Novel mutations in emb B gene of ethambutol resistant isolates of Mycobacterium tuberculosis: A preliminary report.

Background & objectives: Ethambutol (EMB) resistance, thought to be occurring due to mutations in embB gene of Mycobacterium tuberculosis on the rise is a cause of grave concern. The present study was planned to investigate the presence of EMB resistance in M. tuberculosis isolates and to look for prevalent mutations in embB gene. Methods: A total of 591(283 from new and 308 from previously treated cases) sputum samples from the same number of pulmonary tuberculosis cases were cultured. Isolates were tested by 1 per cent proportion method for resistance to isoniazid, rifampicin streptomycin and ethambutol. Minimum inhibitory concentration (MIC) of EMB was measured by absolute concentration method. Ten randomly selected isolates were subjected to single strand conformational polymorphism (SSCP) and direct DNA sequencing to look for mutation in 364 bp segments of embB gene. Results: Of 353 isolates of M. tuberculosis from 591 sputum samples, 62 (17.58%) were resistant to EMB, of which, 16 (25.8%) showed initial resistance and 46 (74.2%) acquired. Mono resistance to EMB was rare. Only two isolates showed resistance to EMB alone. From 62 EMB resistant isolates, 88.7 per cent (55) were resistant to INH, 82.2 per cent (51) to rifampicin and 61.2 per cent (38) were resistant to streptomycin. Co-resistance to isoniazid and rifampicin (multidrug resistant, MDR-TB) with EMB resistance was seen in 41(66.1%) isolates. High level of EMB resistance was seen in 16.5 per cent isolates. SSCP showed altered mobility in 8 of 10 isolates tested. Among the 8 mutants, 4 had known mutations at codon Met 306 being replaced by Val/ Leu. The second most frequent mutation encountered was at codon Phe 287 being replaced by Val, Cys or Leu (novel mutations). Sequence analysis revealed 10 novel mutations in codon 221, 225, 227, 271, 272, 281, 282, 287, 293 and 294 within embB gene. Interpretation & conclusions: Presence of high frequency of EMB resistance, occurrence of high level EMB resistance, co-existence of MDR-TB with EMB resistance and novel mutations in emb B gene of M. tuberculosis clinical isolates reported highlight the need to work on larger samples to identify the diagnostic marker of EMB resistance in mycobacteria.

Novel mutations in emb B gene of ethambutol resistant isolates of Mycobacterium tuberculosis: a preliminary report.

BACKGROUND & OBJECTIVE: Ethambutol (EMB) resistance, thought to be occurring due to mutations in embB gene of Mycobacterium tuberculosis on the rise is a cause of grave concern. The present study was planned to investigate the presence of EMB resistance in M. tuberculosis isolates and to look for prevalent mutations in embB gene. METHODS: A total of 591(283 from new and 308 from previously treated cases) sputum samples from the same number of pulmonary tuberculosis cases were cultured. Isolates were tested by 1 per cent proportion method for resistance to isoniazid, rifampicin streptomycin and ethambutol. Minimum inhibitory concentration (MIC) of EMB was measured by absolute concentration method. Ten randomly selected isolates were subjected to single strand conformational polymorphism (SSCP) and direct DNA sequencing to look for mutation in 364 bp segments of embB gene. RESULTS: Of 353 isolates of M. tuberculosis from 591 sputum samples, 62 (17.58%) were resistant to EMB, of which, 16 (25.8%) showed initial resistance and 46 (74.2%) acquired. Mono resistance to EMB was rare. Only two isolates showed resistance to EMB alone. From 62 EMB resistant isolates, 88.7 per cent (55) were resistant to INH, 82.2 per cent (51) to rifampicin and 61.2 per cent (38) were resistant to streptomycin. Co-resistance to isoniazid and rifampicin (multidrug resistant, MDR-TB) with EMB resistance was seen in 41(66.1%) isolates. High level of EMB resistance was seen in 16.5 per cent isolates. SSCP showed altered mobility in 8 of 10 isolates tested. Among the 8 mutants, 4 had known mutations at codon Met 306 being replaced by Val/ Leu. The second most frequent mutation encountered was at codon Phe 287 being replaced by Val, Cys or Leu (novel mutations). Sequence analysis revealed 10 novel mutations in codon 221, 225, 227, 271, 272, 281, 282, 287, 293 and 294 within embB gene. INTERPRETATION & CONCLUSION: Presence of high frequency of EMB resistance, occurrence of high level EMB resistance, co-existence of MDR-TB with EMB resistance and novel mutations in emb B gene of M. tuberculosis clinical isolates reported highlight the need to work on larger samples to identify the diagnostic marker of EMB resistance in mycobacteria.

Prevalence of multidrug resistant Mycobacterium tuberculosis in Lucknow, Uttar Pradesh.

BACKGROUND & OBJECTIVE: Multi-drug resistant (MDR) Mycobacterium tuberculosis isolates may be transmitted within communities due to dense population and poor hygienic conditions. For proper management and control of MDR-TB, understanding drug susceptibility pattern of M. tuberculosis isolates and their transmission pattern in every health care setting are essential. In the present study, we attempted to describe the current prevalence of MDR-TB in Lucknow district, Uttar Pradesh, and our observations on transmission of MDR isolates among populations in and around this area. METHODS: Patients diagnosed as that of pulmonary tuberculosis (PTB) were enrolled from primary level (PLH), secondary level (SLH) and tertiary level (TLH) healthcare centres from Lucknow district. Detailed history of intake of antitubercular drug in the past was taken to decipher initial/ acquired drug resistance. Sputum samples were cultured on Lowenstein-Jensen media to isolate mycobacteria. Drug susceptibility patterns of isolated M. tuberculosis isolates were recorded using 1 per cent proportion method. Transmission of MDR isolates in community was accessed by random amplified polymorphic DNA (RAPD). Isolates showing same band pattern on RAPD were retyped using different primers targeted to the inverted repeat sequence of IS6110 copies in M. tuberculosis genome. RESULTS: A total of 686 M. tuberculosis isolates were obtained from 1162 patients, of which 318 were from untreated subjects and 368 were from patients who were treated for tuberculosis in the past. Prevalence of MDR was 19.8 per cent, initial and acquired being 13.2 and 25.5 per cent respectively. Prevalence of resistance to any drug, MDR and individual drug resistance to isoniazid, streptomycin, ethambutol and rifampicin was significantly higher in patients who were treated in the past. Drug resistance was significantly higher at tertiary level health care compared to primary level health care. Genotypically similar clusters were seen at all levels of health care. It was not always possible to establish geographic connections within clusters. INTERPRETATION & CONCLUSION: High prevalence of both initial and acquired MDR was noted in M. tuberculosis isolates collected from pulmonary tuberculosis patients. Presence of small clusters of MDR isolates at all health care levels suggests transmission within the studied community.

Screening for HIV infection by health professionals in India.

BACKGROUND: Stigma and discrimination, particularly in access to healthcare, remains a major problem for people Infected with HIV in most parts of India. METHODS: We did a multicentre study (n = 10) with a cross-sectional survey design using a standardized, interviewer-administered questionnaire. RESULTS: A total of 2200 healthcare providers participated. The knowledge, attitude and practice (KAP) related to HIV service delivery were very poor with a mean overall KAP score of only 49.7% (CI: 49.1-50.3). Only 5%, 5% and 1% of the participants scored more than 75% separately for the dimensions of knowledge, attitude and practice, respectively. Only 24.4% and 36.7% of responders knew that HIV screening was not recommended prior to surgery and pre-employment check-up. Many doctors (19.4%) had refused treatment to people living with HIV/AIDS (PLHA) at least some of the time and nearly half (47.2%) identified and labelled them; 23.9% isolated them in separate care areas and 13.3% postponed or changed treatment based on the patient's HIV status. Screening for HIV prior to elective surgery was done by 67% of providers. While 64.7% of responders were aware of the existence of national guidelines on and recommendations for HIV testing, only 38.4% had read the policy document. CONCLUSION: There is a growing need to provide care, support and treatment to a large number of PLHA. The capacity of healthcare providers must be urgently built up so as to improve their knowledge of and attitude to HIV to enable them to deliver evidence-based and compassionate care to PLHA in various healthcare settings.

Alprazolam in chronic tension type headache.

Alprazolam was evaluated in the treatment of 62 patients of chronic tension type headache using a double blind cross over design with random allocation to drug or placebo. The duration of the trial was 4 months with a 2 week run in period and 2 week washout period separating two treatment periods of 4 weeks each. The patients were followed up for 4 weeks at the completion of the trial. 48 patients completed the trial. There was no significant difference in the overall response rate based in terms of percentage reduction in headache frequency per week, however a significant decrease in headache index was observed during treatment with alprazolam as compared to placebo (P < 0.05). The mean analgesic intake per week was also significantly lower during treatment with alprazolam as compared to the run in period. Side effects were seen in 16.67% patients. In none of the patients was it significant enough to require withdrawal from the study.

Nifedipine in migraine and tension headache: a randomised double blind crossover study.

Nifedipine was evaluated in the prophylaxis of 28 patients each of migraine and tension headache using a double blind cross over design with random allocation to drug or placebo group. The duration of the trial was 3 months with a 2 week run-in period and 2 week wash-oat period separating two treatment periods of 4 weeks each. A satisfactory response was obtained in 71.4% of migraineurs (p < 0.001) and 28.6% of patients with tension headache (p = N.S). Minor side effects were observed in 5 patients. Nifedipine is a useful agent for the management of migraine as it reduces frequency and severity of pain but the drug cannot be recommended for tension headache.

Beneficial effects of long-term metoprolol therapy on cardiac haemodynamics in patients with mitral stenosis in sinus rhythm--a randomised clinical trial.

We conducted a placebo controlled randomised clinical trial to evaluate the effects of 6 months therapy with metoprolol on resting and exercise haemodynamics in 31 patients with isolated mitral stenosis in sinus rhythm. Twenty six of them (placebo n = 13, metoprolol n = 13) completed the study protocol. Their mean age was 23.1 +/- 7.9 years and the mean mitral valve area was 0.93 +/- 0.25 cm2. The dose of metoprolol ranged between 50-100 mg per day. The primary outcome variables for the study were the resting and exercise mean pulmonary capillary wedge pressure (PCWP) and cardiac index (CI) and the secondary outcome variables consisted of resting and exercise heart rate, mean pulmonary artery pressure (PAP), mean pulmonary vascular resistance (PVR) and clinical improvement on visual analog scale. These outcome variables were assessed blindly. The resting and exercise mean PCWP (mmHg) increased by 9.1 +/- 3.1 and 16.4 +/- 6.4 on placebo and 2.5 +/- 2.1 and -4.6 +/- 2.3 on metoprolol after 6 months therapy. These differences were statistically significant (p < 0.01). The resting and exercise CI (liters/min/m2) decreased by 0.2 +/- 0.1 and 0.1 +/- 0.1 on placebo and 0.3 +/- 0.5 and 0.3 +/- 1.0 on metoprolol. These haemodynamic effects were accompanied with much better symptomatic improvement in patients treated with metoprolol. The differences in change in mean PAP and PVR in two groups were statistically not significant. Our results suggest that the symptomatic patients with MS, waiting for definitive intervention for 6 months or less, would benefit if given beta blockers during this period.

Etiology of isolated mitral regurgitation: a clinico-echocardiographic study.

One hundred and ninety two consecutive patients with isolated mitral regurgitation (MR) with an audible murmur were studied for determination of etiology. There were 95 males & 97 females (mean age 24.5 +/- 10.8 years; range 13 to 58 years) with 102 patients in NYHA classes I and II, 81 in class III and 9 in NYHA class IV. The etiological grouping was: rheumatic 74 (38.5%), probable rheumatic 28 (15%), mitral valve prolapse 26 (13.5%), dilated cardiomyopathy 15 (8%), infective endocarditis 12 (6%), isochaemic heart disease 10 (5%), miscellaneous group (including rupture chordae tendinae, aortoarteritis etc) 9 (4.5%) and patients with indeterminate etiology 18 (9.5%). Etiology could be determined in 174 out of 192 cases. The clinical methods combined with echocardiography were helpful in 79 cases while echocardiography alone could diagnose etiology in 89 cases. Clinical features alone gave the diagnosis in 6 patients. The findings of gross morphology of the surgically removed mitral valves in 30 patients of this study were similar to their pre-operative etiologic diagnosis based on clinical and echocardiographic features. These findings may be of value in planning treatment and prophylactic strategies in cases of isolated MR.

Falciparum malaria--present day problems. An experience with 425 cases.

Clinical details and present day problems encountered in 425 cases of falciparum malaria (PF) are reported. 10.11% had taken chloroquine prior to reporting to us. Parasitic count done in 23.05% cases lacked correlation with severity of disease. Pattern of fever varied markedly but 5.4% were afebrile throughout and presented only with bodyache and malaise. Apyrexial spell was noted in 5.64%. 28.70% had typical facial looks of anaemia and sallow complexion. Cerebral symptoms were noted in 3.05%. Other symptoms were severe headache 33.4%, pain abdomen 3.29%, gastroenteritis 5.64%, jaundice 2.58% and bronchitis in 7.50%. We encountered subconjunctival haemorrhages with purpura and/or urticaria in four cases, symptoms suggestive of shock lung in 3, pulmonary oedema in 2, severe anaemia (HB less than 4 g%) in seven pregnant ladies, extrapyramidal symptoms in follow up period in 5 and congenital malaria in 2 cases. 83.25% were cured with chloroquine and oxytetracycline. 8.47% (who deteriorated despite the above treatment) were treated with quinine for 6 days. 5.17% (with severe disease) were also given quinine as first line drug. 2.82% (unresponsive to chloroquine and oxytetracycline but with mild disease) were treated with pyrimethamine-sulphamezathine combination for 5 days. One case who did not respond to quinine was treated with quinidine. Recrudescence was seen in 3.67% of patients treated with chloroquine and oxytetracycline. There was no case with renal failure, haemolysis due to G6PD deficiency and black water fever. There was only one death (0.23%) in our series. Self-medication, haphazard therapy and the slogan "Fever may be malaria-take chloroquine" can lead to problems in falciparum malaria.

Beta blockade for patients of mitral stenosis in sinus rhythm.

Twenty patients of isolated mitral stenosis in normal sinus rhythm (age 22 +/- 4 yrs) in whom symptoms of systemic and pulmonary congestion were controlled on diuretics were the subjects of the present study. The effects of addition of Metoprolol 50 mg po bid for 4 weeks on subjective and objective indices of exercise tolerance were evaluated. Metoprolol produced greater than 50% subjective improvement in 80% of these patients. The increase in time to dyspnoea and total work done on treadmill after 90-120 mins, and after 12 hrs of a dose of metoprolol, were both significant (p less than 0.01). In none of the patients, resting heart rate less than 50/mt, resting and exercise systolic BP less than 90 and less than 105 mmHg, respectively, or any important untoward effects were observed. Metoprolol's beneficial effects and safety can be judged in these patients at two hours after first dose in out patients clinic.