Best practices in tobacco control in the South-East Asia Region.

The tobacco epidemic is an increasing threat to public health with the tobacco burden particularly high in WHO's South-East Asia Region (SEAR). The Region has many obstacles to tobacco control, but despite these challenges, significant progress has been made in many countries. Although much work still needs to be done, SEAR countries have nevertheless implemented strong and often innovative tobacco control measures that can be classified as "best practices," with some setting global precedents. The best practice measures implemented in SEAR include bans on gutka, reducing tobacco imagery in movies, and warning about the dangers of tobacco. In a time of scarce resources, countries in SEAR and elsewhere must ensure that the most effective and cost-efficient measures are implemented. It is hoped that countries can learn from these examples and as appropriate, adapt these measures to their own specific cultural, social and political realities.

Clinical and Laboratory Comparison of Different Brands of Amphotericin B Used for the Treatment of Kala-Azar: An Observational Study.

The communication presents clinical response of cases of visceral leishmaniasis to treatment by two different brands of Amphotericin B. FungizoneTM was found to be slightly better than Amphotericin BTM, however, the difference is not statistically significant.

Impact of amphotericin-B in the treatment of kala-azar on the incidence of PKDL in Bihar, India.

BACKGROUND & OBJECTIVE: Of the two reservoirs of infection of kala-azar i.e., patients of kala-azar and post kala-azar dermal leishmaniasis (PKDL), PKDL provides easy access for the sandfly to pick up the parasites. In the last epidemic of 1977 in India, the importance of PKDL as a potential cause of increase in number of kala-azar cases was ignored. During recent years, we found an increase in the cases of kalaazar whereas cases of PKDL were decreasing in Bihar. We undertook this study to find out reasons for this phenomenon. METHODS: These three different settings were selected to study the trends of the disease. (i) Cases of PKDL registered in the Dermatology Department of Patna Medical College Hospital (PMCH), one of the largest and oldest teaching hospital in Bihar, between 1970 and 2005; (ii) Rajendra Memorial Research Institute of Medical Sciences, Patna (RMRIMS), a research institute exclusively devoted to kala-azar (2000 and 2005); and (iii) interviews with two leading dermatologists of Patna selected by lottery on the incidence of PKDL and possible causes of its decrease, if any. The number of cases of kala-azar (visceral leishmaniasis, VL) from Bihar was studied from Malaria Departments of the Government of Bihar and Government of India, the two nodal departments dealing with the kala-azar. RESULTS: Analysis of data from Dermatology Department of PMCH showed increase in number of cases of PKDL from two in 1970 to 12 in 1976, a year before the first epidemic of kala-azar in 1977 with 100,000 cases. Kala-azar cases decreased to 11,120 in 1982 due to control measures taken between 1977- 1979 but cases of PKDL reached 28 and kept on increasing. During 1950 to 1977, low dose and short duration regimen of sodium antimony gluconate (SAG) was mainly used in the treatment of kala-azar. Between 1977-1991 increasing incidence of unresponsiveness to SAG, led to the usage of longer duration and higher dose regimen of SAG, more use of amphotericin B (AMB) for SAG resistant cases and also as a first line drug for kala-azar and PKDL. The number of kala-azar cases started decreasing after control measures taken during 1992-1994 but cases of PKDL continued decreasing. The effect of control measures on the incidence of kala-azar was visible upto 2002, but decrease in number of PKDL cases continued. In 2005 the number of PKDL cases was 14 but number of kala-azar cases reached 21,177 in Bihar. In the interview, the two dermatologists also opined that PKDL was decreasing due to increased use of amphotericin B in the treatment of kala-azar. Trend analysis done on the data of PMCH and RMRIMS showed that PKDL will decrease in coming years and kala-azar will increase. INTERPRETATION & CONCLUSION: Incidence of PKDL decreased in PMCH and RMRIMS and also suggested by two dermatologists that extensive use of amphotericin B in the treatment of kala-azar might be responsible for decrease in number of cases of PKDL.

Dual culture method to determine the relationship of gut bacteria of sandfly (Phlebotomus argentipes) with promastigotes of Leishmania donovani.

A simple dual culture agar plating technique has been developed and evaluated for its efficiency in determining the relationship of gut bacteria of sandfly with Leishmania donovani promastigotes. There are about twenty morphologically distinct bacterial colonies have been isolated from the gut homogenate of Phlebotomus argentipes. In dual culture method, each bacterial isolate was inoculated in one half of the plate and the promastigotes of Leishmania was inculcated in the other half by streaking. After incubation, the type of association was determined based on the presence or absence of promastigotes colonies. The reliability of this method was compared with broth dilution method in 96 well plate.

Cognitive functions in stable schizophrenia & euthymic state of bipolar disorder.

BACKGROUND & OBJECTIVE: Some cognitive deficits in schizophrenia and bipolar disorders persist after the subsidence of active symptoms. We carried out this study to assess and compare the cognitive functioning of patients with stable schizophrenia and bipolar disorder. METHODS: Fifteen each of stable maintained schizophrenic patients and euthymic bipolar-I patients attending outpatient clinic in a tertiary care psychiatric hospital in north India were included in the study as also equal number of age and education matched control subjects. Cognitive assessments were done using Wisconsin's Card Sorting Test (WCST), Spatial Working Memory Test (SWMT) and Continuous Performance Test (CPT). RESULTS: Stable schizophrenia patients performed poorly on all the neurocognitive parameters as compared to both controls and bipolar euthymic patients. Euthymic bipolar patients showed significant difference on executive functions with normal controls. Patterns of cognitive disturbances in tasks of executive function are similar in both groups but are quantitatively more marked in schizophrenia. INTERPRETATION & CONCLUSION: Our results showed that stable schizophrenia patients performed significantly worse on cognitive measures than patients of euthymic bipolar disorder which was consistent with their poorer functional outcome. The results further indicated that stable schizophrenia and euthymic bipolar disorders may be distinguished qualitatively in neuropsychological terms with different profiles of cognitive impairment.

Leaching of lead and cadmium from glass dinnerware.

Heavy metals like lead and cadmium were found to leach out from food contact surface of opal glass dinnerware when treated with five food acids as a leaching solution. The leachates used were: acetic acid, tartaric acid, citric acid, lactic acid and ascorbic acid at three different concentrations 2%, 4%, and 8% (v/v). At room temperature, duration of leaching varied from 1h to 24h in each case. The amount of metals leached in individual acid was found to be maximum at the 4% acid concentration. Release of Pb and Cd was faster in first 2h leaching period. Maximum amount of Pb and Cd were leached in 4% acetic acid at room temperature.

DOTS at a tertiary care center in northern India: successes, challenges and the next steps in tuberculosis control.

BACKGROUND AND OBJECTIVES: The past decade has seen a rapid expansion of directly observed treatment, short-course (DOTS) centers throughout India, under the guidance of the Revised National Tuberculosis Control Programme (RNTCP). While expansion has been rapid and extensive, few reports exist detailing individual DOTS centers' experiences, their challenges, and their successes. We present a brief report on the status of a DOTS center being run at a large tertiary care center in northern India for almost four years (2001-2005). METHODS: The DOTS center followed RNTCP guidelines for the evaluation and treatment of suspected TB cases. A register carrying detailed information of all patients seen at the DOTS center was kept by the senior clinician. Data from this register were extracted and analyzed for descriptive measures. RESULTS: A total of 1490 patients were evaluated. Of the 768 patients with cough, 27 per cent (211) were found to be sputum positive for acid-fast bacilli (AFB). Among patients who were initiated on anti-tuberculosis medications, cure was achieved in 92 per cent (71 of 77) of new sputum smear positive patients; treatment completion was achieved in 91 per cent (91 of 100) of extrapulmonary TB (EPTB) and 75 per cent (46 of 61) of sputum-negative pulmonary TB patients. Overall treatment success was achieved in 86 per cent (229 of 266). INTERPRETATION AND CONCLUSION: Treatment results were in keeping with the RNTCP guidelines. Tertiary care centers appear to be excellent place for education of medical students and operational research. The latter is much needed, as HIV-TB co-infection, multi-drug resistant TB, and EPTB continue to be major public health threats even in the era of DOTS.

Pre- & post-treatment evaluation of immunological features in Indian visceral leishmaniasis (VL) patients with HIV co-infection.

BACKGROUND & OBJECTIVE: The risk of human immunodeficiency virus (HIV) co-infection in patients with visceral leishmaniasis (VL) or kala-azar in endemic areas has posed a major challenge in control programmes. We undertook this study to identify the high risk groups vulnerable to Leishmania-HIV co-infection in VL endemic State of Bihar, India. Further, immunological responses were also evaluated in these patients before and after treatment for VL to see the immune impairment associated with CD4 T cell count. METHODS: A total of 1511 subjects attending Voluntary Counselling and Testing Centre (VCTC) at Patna, Bihar were included in this study. VL was confirmed by splenic or bone marrow aspirates testing for parasite. HIV states was confirmed by two kits. Immunological parameters (CD4, CD8, IFN-gamma, IL-4) were studied in co-infection patients. RESULTS: Of the 280 (18.53%) HIV-positive individuals, eight were diagnosed serologically and pathologically as VL patients co-infected with HIV. The humoral and cellular immune responses were evaluated in 18 Indian VL patients with (n = 8) or without HIV (n = 10) and 10 HIV seropositive subjects. Among the eight confirmed cases of VL, false negative direct agglutination test (DAT) result was observed in two who had HIV co-infection (sensitivity 80%), while none in 10 other VL cases who were HIV negative (sensitivity 100%). A very low CD4 cell count was observed in VL cases that had HIV co-infection compared to HIV negative VL or controls. All VL cases with or without HIV infection had lower Th1/Th2 ratio compared to controls. VL patients with or without HIV infection responded well to anti-leishmanial/anti-retroviral therapy with considerable degree of immunological reconstitution. INTERPRETATION & CONCLUSION: A different immune response was noticed in patients with co-infection of HIV and Leishmania. Anti-leishmanial drug treatment led to improvement in immunological response in co-infected patients. Further studies need to be done to see the effect of combined therapy for VL and HIV on immunological parameters in these patients.

Electricity and the heart.

Understanding of cardiac rhythm requires application of physical principles governing electricity. Over a period of more than 100 years, application of the knowledge of electric current led to the gradual evolution of electrocardiogram, pacemaker, defibrillator, and ultimately electrophysiology. The discovery of electrocardiogram (ECG) by Einthoven in 1902 and that of pacing by Zoll in 1952 were two landmarks in this field.

Preservation of Leishmania donovani promastigotes in blood agar slants.

Long-term cultivation of Leishmania promastigotes by weekly passage to fresh medium was reported to be disadvantageous because needs labor, risk of contamination, lowering in infectivity and virulence pattern. Cryopreservation and Lyophilization require expensive facilities which could be a burden and unaffordable to most laboratories of developing countries where the disease is endemic. These problems could be minimized by simple preservation of Leishmania donovani promastigotes in blood agar slants at 7-8 degrees C for 6-7 months. The preserved promastigotes were examined for viability up to one year at a regular interval of one month. Viable promastigotes were found and revived successfully from all the slants stored up to 7 months after that, the viability of promastigotes was found to be decreased in the slants of 8-9 month storage. No viable promastigotes were recovered from the slants stored up to 11-12 months. By this method, the promastigotes can easily be stored up to 7 months without loss of biological activity. The number of passage of promastigotes to fresh medium has been greatly reduced by this method from 30 times to 01 when compared with weekly passage in liquid medium. This simple and economical method can be recommended for short storage of Leishmania culture without loss of any activity.

Magnitude of unresponsiveness to sodium stibogluconate in the treatment of visceral leishmaniasis in Bihar.

BACKGROUND: The Indian government proposes to eliminate kala-azar, which has been a serious public health problem in Bihar. This study aimed to assess the magnitude of unresponsiveness to sodium stibogluconate in the treatment of new cases of visceral leishmaniasis and to identify the associated factors. METHODS: Patients with clinically and parasitologically confirmed visceral leishmaniasis (n = 182) who had received no prior treatment, were enrolled for the study. The patients were treated with sodium stibogluconate (20 mg/kg body weight; upper limit 850 mg), intramuscularly for 30 days. The vital parameters and side-effects, if any, were monitored. Patients who developed toxicity during treatment were excluded from the study but were given rescue treatment with liposomal amphotericin B. All patients who completed the treatment were followed up for 6 months. RESULTS: Unresponsiveness to sodium stibogluconate at the end of treatment was 43%. It was higher in women (48%) compared to men (40%). A significant association was observed between unresponsiveness and level of endemicity (p = 0.0002), large spleen size (p = 0.04) and immune response (migration inhibition factor) (p = 0.00002). At the end of 6 months' follow up, 27% of patients relapsed, giving a total unresponsiveness rate of 58%. CONCLUSION: Unresponsiveness to sodium stibogluconate is a serious problem in the management of patients with visceral leishmaniasis. In patients with factors associated with nonresponse to sodium stibogluconate, alternative drugs such as miltefosine or amphotericin B should be considered as first-line drugs.

Diagnosis & management of leishmania/HIV co-infection.

Leishmaniasis, a globally prevalent parasitic disease occurs in three forms viz., visceral, cutaneous and mucocutaneous, transmitted by the bite of infected female Phlebotomus sandflies. Visceral leishmaniasis (VL) has 100 per cent fatality rate, if left untreated. India has the largest burden of this disease. HIV infection is also increasing worldwide and several reports indicate rising trend of VL/ HIV co-infection, modifying the traditional anthroponotic pattern of VL transmission. Both VL and HIV tend to lower the cell mediated immunity (CMI) resulting in poor drug response and opportunistic infections involving gastrointestinal, cutaneous, respiratory tract and central nervous system (CNS) may occur. Diagnosis of such co-infected cases is quite difficult. However, newer tests like nested PCR, rk39 immunochromatographic test etc., can be of help. Response to different antileishmanial drugs like sodium antimony gluconate (SAG), amphotericin B is far from satisfactory. However, a new oral drug miltefosine has been found to be promising. Highly active antiretroviral therapy (HAART) need to be given for management of HIV infection along with treatment of other opportunistic infections.

DOTS centre at a tertiary care teaching hospital: lessons learned and future directions.

BACKGROUND: In 1993, Government of India started the Revised National Tuberculosis Control Programme (RNTCP). A model Directly Observed Therapy, Short-Course (DOTS) centre was established at the All India Institute of Medical Sciences (AIIMS) to (i) identify the challenges and opportunities in establishing DOTS centres at tertiary care facilities, (ii) to teach the strategies of RNTCP to medical and paramedical staff, and (iii) to undertake relevant operational research connected with tuberculosis (TB) treatment and control. In this communication, we describe the experience of establishing a DOTS centre at India's premier medical institute and discuss the lessons learned. METHODS: Since September 2001 through November 2002 AIIMS employees and their dependants diagnosed with tuberculosis were enrolled for treatment at AIIMS DOTS centre. One hundred sixty-eight patients were diagnosed as suffering from tuberculosis. Of these 49 patients were referred out and remaining 119 patients were treated at AIIMS DOTS centre. RESULTS: Treatment success was achieved in 80% (20/25) of new smear positive cases and the DOTS centre achieved other targets set up by the RNTCP. As the results of the pilot study at AIIMS DOTS centre were favourable, the facilities of AIIMS DOTS centre were extended to the general public from September 2002 onwards. CONCLUSION: Despite tremendous patient load at tertiary care facilities, it is possible to achieve targets established by the RNTCP. However, additional research needs to be conducted especially relating to drug resistance and surrogate markers of failure under RNTCP.

Comparison of temperament and character profiles of anesthesiologists and surgeons: a preliminary study.

BACKGROUND: Given the high levels of stress in anesthesiologists and also their close working liaison with surgeons, it may be worthwhile to compare the personality profiles of these two groups of professionals. AIM: To compare the personality profiles of surgeons and anesthesiologists, using a well-standardized and validated instrument. SETTINGS AND DESIGN: Survey (cross-sectional) on surgeons and anesthesiologists working in several medical institutes in India. MATERIAL & METHODS: The self-report Temperament and Character Inventory, 125-item version (TCI-125) was mailed out to an incidental sample of surgeons and anesthesiologists working in medical institutes in India. Of the 200 questionnaires sent (100 to anesthesiologists and surgeons each), 93 completed responses were returned (46 anesthesiologists, 47 surgeons; return rate 46.5%). STATISTICAL ANALYSIS: Student's unpaired 't' test; P<0.05 was considered statistically significant. RESULTS: The mean scores of anesthesiologists vis-a-vis surgeons on the various temperament dimensions were Novelty seeking: 8.6 vs. 9.2; Harm avoidance: 7.3 vs. 8.1; Reward dependence: 8.1 vs. 8.0; and Persistence: 3.0 vs. 3.1, respectively. Similar scores for the character dimensions were Self-directedness: 16.9 vs. 15.9; Cooperativeness: 17.5 vs. 16.5; and Self-transcendence: 7.0 vs. 6.7, respectively. There was no significant difference between the surgeons and anesthesiologists on any of the temperament and character variables of personality chosen for the study. CONCLUSION: Personality measures did not differ significantly between surgeons and anesthesiologists in this preliminary investigation. If replicated on a larger and more representative sample, the findings have clinical relevance to improve the working relationship between these two groups of closely working professionals.

Laryngeal mask airway vs endotracheal tube to facilitate bedside percutaneous tracheostomy in critically ill patients: a prospective comparative study.

BACKGROUND: Inadvertent puncture of endotracheal tube (ETT) cuff and accidental tracheal extubation are the potential life threatening complications during percutaneous dilatational tracheostomy (PDT). As an alternative to ETT, the laryngeal mask airway (LMA) has been used sporadically but no large study is available on its use. AIMS: To study the use of LMA during PDT on controlled ventilation in critically sick patients and compare its advantages and disadvantages in relation to ETT. SETTINGS AND DESIGN: This prospective, randomised, comparative study was conducted in intensive care unit of a super-speciality, tertiary care hospital. METHODS AND MATERIAL: The bedside PDT was performed in 60 critically ill patients using Ciaglia's kit. The patients received controlled ventilation of lungs either through ETT or LMA. The feasibility of the procedure and complications were compared in two groups. RESULTS: In LMA group, 33% of patients suffered with potentially catastrophic complications, e.g., loss of airway, inadequate ventilation of lungs leading to significant hypoxia, gastric distension and regurgitation. In ETT group there were 6.6% incidence of ETT impalement, 6.6% cuff puncture and 3.3% accidental tracheal extubation. Despite the technical difficulties (cuff puncture, etc.) the ETT technique was basically safe, whereas despite of the theoretical advantages the LMA technique rendered some patients at considerable risks of hypoxia and gastric regurgitation-aspiration. CONCLUSION: The LMA does not provide safe patent airway to facilitate bedside PDT in critically sick population on controlled ventilation. The ETT is safer for controlled ventilation and should be continued to secure the airway for this purpose until a better alternative is available.

Effect of immunization with lipid associated polysaccharide antigen and anti CD-2 antibodies on class II MHC expression and cellular immune response in BALB/C mice infected with Leishmania donovani.

In a bid to characterize the antigens and immunization mechanisms which may be used to produce a protective response against L. donovani, role of lipid associated polysaccharide (LPS) antigen and whole antigen was evaluated. BALB/C mice were immunized with whole or LPS antigen in combination with one of three putative adjuvents (anti CD-2 antibody/FIA/0.85% Saline). LPS antigen emulsified in anti CD-2 antibody was found to induce significant antibodies in mice on day 28 against challenge with lethal dose of L. donovani. Immunoprophylactic properties of LPS and whole antigen was investigated on day 40 through cytokine elicitation (IL-2), MIF) in culture supernatants of spleen cells, but before that MHC-II expressed on macrophage was studied. The LPS antigen in combination with anti CD-2 antibody was found to be most immuno-reactive inducing higher MHC-II expression on macrophages which was associated with substantial rise in the level of MIF and IL-2. It coincided with decline in antibody titre in 100% mice immunized with LPS antigen while Leishmania injected as whole antigen failed to induce specific macrophage and T-cell response with all the above formulations. We surmise from our data that lipid associated polysaccharide antigen linked to anti CD-2 antibody has potential for eliciting protective immunity against Leishmania.

Amphotericin B in resistant kala-azar in Bihar.

BACKGROUND. During the recent epidemic of kala-azar in Bihar, we identified a group of patients who were unresponsive to the two commonly used drugs--sodium stibogluconate and pentamidine. We evaluated the use of amphotericin B in these patients because it has been shown to be active in experimental animals against amastigotes and promastigotes, it has been found to be useful in South American patients and is now recommended by the World Health Organization as a second line drug. METHODS. We selected 300 patients who were unresponsive to sodium stibogluconate and pentamidine (out of 500 patients with kala-azar confirmed by demonstration of Leishmania donovani bodies in their splenic aspirates). Amphotericin B was given in a dose of 1 mg/kg body weight on alternate days starting with 0.05 mg/kg body weight with daily increments till a 1 mg dose was reached. A total dose of 20 mg/kg was given initially and repeated if the parasites persisted. The investigations done before and after treatment were splenic or bone marrow aspiration, measurement of the spleen and liver size, body weight, total and differential white cell counts, haemoglobin level, total serum protein, blood urea, serum creatinine, serum potassium, blood sugar, serum alanine and aspartate transaminase, electrocardiography and a chest X-ray. The efficacy of treatment was assessed at the end of treatment and after 6 months of follow up. RESULTS. After treatment with amphotericin B, 298 (99%) of the patients had been cured of their disease as evidenced by the disappearance of fever, reduction of hepatosplenomegaly, clearance of the parasites from the spleen and bone marrow and an absence of relapse on 6 months of follow up. Two hundred and sixty-eight (89%) patients required 1 g of the drug, 24 (8%) required 1.5 g and 6 (2%) required 2 g. All patients had shivering and fever during the infusion. Two had a cardiac arrest from which they could not be revived. Other complications included anorexia, stomatitis, jaundice, hypokalaemia and a rise in blood urea. However, these were only mild and improved after treatment was stopped. CONCLUSION. Amphotericin B is an effective drug for patients with kala-azar unresponsive to treatment with sodium stibogluconate and pentamidine, but it should be administered under close medical supervision.