Clinical response of newly diagnosed HIV seropositive & seronegative pulmonary tuberculosis patients with the RNTCP Short Course regimen in Pune, India.

Background & objectives In the Revised National Tuberculosis Control Programme (RNTCP) in India prior to 2005, TB patients were offered standard DOTS regimens without knowledge of HIV status. Consequently such patients did not receive anti-retroviral therapy (ART) and the influence of concomitant HIV infection on the outcome of anti-tuberculosis treatment remained undetermined. This study was conducted to determine the results of treatment of HIV seropositive pulmonary tuberculosis patients with the RNTCP (DOTS) regimens under the programme in comparison with HIV negative patients prior to the availability of free ART in India. Methods Between September 2000 and July 2006, 283 newly diagnosed pulmonary TB patients were enrolled in the study at the TB Outpatient Department at the Talera Hospital in the Pimpri Chinchwad Municipal Corporation area at Pune (Maharashtra): they included 121 HIV seropositive and 162 HIV seronegative patients. They were treated for tuberculosis as per the RNTCP in India. This study was predominantly conducted in the period before the free ART become available in Pune. Results At the end of 6 months of anti-TB treatment, 62 per cent of the HIV seropositive and 92 per cent of the HIV negative smear negative patients completed treatment and were asymptomatic; among smear positive patients, 70 per cent of the HIV-seropositive and 81 per cent of HIV seronegative pulmonary TB patients were cured. Considering the results in the smear positive and smear negative cases together, treatment success rates were substantially lower in HIV positive patients than in HIV negative patients, (66% vs 85%). Further, 29 per cent of HIV seropositive and 1 per cent of the HIV seronegative patients expired during treatment. During the entire period of 30 months, including 6 months of treatment and 24 months of follow up, 61 (51%) of 121 HIV positive patients died; correspondingly there were 6 (4%) deaths among HIV negative patients. Interpretation & conclusions The HIV seropositive TB patients responded poorly to the RNTCP regimens as evidenced by lower success rates with chemotherapy and high mortality rates during treatment and follow up. There is a need to streamline the identification and management of HIV associated TB patients in the programme with provision of ART to achieve high cure rates for TB, reducing mortality rates and ensuring a better quality of life.

Diagnosis of spontaneous bacterial peritonitis: Role of tween 80 and triton X in ascitic fluid cultures.

A patient with alcoholic cirrhosis of the liver, portal hypertension with hepatic encephalopathy and spontaneous bacterial peritonitis (SBP) was admitted in an obtunded condition. Attempts at delineating the aetiology of the SBP using conventional cultures as well as automated systems were not successful. The use of non-anionic surfactant agents such as Tween 80-incorporated blood agar and Triton X treatment of the specimens facilitated the growth of Klebsiella pneumoniae from the ascitic fluid, which otherwise would have been concluded to represent culture-negative neutrocytic ascites. Thus, the use of the aforementioned agents could be explored in elucidating the aetiology of body cavity infections when conventional methods fail.

Modified PAP method to detect heteroresistance to vancomycin among methicillin resistant Staphylococcus aureus isolates at a tertiary care hospital.

This study was an attempt at developing, establishing, validating and comparing the modified PAP method for detection of hetero-vancomycin resistant Staphylococcus aureus (h-VRSA) with the routine antimicrobial susceptibility testing (using the BSAC standardized disc diffusion method), minimum inhibitory concentrations of vancomycin using standard E-test methodology and the Hiramatsu's screening method. A total of 50 methicillin resistant Staphylococcus aureus obtained from various clinical specimens, along with the Mu 3 and Mu 50 strains as controls, were studied. No VRSA isolates were obtained. However, four of the test strains were positive by the Hiramatsu's screening method, of which only one isolate could be confirmed by the modified PAP analysis method. This isolate was a coloniser from the drain fluid of a liver transplant recipient. The sensitivity, specificity, positive predictive value and the overall efficiency of the Hiramatsu's screening method with the modified PAP analysis as the gold standard were found to be 100, 93.8, 25 and 94%, respectively. It is very essential for clinical laboratories to screen for h-VRSA, given the increasing use of glycopeptide antibiotics in therapy and the potential for failed therapy in patients infected with these strains.

A case of acute myeloid leukemia-M2 with trisomy 4 in addition to t(8;21).

t(8;21)(q22;q22) is the most frequently observed karyotypic abnormality associated with acute myeloid leukemia (AML), specifically in FAB-M2. Short-term unstimulated bone marrow (BM) and peripheral blood lymphocyte culture showed 47,XX, +4,t(8;21) in all metaphase plates; and interphase and metaphase results of AML-ETO fusion was positive and trisomy of 4 was confirmed with WCP probes. Trisomy 4 in AML with t(8;21) is a rare numerical abnormality. Here we present such case of patient which may constitute a distinctive subtype.

Cyclosporiasis in an infant.

This report describes cyclosporiasis in a seven month old infant who presented with incessant crying and refusal of feeds. The routine modified ZN stained smears showed the oocysts of Cyclospora when all other tests failed to reveal enteric pathogens. The need for the clinical laboratory to screen faeces samples for all possible pathogens in a given clinical situation needs to be emphasized.

Separation and recovery of radioactive and non-radioactive toxic trace elements from aqueous industrial effluents.

An update is presented on liquid membrane-based processes as viable and relevant alternatives to conventional approaches such as precipitation, solvent extraction, ion exchange processes and electrochemical techniques for the removal and recovery of some toxic and/or valuable trace metal ions including some actinides and fission products e.g. U, Am, Y etc and As, Cd, Co, Cr, Cu, Hg, Ni, Pb, Zn etc from radioactive as well as non-radioactive aqueous waste solutions respectively. In particular, results of experiments aimed at developing supported liquid membrane(SLM)-based process using commercially available porous membranes and indigenously prepared track--etch membranes (TEMs) have been critically examined in laboratory studies to generate basic data needed to evaluate their utility for continuous operation without regeneration. These include effect of pore size, porosity, optimum pore size and their reusability. It is clearly demonstrated that indigenously prepared 10 microm thick TEMs with a porosity in the range of 2-5% give comparable transport rates for metal ions-matching with that of commercial membranes of much higher thickness (160 microm) and higher porosity of 60-85%. The smaller thickness of TEMs more than compensates for their lower porosity. It is shown that because of their well defined pore characteristics TEMs could serve as model supports in SLM studies. By comparing the values of permeability coefficient (P) for TEM and polytetraflouroethylene (PTFE) supports for the transport of Pb2+ chosen as a typical divalent metal ion, and using di-2 ethyl hexyl phosphoric acid (D2EHPA) as the carrier, it is unambiguously proved that diffusion of the metal complex across the membrane is the rate controlling step in metal ion transport in SLM-based processes. An overview of the experimental findings along with future outlook and suggestions for further work are presented in this paper.

Polymerase chain reaction based diagnosis of systemic fungal infections and sensitivity testing of the fungal isolates.

PURPOSE: To highlight the usefulness of polymerase chain reaction (PCR) for the rapid diagnosis of systemic fungal infections. METHODS: Clinical samples were collected from 50 clinically suspected cases of systemic mycosis and subjected to smear, culture, antifungal sensitivity and PCR (based on 18S rRNA gene). RESULTS: Of the 50 clinical specimens tested by PCR, 39 were found to be positive. PCR gave more positive results than smear and culture examination. Out of the 50 clinical specimens 35 were found to be fungal culture positive. The sensitivity testing results of these fungal isolates showed that there was a good correlation between the in vitro results and the clinical response of the patient to antifungal therapy. Itraconazole exhibited maximum antifungal activity followed by fluconazole, ketoconazole and amphotericin B. CONCLUSIONS: PCR technology provides rapid and accurate diagnosis of fungal infection, however, it must be used with caution to avoid false positives.

Diabetes mellitus in Dombivli--an urban population study.

OBJECTIVE: The present study was undertaken with the following aims and objectives. a) To determine the prevalence of diabetes. b) To compare the prevalence of newly diagnosed diabetic subjects, diagnosed by the ADA and WHO criteria. c) To determine to what extent prevalence rates are affected by gender, age and body mass index. METHODS: The study population consisted of 520 subjects aged 20 years and above selected by random sampling. Blood glucose both fasting and post glucose (75 gms) two hours sample were analyzed. Baseline clinical data like height, weight and blood pressure were recorded. Known cases of diabetes were excluded from the study. RESULTS: The prevalence of diabetes (fasting blood glucose) as per WHO criteria was 4.61% while it was 7.5% as per ADA criteria. The prevalence according to the two hour glucose reading was 6.15%. The mean glucose level increase with age. With increasing BMI the percentage of diabetic subjects also increases. The prevalence of impaired glucose tolerance (IGT) was 8.6% in subjects below 50 years and 13.4% in subjects older than 50 years. IGT values also increase with increasing age and BMI. 1.3% of subjects had normal fasting glucose level (< 126 mgm%) but high post glucose levels (> 200 mgm%). CONCLUSIONS: The prevalence of diabetes and IGT is higher as compared to earlier studies. The mean blood glucose and IGT increase with increasing age and BMI. Several subjects had normal fasting blood glucose but increased two hour blood glucose level indicating that fasting glucose alone should not be used to diagnose DM. Urbanization and life style of residents of Dombivli contribute to the high prevalence.

L-carnitine moderately improves the exercise tolerance in chronic stable angina.

OBJECTIVES: To study the safety and efficacy (with reference to exercise ECG testing) of oral L-carnitine in chronic stable angina. METHODS: Forty-seven patients, 30 men and 17 women, aged 56 +/- 8 years, were randomized to receive L-carnitine (n = 28) or placebo (n = 19) in the dose of 2 g/day for 3 months. The adjuvant treatment was not changed during the study. Patients were evaluated by computerized stress test (CST) done at the beginning and end of the trial. The parameters assessed were exercise duration, time to onset of ST changes, total ST score at peak exercise, rate-pressure product at peak exercise, and time needed for the ST changes to recover to baseline. RESULTS: The two groups were comparable at the beginning of the study. There was no change in the CST parameters in the placebo group at the end of 3 months. In the L-carnitine group there was a statistically significant improvement in the exercise duration from 7.8 +/- 2.2 min to 8.6 +/- 1.8 min (p = 0.006) and in the time needed for the ST changes to revert to baseline from 7.2 +/- 3.9 min to 5.7 +/- 3.8 min (p = 0.019). No change was noted in the time to onset for ST depression, ST score and double product. There were no systemic adverse effects or coronary events in either group. CONCLUSION: Oral L-carnitine is safe and moderately improves the duration of exercise and time to recovery of ST changes in patients with chronic stable angina.

Radiofrequency ablation: a cure for tachyarrhythmias.

Radiofrequency (RF) ablation is a new modality of pennanently curing patients with various tachycardias using radiofrequency energy, a technique evolved in the past decade. RF ablation was performed on 913 patients with different tachyarrhythmias from April, 1994 to July, 1999. There were 491 men and 422 females aged 42 +/- 34 years (range 1 to 76 years). Supraventricular tachycardia (SVT) was present in 462 patients, accessory pathway mediated atrioventricular re-entrant tachycardia (AVRT) in 355 patients (377 accessory pathways) and idiopathic ventricular tachycardia (VT) in 96 patients. Amongst the patients with SVT, 402 had atrioventricular nodal re-entrant tachycardia (AVNRT), 22 had atrial flutter, 20 had ectopic atrial tachycardia and 18 had atrial fibrillation. RF successfully abolished the tachycardia in 400/402 patients (99.5%) with AVNRT, 330/377 (87.5%) accessory pathways in patients with AVRT, 14/22 patients (63.6%) of atrial flutter, 18/20 patients (90%) of atrial tachycardia and 79/96 patients (82.3%) with idiopathicVT. Successful AV nodal ablation with pacemaker implantation was done in 10/18 patients with chronic atrial fibrillation with fast ventricular rate and tachycardia induced cardiomyopathy. AV nodal modulation for atrial fibrillation was tried in the remaining 8 patients and was successful in 4 (4/8). The overall success rate for all arrhythmias was 93.6%, and there was no mortality. At a follow-up of 6.8 +/- 5.4 months, there was a recurrence in 34/420 patients (8%), in whom successful re-ablation was performed. One patient with AVNRT and another with a parahisian pathway developed complete heart block and were given pacemakers. One patient developed inferior wall infarction on the next day post RF. There were 4 patients who had pericardial tamponade necessitating pericardiocentesis and 2 patients developed deep vein thrombosis, which was treated conservatively. Thus RF ablation is an effective, safe and curative therapy for various arrhythmias.

Does left ventricular function improve with L-carnitine after acute myocardial infarction?

A double blind randomized placebo controlled clinical trial was carried out to assess the efficacy and safety of L-carnitine in patients suffering from acute anterior wall myocardial infarction with respect to left ventricular function. Sixty patients (34 men, 26 women, mean age 56+11 yr.) with acute anterior wall myocardial infarction were randomized to placebo and L-carnitine. All the patients were given intravenous L-carnitine / placebo in the dose of 6gm/day for the first seven days followed by oral L-carnitine / placebo 3 gm/day in three divided doses for a period of three months. Echocardiography was performed for regional wall motion abnormality, left ventricular end systolic volume (ESV), end diastolic volume (EDV) and ejection fraction (EF) on admission, after seven days and after three months of the infarction. Forty-four patients completed the study. There were three deaths, two in the placebo and one in the L-carnitine group (p>0.05). Thirteen patients were lost to follow up. Echo parameters in both groups were comparable (p>0.05). The duration of chest pain prior to initiation of the I.V. L-carnitine was 7.5 + 5.2 hrs in the L-carnitine group and 7 + 4 hrs in the placebo group (p>0.05). There was no statistical difference in the EF, ESV and EDV on admission, at discharge and after three months in the L-carnitine and the placebo groups (p>0.05). No significant adverse effects were noted. L-carnitine, though a safe drug, does not affect the left ventricular function in patients with myocardial infarction.

Sickle cell syndromes in and around Bardoli.

The study comprised of 2 groups. In group I sickling test was done in students studying in a school which mainly caters to the educational needs of the backward community. Out of 130 students examined 24 were found to be sicklers. The distribution of this cases among various castes/tribes were as follows--Choudharys (Cd)-13, Gamits (Gt)-4, Dhodhia Patels (DP)-4, Koknis (K)-2 and Koli Patel (KP)-1. In group II, patients admitted in the hospital between Jan '81 to June '82 were studied. The prevalence of sickle cell syndrome was 1.74%. The most common mode of presentation were limb pains and weakness. Hemoglobin values ranged from 3.0 gram% to 12 gms%. 35 cases of HbSS, 149 cases of HbAS and 1 case of Sickle Beta thalassemia were seen. The distribution of the cases amongst the various tribes and castes were as follows-Cd-93, Gt-56, DP-23, KP-7, K-4 and Rathods (R)-2. No cases were found in Anavil Brahmins or Patidar Patels. Clinical and pathological observations included palpable splenomegaly in 54 cases, splenic abscess in 1 case, isothenuria in large number of patients, microscopic hematuria in 6 cases and frank hematuria in 1 case. Osteomyelitis and cholecystitis were seen in one case each.

Myelodysplastic syndrome. A clinical and pathological analysis of 88 patients.

Eighty eight patients with myelodysplastic syndromes were studied to determine the clinical and pathological features and the prognosis. All the patients had anemia. Neutropenia was seen in 44% and thrombocytopenia in 78% patients. The subtypes included refractory anemia in six, refractory anemia with ringed sideroblasts in three, refractory anemia with excess blasts in 30, refractory anemia with excess blasts in transformation in 32 and chronic myelomonocytic anemia in 17 patients. Forty four patients who received chemotherapy were evaluable for response. Three of the 15 patients treated with hydroxyurea achieved partial remission. Eighteen patients were treated with low dose cytosine arabinoside and complete remission was achieved in five and partial response in six patients. Aggressive chemotherapy was given to 11 patients at the onset of the illness resulting in complete remission in six and partial response in two patients. Nineteen of the 88 patients transformed to acute myeloid leukemia. The crude survival of all the patients ranged from 15 days to 22.5 months. The mortality was due to hemorrhage in 15% and septicemia in 85%. Our data reveals ineffectiveness of the current therapy and emphasizes on the need to develop newer therapeutic approaches.