Assessment of Knowledge, Attitude and Practice related to Tuberculosis among Rural and Urban Community of North India

Tuberculosis is known as one of the long-standing and dominating health problems affecting people and the extent further escalates in a developing country like India. A pre-evaluated feedback structured questionnaire was validated and adopted to get their quantitative data from 424 respondents. In the present study urban respondents (60.8%) gave affirmative responses regarding awareness of TB, especially with mobile media as their major source of information, followed by information from healthcare workers. Rural respondents were less expressed and deficient on knowledge of TB transmission and preventive methods. Prevention practices toward TB are claimed to be high in urban population because 79.48% believed that early diagnosis, prompt treatment and avoiding poor hygiene and crowded environment are effective strategies to cease the transmission of TB. Effective preventive and informative strategies should be employed in rural border areas to make up for the knowledge gap found among rural and urban populations in this study.

Spectral domain optical coherence tomography for measuring tear film meniscus height and its relationship with epiphora

Purpose: To evaluate the relationship between tear meniscus height (TMH) values measured by optical coherence tomography (OCT) and the severity of epiphora (Munk scoring). Methods: In this prospective cross-sectional study, consecutive patients with epiphora were studied. All patients underwent Munk epiphora scoring, lacrimal syringing, and detailed ophthalmological examination. Using OCT, the TMH (i.e., the line intersecting level of tear meniscus and lower eyelid) values were calculated. The relationship between TMH and epiphora was analyzed by comparing TMH values across various grades of epiphora using Kruskal–Wallis test. Results: A total of 38 patients (56 eyes) were included. The mean age was 55 ± 11.1 years with equal distribution of males and females. The mean TMH values were 238 ± 141.3, 396.6 ± 159.5, 707.1 ± 288.8, and 809.5 ± 419.4 ?m in grades 1, 2, 3, and 4 of epiphora, respectively. A significant difference in TMH was found among grades 2, 3, and 4 (P = 0.0007). On post hoc analysis, only grade 2 was significantly different from grades 3 and 4 (P = 0.0008 and P = 0.002 respectively), but grades 3 and 4 were comparable (P = 0.62). Conclusion: Levels of TMH were found to increase with increasing severity of epiphora. TMH values were comparable in Munk grades 3 and 4.

Primary limbal stem cell transplantation in the surgical management of extensive ocular surface squamous neoplasia involving the limbus

Purpose: To determine the role of primary limbal stem cell transplantation (LSCT) in managing extensive ocular surface squamous neoplasia (OSSN) with more than 3 quadrants of limbal involvement to prevent manifestations of limbal stem cell deficiency. Methods: A multi-center, comparative, and interventional clinical study of cases and historical controls was done. Patients with a limbal mass suggestive of OSSN involving more than 3 quadrants of limbus (> 9 clock hours) and no local, regional or systemic metastasis, who underwent primary surgical excision with or without adjuvant chemotherapy and had a minimum follow-up of 12 months were included in this study. Two historical controls underwent tumor excision with only amniotic membrane grafting. Three cases underwent tumor excision along with LSCT in the form of conjunctival limbal autograft (CLAG) or simple limbal epithelial transplant (SLET). Results: None of the eyes had any recurrences of OSSN during the follow-up period. Cases with primary LSCT with tumor excision showed better ocular surface stability in the long term. Conclusion: Concomitant LSCT either in the form of CLAG or SLET appears to provide better long-term outcomes and is advocated while excision of extensive OSSN involving the limbus.

Bilateral herpes simplex keratitis reactivation after lacrimal gland botulinum toxin injection

Botulinum toxin A (BTA) injections into lacrimal gland are being used for refractory epiphora due to intractable lacrimal disorders with success rates reported from 18% to 86%. Most common side effects are transient ptosis and diplopia. We report a case of a 59-year-old female injected with 2.5 units of BTA injection in each lacrimal gland for functional epiphora. The patient had a history of herpes simplex viral keratitis that was quiescent for more than 2 years. After 3 weeks, she developed reactivation of viral keratitis bilaterally, which was successfully managed with antivirals and topical steroids. Reactivation of quiescent herpes simplex keratitis is a possibility after lacrimal gland BTA and caution should be exercised in such cases.

Is universal sample processing methodology better than conventional techniques for detection of tuberculosis.

Background: The identification of infectious cases is a crucial first step for tuberculosis control programmes worldwide. It relies exclusively on the detection of acid‑fast bacilli in sputum by smear microscopy. Therefore, there is an urgent and definite need to improve the sensitivity of smear microscopy. Objective: The USP method was compared with the two most commonly used conventional methods of smear microscopy namely; direct smear microscopy and the microscopy by modified Petroff’s method. Materials and Methods: Two samples from each patient were taken from 197 patients of presumptive tuberculosis. One smear was made for direct Ziehl‑Neelsen staining and two smears were made after processing by two concentration methods i.e., modified Petroff’s and USP solution. LJ media were inoculated for culture after processing by both concentration methods. Results: Among 197 cases 93 were culture positive by either method. Out of 93 culture‑positive sample, 78.5% were direct smear positive, 89% were 4%NaOH smear positive and 96% were USP smear‑positive samples but difference in diagnostic accuracy of USP (96%) and modified Petroff method (93%) is not statistically significant (P > 0.01). Conclusion: The present study evaluated the smear microscopy by USP method with two conventional methods, direct microscopy and microscopy by modified Petroff’s method. The study concludes that although USP method is more sensitive than conventional methods, it is not feasible to include it in diagnosis of early tuberculosis within RNTCP.

Regression equations for spirometry in children aged 6 to 17 years in Delhi region.

Background. Most of the studies carried out in India to develop regression equations for spirometry in children are now several years-to-decades old and had used equipment and measurement protocols that have since changed. Prediction equations using the current standardisation protocols for spirometry are not available. The lung health of the population may have changed too. Objective. To develop regression equations for spirometry for children aged 6 to 17 years of north Indian origin in Delhi region. Methods. School children of north Indian origin, as determined by mother tongue and parentage, aged 6 to 17 years were screened by a health questionnaire and physical examination and those found “normal” underwent spirometry according to the standardised procedure recommended by the American Thoracic Society/ European Respiratory Society (ATS/ERS) task force in 2005. Pearson’s correlation analysis was carried out to identify the predictor variables for spirometric parameters. Prediction equations were developed using the multiple linear regression procedure. The independent variables were entered in sequence of height, age and weight. R2, adjusted R2 and R2 change, standard errors of the estimate (SEE), and estimates of regression coefficients were obtained and the goodness of fit was examined. Results. Data was obtained in 365 boys and 305 girls. Forced vital capacity (FVC), forced expiratory volume in one second(FEV1), peak expiratory flow rate (PEFR), forced expiratory flow rate at 50% and 75% exhalation of vial capacity (F50 and F75) and mean forced expiratory flow rate over the middle 50% of the vital capacity (F25-75) showed moderate to strong correlations with age, height and weight in both boys and girls. In both genders, the equations explained very high variability of FVC, FEV1 and PEFR as shown by the R2 values. The explained variability for flow rates was lesser, with that for F75 being the least. Conclusions. Regression equations for spirometry variables for children of north Indian origin in Delhi region have been developed. These represent the first such effort from India after the publication of the ATS/ERS task force 2005 guidelines on standardisation of spirometry.

Investigation of an outbreak of chikungunya in Malegaon Municipal areas of Nasik district, Maharashtra (India) and its control.

BACKGROUND & OBJECTIVES: An outbreak of chikungunya fever occurred in Malegaon town of Nasik district of Maharashtra state, India during February and March 2006. A total of 4530 fever cases were reported during this period including 1781 cases which were admitted in different hospitals of the town. An entomological and epidemiological investigation was carried out in the affected villages during the outbreak to study the possible causes of the outbreak and to isolate the virus responsible. METHODS: Entomological evaluation was done as per WHO guidelines. Sera samples were collected by venipuncture from clinically suspected chikungunya patients in hospitals and also during house-to-house survey in affected villages. IgM antibodies to dengue virus were detected using IgM capture ELISA (PANBIO) and by "Haemagglutination inhibition test" for detection of antibodies against Chikungunya virus. Acute sera samples were inoculated in cell lines for virus isolation. The isolates were confirmed by RT-PCR. RESULTS: On investigation, it was found that water storage containers like cement tanks, plastic containers or earthen pots placed in front of the individual houses were the potential breeding sites for Aedes aegypti. Entomological survey carried out in the most affected areas revealed high Aedes indices. House, container and breteau indices were found to be 27.2, 16.19 and 35.1, respectively. Out of the 13 acute sera samples collected, virus was isolated in 10 samples. The isolates were confirmed by RT-PCR and sequencing using primers from nsP1 gene of Chikungunya virus (CHIKV, Accession No. EF077609, EF077610). Of the 17 convalescent sera tested, significant level of HI antibodies to CHIKV was detected in five samples. One sample was positive for IgM antibodies against dengue virus. Based on clinico-epidemiological features and laboratory findings, the illness was confirmed to be of chikungunya viral disease. CONCLUSION: Control measures targeting the vector population and personal protective measures against the mosquito bites were instituted. Extensive IEC campaign with the involvement of community and religious leaders helped in containment of the disease.

Pseudo-aneurysm of left ventricle.

A 16 years boy who presented with pain chest, precordial bulging with abnormal chest movement and fever was diagnosed to have pseudo-aneurysm of left ventricle with infective endocarditis.

Chikungunya fever: a re-emerging viral infection.

Chikungunya (CHIK) fever is a re-emerging viral disease characterized by abrupt onset of fever with severe arthralgia followed by constitutional symptoms and rash lasting for 1-7 days. The disease is almost self-limiting and rarely fatal. Chikungunya virus (CHIKV) is a RNA virus belonging to family Togaviridae, genus Alphavirus. Molecular characterization has demonstrated two distinct lineages of strains which cause epidemics in Africa and Asia. These geographical genotypes exhibit differences in the transmission cycles. In contrast to Africa where sylvatic cycle is maintained between monkeys and wild mosquitoes, in Asia the cycle continues between humans and the Aedes aegypti mosquito. CHIKV is known to cause epidemics after a period of quiescence. The first recorded epidemic occurred in Tanzania in 1952-1953. In Asia, CHIK activity was documented since its isolation in Bangkok, Thailand in 1958. Virus transmission continued till 1964. After hiatus, the virus activity re-appeared in the mid-1970s and declined by 1976. In India, well-documented outbreaks occurred in 1963 and 1964 in Kolkata and southern India, respectively. Thereafter, a small outbreak of CHIK was reported from Sholapur district, Maharashtra in 1973. CHIKV emerged in the islands of South West Indian Ocean viz. French island of La Reunion, Mayotee, Mauritius and Seychelles which are reporting the outbreak since February, 2005. After quiescence of about three decades, CHIKV re-emerged in India in the states of Andhra Pradesh, Karnataka, Maharashtra, Madhya Pradesh and Tamil Nadu since December, 2005. Cases have also been reported from Rajasthan, Gujarat and Kerala. The outbreak is still continuing. National Institute of Communicable Diseases has conducted epidemiological, entomological and laboratory investigations for confirmation of the outbreak. These have been discussed in detail along with the major challenges that the country faced during the current outbreak.

Development and evaluation of an in vitro isolation of street rabies virus in mouse neuroblastoma cells as compared to conventional tests used for diagnosis of rabies.

In vitro isolation of rabies virus using mouse neuroblastoma cells (MNA) was evaluated. The sensitivity and reliability of in vitro procedure was performed in comparison with mouse inoculation test (MIT), the in vivo method of virus isolation, direct fluorescent antibody test (FAT) and Sellers staining. Of the 33 animal brain samples tested, 24 (72.72%) were positive by MIT. Sensitivity of Sellers stain, FAT and rapid tissue culture infection test (RTCIT) was found to be 54.16, 100 and 91.6% respectively. Concordance of Sellers stain, FAT, RTCIT with MIT was found to be 66.6, 100 and 93.93% respectively. Two samples which were positive by FAT and MIT showed gross contamination in cell lines, which is one of the drawbacks of RTCIT. However, rabies virus could be isolated in MNA cells from two of the eight human cerebrospinal fluid (CSF) samples from clinico-epidemiologically suspected cases of rabies. Both MIT and FAT showed negative results in the two CSF samples. RTCIT appears to be a fast and reliable alternative to MIT and holds promise in antemortem diagnosis of rabies, which is otherwise, a challenging task for a reference laboratory.

Postprandial lipid abnormalities in type 2 diabetes mellitus.

AIM AND OBJECTIVES: To study the postprandial lipid abnormalities in patients with type 2 diabetes mellitus. MATERIAL AND METHODS: Postprandial lipids were studied in 20 male type 2 diabetic subjects (age 49.75 +/- 4.82 years) and 20 age and sex matched healthy controls (age 49.55 +/- 4.82 years) after an oral fat challenge which consisted of a meal providing 729 keal/m2 body surface area with 68 gm fat. RESULTS: Average duration of diabetes among diabetic was 2.32 +/- 3.03 years. The body mass index (cases 25.84 +/- 4.52; controls 25.74 +/- 5.0; p > 0.05) and waist-hip ratio (cases 1.06 +/- 0.13; controls 1.14 +/- 0.2; p > 0.05) were similar in both groups. While fasting serum lipids were not significantly different between the two groups, a number of serum lipid abnormalities were noted in type 2 diabetic subjects in the postprandial state. These included a higher triglyceride-area under curve (AUC) (cases 1298.08 +/- 485.2 vs. controls 922.15 +/- 390.47 mg/dl/8h; p=0.01), a higher triglyceride-area under incremental curve (AUIC) (cases 549.68 +/- 382.24; control 294.75 +/- 172.6 mg/dl/8h; p=0.01), a higher peak triglyceride level (cases 425.2 +/- 204.47 mg%, controls 283.9 +/- 11.6.94 mg%, p=0.01), a lower HDL-AUC (cases 130.35 +/- 33.55 vs. controls 168.48 +/- 56.01 mg/dl/8h, p=0.013) and a lower HDL nadir (Cases 28.05 +/- 10.94 mg%, controls 37.13 +/- 13.52 mg%, p < 0.02). Triglyceride AUC correlated significantly with fasting serum triglyceride (r=0.62) and BMI (r=0.7), but not with waist hip ratio or fasting serum insulin levels. Postprandial lipaemia did not correlate with age, duration of diabetes, fasting blood glucose or glycosylated hemoglobin. CONCLUSION: In conclusion, make type 2 diabetics demonstrate significant postprandial lipid abnormalities, particularly of triglycerides, which appear to be independent of glycaemic control.

Dengue fever with acute liver failure.

A virus belonging to the Flaviviridae group causes dengue haemorrhagic fever. Dengue presenting as acute liver failure is rare. Dengue is endemic in India. The last epidemic of dengue occurred in Delhi in 2003. During this epidemic, 2185 confirmed cases of dengue were reported. Dengue virus serotypes 2 and 3 were responsible for this epidemic. A 19-yr-old male presented to our hospital with the complaints of fever for 12 days, during this epidemic. He was diagnosed as having dengue shock syndrome, stage IV with acute liver failure. He had primary dengue infection. He made complete recovery with supportive management.

Detection of antibodies to Taenia solium in sera of patient with epilepsy using ELISA.

Enzyme linked immunosorbent assay (ELISA) was used for detection of antibodies to cysticerci of Taenia solium in patients suffering from suspected neurocysticercosis. Serum antibodies to cysticercosis were detected in 10.4% of the patients. Antibodies were absent in healthy controls. No cross-reactivity was observed in sera from patients with other parasitic diseases viz. toxoplasmosis, filariasis and kala-azar. However sera from patients with hydatid disease showed cross reactions in 20%. Age group distribution showed gradual non-significant increase in seropositivity rates with advancing age. No significant gender difference, was observed. Analysis of dietary habits of patients showed statistically significant difference in seropositivity rates in non-vegetarians (15.4%) as compared to vegetarians (6.9%) (P value < .001).

A case for partial patellectomy.

The treatment of fractures of the the patella is a subject of controversy. Partial patellectomy with retention of a major fragment and suture of the quadriceps to it, seems reasonable. 18 cases of patella fracture underwent such a procedure. The average age of the patients was 47 years. Maximum recovery took an average of 5 months. There were 6 excellent results, 9 good, 3 fair. Results were assessed on the basis of pain, muscle wasting, quadriceps power, and range of knee motion. Total patellectomy and patella fixation as alternative modes of treatment are discussed. Partial patellectomy, whenever possible, is a good choice.

Prevalence of toxoplasmosis in Indian women of child bearing age.

A total of 2075 women in child bearing age and with past bad obstetrical history were serologically examined by the indirect immunofluorescence antibody test for Toxoplasma antibodies. 160 (7.72%) serum samples were positive with a titre of 1:64 or more. Maximum prevalence as well as highest titres of antibodies were seen in women aged 36 years and above indicating repeated infections. No association between seropositivity and contact with animals was observed. The low overall prevalence is due to infrequent and uncommon practices of ingesting undercooked or uncooked food especially meat.

Serum sialic acid--an important cancer marker.

Total serum sialic acid (TSA), Lipid associated sialic acid (LASA), Total protein (TP) and TSA/TP factor (as cancer markers) have been estimated in 78 patients of cancer stomach, breast, colorectal region and gall bladder, before and after treatment and of varying degrees of metastasis and compared to 30 healthy controls. A significant rise in TSA and TSA/TP factor and a decrease in serum total protein levels was found in all cases of cancer. This increase was directly proportional to the degree of metastasis i.e. tumour burden. Serum TP levels were found decreased in all patients. Rise in LASA levels was not significant. Raised TSA/TP levels became lower to certain extent after effective therapy. Hence it can be inferred that although TSA and TSA/TP are not specific they are however, sensitive markers regarding detection of malignancy and useful in monitoring cancer progression and/or recurrent while evaluating the efficacy of various cancer therapies.

Serodiagnosis of Indian kala-azar: evaluation of IFA, ELISA and CIEP tests.

The sensitivity and specificity of three serological tests viz. indirect immunofluorescent antibody test (IFAT), enzyme linked immunosorbent assay (ELISA) and counterimmunoelectrophoresis (CIEP) for the diagnosis of Indian kala-azar were evaluated. Of the 209 patients in whom Leishmania donovani parasite could be demonstrated in bone marrow, 207 (99.04 per cent) could be diagnosed with IFAT, 203 (96.6 per cent) with CIEP and 208 (99.5 per cent) with ELISA. None of these serological tests was positive in 40 healthy individuals and 10 patients each with tuberculosis, toxoplasmosis and malaria. In only one out of 10 patients with malaria ELISA alone gave false positive result. Of the 119 patients who had clinical features simulating kala-azar but were negative for Leishmania donovani in bone marrow and responded to treatment other than that for Indian Kala-azar, IFAT, CIEP and ELISA were false positive in three (2.5 per cent), nil and three (2.5 per cent) cases, respectively. The use of serodiagnostic tests like ELISA for mass screening and CIEP in less well equipped peripheral laboratories is suggested.