Today's researchers attempt to zoom much further into the cell. They seek to probe and image the wheels and cogs of all living systems - biomolecules. Since these molecules are typically nano-sized, this is no easy feat. Most optical tools are limited by the infamous diffraction limit, which only allows them to discern details larger than half the wavelength of light, almost of the order of microns. Researchers have developed ingenious tools that overcome this constraint and capture the nano-world. One such invaluable technique is fluorescence spectroscopy. Biochemists discovered a whole host of fluorescing molecules that can be chemically coupled to particular proteins. These molecules act as markers that allow researchers to "see" proteins as they move and interact.

The fluorescence signal does suffer from fluctuations or noise as a consequence of changes and thermal motions in the tagged system. A smart statistical physics based technique called Fluorescence Correlation Spectroscopy (FCS), uses this very noise to uncover a wealth of quantitative information about the system. The fluctuations in the fluorescence are recorded as a function of time. Several parameters related to the underlying physical properties are extracted from this data. Some examples include the number of molecules (or sample concentration) and their size. FCS works best when a very small volume of solution is in focus, keeping the spotlight on a few molecules diffusing in and out of that volume. "The technique and the ideas are old, from the 70s, but we have been able to make instruments in the lab, from scratch, which measure very little volume with incredible sensitivity", said Dr. Maiti, a professor in the Department of Chemical Sciences at Tata Institute of Fundamental Research, Mumbai.

What's more, FCS can be combined with a variety of techniques to measure different physical properties. One example is Fluorescent Resonance Energy Transfer (FRET), a popular technique, in which molecules are tagged with two different "labels" that talk to each other. The strength of their communication depends on the separation between them and is a way of very accurately measuring distances of the order of nanometers. Using this combination of techniques, Dr. Maiti and his colleagues have made some important discoveries about the anomalous aggregation of the amyloid beta protein, which has been implicated as the cause of Alzheimer's disease. "There is a persistent suspicion that as the aggregation happens, it is actually the folding underneath that is changing, making a stable monomer into an unstable, sticky monomer," he said. As these sticky monomers clump together, the particle sizes multiply and they become more cumbersome and slow down. FCS picks up this lowered speed, and can monitor the aggregation as it happens. Meanwhile, the change in the protein's conformation can be inferred by monitoring the distance between its ends using FRET.

One heartening revelation from Dr. Maiti's experiments is that the process of aggregation, which makes the protein toxic, is actually reversible. His research team found that small aggregates of a few proteins spontaneously unravel into monomers given sufficient time. One can now ask whether this reversal can be speeded up by a catalyst, some possible candidate for a drug. But a recent discovery brings less welcome news. Until now, scientists suspected that toxicity sets in when there are aggregations of 10 or more monomers. However, very recent measurements by Dr. Maiti and his group show that these small aggregates, the dimers and trimers, show a propensity to attach to cells, an ominous sign of increased bio-activity and toxicity. So they may cause harm before they have time to revert back to their docile selves. These are but glimpses of the protein's mis-behaviour. To effectively arrest their errant ways, we need a clearer picture, an atomic level understanding of their structure. "I know already that they fold differently, but I can't quite visualize that," said Dr. Maiti. An age-old technique could help do just that.

Raman spectroscopy is a well-established optical method that can be used to investigate a material's atomic structure and chemical composition from the unique way it scatters light. Unfortunately, it is not a very sensitive technique, especially for biomolecules, many of which scatter light rather weakly. Ten years ago, researchers found that attaching samples to a specially prepared metallic surface, made a huge difference. Nano-sized irregularities on the surface enhance the light's electric field, which consequently magnifies the output Raman signal by many orders of magnitude, making it possible to probe even single molecules. Dr. Maiti and his collaborators hope to use this technique to map the detailed structure of the wayward protein.

Scientists continue to add new twists to other old technologies, tailoring them to meet current research needs - even to that old workhorse, the microscope. After three centuries of pioneering work that have made it tremendously powerful and sophisticated, there is still, room for improvement. "As a physicist, I think there is a huge amount of physics left to be explored and exploited in microscopy," says Dr. G. V. Pavan Kumar, assistant professor in the Department of Physics at IISER, Pune. His work continues the legacy of physicists before him whose efforts have helped overcome its limitations through the ages.

Biological samples are largely transparent and staining them with contrast agents was one way to make them visible to microscopes. But this required the specimens to be killed and fixed before staining. Was there a way to look at living cells? Transparent samples that don't affect light amplitude, diffract light and modify its phase, which is imperceptible to our eye. The Dutch mathematician and physicist, Frits Zernike, discovered a method to convert these phase changes into contrasts in intensity, which we can see. By means of a special disk and a phase plate, he separated and increased the phase difference between direct light and light diffracted by the specimen. The subsequent interference of the separated light waves resulted in a visible amplitude contrast.

Until recently, phase-contrast was a qualitative method to see cells and tissues non-invasively. Efforts are now focused on extracting quantitative information from the phase change. Several experimental approaches are being tried. Dr. Pavan Kumar and his colleagues are currently dabbling with one such state-of-the-art technique, which could benefit both material science and biology. They have technology that can tailor a phase pattern into the light shone on the sample. The diffracted light whose phase is modified by the sample, is compared with a reference beam by interference, and phase difference information is extracted, from which a very accurate image of the sample is constructed. The image has information about cellular structures and motions on a nanometer scale. "Among other things, this is a method of label-free imaging, which has great advantages in biology," says Dr. Kumar.

The ongoing quest for nanoscale clarity has many takers. Maybe not drapers any more, but certainly chemists, physicists and engineers among others. Their efforts will go a long way in furthering our understanding of the wonderful mechanisms of biology and hopefully, give us ways to correct those that go wrong. Biology, however, is not merely a muse for innovators. After all, it has been experimenting with the nano-world eons longer than us and has learnt a trick or two, which we can only hope to mimic.

Many of us are guilty of having popped in antibiotics for an infection after a quick self-diagnosis. Amoxicillin for UTI, erythromycin/tetracycline for Strep throat or even a cold, are fairly common. Antibiotics are ineffective for cold or other viral infections, but this is not common knowledge. There is definitely a certain convenience and ease associated with unregulated availability of antibiotics, but it also leads to a huge menace – development of antibiotic resistance among bacteria. Though, this will affect the health of just about everyone, there is not much that is being done to curb such rampant antibiotic use/abuse. However, things are going to change from now on… maybe I should say hopefully going to change.

At a recent conference of Clinical Infectious Disease Society (CIDS), in Chennai on 25^th to 26^th August, it was decided that the India's drug regulators would put restrictions on the sale of antibiotics. This of course is not new, there are over 536 drugs that require prescriptions for sale in India and antibiotics fall into that list. The proposal now is to treat antibiotics, especially some of the broad spectrum ones such as Carbapenems within a special category, which will have prominent red labels¹. Their sales will also be monitored via surprise inspections of pharmacies. Though useful, going a step further and restricting their availability only within hospital pharmacies would also be a good idea, as monitoring will then become easier. Restricting drug availability though, has its downslide: health care is not amply available in rural India and wherever it is the centers are not well staffed. Which means, pharmacies, if they exist, are the resident's best bet to treatment. So regulating antibiotic availability seems to be a double-edged sword.

Either way, it is a start for a country that is not only endemic to many infectious diseases but is also faced with a massive threat of emerging drug resistance among bacteria. Multidrug resistant, Mycobacterium tuberculosis is spreading, so is artemisinin resistant Malaria. A new resistant gene isolated from a patient hospitalized in New Delhi with Klebsiella pneumoniae infection, in 2010 is causing concern among clinicians. This gene dubbed – New Delhi metallo-ß-lactamase (NDM-1) is present on a plasmid and easily transferrable across species². The gene confers bacterial resistance to a broad range of antibiotics including Carbapenems.

Carbapenems belong to the same class of antibiotics as penicillin and cephalosporin: ß- lactam. They are, however, unique in many ways, the structure of carbapenems, makes them highly resistant to most ß-lactamases that render penicillin and other similar antibiotics ineffective. In fact, in some cases they can even act to inhibit ß-lactamases³. Unlike the traditional ß-lactams, the carbapenems are effective against a broad spectrum of Gram negative and Gram-positive bacteria. These are undeniably the best drug in our armory against the bacteria and clinically, they have often been used as a last resource against multidrug resistance infections. Therefore, it is not surprising that the emergence of strains such as the NDM is alarming.

Another point of concern is that unlike in the western countries, where multi-drug resistance is still largely restricted to hospitals, in India, many resistant bacteria are found in community infections. To add to the concern is the fact that much of this resistance is developing within the Gram Negative group of bacteria. This group traditionally has lesser antibiotics available for treatment. There aren't many drugs in the pipeline against the Gram Negatives (also see related article by Pavan).

It is possible for us to make a concerted effort and prevent further spread of antibiotic resistance bacteria. That is exactly what a report by the Global antibiotic resistance partnership (GARP)⁴-India says. This group chaired by Professor Nirmal Ganguly, carried out a situation analysis of antibiotic use in India. The main aim was to develop implementable policy proposals as well as create awareness of a worldwide threat. The report outlines the situation, as it exists in India, pointing out key issues related to development of antibiotic resistance and the measures that need to taken to combat it. Dr. Ramasubramanium touches upon some of these in his article. Some of the interventions mentioned in the report include – Vaccination, safety protocols in hospitals, and public education.

As the GARP-India committee points out in the report⁴, the benefit of vaccines in saving antibiotics is often overlooked. Vaccines against bacterial diseases such as Hemophilus influenzae (HiB), S. pneumoniae (which cause Pneumonia), and V. Cholerae (cholera) could effectively save lives, increase health and as a bonus minimize the use of antibiotics. Moreover, vaccinations are already part of a widespread public health agenda, therefore the investments –both manpower and infrastructure, required to inform and promote bacterial vaccines will be far less.

Vaccinations, coupled with increased control of hospital acquired infections by following safety rules and protocols (this one needs clarification). The most simple and effective of these is washing hands before seeing a new patient or collecting a sample. This can prevent or minimize spread of infections. The same applies to the use of gloves, in the name of judicious use, the same glove is used over long period of time, worn, removed and re-worn. Such mis-use defies the purpose of gloves, which is to prevent the contact with the sample.

Finally, an aspect that cannot be stressed upon enough is educating both the healthcare workers as well as the public about the proper use of antibiotics. The emerging antibiotic resistance though a threat can still be controlled. The life span of the available antibiotics can be extended by the adopting ways that would involve not just drug regulation authorities, but scientists, pharma & biotech industry, public health workers and the general public to work together to circumvent this threat.

Further reading:

1. Erica Westly, India moves to tackle antibiotic resistance, Nature, Sept. 13, 2012
2. Kumaraswamy et al., Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study, Lancet Infect Dis. 2010 September; 10(9): 597–602.
3. Papp-Wallace et al, Carbapenems: past, present, and future, Antimicrob Agents Chemother. 2011 Nov;55(11):4943-60.
4. http://www.cddep.org/projects/global_antibiotic_resistance_partnership

Telemedicine obviously has the biggest impact in rural areas considering that the mobiles cover 83% of Indians². When employed telemedicine can reduce infant and maternal mortality by 90% by sending text reminders about immunization, helping diagnose pregnancy complications and providing timely intervention to contain diarrhoea, pneumonia in new born infants This is an area where the government has invested money while the private sector implements it via point of care stations e.g. Narayana Hrudayalaya’s tele cardiology is supported by the Karnataka Government and ISRO³. Such public private partnerships have been forged in Tripura, Bihar and Uttar Pradesh. Sanjay Sharma, the Executive Director at APTA Healthcare Advisers, points out the work by World Health Partners, one of the private players that has been particularly successful in Uttar Pradesh. They have trained people traditionally engaged in healthcare to be Sky care providers, set up rural kiosks and established an ecosystem of entrepreneur-run Sky Health centers. The care providers perform first line diagnosis and refer the needy to health centers. Doctors in Delhi are wired to these health centres. The consultation charge ranges from Rs. 10 to 50 making it affordable.

Other key players include Apollo hospitals, Fortis, AIIMS, Aravind eye care, Sankara Nethralaya and Narayana Hrudayalaya. Narayana Hrudayalaya has treated over 30,000 cardiac patients making it World’s largest tele-cardiology programme⁴ .

However, not all is rosy as it seems. For telemedicine to be widely implemented, it has to be profitable to both vendors and patients. Bandwidth costs, training and maintaining personnel at the point of care centre increase costs while confidence of the patient is low when the doctor untrained in tele-health attends to them. “Lack of focus on training the technical staff and lack of domain knowledge with the policy makers on the subject has been a big hindrance in evolution of telemedicine” adds Rajendra Gupta, Member of Advisory Group at Ministry of Health & Family Welfare. Sanjay points out that unless tele-health teaching modules are incorporated during medical Studies, it would be hard to get doctors accustomed to practicing tele-health since the majority of senior doctors do not do so.

However there are reasons to be optimistic considering the promising results achieved in maternal and infant mortality and eye care segments. Aravind eye care looked at over 2.5 lakh cases last year alone through telemedicine and has brought down the cost of consultation from Rs. 350 to Rs. 147 while Shankar Nethralaya looked at 2 lakh cases between 2008-2010.

So how does the future of telemedicine look like? Technavio’s Global Telemedicine Market 2010-2014 report forecasts the growth of global telemedicine market at 19% Compounded Annual Growth rate. Yet another report (Telemedicine Market in Brazil, Russia, India, China) estimates a market size of $418.4 million by the year 2014 in BRIC countries. This means the monetary opportunity is large enough for both existing and new players. Simple top of the head calculations also point to the immense market potential. If one considers the 1 billion population and assumes 50% need to consult a specialist doctor once a year, that gives 500 million. Now even if 1% of these consultations were to occur via telemedicine that would be a whooping 5 million cases.

Telemedicine can also be useful in addressing gaps in Psychiatry where, the doctor to patient ratio is an appalling 1: 1,00,000 or in management of chronic diseases like diabetes where daily or regular intervention can help make lifestyle changes and manage the disease better or expand in new areas such as tele-dermatology and tele-surgery. Development of mobile both, phones and portable devices monitoring vital clinical signs will spur tele-monitoring to reduce emergency situations by supporting timely clinician intervention.

Perhaps what we will see in the future is telemedicine working as,

1. an enabler and a feeder system to the existing hospital network
2. mitigating the number of emergencies by providing rapid diagnosis, point of care solutions and continuous monitoring
3. catalyzing disruptive innovations in medical devices, monitoring, mobile technology
4. a reason around which an ecosystem comprising of health kiosks, pharmacies and lab services will be built.

References:

1. http://www.who.int/macrohealth/action/en/rep04_india.pdf
2. http://articles.economictimes.indiatimes.com/2012-07-18/news/32731028_1_mobile-internet-mobile-phone-mobile-payments
3. http://casi.ssc.upenn.edu/system/files/Public-Private+Partnerships+for+Health+Care+in+Punjab+-+Nirvikar+Singh+(CASI+Working+Paper)_1.pdf
4. http://www.narayanahospitals.com/services/telemedicine/introduction/

I like to thank Rajendra Gupta and Sanjay Sharma for their valuable inputs.