients and controls was measured by quantitative real-time RT-PCR. Distribution of G allele at position −656 (P < 0.0001) and double haplotypes GGC/GGA (P = 0.05) were found to be significantly associated with controls while genotypes TT (P < 0.0001) and single haplotypes TGA (P = 0.0002), with cases. The inheritance of G allele at the position −656 might be considered as a protective allele for VL.
doi:10.1155/2014/852104
PMCID: PMC4227453  PMID: 25405235
18.  In vitro Susceptibility of Leishmania donovani to Miltefosine in Indian Visceral Leishmaniasis 
Promastigote miltefosine (MIL) susceptibility was performed on Leishmania donovani isolates from Indian patients with visceral leishmaniasis treated with MIL. Isolates that were obtained before the onset of MIL treatment, after completion of treatment (29th day), or at the time of treatment failure, were screened using in vitro promastigote assay. The MIL susceptibility of the pre-treatment isolates (N = 24, mean IC50 ± SEM = 3.74 ± 0.38 μM) was significantly higher than that of the post-treatment group (N = 26, mean IC50 ± SEM = 6.15 ± 0.52 μM; P = 0.0006) but was similar in the cured patients (N = 22, mean IC50 ± SEM = 5.58 ± 0.56 μM) and those who failed treatment (N = 28, mean IC50 ± SEM = 4.53 ± 0.47 μM). The pre/post-treatment results thus showed a 2-fold difference, whereas isolated from cured versus failed patients showed a similar susceptibility, suggesting that this higher tolerance is not responsible for MIL-treatment failure. Our work highlights the need for careful monitoring of MIL susceptibility for implementation in national VL elimination programs.
doi:10.4269/ajtmh.13-0096
PMCID: PMC3795107  PMID: 23980130
19.  Leishmania Specific CD4 T Cells Release IFNγ That Limits Parasite Replication in Patients with Visceral Leishmaniasis 
Visceral leishmaniasis (VL) is associated with increased circulating levels of multiple pro-inflammatory cytokines and chemokines, including IL-12, IFNγ, and TNFα, and elevated expression of IFNγ mRNA in lesional tissue such as the spleen and bone marrow. However, an immunological feature of VL patients is that their peripheral blood mononuclear cells (PBMCs) typically fail to respond to stimulation with leishmanial antigen. Unexpectedly, it was recently shown that Leishmania specific IFNγ, can readily be detected when a whole blood stimulation assay (WBA) is used. We sought to define the conditions that permit whole blood cells to respond to antigen stimulation, and clarify the biological role of the IFNγ found to be released by cells from VL patients. CD4+ T cells were found to be crucial for and the main source of the IFNγ production in Leishmania stimulated whole blood (WB) cultures. Complement, antibodies and red blood cells present in whole blood do not play a significant role in the IFNγ response. The IFNγ production was reduced by blockade of human leukocyte antigen (HLA)-DR, indicating that the response to leishmanial antigens observed in WB of active VL patients is a classical HLA- T cell receptor (TCR) driven reaction. Most importantly, blockade of IFNγ in ex-vivo splenic aspirate cultures demonstrated that despite the progressive nature of their disease, the endogenous IFNγ produced in patients with active VL serves to limit parasite growth.
Author Summary
Our research aims to understand the immune failure underlying progression of human visceral leishmaniasis (VL). A key immunological feature of VL patients is that their peripheral blood mononuclear cells (PBMCs) do not respond to stimulation with leishmanial antigen. Surprisingly, when employing a whole blood assay we discovered significant levels of IFNγ in response to soluble Leishmania donovani antigen (WBA) in VL patients. We were interested to understand the relevance of the IFNγ to the anti-parasitic response. Animal models and in vitro studies have shown that IFNγ is a key effector cytokine required for control of the infection, however, the role of endogenous IFNγ in control of parasites in VL patients, has not been demonstrated. Our results show that CD4 cells were required for and were the source of Leishmania specific IFNγ in WBA of VL patients. Optimal IFNγ response required interaction with HLA-DR, supporting that VL is not due to an intrinsic Th1 response defect per se. The Leishmania driven IFNγ appears to limit parasite growth in patients with active VL, since blockade of IFNγ ex-vivo in splenic aspirate cultures enhanced parasite survival. This suggests that IFNγ may have been prematurely dismissed as an adjunct therapy in treatment of VL.
doi:10.1371/journal.pntd.0003198
PMCID: PMC4183461  PMID: 25275531
20.  Determinants of survival in adult HIV patients on antiretroviral therapy in Eastern Uttar Pradesh: A prospective study 
Background & objectives:
The National AIDS Control Organization (NACO) of India has been providing free ARV (antiretroviral) drugs since 2004. By 2012, 486,173 patients had received treatment through the antiretroviral therapy (ART) centres. The objective of this observational study was to assess the factors determining survival of patients on ART under routine programme conditions in an ART centre in north India five years after its inception.
Methods:
Treatment naive HIV positive patients who were enrolled in the ART centre between May 2009 and May 2010 and started on ART as per the Revised NACO guidelines 2009, were included in the study and outcome was assessed after two years of follow up.
Results:
A total of 1689 patients were included in the analysis, of whom 272 (16.10%) expired, 205 (12.13%) were lost to follow up (LFU), 526 (31.14%) were transferred out to other facilities and 686 (40.63%) were alive at the end of two years. Majority (92%) of the deaths occurred in the first six months of therapy. Age >30 yr, male gender, poor functional status, haemoglobin level <11 g/dl, body weight <45 kg and CD4 count <100/μl at baseline had significantly higher relative hazard of death. Most LFU also occurred in the first six months and these patients had significantly low CD4 count, weight, haemoglobin level and higher number of patients in Stages III and IV as compared to those who survived.
Interpretation & conclusions:
The study findings revealed poor survival in the first six months of therapy especially in those with severe immunosuppression. This emphasizes the need for early enrolment into the programme. The high LFU occurring early after initiation of therapy suggests the urgent need to build an efficient patient retrieval system in the programme.
PMCID: PMC4277134  PMID: 25488442
Antiretroviral therapy; CD4; HIV/AIDS; survival analysis
21.  Th1 Stimulatory Proteins of Leishmania donovani: Comparative Cellular and Protective Responses of rTriose Phosphate Isomerase, rProtein Disulfide Isomerase and rElongation Factor-2 in Combination with rHSP70 against Visceral Leishmaniasis 
PLoS ONE  2014;9(9):e108556.
In visceral leishmaniasis, the recovery from the disease is always associated with the generation of Th1-type of cellular responses. Based on this, we have previously identified several Th1-stimulatory proteins of Leishmania donovani -triose phosphate isomerase (TPI), protein disulfide isomerase (PDI) and elongation factor-2 (EL-2) etc. including heat shock protein 70 (HSP70) which induced Th1-type of cellular responses in both cured Leishmania patients/hamsters. Since, HSPs, being the logical targets for vaccines aimed at augmenting cellular immunity and can be early targets in the immune response against intracellular pathogens; they could be exploited as vaccine/adjuvant to induce long-term immunity more effectively. Therefore, in this study, we checked whether HSP70 can further enhance the immunogenicity and protective responses of the above said Th1-stimulatory proteins. Since, in most of the studies, immunogenicity of HSP70 of L. donovani was assessed in native condition, herein we generated recombinant HSP70 and tested its potential to stimulate immune responses in lymphocytes of cured Leishmania infected hamsters as well as in the peripheral blood mononuclear cells (PBMCs) of cured patients of VL either individually or in combination with above mentioned recombinant proteins. rLdHSP70 alone elicited strong cellular responses along with remarkable up-regulation of IFN-γ and IL-12 cytokines and extremely lower level of IL-4 and IL-10. Among the various combinations, rLdHSP70 + rLdPDI emerged as superior one augmenting improved cellular responses followed by rLdHSP70 + rLdEL-2. These combinations were further evaluated for its protective potential wherein rLdHSP70 + rLdPDI again conferred utmost protection (∼80%) followed by rLdHSP70 + rLdEL-2 (∼75%) and generated a strong cellular immune response with significant increase in the levels of iNOS transcript as well as IFN-γ and IL-12 cytokines which was further supported by the high level of IgG2 antibody in vaccinated animals. These observations indicated that vaccine(s) based on combination of HSP70 with Th1-stimulatory protein(s) may be a viable proposition against intracellular pathogens.
doi:10.1371/journal.pone.0108556
PMCID: PMC4182492  PMID: 25268700
22.  Comparative proteomics and glycoproteomics of plasma proteins in Indian visceral leishmaniasis 
Proteome Science  2014;12:48.
Background
Visceral leishmaniasis (VL) is a deadly parasitic diseases caused by Leishmania donovani; it is a major health problem in many countries. A lack of proper understanding of the disease biology, poor diagnostic methods and increasing drug resistance are the main reasons for the growing burden of VL infection. Comparative plasma proteomics are a relatively useful technique that can be used to investigate disease-associated alterations that can help in understanding host responses against pathogens, and might be useful in disease management and diagnosis.
Result
In this study, a comparative proteomics and glycoproteomics approach using 2DE and 2D-DIGE was employed between early diagnosed VL patients of all age groups and healthy endemic and non-endemic controls in order to aid the recognition of disease-associated alterations in host plasma. Comparative proteomics was performed by the depletion of seven highly abundant plasma proteins. Comparative glycoproteomics was performed by the depletion of albumin and IgG, followed by purification of plasma glycoproteins using a multi lectin affinity column. From these two approaches, 39 differentially expressed protein spots were identified and sequenced using MALDI-TOF/TOF mass spectrometry. This revealed ten distinct proteins that appeared in multiple spots, suggesting micro-heterogeneity. Among these proteins, alpha-1-antitrypsin, alpha-1-B glycoprotein and amyloid-A1 precursor were up-regulated, whereas vitamin-D binding protein, apolipoprotein-A-I and transthyretin were down-regulated in VL. Alterations in the levels of these proteins in VL-infected plasma were further confirmed by western blot and ELISA.
Conclusions
These proteins may be involved in the survival of parasites, resisting neutrophil elastase, and in their multiplication in macrophages, potentially maintaining endogenous anti-inflammatory and immunosuppressive conditions. Consequently, the results of this study may help in understanding the host response against L.donovani, which could help in the discovery of new drugs and disease management. Finally, these alterations on protein levels might be beneficial in improving early diagnosis considering those as biomarkers in Indian VL.
Electronic supplementary material
The online version of this article (doi:10.1186/s12953-014-0048-z) contains supplementary material, which is available to authorized users.
doi:10.1186/s12953-014-0048-z
PMCID: PMC4179796  PMID: 25276097
Visceral leishmaniasis; Plasma glycoproteomics; MARS column; M-LAC column; 2D-DIGE; MALDI-TOF/TOF mass spectrometry
23.  Efficacy and Safety of Amphotericin B Emulsion versus Liposomal Formulation in Indian Patients with Visceral Leishmaniasis: A Randomized, Open-Label Study 
Background
India is home to 60% of the total global visceral leishmaniasis (VL) population. Use of long-term oral (e.g. miltefosine) and parenteral drugs, considered the mainstay for treatment of VL, is now faced with increased resistance, decreased efficacy, low compliance and safety issues. The authors evaluated the efficacy and safety of an alternate treatment option, i.e. single infusion of preformed amphotericin B (AmB) lipid emulsion (ABLE) in comparison with that of liposomal formulation (LAmB).
Methods
In this multicentric, open-label study, 500 patients with VL were randomly assigned in a 3∶1 ratio to receive 15 mg/kg single infusion of either ABLE (N = 376) or LAmB (N = 124). Initial cure (Day 30/45), clinical improvement (Day 30) and long term definitive cure (Day 180) were assessed.
Findings
A total of 326 (86.7%) patients in the ABLE group and 122 (98.4%) patients in the LAmB group completed the study. Initial cure was achieved by 95.9% of patients in the ABLE group compared to 100% in the LAmB group (p = 0.028; 95% CI: −0.0663, −0.0150). Clinical improvement was comparable between treatments (ABLE: 98.9% vs. LAmB: 98.4%). Definitive cure was achieved in 85.9% with ABLE compared to 98.4% with LAmB. Infusion-related pyrexia (37.2% vs. 32.3%) and chills (18.4% vs. 18.5%) were comparable between ABLE and LAmB, respectively. Treatment-related serious adverse events were fewer in ABLE (0.3%) compared to LAmB (1.6%). Two deaths occurred in the ABLE group, of which one was probably related to the study drug. Nephrotoxicity and hepatotoxicity was not observed in either group.
Conclusions
ABLE 15 mg/kg single infusion had favorable efficacy and was well tolerated. Considering the demographic profile of the population in this region, a single dose treatment offers advantages in terms of compliance, cost and applicability.
Trial Registration
www.clinicaltrials.gov NCT00876824
Author Summary
Visceral leishmaniasis (VL) is highly prevalent in northeastern India, particularly the state of Bihar and its bordering areas with Bangladesh and Nepal. The current standards of treatment, namely, miltefosine (oral) and pentavalent antimonials (parenteral) have long treatment durations and are faced with increasing resistance, decreased efficacy, low compliance and safety issues. In this regard, lipid formulations of amphotericin B (AmB) have become an attractive treatment option due to their high efficacy, shorter treatment regimens and favorable safety profiles. This Phase III study evaluated the efficacy and safety of preformed AmB lipid emulsion (ABLE) versus liposomal AmB (LAmB) (both 15 mg/kg single dose infusions) in the treatment of VL. ABLE showed favorable efficacy measured in terms of initial cure at Day 30/45, and overall clinical improvement. ABLE was well tolerated and its adverse event profile was consistent with previously documented findings. Based on the favorable efficacy and safety profile of ABLE, and considering the demographic profile of the population in the endemic region, a single dose treatment may offer advantages in terms of compliance, cost and applicability.
doi:10.1371/journal.pntd.0003169
PMCID: PMC4169371  PMID: 25233346
24.  Essential role of the cancer stem/progenitor cell marker nucleostemin for indole-3-carbinol anti-proliferative responsiveness in human breast cancer cells 
BMC Biology  2014;12:72.
Background
Nucleostemin is a GTPase residing in the nucleolus that is considered to be an important cancer stem/progenitor cell marker protein due to its high expression levels in breast cancer stem cells and its role in tumor initiation of human mammary tumor cells. It has been proposed that nucleostemin may represent a valuable therapeutic target for breast cancer; however, to date evidence supporting the cellular mechanism has not been elucidated.
Results
Expression of exogenous HER2, a member of the EGF receptor gene family, in the human MCF-10AT preneoplastic mammary epithelial cell line, formed a new breast cancer cell line, 10AT-Her2, which is highly enriched in cells with stem/progenitor cell-like character. 10AT-Her2 cells display a CD44+/CD24-/low phenotype with high levels of the cancer stem/progenitor cell marker proteins nucleostemin, and active aldehyde dehydrogenase-1 (ALDH-1). The overall expression pattern of HER2 protein and the stem/progenitor cell marker proteins in the 10AT-Her2 cell population is similar to that of the luminal HER2+ SKBR3 human breast cancer cell line, whereas both MCF-7 and MDA-MB-231 cells display reduced levels of nucleostemin and no detectable expression of ALDH-1. Importantly, in contrast to the other well-established human breast cancer cell lines, 10AT-Her2 cells efficiently form tumorspheres in suspension cultures and initiate tumor xenograft formation in athymic mice at low cell numbers. Furthermore, 10AT-Her2 cells are highly sensitive to the anti-proliferative apoptotic effects of indole-3-carbinol (I3C), a natural anti-cancer indole carbinol from cruciferous vegetables of the Brassica genus such as broccoli and cabbage. I3C promotes the interaction of nucleostemin with MDM2 (murine double mutant 2), an inhibitor of the p53 tumor suppressor, and disrupts the MDM2 interaction with p53. I3C also induced nucleostemin to sequester MDM2 in a nucleolus compartment, thereby freeing p53 to mediate its apoptotic activity. Small interfering RNA knockdown of nucleostemin functionally documented that nucleostemin is required for I3C to trigger its cellular anti-proliferative responses, inhibit tumorsphere formation, and disrupt MDM2–p53 protein–protein interactions. Furthermore, expression of an I3C-resistant form of elastase, the only known target protein for I3C, prevented I3C anti-proliferative responses in cells and in tumor xenografts in vivo, as well as disrupting the I3C-stimulated nucleostemin–MDM2 interactions.
Conclusions
Our results provide the first evidence that a natural anti-cancer compound mediates its cellular and in vivo tumor anti-proliferative responses by selectively stimulating cellular interactions of the stem/progenitor cell marker nucleostemin with MDM2, which frees p53 to trigger its apoptotic response. Furthermore, our study provides a new mechanistic template that can potentially be exploited for the development of therapeutic strategies targeted at cancer stem/progenitor cells.
doi:10.1186/s12915-014-0072-6
PMCID: PMC4180847  PMID: 25209720
nucleostemin; cancer stem/progenitor cell marker; indole-3-carbinol; elastase signaling; nucleostemin–MDM2 interaction; anti-proliferative response in breast cancer cell; tumor xenograft; tumorsphere
25.  Characterization and evaluation of amine-modified graphene amphotericin B for the treatment of visceral leishmaniasis: in vivo and in vitro studies 
Amphotericin B (AmB) has been the first-line treatment for visceral leishmaniasis (VL), a neglected protozoan disease, especially in regions like Bihar, India, where resistance to antimonials is widespread. However, adverse drug reactions are a major limiting factor. We evaluated a novel formulation of AmB conjugated to amine-modified graphene (f-Gr) for safety and efficacy over conventional AmB. The f-Gr was prepared in a gentle one-step process of noncovalent (amine) functionalization with the help of amino acid L-cysteine. This f-Gr was further conjugated to AmB by peptide bond. The conjugate (f-Gr-AmB) was characterized by Raman spectroscopy, Fourier transform infrared spectroscopy, scanning electron microscopy, and transmission electron microscopy. f-Gr-AmB was found to exhibit lesser cytotoxicity toward J774A.1 cells than AmB, and did not induce any hepatic or renal toxicity in Swiss albino mice. In vitro antileishmanial assay in J774A.1 cells showed significantly enhanced efficacy of f-Gr-AmB over AmB. Furthermore, percentage inhibition of amastigote replication in a hamster model of VL was significantly higher in the f-Gr-AmB treated group (87.8%) compared to the AmB group (70.4%). These results suggest that f-Gr-AmB could be a safe and effective alternative to conventional AmB in the treatment of VL.
doi:10.2147/DDDT.S63994
PMCID: PMC4159315  PMID: 25214767
antileishmanial; efficacy; cytotoxicity; macrophage; Raman spectroscopy; amastigote

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