Effect of individual nutrition education on perceptions of nutritional iron supplementation, adherence to iron - folic acid intake and Hb levels among a cohort of anemic South Indian pregnant women.

OBJECTIVE: The objective of the study was to evaluate the effect of individual nutrition education on nutritional knowledge, attitude, practices, adherence to iron-folic acid intake, and hemoglobin levels among anemic South Indian pregnant women. METHODS: This intervention study was conducted from December 2020 to March 2021 in a secondary care level women and child hospital at Puducherry, India. The intervention group (n = 59) and comparison group (n = 58) included mild to moderately anemic pregnant women attending antenatal clinics (Mild anemia - Hb levels between 10.0 and 10.9 g/dL, Moderate anemia - Hb levels between 7.0 and 9.9 g/dL). Individual nutrition education intervention and SMS alerts for four weeks were given to the pregnant women. Baseline data and hemoglobin levels were measured at the time of enrollment. Maternal adherence to iron-folic acid tablets (IFA) was assessed using a five-item Medical Adherence Rating Scale (MARS-5). End line data were collected after 4 weeks of nutrition education intervention. RESULTS: At the end of the individual nutrition education intervention, there was a significant improvement in the hemoglobin level in the intervention group compared to the comparison group (p < .02). The change in the knowledge, attitude and practice scores regarding nutritional management of anemia and maternal adherence to iron-folic acid intake were significantly high in the intervention group over the comparison group (p < .001). CONCLUSION: Individual nutrition education was significantly associated with improved nutritional knowledge, attitude, practice, adherence to IFA intake and hemoglobin levels in anemic pregnant women.

Rapid molecular diagnostics for multi-drug resistant tuberculosis in India.

INTRODUCTION: Rapid molecular diagnostic methods help in the detection of TB and Rifampicin resistance. These methods detect TB early, are accurate and play a crucial role in reducing the burden of drug resistant tuberculosis. Areas covered: This review analyses rapid molecular diagnostic tools used in the diagnosis of MDR-TB in India, such as the Line Probe Assay and GeneXpert. We have discussed the burden of MDR-TB and the impact of recent diagnostic tools on case detection and treatment outcomes. This review also discusses the costs involved in establishing these new techniques in India. Expert commentary: Molecular methods have considerable advantages for the programmatic management of drug resistant TB. These include speed, standardization of testing, potentially high throughput and reduced laboratory biosafety requirements. There is a desperate need for India to adopt modern, rapid, molecular tools with point-of-care tests being currently evaluated. New molecular diagnostic tests appear to be cost effective and also help in detecting missing cases. There is enough evidence to support the scaling up of these new tools in India.

Dilemmas in the diagnosis and treatment of intracranial tuberculomas.

Tuberculosis (TB) remains a major public health problem across the globe. A common form of extrapulmonary TB (EPTB) with high mortality and morbidity is neuro TB or tuberculosis of the nervous system. The management of brain TB remains a big challenge due to the lack of specific diagnostic tools and appropriate treatment guidelines. In this context, this manuscript discusses clinical, diagnostic and treatment dilemmas in the management of intracranial tuberculomas. Brain tuberculoma may occur at any site within the cranium, no part of the brain substance or ventricular surface being exempt. The diagnosis of tuberculoma is often based on imaging techniques such as CT brain and MRI/MRS, even though, no radiological feature is confirmative or specific for tuberculoma. In this regard, a promising development is a new MRS marker that is currently being assessed. Based on a single peak at 3.8ppm, it may differentiate tuberculoma from tumors. This lack of diagnostic tools results in an increased cost to patient on average three times that for pulmonary TB. The increase in cost stems from multiple laboratory tests with diagnosis often achieved only after biopsy. As for treatment, the choice of drugs for treatment and the duration for treatment is also not clearly understood. The recent increase in drug resistant TB adds to the problem. The possible pitfalls during treatment include paradoxical response, hyponatremia, and development of hydrocephalus. These and other treatment related complications require follow-up and monitoring. A fraction of patients may even require emergency surgery due to increased intracranial tension. This can further increase cost to the patient and family. Overall, there is a need for continued efforts to develop new diagnostic tools for brain TB. Until such tools are available, high degree of awareness among treatment providers is necessary to avoid delays in diagnosis and increased costs.

Current and developing therapies for the treatment of multi drug resistant tuberculosis (MDR-TB) in India.

INTRODUCTION: India accounts for 25% of the global burden of MDR-TB. In 2016, the India's Revised National TB Control Programme reported a success rate of 46% among 19,298 MDR-TB patients treated under the programme. This suboptimal treatment outcome warrants an urgent need for newer drugs and newer regimens in the treatment of MDR-TB. India requires new shorter, cheap, safe and effective anti-TB regimen to treat MDR-TB. Areas covered: We used different search strategies to obtain relevant literature from PubMed, on Indian experiences of developing therapies for the treatment of MDR-TB. Further information from the Central TB Division Government of India on programmatic management of resistant TB was collected. Expert opinion: In 2016 WHO recommended a shorter MDR-TB regimen of 9-12 months (4-6 Km-Mfx-Pto-Cfz-Z-Hhigh-dose-E /5 Mfx-Cfz-Z-E) may be used instead of longer regimens. Currently, conducting trials involving newer drugs such as bedaquiline, have been proposed. The regimen will be of a shorter duration containing isoniazid, prothionamide, bedaquiline, levofloxacin, ciprofloxacin, ethambutol and pyrazinamide (STREAM regimen). To successfully treat MDR-TB one requires new classes of antibiotic and newer diagnostic tests. This represents an enormous financial and technical challenge to the programme managers and policy makers.

A lengthy primary intramedullary tuberculoma of the spinal cord extending from C4 to D8: A case report.

Spinal intramedullary tuberculoma is a rare cause of spinal cord compression. We report a case that had an intramedullary spinal cord tuberculomas where the diagnosis was made by MRI and biopsy. The clinical presentation was that of a cord compression in a 30-year-old male febrile patient. This case of intramedullary spinal tuberculoma with a longitudinally extending lesion of the cervicothoracic spine from C4 to D8 is presented for the rarity of its presentation.

Optimal Siting and Sizing of Multiple DG Units for the Enhancement of Voltage Profile and Loss Minimization in Transmission Systems Using Nature Inspired Algorithms.

Power grid becomes smarter nowadays along with technological development. The benefits of smart grid can be enhanced through the integration of renewable energy sources. In this paper, several studies have been made to reconfigure a conventional network into a smart grid. Amongst all the renewable sources, solar power takes the prominent position due to its availability in abundance. Proposed methodology presented in this paper is aimed at minimizing network power losses and at improving the voltage stability within the frame work of system operation and security constraints in a transmission system. Locations and capacities of DGs have a significant impact on the system losses in a transmission system. In this paper, combined nature inspired algorithms are presented for optimal location and sizing of DGs. This paper proposes a two-step optimization technique in order to integrate DG. In a first step, the best size of DG is determined through PSO metaheuristics and the results obtained through PSO is tested for reverse power flow by negative load approach to find possible bus locations. Then, optimal location is found by Loss Sensitivity Factor (LSF) and weak (WK) bus methods and the results are compared. In a second step, optimal sizing of DGs is determined by PSO, GSA, and hybrid PSOGSA algorithms. Apart from optimal sizing and siting of DGs, different scenarios with number of DGs (3, 4, and 5) and PQ capacities of DGs (P alone, Q alone, and P and Q both) are also analyzed and the results are analyzed in this paper. A detailed performance analysis is carried out on IEEE 30-bus system to demonstrate the effectiveness of the proposed methodology.

Randomized clinical trial of thrice-weekly 4-month moxifloxacin or gatifloxacin containing regimens in the treatment of new sputum positive pulmonary tuberculosis patients.

BACKGROUND: Shortening tuberculosis (TB) treatment duration is a research priority. This paper presents data from a prematurely terminated randomized clinical trial, of 4-month moxifloxacin or gatifloxacin regimens, in South India. METHODS: Newly diagnosed, sputum-positive HIV-negative pulmonary TB patients were randomly allocated to receive gatifloxacin or moxifloxacin, along with isoniazid and rifampicin for 4 months with pyrazinamide for first 2 months (G or M) or isoniazid and rifampicin for 6 months with ethambutol and pyrazinamide for first 2 months (C). All regimens were administered thrice-weekly. Clinical and bacteriological assessments were done monthly during treatment and for 24 months post-treatment. The Data and Safety Monitoring Board recommended termination of the trial due to high TB recurrence rates in the G and M regimens. RESULTS: Of 416 patients in intent-to-treat analysis, 6 (5%) of 124, 2 (2%) of 110 and 2 (2%) of 137 patients with drug-susceptible TB in the G, M and C arms respectively had unfavorable response at the end of treatment; during the next 24 months, 17 (15%) of 115, 11 (11%) of 104 and 8 (6%) of 132 patients respectively, had TB recurrence. Of 38 drug-resistant patients 1 of 8 and 3 of 26 in the G and C arms respectively had unfavourable response at the end of treatment; and TB recurrence occurred in 2 of 7 and 2 of 23 patients, respectively. The differences in TB recurrence rates between the G and C arms was statistically significant (p = 0.02). Gastro-intestinal symptoms occurred in 23%, 22% and 9% of patients in the G, M and C arms respectively, but most reactions were mild and manageable with symptomatic measures; 1% required regimen modification. CONCLUSIONS: 4-month thrice-weekly regimens of gatifloxacin or moxifloxacin with isoniazid, rifampicin and pyrazinamide, were inferior to standard 6-month treatment, in patients with newly diagnosed sputum positive pulmonary TB. TRIAL REGISTRATION: Clinical Trials Registry of India CTRI/2012/10/003060.

Prevalence and Risk Factors of HIV Infection among Clients Attending ICTCs in Six Districts of Tamilnadu, South India.

Objective. To assess the HIV serostatus of clients attending integrated counseling and testing centres (ICTCs) in Tamilnadu, south India (excluding antenatal women and children), and to study its association with demographic, socioeconomic, and behavioral risk factors. Design. In a prospective observational study, we interviewed clients attending 170 ICTCs from six districts of Tamilnadu during 2007 utilizing a standard pretest assessment questionnaire. All the clients were tested for HIV with rapid test kits. Multiple logistic regression analysis was used to identify determinants of HIV infection. Results. Of 18329 clients counseled, 17958 (98%) were tested for HIV and 732 (4.1%; range 2.6 to 6.2%) were tested positive for HIV. Median age of clients was 30 years; 89% had never used condoms in their lives and 2% gave history of having received blood transfusion. In multivariate analysis HIV seropositivity was associated with HIV in the family (adjusted odds ratio) (AOR 11.6), history of having sex with sex workers (AOR 2.9), age ≥31 years (AOR 2.8); being married (AOR 2.5), previously tested for HIV (AOR 1.9), illiteracy (AOR 1.7), unemployment (AOR 1.5), and alcoholism (AOR 1.5). Conclusion. HIV seroprevalence being high in ICTC clients (varied from 2.6 to 6.2%), this group should also be included in routine programme monitoring of sero-positivity and risk factors for better understanding of the impact of the National AIDS Control Programme. This would help in evolving appropriate policies and strategies to reduce the spread of HIV infection.

Outcome of standardized treatment for patients with MDR-TB from Tamil Nadu, India.

BACKGROUND & OBJECTIVES: Programmatic management of MDR-TB using a standardized treatment regimen (STR) is being implemented under the Revised National Tuberculosis Control Programme (RNTCP) in India. This study was undertaken to analyse the outcomes of MDR-TB patients treated at the Tuberculosis Research Centre, Chennai, with the RNTCP recommended 24 months STR, under programmatic conditions. METHODS: Patients failed to the category II re-treatment regimen and confirmed to have MDR-TB, were treated with the RNTCP's STR in a prospective field trial on a predominantly ambulatory basis. Thirty eight patients were enrolled to the trial from June 2006 to September 2007. RESULTS: Time to culture conversion was two months or less for 82 per cent of patients. Culture conversion rates at 3 and 6 months were 84 and 87 per cent respectively. At the end of treatment, 25 (66%) were cured, 5 defaulted, 3 died and 5 failed. At 24 months, 30 (79%) patients, including 5 defaulters, remained culture negative for more than 18 months. Twenty two (58%) patients reported adverse drug reactions (ADRs) which required dose reduction or termination of the offending drug. No patient had XDR-TB initially, but 2 failure cases emerged as XDR-TB during treatment. INTERPRETATION & CONCLUSIONS: Outcomes of this small group of MDR-TB patients treated with the RNTCP's STR is encouraging in this setting. Close attention needs to be paid to ensure adherence, and to the timely recognition and treatment of ADRs.

Why do tuberculosis suspects bypass local services to attend tuberculosis sanatorium?

BACKGROUND: The Government Hospital of Thoracic Medicine (GHTM), Tambaram, in Kanchipuram district (formerly known as tuberculosis [TB] sanatorium), Tamil Nadu, draws patients from all over India although RNTCP services have been in place country-wide for a number of years. OBJECTIVE: To document the reasons for patients with chest symptoms attending GHTM, Tambaram. MATERIALS AND METHODS: In a prospective observational study, on a simple random sample basis, TB suspects attending the out-patient department of GHTM during the period January-March, 2006, were interviewed using a semi-structured interview schedule. Information on demographic, socio-economic characteristics and reasons for attending GHTM for health care was collected. RESULTS: A total of 2,023 respondents attended GHTM during the study period; 56% were males, 67% were aged <45 years, 63% were literates and the average annual family income was Rs 25,000. Multiple reasons for attending GHTM were given: popularity of the centre (82%), perceived availability of good treatment (52%), referral by earlier treated patients (36%), expectation of specialized care (22%), referred by treating physicians (13%), and came for inpatient care (11%). CONCLUSION: Despite the availability of local RNTCP health services, many patients with chest symptoms made use of GHTM services due to the reputation of the former "TB sanatorium" in the community. The findings suggest that there is a need to improve community awareness of the availability of free diagnostic and treatment facilities locally under RNTCP.

Assessment of long term status of sputum positive pulmonary TB patients successfully treated with short course chemotherapy.

BACKGROUND: Long term status of pulmonary tuberculosis (PTB) patients treated with short course chemotherapy (SCC) regimens remains unknown. OBJECTIVE: To assess the clinical, bacteriological, radiological status and health related quality of life (HRQoL) of PTB patients 14-18 years after successful treatment with SCC. METHODOLOGY: In a cross-sectional study, cured PTB patients treated during 1986-1990 at the Tuberculosis Research Centre (TRC) were investigated for their current health status including pulmonary function tests (PFT). The St Georges respiratory questionnaire (SGRQ) was used to assess the HRQoL. RESULTS: The mean period after treatment completion for the 363 eligible participants was 16.5 yrs (range 14-18 yrs., 84% coverage); 25 (7%) had been re-treated and 52 (14%) died. Among the investigated, 58 (29%) had persistent respiratory symptoms; 170 (86%) had radiological sequelae but none had active disease. Abnormal PFT was observed in 96 (65%) with predominantly restrictive type of disease in 66 (45%). The SGRQ scores for activity and impact were high implying impairment in HRQoL. CONCLUSION: Assessment of long term status of cured PTB patients showed an impairment of lung functions and HRQoL highlighting the need to address these issues in the management of TB that may provide added value to patient care.

Socioeconomic inequalities of tuberculosis in India.

BACKGROUND: The association between poverty and tuberculosis (TB) is well established and widespread. OBJECTIVE: To study the socioeconomic inequalities of TB in India. METHODS: Information related to socioeconomic inequalities of TB in India was reviewed, including study of varying prevalence and infection, regional disparities and demographic disparities of disease of TB with a view to establish a link between TB and poverty, in terms of income, standard of living, house type and social class. RESULTS: The burden of TB for India for the year 2000 was estimated to be 8.5 million and the annual risk of TB infection varied from 1 to 2%. The TB prevalence was significantly higher among people living below the poverty line compared with those above the poverty line (242 versus 149/100,000 population). Among the marginalized people, TB was 1.5 times more prevalent. TB was disproportionately high among the poor. CONCLUSION: Poverty and inequality were very closely linked. Today's great health challenge is equity: accelerating health progress in poor and socially excluded groups.

Psycho-social dysfunction: perceived and enacted stigma among tuberculosis patients registered under revised national tuberculosis control programme.

OBJECTIVE: To examine the perceived and enacted stigma experienced by TB patients and the community. METHODS: We interviewed 276 TB patients registered for treatment during January-March 2004 in government health facilities of two Tuberculosis Units of south India. Data on perceived and enacted stigma were collected after two months of starting treatment, using a semi-structured interview schedule. In addition, four Focus Group Discussions were conducted among Directly Observed Treatment (DOT) providers and community members. Narrative summaries were also taken down to collect additional qualitative information. RESULTS: Of the 276 patients, 190 (69%) were males. There was no significant difference between the genders in relation to social stigma. Perceived stigma was higher than enacted stigma in both genders and significantly higher among males (Low self esteem p < 0.05), change of behavior of community (p < 0.05), ashamed to cough in front of others (p < 0.05). CONCLUSION: Considering the social and emotional impact of the disease, it is essential to adopt support strategies to enhance acceptance and for a successful health programme.

Evaluation of an intermittent six-month regimen in new pulmonary tuberculosis patients with diabetes mellitus.

BACKGROUND: The treatment of tuberculosis (TB) with category I regimen of the Revised National Tuberculosis Control Programme (RNTCP) for patients with diabetes mellitus (DM) needs evaluation. OBJECTIVE: To assess the cure and relapse rates in 3 years, among the new smear-positive TB patients with Type-2 DM (DMTB) treated with CAT-I regimen (2E3H3R3Z3/4R3H3) of RNTCP. METHODOLOGY: TB suspects attending the diabetology units and the TB research centre (TRC) Chennai, were investigated. Eligible DMTB cases were enrolled. Baseline estimation of cardiac, renal, liver function tests and glycosylated-HBA1c were undertaken. All patients received 2E3H3R3Z3/4R3H3 under supervision at TRC. Clinical and sputum (smear and culture) examinations and monitoring of diabetic status were undertaken every month up to 24 months, then once in 3 months up to 36 months. RESULTS: Of 100 patients admitted, 7 were excluded for various reasons from analysis. Of 93 patients, 87 (94%) had a favourable response at the end of treatment. Pre and post treatment mean glycosylated-HBA1c were 9.7% and 8.4% (>7% poor control). During follow-up period, 6 died and one lost to follow-up. Of the remaining, four relapsed. CONCLUSION: Category-I regimen, recommended for all the new smear-positive patients in the Indian TB programme, is effective in the treatment of DMTB patients, despite poor control of diabetes.

Sputum conversion at the end of intensive phase of Category-1 regimen in the treatment of pulmonary tuberculosis patients with diabetes mellitus or HIV infection: An analysis of risk factors.

BACKGROUND & OBJECTIVE: New smear-positive pulmonary tuberculosis (PTB) patients in the Revised National Tuberculosis Control Programme (RNTCP) are treated with a 6-month short-course chemotherapy (SCC) regimen irrespective of co-morbid conditions. We undertook this retrospective analysis to compare sputum conversion rates (smear, culture) at the end of intensive phase (IP) of Category-1 regimen among patients admitted to concurrent controlled clinical trials: pulmonary tuberculosis alone (PTB) or with type 2 diabetes mellitus (DM-TB) or HIV infection (HIV-TB), and to identify the risk factors influencing sputum conversion. METHODS: In this retrospective analysis sputum conversion rates at the end of intensive phase (IP) in three concurrent studies undertaken among PTB, DM-TB and HIV-TB patients, during 1998 - 2002 at the Tuberculosis Research Centre (TRC), Chennai, were compared. Sputum smears were examined by fluorescent microscopy. HIV infected patients did not receive anti-retroviral treatment (ART). Patients with DM were treated with oral hypoglycaemic drugs or insulin (sc). RESULTS: The study population included 98, 92 and 88 patients in the PTB, DM-TB and HIV-TB studies. At the end of IP the smear conversion (58, 61, and 62%) and culture conversion (86, 88 and 92%) rates were similar in the three groups respectively. The variables associated with lack of sputum smear or culture conversion were age >45 yr, higher pre-treatment smear and culture grading, and extent of the radiographic involvement. INTERPRETATION & CONCLUSION: Our findings confirm that the current policy of the control programme to treat all pulmonary TB patients with or with out co-morbid conditions with Category-I regimen appears to be appropriate.

Management of multi drug resistance tuberculosis in the field: Tuberculosis Research Centre experience.

SETTING: Multi-drug TB resistant (resistant to isoniazid and rifampicin) patients identified from a rural and urban area. OBJECTIVE: To study the feasibility of managing MDR TB patients under field conditions where DOTS programme has been implemented. METHODS: MDR TB Patients identified among patients treated under DOTS in the rural area and from cases referred by the NGO when MDR TB was suspected form the study population. Culture and drug susceptibility testing were done at Tuberculosis Research Centre (TRC). Treatment regimen was decided on individual basis. After a period of initial hospitalization, treatment was continued in the respective peripheral health facility or with the NGO after identifying a DOT provider in the field. Patients attended TRC at monthly intervals for clinical, sociological and bacteriological evaluations. Drugs for the month were pre-packed and handed over to the respective center. RESULTS: A total of 66 MDR TB patients (46 from the rural and 20 from the NGO) started on treatment form the study population and among them 20 (30%) were resistant to one or more second line drugs (Eto, Ofx, Km) including a case of "XDR TB". Less than half the patients stayed in the hospital for more than 10 days. The treatment was provided partially under supervision. Providing injection was identified to be a major problem. Response to treatment could be correctly predicted based on the 6-month smear results in 40 of 42 regular patients. Successful treatment outcome was observed only in 37% of cases with a high default of 24%. Adverse reactions necessitating modification of treatment was required only for three patients. IMPLICATIONS: Despite having reliable DST and drug logistics, the main challenge was to maintain patients on such prolonged treatment by identifying a provider closer to the patient who can also give injection, have social skills and manage of minor adverse reactions.

An economic commentary on the occurrence and control of HIV/AIDS in developing countries: special reference to India.

HIV infection has a complex relationship with poverty, but affects both the rich and poor. HIV/AIDS represents the deadliest emergency and the greatest social, economic and health crisis of modern times. The HIV pandemic affects developed and developing countries differently, with up to 95% of new HIV infections now occurring in developing countries. In India, an estimated 4.58 million people were living with HIV/AIDS. The nation's public health budget could swell by at least 30% and the estimated annual cost of HIV/AIDS appears to be approximately 1% of the gross domestic product. Households affected by an HIV/AIDS-related death can be forced to sell their means of production to cover the high economic burden of treatment and other costs associated with HIV/AIDS. Eventually, the household will dissolve, as parents die and orphaned children are sent to relatives for care and upbringing. Therefore, the poverty will pass onto the next generation. This article looks at the association between poverty and the HIV/AIDS pandemic, and suggests areas in which economics can help to develop solution to them.