A prospective study of non-tuberculous mycobacterial disease among tuberculosis suspects at a tertiary care centre in north India

Background & objectives: The burden of non-tuberculous mycobacterial (NTM) disease is increasing worldwide. The disease shares clinicoradiological features with tuberculosis (TB), Nocardia and several fungal diseases, and its diagnosis is frequently delayed. The present study was performed to determine the frequency of NTM disease among TB suspects in a tertiary care centre in north India. Methods: In this prospective study, mycobacterial culture isolates from pulmonary and extrapulmonary specimens among TB suspects were tested with immunochromatographic assay (ICA). All ICA-negative isolates were considered as NTM suspects and further subjected to 16S-23S rRNA internal transcribed spacer gene sequencing for confirmation and species identification. Patients with active disease were treated with drug regimen as per the identified NTM species. Follow up of patients was done to determine clinical, radiological and microbiological outcomes. Results: Of the 5409 TB suspects, 42 (0.77%) were diagnosed with NTM disease. Patients with active disease consenting for treatment were treated and followed up. Thirty four patients had NTM pulmonary disease (NTM-PD) and the remaining eight had extrapulmonary NTM (EP-NTM) disease. Mycobacterium intracellulare and M. abscessus, respectively, were most frequently isolated from NTM-PD and EP-NTM patients. Fifteen NTM-PD and seven EP-NTM patients successfully completed the treatment. Ten patients died due to unrelated causes, five were lost to follow up and another four declined the treatment. Interpretation & conclusions: Our study showed that the frequency of NTM disease was low among TB suspects at a large tertiary care centre in north India and this finding was similar to other Indian studies. More studies need to be done in other parts of the country to know the geographical variation in NTM disease, if any.

Repetitive transcranial magnetic stimulation in chronic tension-type headache: A pilot study

Background & objectives: Tension-type headache (TTH) is the most common type of primary headache disorder. Its chronic form is often the most ignored and challenging to treat. Transcranial magnetic stimulation (TMS) is a novel technique in the treatment of chronic pain. The aim of this pilot study was to explore the effect of low-frequency repetitive TMS (rTMS) on pain status in chronic TTH (CTTH) by subjective and objective pain assessment. Methods: Patients (n=30) diagnosed with CTTH were randomized into rTMS (n=15) and placebo (n=15) groups in this study. Pre-intervention detailed history of patients was taken. Numerical Rating Scale (NRS) for Pain and questionnaires [Headache Impact Test-6 (HIT-6), McGill Pain Questionnaire, Pain Beliefs Questionnaire, Coping Strategies Questionnaire, State-Trait Anxiety Inventory Test, Hamilton Rating Scale for Depression and WHO-Quality of Life Questionnaire-Brief version] were filled, and objective assessments such as nociceptive flexion reflex (NFR) and conditioned pain modulation were done. The tests were repeated after 20 sessions (5 days/week). In the rTMS group, 1200 pulses in eight trains of 150 pulses each were given at 1Hz over the right dorsolateral prefrontal cortex (RDLPFC). In the placebo group, the rTMS coil was placed such that magnetic stimulation did not reach the cortex. Results: The NRS score decreased significantly (P<0.001) and NFR thresholds increased significantly (P=0.011) in the rTMS group when compared to placebo group. Interpretation & conclusions: Subjective improvements in the NRS, HIT-6, McGill Present Pain Intensity, trait of anxiety and psychological pain beliefs were observed. The increase in the thresholds of NFR served as an objective marker for improvement in pain status. Further studies need to be done to confirm our preliminary findings.

Patient profile based management approach for Optimal Treatment of Angina: a consensus from India cases

Chronic stable angina (CSA) is an incapacitating disorder. The pain can hinder the routine chores of an individual and significantly impact one’s quality of life (QoL). However, the good news is that this can be treated and the QoL can be improved. The key to apt management lies in the accurate early diagnosis of this condition, followed by a detailed evaluation and accordingly planned management, which should be regularly revised and be backed by an adequate follow-up. OPTA-OPtimal Treatment for chronic stable Angina-is an educational initiative to assist the clinicians in India with screening and diagnostic tools, strengthened by updated guideline-directed management to ensure satisfactory patient outcomes. OPTA aims to improve clinical outcomes by providing optimized pharmacotherapy for patients with stable angina. This expert consensus document intends to provide information for better understanding of the condition by clinicians and to ensure an early, accurate diagnosis, followed by optimal management of angina. For better clinical and practical understanding of Indian clinical scenario, the most commonly encountered patient profiles are briefly described here. These inputs and an extensive literature review were blended to develop the recommendations for clinicians across the country. An attempt is made to include clinical recommendations that meet the needs of the majority of patients in most circumstances in the Indian scenario. However, the ultimate judgment regarding individual case management should be based on clinician’s discretion. This expert consensus document is not a substitute for textbooks and/or a clinical judgment.

Panchagavya Ghrita, an Ayurvedic formulation attenuates seizures, cognitive impairment and oxidative stress in pentylenetetrazole induced seizures in rats.

Panchagavya Ghrita (PG), according to Ayurvedic formulary of India (AFI), is used to treat epilepsy (apasmara), fever (jvara), mania (unmade) and jaundice (kamala). In the present study, we examined its effect on convulsions, oxidative stress and cognitive impairment in pentylenetetrazole (PTZ) induced seizures in rats. PG @ 250, 500, 1000, 2000 and 4000 mg/kg was administered orally for 7 days to male Wistar rats. On day 7, PTZ (60 mg/kg) was injected intraperitoneally 2 h after the last dose of PG. Sodium valproate (300 mg/kg) was used as positive control. Latency to myoclonic jerks, clonus and generalized tonic clonic seizures (GTCS) were recorded for seizure severity. Cognitive impairment was assessed using elevated plus maze and passive avoidance tests. Malondialdehyde and reduced glutathione levels were measured in rat brain. The results have shown that pretreatment with PG @ 500, 1000, 2000 and 4000 mg/kg exhibited 16.6, 33.3, 50 and 100% protection against occurrence of GTCS. The pretreatment with PG has significantly improved cognitive functions and the oxidative stress induced by seizures demonstrating its protective effect against PTZ induced seizures, and further, use of PG as an anticonvulsant in Ayurvedic system of medicine.

Identification and characterization of the Sudanese Bacillus thuringiensis and related bacterial strains for their efficacy against Helicoverpa armigera and Tribolium castaneum.

Forty-four isolates of Bacillus thuringiensis like bacteria from various sources in different locations from Sudan were tested for their insecticidal activity. The toxicity of these isolates ranged from 6.6 to 70% to the neonates of cotton bollworm, Helicoverpa armigera at 10 ppm concentration. The most effective ones are Kb-29, St-6 and Wh-1 comparable with HD-1.  Toxicity of isolates to larvae of the red flour beetle, Tribolium castaneum ranged from 20 to 100%. Isolates St-2 and St-23 gave 100% larval mortality within 15 days of exposure and were at par with Ab-8, Ab-12, Kb-26, Kb-30, Om-4, Po-2, Po-5, Po-7, Sa-8 and Wh-5 and were also comparable with E. coli clone expressing Cry3 toxin. The most effective five isolates viz., Kb-29, St-2, St-6, St-23 and Wh-1 belonged to B. thuringiensis. The St-6 isolate, which also showed high toxicity to T. castaneum larvae, had cry1 genes along with coleopteran active cry28 genes, but not cry3 genes. Of the 25 isolates characterized with 16s DNA sequencing, seven belonged to Paenibacillus spp., one Lysinibacillus sphaericus, one Bacillus pumilus, four Bacillus spp., and rest 12 belonged to B. thuringiensis. Biochemical characterization in each species showed variation. The present study shows potential of some isolates like Kb-29, St-2, St-6, St-23 and Wh-1 as promising bioinsecticides.

Predictors of Aggressive Behaviours in Drug De-Addiction Centre.

Aim: Associations have been reported between aggression and psychoactive substance use. This study aimed to assess the prevalence and nature of aggressive incidents and to examine the factors associated with aggression in patients in a drug de-addiction unit. Method: Forms of aggression and their severity were assessed based on questions of Overt Aggression Scale (OAS). Data were collected from inpatients about the nature of their aggressive incident during a 12-month period. The characteristics of those patients involved in aggressive incidents were compared with those of others who had not been aggressive. Results: Fifty out of 83 patients admitted during this period were involved in some form of aggressive behaviour. Pattern of aggressive behaviour exhibited by patients were in the form of verbal aggression 60.24% (N=50); Object aggression 28.9% (N=24); Aggression toward other 32.53% (N=27) and Aggression toward self 2.41% (N=2). There were high correlations of one form of aggression in presence of other forms. Most common diagnosis was alcohol dependence. On the whole aggression was found to be higher in the alcohol withdrawal with delirium group. While all other forms of violence showed increase with past histories, statistical significance was there only in aggression towards others (p=0.043). Aggressive behaviours generally reported less in voluntarily admitted patients. Comparison of aggressive behaviour in relation to family type, locality, religion, family history of violence did not yield any significant variation. Conclusion: Like weather forecasting, predictions of future violence will not always be correct. However, in order to prevent aggressive incidents, present study revealed that particular attention and increase support required in patients living in the nuclear family, unwilling for admission, past history of aggressive incidents and diagnoses of alcohol withdrawal. Verbal aggression could be considered as strong predictor for other type of assault.

Evaluation of EEG in Child Guidance Clinic.

Background: Electroencephalographic (EEG) abnormalities occur in patients with various idiopathic psychiatric disorders. Among the psychiatric patients, children have shown more EEG abnormalities as compared to the adult cases. The present study therefore examined the pattern of EEG abnormalities in children’s attending child guidance clinic of psychiatry department. Method: Electrodes were positioned according to the 10 – 20 system, using a common reference electrode. EEG recordings from 138 hospitalized psychiatric patients were graded blind to diagnosis and treatment for type of EEG abnormalities. Types of clinical diagnosis were evaluated for association with pattern EEG abnormalities. Results: EEG abnormalities occurred in 53.62% (N = 74) subjects, whereas 46.38% (N = 64) showed no abnormality in EEG record. Generalized abnormalities was observed in 37.84% (N = 28) subjects. EEG abnormality in clinically diagnosed epilepsy were commonest 64.62% (N = 42), followed by dissociative (conversion) vs. epilepsy 62.5% (N = 5), pervasive developmental disorder (PDD) 56.67% (N = 17), and mental retardation with epilepsy 28.57% (N = 10). Conclusions: EEG abnormality risk varied widely among children’s with different diagnoses referred/attending Child Guidance Clinic of psychiatry department. Risk was particularly high in clinically diagnosed epilepsy.

Non Cerebral Activity in Patients of Schizophrenia: EEG Study.

Non Cerebral Activities (NCA) can mimic almost any kind of cerebral electrical activity and lead to serious misinterpretation if artefact periods remain in the recording. We focused on NCA detection in EEG of Patients with Schizophrenia. Out of 35 schizophrenia patients the presence of muscle and eye blink artefacts were higher in there percentages i.e. 86% and 92%. Fifteen patients (42.8%) reported as EEG of doubtful significance, which is higher in psychiatric patient’s then general population of epileptics.

Geriatric Mental Health in a Tertiary Care Centre: Socio-Demographic and Clinical variables.

Background: Nearly 50% of the aged have some physical ailment and are in need of active health care. Geriatric psychiatry is a sub-specialty of psychiatry, which deals with psychopathology occurring in the elderly and the various aetiological factors which cause the mental disorders in old age. Method: This is a descriptive study with sampling in a tertiary centre where the diagnoses were made based on the tenth edition of the International Statistical Classification of Diseases and Related Health Problems (ICD- 10) and were evaluated for sociodemographic and clinical variables as well as general medical conditions. Results: Mean age of the patients was 69.81 years, male constituted 73.58% and female 26.42%, Hindu were 56.60% and Islam 43.40%. Mean duration of stay in psychiatry ward was 5.7 days. 77.36% of patients were discharged on advice, 15.09% were transferred to another department, 1.89% absconded, 1.89% referred to another hospital and 3.77% referred to another department. 9.62% patients had general medical conditions alone and 40.38% had psychiatric disorders alone while 50% had combined psychiatric disorders with general medical conditions. 42.31% patients had organic, including symptomatic, mental disorders; 3.85% had mental and behavioural disorders due to psychoactive substance use; 26.92% had schizophrenia, schizotypal and delusional disorders; 28.85% had mood [affective] disorders; 5.77% patients had neurotic, stress-related and somatoform disorders. Conclusion: Within the limitations of nongeneralizability of findings, present study throws light in important areas of geriatric mental health including general medical conditions.

EEG Study in Excellent and Poor Achiever Students.

Objective: To assess the EEG amplitude and frequency of poor and excellent achievers. Method: The 15% highest achieving students and the 15% lowest achieving students from the three faculties were selected to be included in the study sample. EEG was carried out according to the 10–20 system, using a common reference electrode. The Bipolar recording of 10 minutes of two runs i.e. anterior, posterior and transverse has been taken into account for the analysis of data. Results: There are significant differences in the amplitudes of certain lobes of both hemispheres of poor and excellent achievers. Particularly, poor achievers have higher amplitudes. The frequency of excellent achievers of certain lobes is found to be significantly higher than those of the poor achievers. Conclusion: The relationship of amplitude and frequency with academic achievement are inconclusive, nothing can be said with confidence about the role played by the amplitude in determining the academic achievement of poor achievers. It is difficult to understand the specific roles played by the frequencies of the different lobes in determining the academic achievement of excellent achievers. Hence, further researches should be undertaken to study the cause and effect relationship between amplitude and frequency of the different lobes and academic achievements of’ students.

Problems in Disposal of Long Staying Criminal Psychiatric Patients in Mental Hospital, Varanasi.

Aim – The purpose of the study was to assess, the problems in disposal of long stay criminal mental patients, from mental hospital Varanasi, despite of their improvements and types of crime. Method – In this study 202 criminal mental patients taken from the mental hospital Varanasi. Those patients were admitted between years of 1948-2002. Out of 202, 193 were male criminal patients and 9 were female. Patients were divided into two groups, convicted and nonconvicted. The patients were analysed on the basis, of duration of stay in hospital, despites of their fitness, types of crime, time of discharges and types of mental disorders. Results –The incidence of crime committed were significantly higher in male patient in the age group of (18-40) years 75%, nearly 53%, patients committed crime below 30 years and, 5% crime committed above the age of 50 years. Similar finding reported as (Gluecks 1943, Baldev et al 1970). 75% patients were suffering from Schizophrenia. 67% patients stayed in the mental hospital less than 5 years but remaining patient stayed more than 6 years. 2% patient stayed more than 45 years. Conclusion – A part of criminal patient stayed in the mental hospital because of legal, administrative, medical, and communication problems with respective jails.

Prevention of hypotension during propofol induction: a comparison of preloading with 3.5% polymers of degraded gelatin (Haemaccel) and intravenous ephedrine.

The present study compared the efficacy of preloading with colloid "Haemaccel" with vasoconstrictor (intravenous ephedrine sulphate) in preventing hypotension during propofol induction. This prospective, randomized study included 120 patients of Amercan Society of Anaesthesiologists (ASA) physical status I and II ageing 21 to 50 years of both gender coming for routine surgery. Patients were randomly allocated into three groups with 40 patients in each. Group A (control) did not receive any study medication, group B received Haemaccel (10 ml/kg intravenously over 10-15 minutes) and group C received injection ephedrine (0.2 mg/kg iv) prior to induction of anaesthesia. Propofol (2.5 mg/kg iv) was used for induction of anaesthesia. Heart rate and blood pressure were recorded before induction (baseline) and then every minute for 5 minutes after administering propofol. Anaesthesia was continued with standard technique thereafter. Hypotension was defined as fall in systolic blood pressure more than 20% from the basal value. The incidence of hypotension in Haemaccel (23.1%) or ephedrine group (22.5%) was significantly less than the control group (67.5%, P<0.01). We conclude that though preloading with colloid (Haemaccel) or prior injection of sympathomimetic (ephedrine) are not fully efficacious in preventing hypotension caused by propofol induction, both decrease the incidence in significant number of patients with heart rate less than baseline value in the colloid group.

Role of temporalis muscle over activity in chronic tension type headache: effect of yoga based management.

The role of central versus peripheral mechanisms has always been questioned while explaining the etiopathogenesis of chronic tension type headache (CTTH). The following study was done to study the role of muscle spasm in CTTH. 15 patients of CTTH and 7 age matched controls were included in the study and their m. temporalis EMG was recorded for one minute each during rest, mental activity and maximal voluntary contraction and subjective pain scoring was done by visual analogue scale. The results revealed significant overactivity of m.temporalis in CTTH patients at rest when compared with control subjects (P = 0.01 and 0.03 left and right side respectively). After respective interventions namely non steroidal anti inflammatory drugs, botulinum toxin injections and yogic life style course, the EMG records revealed decrease in the mean EMG amplitude of m. temporalis during rest and mental activity more significantly after yoga based interventions (P = 0.03) and subjective pain scores decreased from 7.00 +/- 2.10 to 2.00 +/- 1.26 (P = 0.02) supporting the beneficial effect of such non invasive techniques.

Hyperacute thrombolysis with IV rtPA of acute ischemic stroke: efficacy and safety profile of 54 patients at a tertiary referral center in a developing country.

BACKGROUND: Given the constraints of resources, thrombolysis for acute ischemic stroke (AIS) is under evaluation in developing countries. Prothrombin time (PT), platelet count and activated partial thromboplastin time (aPTT) may not be feasible within the time window. AIM: To evaluate the safety and efficacy of thrombolysis in selected patients without the coagulation profile. DESIGN: Open, nonrandomized, observational study. MATERIALS AND METHODS: Fifty-four stroke patients were classified using TOAST criteria (large artery atherosclerotic = 13; cardioembolic = 12; small vessel occlusion = 22; other determined etiology =three; undetermined etiology = four). The mean time to reach emergency was 2.4h (1.15-3.4), the mean door to CT, 24 min (10-47) and the door to recombinant tissue plasminogen activator (r-tPA) injection, 26.8 min (25-67). The NIHSS scores ranged from 11 to 22 (mean = 15.5 +/- 2.7). Patients with history of liver or renal disease or those on anticoagulants were excluded. The PT, aPTT and platelet count were not done. Recombinant tissue plasminogen activator was administered at a dosage of 0.9 mg/Kg. RESULTS: Thirty-five patients (65%) significantly improved on NIHSS at 48 h (> or =4 points) (mean change = 10; range= 4-17). At one month, 43 (79%) improved on Barthel Index (mean change = 45%). One each developed small frontal lobe hemorrhage and recurrent stroke; one died of aspiration; and eight showed no improvement. CONCLUSIONS: Hyperacute thrombolysis was found useful and safe in selected patients with AIS even without the coagulation studies.

Samarium-153 ethylenediamine tetramethylene phosphonate therapy for bone pain palliation in skeletal metastases.

BACKGROUND: Systemic therapy with radionuclides may be used for the treatment of patients with painful skeletal metastases owing to its efficacy, low cost and low toxicity. Imported radionuclides for pain palliation, like Strontium-89 are expensive; particularly for developing countries. In the Indian scenario, Samarium-153 (Sm-153) is produced in our own reactors and as a result, it is readily available and economical. AIM: We undertook this study to determine the efficacy and toxicity of single-dose Sm-153 ethylenediamine tetramethylene phosphonate as a palliative treatment for painful skeletal metastases. MATERIALS AND METHODS: Eightysix patients with painful skeletal metastases from various primaries, were treated with Sm-153 EDTMP at a dose of 37 MBq/kg. The effects were evaluated according to change in visual analogue pain score, analgesic consumption, Karnofsky performance score, mobility score and blood count tests, conducted regularly for 16 weeks. STATISTICS: Repeated measures analysis. RESULTS: The overall response rates were 73%, while complete response was seen in 12.4%. Reduction in analgesic consumption with improvement in Karnofsky performance score and mobility score, was seen in all responders. Response rates were 80.3 and 80.5% in breast and prostate cancer, respectively. One case, each of Wilms tumor, ovarian cancer, germ cell tumor testis, multiple myeloma, primitive neuroectodermal tumor and oesophageal cancer, did not respond to therapy. No serious side-effects were noted, except for fall in white blood cell, platelet and haemoglobin counts, which gradually returned to normal levels by six-eight weeks. CONCLUSION: Sm-153 EDTMP provided effective palliation in 73% patients with painful bone metastases: the major toxicity was temporary myelosuppression.

Assessment of nutritional status of pre-schoolers in slum areas of Udaipur City.

The present study was conducted in pre-schoolers (2-6 years) from ten different slums of Udaipur City in Rajasthan with the aim to their nutritional status. From the data collected and observations recorded was observed that majority of the subjects were from nuclear family with monthly family income of less than Rs.1500/-. Developmental pattern of these subjects indicated that the height with age of bothe male and female subjects increased, however, their body weight did not increase. More than 50% of these pre-schoolers showed symptoms of protein energy malnutrition and anaemia, while 22% had pigeon chest deformity due to vitamin D and calcium deficiency. Classification for degree of malnutrition as per IAP showed that majority of these subjects (66%) were under weight (Grade I and II). Waterlow's classification revealed that majority of these pre-schoolers were wasted (30%) or wasted and Stunted (42%). This malnutrition was either of PCM (past chronic) or CLM (current long duration) type as per Seoane and Latham's classification.

Angiotensin converting enzyme gene polymorphism in Indian children with steroid sensitive nephrotic syndrome.

CONTEXT: Nephrotic syndrome is one of the commonest renal problem encountered in children. It is difficult to predict at onset, the clinical course in terms of steroid responsiveness or resistance. Angiotensin converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism has been studied as a predictor of clinical course in common multi-factorial diseases including focal segmental glomerulosclerosis. There is no study available from our country till date to find out any correlation of the steroid response in idiopathic nephrotic syndrome and ACE gene polymorphism. AIM: To study distribution and correlation of ACE gene I/D polymorphism in idiopathic steroid sensitive nephrotic syndrome. SETTINGS & DESIGN: Case-control retrospective study. SUBJECTS & METHODS: We studied ACE gene polymorphism in 90 consecutive patients (82% males, 18% females) with steroid sensitive idiopathic nephrotic syndrome and 300 normal controls (NC). STATISTICAL ANALYSIS: Chi-square test and Fisher's exact test (for cases with insufficient expected cell frequencies). RESULTS: The mean age of onset was 5.3 +/- 4 years. Steroid sensitive (SS) patients showed II (SS-48%, NC-26%) genotype was more frequent than normal controls (p=0.002). There was no significant difference in genotype frequencies among steroid SS subgroups. CONCLUSIONS: In our study II genotype was more frequent in steroid sensitive nephrotic syndrome children in comparison to normal controls. Further functional studies with large number of children are required to investigate the role of II genotype in steroid sensitive nephrotic syndrome. Comparison of the genotypic frequency with steroid resistant patients may provide information, which might be useful in clinical practice.

Obstructive sleep apnoea: a case-control study.

INTRODUCTION: Obstructive sleep apnoea (OSA), is characterized by loud snoring and excessive daytime sleepiness. Though the gold standard for diagnosis is overnight polysomnography (PSG), sleep questionnaires have also been used to diagnose this with good predictive value. MATERIAL AND METHODS: A pre-designed proforma with clinical details, symptom-specific questions for diagnosis of OSA, and Epworth Sleepiness Scale (ESS) was administered to 20 patients presenting to the Sleep Disorder Clinic of our hospital and to 40 age and sex-matched relatives (control group). The students 't-test' and chi-square were used as the statistical tests. RESULTS: There were 20 patients with a mean age of 41+/- 8 years, and 40 controls with a mean age of 41 +/- 6 years (P=>0.05). Seven had family history of snoring in the study group and 3 in the control group (P=0.02). Four had met with road traffic accidents in the study group and none in the control group (P=0.001). The body mass index (BMI) was 29.9 (SD 4.4) in the study group and 24.5 (SD3.5) in the controls (P=0.001). The mean ESS was 13.3 +/- 6 in the patients and 4.2+ 4 in the controls (P=0.001). A larger number of patients with OSA had hypertension: 5/20 vs. 3/40 (P=0.01). CONCLUSION: Patients with OSA had significantly higher BMI and ESS score, and were more likely to have hypertension and road traffic accidents. Increased awareness of this entity is essential.