Vertebral and Intraspinal Anomalies in Indian Population with Congenital Scoliosis: A Study of 119 Consecutive Patients

STUDY DESIGN: Retrospective case study by clinical and radiological data analysis. PURPOSE: To analyze different types of vertebral anomalies and the incidence of associated intraspinal anomalies in the Indian population. OVERVIEW OF LITERATURE: This is the largest study of congenital scoliosis and associated intraspinal anomalies in Indian population. Incidence of intraspinal anomaly in this series is 47% which is higher than previous literature. Hemivertebra was the most common anomaly as seen in previous studies. METHODS: A total of 119 patients with congenital scoliosis who underwent surgery between December 2006 and December 2012 were studied. Data was reviewed with medical records, plain radiographs, and magnetic resonance imaging (MRI) scans. RESULTS: Thoracolumbar curve was most common, seen in 43.6% of patients. In addition to scoliotic deformity, kyphosis was seen in 26% of patients. Failure of formation, the most common vertebral anomaly, was seen in 51.2% of patients, failure of segmentation was seen in 19.3% of patients, and there were 29.4% patients having both formation and segmentation anomalies. Hemivertebra was the most common vertebral anomaly seen in 66.3% of patients and for whom 63.2% were in thoracic spine. Intraspinal anomalies were associated with 47% of patients with congenital scoliosis. Tethered cord was the most common intraspinal abnormality and was found in 48.2% patients with intraspinal anomalies. The patients with failure of segmentation and mixed deformities were found to have a significantly higher incidence of intraspinal anomalies (65% and 57%, respectively) than those with failure of formation (34%). Out of 31 patients with kyphotic deformity 29% had intraspinal anomalies, and amongst them tethered cord was the most common anomaly seen in 66% patients. Out of 12 patients with neurocutaneous markers, 83% patients had intraspinal anomaly. CONCLUSIONS: Intraspinal anomalies were seen in 47% of patients with congenital scoliosis in the Indian population. Tethered cord was the most common intraspinal anomaly, seen in 48% cases of congenital scoliosis. Hemivertebra was seen in 66% cases and was the most common vertebral defect. Hence MRI imaging of whole spine should be done in all cases of congenital scoliosis before any surgical intervention. Special attention should be given to physical examination and visualization of any neurocutaneous markers, which are associated with a higher incidence of intraspinal anomalies; absence of a neurocutaneous marker, however, does not rule out intraspinal anomaly.

Pharmacokinetics of lamivudine & stavudine in generic fixed-dose combinations in HIV-1 infected adults in India.

Background & objectives: Antiretroviral drug concentrations are important determinants of clinical response to a drug accounting for both toxicity and efficacy. Several factors such as age, ethnicity, body weight and patients’ immune status may influence antiretroviral drug concentrations. The aim of the study was to determine the influence of immunological status, sex and body mass index on the steady state pharmacokinetics of lamivudine (3TC) and stavudine (d4T) in HIV-infected adults, who were undergoing treatment with generic fixed dose combinations (FDC) of these drugs in India. Methods: Twenty seven HIV-1 infected patients receiving antiretroviral treatment (ART) for at least two weeks at the Government ART clinic at Tambaram, Chennai, took part in the study. Serial blood samples were collected predosing and at different time points after drug administration. Plasma 3TC and d4T levels were estimated by HPLC. Results: The patients’ immune status, sex or body mass index had no impact on the pharmacokinetics of 3TC. In the case of d4T, peak concentration was significantly lower in patients with CD4 cell counts < 200 cells/μl than those with ≥ 200 cells/ μl (P < 0.05), but were within the therapeutic range. The mean CD4 cell counts increased from 101 cells/μl at initiation of ART to 366 cells/μl at 12 months of treatment. Interpretation & conclusions: Blood levels of 3TC and d4T drugs that are part of generic FDCs commonly used by HIV-infected individuals in India were within the therapeutic range and not influenced by nutritional or immune status. There was a significant improvement in CD4 cell counts over 12 months of treatment. Indian generic FDCs manufactured and used widely in the developing world provide effective concentrations of antiretroviral drugs.

Post-HAART tuberculosis in adult patients with HIV in India; Incidence, Clinical and Immunological profile.

Bacground: Highly Active Antiretroviral Therapy (HAART) was introduced in National AIDS Control Programme in 2004 to reduce the morbidity and mortality among those affected with HIV/AIDS. Tuberculosis, being an important coinfection, its emergence / occurrence in post-HAART period has potential implications. Objective:: Primary objectives were to study the incidence of post- HAART tuberculosis in HIV patients and to identify the possible risk factors. It was also intended to understand the clinical and immunological profile of this important condition. Methodology: Eligible adults and adolescents with HIV disease enrolled on HAART at Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, from April, 2004 to March, 2007, formed the study population. They were monitored and screened for the occurrence of tuberculosis after commencing HAART. Clinical details and immunological profile of these patients were analysed. Results: Two hundred and sixty-two patients (5.1%) of 5099 patients followed-up for one to four years were found to have Post HAART TB with 100-person year risk of 2.83. Post HAART TB occurred predominantly in men (67.6%) and in 31- 44 years age group (69.8%) with 100-person year risk being 3.26 and 2.83 respectively. Pulmonary, Extra-pulmonary and disseminated tuberculosis were found to occur in the frequencies of 78%, 16% and 6% respectively. A total of 144 patients (54.9%) developed tuberculosis within six months and this number increased to 202 (77%) by 12 months. 230 patients (87.7%) had base level CD4 cell count < 200 / mm3. Conclusion: Tuberculosis was found to occur pre-dominantly in adult male patients with HIV during the first year after the initiation of HAART. Significantly, occurrence of Post HAART TB remained almost the same (5%) among patients treated for TB prior to the initiation of HAART.

Demographic & clinical profile of HIV infected children accessing care at Tambaram, Chennai, India.

BACKGROUND & OBJECTIVE: Human immunodeficiency virus (HIV) is severely affecting the poorly educated and economically disadvantaged in Indian society. When children start developing clinical manifestations, needing treatment, they have to travel long distances for accessing care and support at tertiary institutions. This places an extra burden on patients, who are already struggling to cope with their illness. Sufficient data are needed for the government to evolve appropriate policy for providing care to the children affected with HIV. We undertook this study to present the socio-demographic characteristics, signs and symptoms, clinical profile, distance travelled and follow up pattern of HIV positive children who accessed care for the first time in a referral hospital at Chennai, India. METHODS: Electronic medical records from patients diagnosed with HIV between 2002 and 2004 at the Government Hospital for Thoracic Medicine (GHTM) in Tambaram (Chennai) in India were analyzed to understand care-seeking behaviours. Demographic variables such as age, sex, education and occupation, data on clinical manifestations were examined together with geographic information. RESULTS: At GHTM 1,768 new paediatric patients accessed care from 2002 to 2004. Children aged less than 5 yr were 49.9 per cent; 1115 children had (63%) tuberculosis. Significantly, 14.9 and 20.6 per cent children had extra-pulmonary TB and disseminated TB respectively. Lower respiratory infection (15.8%), Pneumocystis carinii pneumonia (15.20%), oral/oesophageal candidiasis (13.5%), wasting (6.1%) and diarrhoeal disorders (3.5%) were the common clinical manifestations. In all 47 per cent children traveled between 200-400 km from home and 14 per cent travelled over 400 km. INTERPRETATION & CONCLUSION: Our findings showed that tuberculosis should be regarded as the indicator disease for HIV infection in children, especially when they have clinical manifestations of progressive, non pulmonary and disseminated disease. The primary and secondary health care centres should have the trained capacity to diagnose and treat HIV disease and opportunistic infections so as the children to have much needed care and support nearer to their residence.

Effectiveness of Management of HIV-TB Patients Under Programme Conditions in India.

HIV patients, on antiretroviral therapy (ART), with co-existing tuberculosis patients were assesed for clinical and immunological progress at GHTM ART centre for effectiveness of management programme. Six hundred and twenty two HIV-TB patients are placed under both Anti-TB Treatment (DOTS) and ART. While 337 patients are continuing their ATT, details of the remaining 283 patients are provided. 214 patients (76%) completed their treatment successfully. 29 patients (10%) expired before completing treatment for TB and 40 patients (14%) were treatment defaulters. Immunologicallly CD4 cells registered significant increase from 101(mean) to 306 (mean) in 202 treatment-completed patients (p=.001). Linking HIV patients on ART to their nearest DOTS centres for treating tuberculosis is feasible. High Mortality, even before completing the prescribed course of ATT is attributable to low immunity and complicating opportunistic infections. Referral and linkage services shall be improved and strengthened for enhanced treatment adherence.

Long term follow up of HIV-infected patients with tuberculosis treated with 6-month intermittent short course chemotherapy.

BACKGROUND: Tuberculosis occurs in 60%-70% of HIV-positive persons in India. The outcome of HIV-positive patients treated with 6-month intermittent short course antituberculosis regimens in India is not well described. METHODS: This was a prospective observational feasibility study of 71 patients with HIV and tuberculosis who were treated with category I regimen of the Revised National Tuberculosis Control Programme (ethambutol, isoniazid, rifampicin and pyrazinamide thrice weekly for the initial 2 months followed by rifampicin and isoniazid thrice weekly for the next 4 months). Sputum was examined by smear and culture for Mycobacterium tuberculosis every month up to 24 months. Chest X-ray, CD4 cell count and viral load were done prior to and at the end of treatment. None of the patients received antiretroviral therapy. RESULTS: We present here the treatment response of patients with sputum culture-positive pulmonary tuberculosis to category I regimen. By efficacy analysis, among 43 patients treated with category I regimen, sputum smear conversion was observed in 79% and culture conversion in 82% at the second month. A favourable response was seen in 72% of patients. The mean (SD) CD4% fell from 12.6 (5.9) to 8.9 (4.9) (p < 0.001) with no significant change in mean (SD) CD4 cell count (169 [126] to 174 [158]; ns) at the end of treatment. Viral load change from 1.8 x 10(5) at baseline to 1.3 x 10(5) at the end of treatment was not statistically significant. Thirty-one patients, who completed the full course of treatment, were declared cured and were followed up for 24 months. Twelve had recurrent tuberculosis (39%); 16 of 43 (37%) patients had died by the end of 24 months, two-thirds due to causes other than tuberculosis. CONCLUSION: Though the early bacteriological response to intermittent short course antituberculosis regimen was satisfactory, the overall outcome was adversely affected by the high mortality (during and after completion of treatment) and recurrence rate among HIV-infected patients with tuberculosis. Immune status deteriorated in spite of antituberculosis treatment, highlighting the need for antiretroviral treatment in addition to antituberculosis treatment to improve the long term outcome. The results of this pilot study need to be confirmed by larger studies.

Miliary tuberculosis in human immunodeficiency virus infected patients not on antiretroviral therapy: clinical profile and response to shortcourse chemotherapy.

BACKGROUND: An increase in tuberculosis (TB) incidence has been associated with human immunodeficiency virus (HIV). AIMS: To describe the clinical characteristics and treatment outcome of patients with HIV and miliary TB treated with short-course intermittent chemotherapy in the absence of access to highly active antiretroviral therapy (HAART). SETTINGS AND DESIGN: Prospective study of HIV infected adults referred to a TB clinic between July 1999 and July 2004. MATERIALS AND METHODS: On diagnosis of miliary TB, patients were treated with a standard regimen of two months of isoniazid, rifampicin, ethambutol and pyrazinamide followed by four months of isoniazid and rifampicin (2EHRZ 3 /4RH 3 ) thrice weekly and followed up for 24 months. Patients were reviewed clinically every month and two sputa were collected. Chest radiographs and blood investigations were done at two months, end of treatment and every six months thereafter. RESULTS: Of 498 patients with HIV and tuberculosis, 31 (6%) were diagnosed as miliary tuberculosis. At diagnosis, sputum smear was positive for acid-fast bacilli (AFB) in 14 patients (45%) and Mycobacterium tuberculosis was isolated in 21 (68%). The mean CD4 cell count was 129 +/- 125 cells/mm3 . Twenty-five patients were declared cured at the end of treatment (81%) while one (3%) died and five (16%) failed. The recurrence rate was 19.4/100 person-years and the median survival was 17 months (95% CI 14 to 20). None of the patients received antiretroviral therapy. CONCLUSIONS: Miliary TB tends to occur among HIV infected patients with severe immunosuppression. Though the initial response to short-course chemotherapy was encouraging, a high recurrence rate and mortality was observed indicating poor prognosis in HIV.

Immune reconstitution syndrome in a child with TB and HIV.

Immune reconstitution syndrome (IRS) is the transient worsening or appearance of new signs, symptoms or radiological manifestation of an opportunistic infection occurring after the initiation of Highly active antiretroviral therapy (HAART) and is not due to treatment failure or new infection. We describe a case of a HIV infected child with tubercular (mediastinal) lymphadenitis with worsening of clinical and radiological features on starting HAART.

Translaminar facetal screw (Magerl's) fixation.

Translaminar facet screw fixation (TLFS) achieves stabilization of the vertebral motion segment by screws inserted at the base of the spinous process, through the opposite lamina, traversing the facet joint, and ending in the base of the transverse process. It is simple, does not require any specialized equipment, and has the advantages of being a procedure of lesser magnitude, lesser operative time, less cost and few complication rate. Recently there is growing interest in this technique to augment the anterior lumbar fusions to achieve global fusion less invasively. In this review article, we discuss the clinical and biomechanical considerations, surgical technique, indications, contraindications and recent developments of TLFS fixation in lumbar spine fusion.

Colonization of mycoplasma in the upper respiratory tract of AIDS patients with pulmonary symptoms in Chennai, India.

BACKGROUND & OBJECTIVE: Mycoplasmas have been implicated in causing minor to severe respiratory infections in man. Mycoplasmas are considered to act as cofactors in patients with AIDS. A preliminary study was conducted to isolate mycoplasmas from sputum specimens of AIDS patients and non-HIV patients with underlying pulmonary symptoms and signs. METHODS: A total of 130 sputum samples (100 from AIDS patients and 30 from non-HIV) were cultured on standard pleuropneumonia-like organisms (PPLO) glucose agar up to 3 wk. The plates were examined for the presence of fried-egg colonies characteristic of Mycoplasma. Subsequently the plates were stained using Diene's stain. Sputum specimens from the AIDS patients were also screened for other bacterial pathogens. RESULTS: Mycoplasmas were detected from 36 (36%) of the AIDS patients and only 5 (16.6%) of the non HIV control individuals with underlying pulmonary symptoms. Data on the detection rates of other microorganisms from the AIDS cases were also analysed. INTERPRETATION & CONCLUSION: This preliminary study provided supportive evidence that mycoplasma colonized in upper respiratory tract of individuals with AIDS to a larger extent than that of the non HIV subjects with pulmonary symptoms. Further studies need to be done to characterize mycoplasma isolates to species level.

Feasibility of Community DOT Providers for Tuberculosis Treatment in HIV infected individuals - A Pilot Study.

Background: This paper summarises our experiences about the role of community DOT providers in management of TB treatment in HIV infected persons in a mainly rural population of Tamilnadu. Objectives: To evaluate the feasibility of employing Community DOT providers for the treatment of tuberculosis in HIV infected persons, to study patients’ acceptance of Community DOT providers in the closely-knit village communities and to find out the attitude and awareness of DOT Providers on TB and DOT. Method: A total of 62 tuberculosis patients (58 males and 4 females) with HIV infection attending the Government Hospital for Thoracic Medicine, Tambaram and Chennai between July 1999 and July 2002 were selected for this study. Patients were given all the doses under supervision (clinic-based DOT) during the initial intensive phase and through Community DOT providers in the continuation phase. Data was collected both from the patients and their DOT providers about their views on DOT, advantages of DOTS, drug intake, treatment adherence, problems faced by the patients and their DOT Providers in addition to the level of awareness of Community DOT Providers on tuberculosis and DOTS. Results: Regarding treatment adherence, 95% of 62 patients had taken >75% of drugs and 39% had taken 100% drugs. DOT was appreciated both by the patients and their DOTS Providers since it is cost-effective and patient-friendly. Conclusions: Community contribution to TB care even among HIV infected population is feasible, affordable and costeffective. There is a need for greater health education and training on tuberculosis and DOTS for community DOT Providers.

Prevalence of acquired MDR-TB and HIV co-infection.

BACKGROUND: Mounting prevalence of primary and acquired multidrug-resistant tuberculosis in India is a sorry reminder of all round failure in our fight against tuberculosis and also of the necessity for new effective strategies. OBJECTIVES: (1) To assess the prevalence and pattern of drug resistant pulmonary tuberculosis among treated patients or on those on treatment without adequate response and (2) to evaluate HIV seropositivity among MDR-TB patients. METHODS: Pulmonary TB patients, who had at least six months of unsuccessful anti-tuberculous treatment were selected for the study. Their sputum specimens were examined for M. tuberculosis culture and drug sensitivity pattern and serological examinations for HIV infection were carried out. RESULTS: Sputum specimens of 618 patients' (61.8%) of a total of 1000 examined had shown culturable M. tuberculosis. Four hundred ninty-five patients (49.5%) were found to expectorate tubercle bacilli resistant to one or more anti TB drugs. MDR-TB was detected in 339 patients (33.9%). HIV seropositivity among MDR-TB was 4.42%. Significantly, 245 patients (24.5%) had tubercle bacilli resistant to one or more reserve drugs too (ethionamide, kanamycin and/or ofloxacin). CONCLUSIONS: Prevalence of MDR-TB was high in the study population. It is essentially an acquired condition. Its association with HIV disease was at present on the lower side, an observation contrary to published western literature. Higher rates of resistance for reserve drugs (ethionamide, kanamycin and/or ofloxacin) in patients who never had these drugs in their earlier treatment schedules suggest the possibility of emerging spontaneous drug resistant mutants.

Primary lung cancer in non-tuberculous upper lobe lesions.

Tuberculosis is not only the commonest infectious disease of the lungs in India, but it is also the most commonly overdiagnosed entity whenever upper lobe lesions are seen on a chest roentgenogram. Over a two year period (1990-1992), 150 non-tuberculous upper lobe lesions in high risk group patients (middle aged and elderly; chronic smokers) were investigated Sixty-two patients (41.3%) were found to have primary malignant tumours of whom 67.7% had squamous cell carcinoma. Routine screening for malignancy in high risk patients with non-tuberculous upper lobe lesions should be undertaken.