Consensus & Evidence-based INOSA Guidelines 2014 (First edition).

Obstructive sleep apnoea (OSA) and obstructive sleep apnoea syndrome (OSAS) are subsets of sleep-disordered breathing. Awareness about OSA and its consequences amongst the general public as well as the majority of primary care physcians across India is poor. This necessiated the development of the INdian initiative on Obstructive Sleep Apnoea (INOSA) guidelines under the auspices of Department of Health Research, Ministry of Health & Family Welfare, Government of India. OSA is the occurrence of an average five or more episodes of obstructive respiratory events per hour of sleep with either sleep related symptoms or comorbidities or >15 such episodes without any sleep related symptoms or comorbidities. OSAS is defined as OSA associated with daytime symptoms, most often excessive sleepiness. Patients undergoing routine health check-up with snoring, daytime sleepiness, obesity, hypertension, motor vehicular accidents and high risk cases should undergo a comprehensive sleep evaluation. Medical examiners evaluating drivers, air pilots, railway drivers and heavy machinery workers should be educated about OSA and should comprehensively evaluate applicants for OSA. Those suspected to have OSA on comprehensive sleep evaluation should be referred for a sleep study. Supervised overnight polysomnography (PSG) is the “gold standard” for evaluation of OSA. Positive airway pressure (PAP) therapy is the mainstay of treatment of OSA. Oral appliances are indicated for use in patients with mild to moderate OSA who prefer oral appliances to PAP, or who do not respond to PAP or who fail treatment attempts with PAP or behavioural measures. Surgical treatment is recommended in patients who have failed or are intolerant to PAP therapy.

Occurrence of Non-Tuberculous Mycobacterium in clinical samples - a potential pathogen.

Background: Silent presence of non-tuberculous mycobacterium (NTM) has been observed since the last 100 years, but now the increasing incidence of NTM is of great concern for clinical microbiologists as well as clinicians. Although many advanced efforts are being made for identification and control of Mycobacterium tuberculosis, still the silently growing menace of non-tuberculous mycobacteria is receiving negligible attention. Objectives: This study was aimed to find NTMs in positive cultures and identify them up to species level. Material & Methods: During the study period, i.e. from January 2009 to June 2011, a total of 4104 positive cultures were subjected to species identification by different morphological and biochemical tests. All the tests for identification were performed as per standard procedure along with the standard strains of NTM provided by JALMA, Agra. Results: The identification of positive cultures showed 4044/15581 (25.95%) Mycobacterium tuberculosis complex and 60/15581(0.38%) NTM. The mycobacterium species identification results showed that out of total 60 NTM, 21 different species of NTM were found and they belonged to all the four groups of runyon. The most common species identified in this study was M.simiae (07) followed by M.avium(06), M.gordonae(05), M.kansasii(05), M.fortuitum(05), M.chelonae(05), M.pheli(05), M.terrae(04), M.szulgai(02), M.vaccae(02), M.flavescens(02), M. trivale(02), M.malmoense(01), M.scrofulaceum(01), M.intracellulare(01), M.xenopi(01), M.ulcerans(01), M.tusciae(01), M.triplex(01), M.septicum(01), M.mucogenicum(01). Conclusion: The isolation of NTMs from different clinical samples indicated that they may be the causative agents for pulmonary and extra-pulmonary non-tuberculous diseases. Elaborate and focused studies are needed to differentiate NTMs amongst commensal/colonizer, pathogen and laboratory contaminants.

Rapid identification of clinical mycobacterial isolates by protein profiling using matrix assisted laser desorption ionization-time of flight mass spectrometry.

Purpose: The purpose of this study was to evaluate the identification of Mycobacterium tuberculosis which is often plagued with ambiguity. It is a time consuming process requiring 4-8 weeks after culture positivity, thereby delaying therapeutic intervention. For a successful treatment and disease management, timely diagnosis is imperative. We evaluated a rapid, proteomic based technique for identification of clinical mycobacterial isolates by protein profiling using matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). Materials and Methods: Freshly grown mycobacterial isolates were used. Acetonitrile/trifluoroacetic acid extraction procedure was carried out, following which cinnamic acid charged plates were subjected to identification by MALDI-TOF MS. Results: A comparative analysis of 42 clinical mycobacterial isolates using the MALDI-TOF MS and conventional techniques was carried out. Among these, 97.61% were found to corroborate with the standard methods at genus level and 85.36% were accurate till the species level. One out of 42 was not in accord with the conventional assays because MALDI-TOF MS established it as Mycobacterium tuberculosis (log (score) >2.0) and conventional methods established it to be non-tuberculous Mycobacterium. Conclusions: MALDI-TOF MS was found to be an accurate, rapid, cost effective and robust system for identification of mycobacterial species. This innovative approach holds promise for early therapeutic intervention leading to better patient care.

Contribution of medical colleges to tuberculosis control in India under the Revised National Tuberculosis Control Programme (RNTCP): Lessons learnt & challenges ahead.

Medical college faculty, who are academicians are seldom directly involved in the implementation of national public health programmes. More than a decade ago for the first time in the global history of tuberculosis (TB) control, medical colleges of India were involved in the Revised National TB Control Programme (RNTCP) of Government of India (GOI). This report documents the unique and extraordinary course of events that led to the involvement of medical colleges in the RNTCP of GOI. It also reports the contributions made by the medical colleges to TB control in India. For more than a decade, medical colleges have been providing diagnostic services (Designated Microscopy Centres), treatment [Directly Observed Treatment (DOT) Centres] referral for treatment, recording and reporting data, carrying out advocacy for RNTCP and conducting operational research relevant to RNTCP. Medical colleges are contributing to diagnosis and treatment of human immunodeficiency virus (HIV)-TB co-infection and development of laboratory infrastructure for early diagnosis of multidrug-resistant and/or extensively drug-resistant TB (M/XDR-TB) and DOTS-Plus sites for treatment of MDR-TB cases. Overall, at a national level, medical colleges have contributed to 25 per cent of TB suspects referred for diagnosis; 23 per cent of ‘new smear-positives’ diagnosed; 7 per cent of DOT provision within medical college; and 86 per cent treatment success rate among new smear-positive patients. As the Programme widens its scope, future challenges include sustenance of this contribution and facilitating universal access to quality TB care; greater involvement in operational research relevant to the Programme needs; and better co-ordination mechanisms between district, state, zonal and national level to encourage their involvement.

Presumptive identification of Mycobacterium tuberculosis complex based on cord formation in BACTEC MGIT 960 medium.

We considered samples received for culture of mycobacteria using BACTEC MGIT 960 system over a period of 1 year. Tubes flagged positive by MGIT were evaluated for presence of serpentine cording. The cord formation was compared with isolates identified as Mycobacterium tuberculosis complex (MTC) based on p-nitrobenzoic acid (PNB) test. Cords were found in 591 isolates of which 584 (98.8%) were confirmed as MTC. The sensitivity and specificity of cord formation were found to be 99.7% and 89.9%, respectively.

Seizures with single therapeutic dose of isoniazid.

Isoniazid (INH) is an integral component of treatment of tuberculosis. An acute overdose is potentially fatal and is characterised by the clinical triad of repetitive seizures unresponsive to the usual anticonvulsants, metabolic acidosis with a high anion gap and coma. A case of isoniazid induced seizures after therapeutic dose of 600 mg. as a part of CAT I thrice weekly intermittent anti-tuberculosis regimen for pulmonary tuberculosis is reported. The frequency of the usage of Isoniazid as antituberculosis therapy requires that physicians be aware of such toxicity.

A pilot study of same day sputum smear examination, its feasibility and usefulness in diagnosis of Pulmonary TB.

Introduction'. A large number of tuberculosis cases are continuously being reported from India and other developing countries leading to high morbidity and mortality. In spite of many newer tests available for diagnosing a case of tuberculosis, smear microscopy of sputum is still the preferred test under programmatic conditions. The current national and international guidelines recommend two sputum smear examinations in two days for diagnosing cases of tuberculosis, which is time consuming, tedious, needs multiple visits, leading to high dropout of infectious cases. In the background of existing limitations of smear microscopy, we attempted to complete the diagnosis of tuberculosis on same day by serial collection of the spot sputum specimen and analyze its advantages, feasibility and viability. Material & Methods: The study was undertaken by the Department of Microbiology, Lala Ram Sarup Institute of Tuberculosis and Respiratory Diseases during May 2010 to April 2011. Sputum specimens were collected from 330 randomly selected tuberculosis suspects who attended OPD of hospital, patients submitted spot and home collected morning sputum sample in a standard method and spot and additional spot sputum(X- spot) collected one hour after the flrst spot sample as per the proposed front loading method. All the samples received were stained by acid fast Ziehl-Neelsen (ZN) stain and examined on the same day. The sputum sample was pooled and cultured in Lowenstein Jensen (U) media in duplicate set of bottles. The results of two different microscopic methods were compared with the gold standard culture test. Results: Out of the total 330 TB suspects, 70.60% were males and 29.39% females. The most common complaint was of cough with sputum (88.18%), chest pain (70.21%), fever (55.15%) and loss of appetite (43.03%). Upon examining the total sputum slides, 18.48 % were positive for acid fast bacilli. The smear positivity was 61/330(l8.48%) by standard methods and in proposed new method 43/330(13.03%). Sensitivity of the standard and proposed new method smear microscopy was 58.25% and 40.07% respectively and specificity was 99.55% in both the methods. Conclusion: Same day smear microscopy for diagnosing tuberculosis by a proposed new method of smear examination in the case of suspected tuberculosis seems not a promising step towards improving the quality of sputum smear examination. The results of sensitivity and specificity of the two approaches were not similar. More than eighty per cent responded in favour of same day sputum delivery system and getting result on same day. This study can be confirmed on larger scale and preference of patients can be examined in peripheral laboratory also before taking it up for consideration in the national tuberculosis programme.

A retrospective study of seasonal variation in the number of cases diagnosed at a tertiary care tuberculosis hospital.

Objective. To study the seasonality of tuberculosis (TB) in a tertiary care tuberculosis and respiratory hospital in Delhi. Methods. Data from a tertiary care respiratory hospital in south Delhi over a six years period from April 2002 to March 2008 were analysed. Results. Symptomatics: A total of 192,863 patients were registered newly in the hospital during this period. Maximum number of symptomatic patients reported to the out-patient department during April-June and the minimum during October-December. An increase of about 25% in symptomatics was observed (p<0.05) in the period from April to June in comparison to October to December. The amplitude of seasonal variation was estimated as 11% of the annual mean symptomatics. Tuberculosis cases: The maximum sputum-positive TB cases were diagnosed during the period from April to June and the number was least during October to December. There was an increase of about 34% in sputum-positive cases (p<0.001) during the period from April to June against October to December. The amplitude of seasonal variation was estimated as 14.4% of the annual mean smear-positives per quarter. The extra-pulmonary TB (EPTB) cases were the maximum during April-June. Chest symptomatics of all types of TB cases were the lowest in January. Conclusions. A seasonal pattern of TB was observed for pulmonary TB and EPTB cases. This information would be useful for administration and managers to take extra care to arrange and provide extra facilities during the peak seasons.

Prevalence of XDR TB cases - A retrospective study from a tertiary care TB Hospital.

Background: The emergence of XDR –TB strains is a major roadblock in the successful implementation of TB control programmes. This further leads to high morbidity and mortality, especially in immuno-compromised patients. Identification and observation of resistance patterns of XDR-TB strains may help clinicians manage MDR-TB cases, the treatment line of which is expensive, time-taking and involves intake of toxic drugs with many side-effects. Our study is aimed to find out the prevalence of XDR-TB among the MDR-TB strains isolated in a tertiary care hospital. Material & Methods: The study population consisted of 223 patients of tuberculosis who were culture positive and Mycobacterium tuberculosis was resistant to Rifampicin and Isoniazid during January 2007 to December 2009. Each patient had submitted two sputum samples i.e. spot and morning. The identified Mycobacterium tuberculosis complex was subjected to drug sensitivity testing by first and second line drugs by proportion and absolute concentration methods as per standard procedure . Results : The results showed that 20.17% strains (45/223) were XDR-TB strains. Most of these strains showed resistance to four drug combination viz. KM, ETH, OFX & PAS (5.82%), KM & OFX (3.13%), OFX, KM and ETH (1.79%), 1.34% strains showed resistance to all the drugs i.e. pan resistance and other combinations in the remaining strains. Nearly 80% of the XDR-TB strains showed resistance to three or more drugs combination pattern. Conclusion: The multidrug resistant TB cases need urgent and timely sensitivity report for second line ATT drugs to help clinicians start proper drug combinations to treat MDR-TB patients.

Smear microscopy as surrogate for culture during follow up of pulmonary MDR-TB patients on DOTS plus treatment.

Background: DOTS Plus site at LRS Institute, New Delhi, covering 1.8 million population. Aims: To ascertain if sputum smear could be used as a surrogate for culture during intensive phase of treatment of MDRTB patients thereby enabling early shift from intensive phase to continuation phase, reducing the need for frequent cultures and saving time and cost in their management. Methods: The study is a retrospective analysis of 138 MDR-TB patients on DOTS Plus treatment whose sputum samples were simultaneously subjected to smear microscopy and culture, monthly during Intensive Phase and once in two months during Continuation Phase. Sputum results in the treatment card were supplemented from laboratory register, if required, and analyzed. Predictive values, sensitivity and specificity of smear were compared with culture results. Results: The Negative Predictive Value (NPV) of smear was high from the 3rd month onwards (above 91%), at four months 98% or more and approached 100% from eight months onwards. The specificity of smear test gradually increased during treatment and from five months onwards, it was above 90%. Conclusions: Considerable correlation was observed between sputum smear and culture during follow up of DOTS Plus treatment in the Intensive Phase. Accordingly, sputum smears can be recommended instead of culture.