Magnetic domain wall tweezers: a new tool for mechanobiology studies on individual target cells.

In vitro tests are of fundamental importance for investigating cell mechanisms in response to mechanical stimuli or the impact of the genotype on cell mechanical properties. In particular, the application of controlled forces to activate specific bio-pathways and investigate their effects, mimicking the role of the cellular environment, is becoming a prominent approach in the emerging field of mechanobiology. Here, we present an on-chip device based on magnetic domain wall manipulators, which allows the application of finely controlled and localized forces on target living cells. In particular, we demonstrate the application of a magnetic force in the order of hundreds of pN on the membrane of HeLa cells cultured on-chip, via manipulation of 1 µm superparamagnetic beads. Such a mechanical stimulus produces a sizable local indentation of the cellular membrane of about 2 µm. Upon evaluation of the beads' position within the magnetic field originated by the domain wall, the force applied during the experiments is accurately quantified via micromagnetic simulations. The obtained value is in good agreement with that calculated by the application of an elastic model to the cellular membrane.

Critique of the review of 'Water fluoridation for the prevention of dental caries' published by the Cochrane Collaboration in 2015.

The Cochrane Review on water fluoridation for the prevention of dental caries was published in 2015 and attracted considerable interest and comment, especially in countries with extensive water fluoridation programmes. The Review had two objectives: (i) to evaluate the effects of water fluoridation (artificial or natural) on the prevention of dental caries, and (ii) to evaluate the effects of water fluoridation (artificial or natural) on dental fluorosis. The authors concluded, inter alia, that there was very little contemporary evidence, meeting the Review's inclusion criteria, that evaluated the effectiveness of water fluoridation for the prevention of dental caries. The purpose of this critique is to examine the conduct of the above Review, and to put it into context in the wider body of evidence regarding the effectiveness of water fluoridation. While the overall conclusion that water fluoridation is effective in caries prevention agrees with previous reviews, many important public health questions could not be answered by the Review because of the restrictive criteria used to judge adequacy of study design and risk of bias. The potential benefits of using wider criteria in order to achieve a fuller understanding of the effectiveness of water fluoridation are discussed.

Study of Depression among the Nursing Students in a University Medical College of Nepal.

Nursing students pass through many stressful situations during their academic course. Depression is frequently observed in this student group. Objective To quantify and compare the level of depression among the students undertaking undergraduate and graduate level nursing education in Kathmandu University School of Medical Sciences, Nepal. Method A questionnaire based cross-sectional study was carried out among all the students of Proficiency Certificate Level, Bachelor in Nursing Sciences and B.Sc. Nursing in Kathmandu University School of Medical Sciences, studying in different years during the academic year (2013-14) using Beck Depression Inventory. Descriptive statistics was used for computing scores of Beck Depression Inventory while Pearson correlation was used for analysis of association. Result Among the total 227 students consenting for the study, 212 were amenable for analysis. All of the participants were females, with mean age 20.10 (± 2.2). Almost 40% were found to be having depressive symptoms in variable degrees of severity (Mild-27.4%, Moderate-9%, Severe-1.4%). Frequency of depression was higher among the senior grade students. Agitation, fatigability and sadness were the items having highest mean score; (0.82 ± 0.72), (0.76 ± 0.63), and (0.74 ± 0.52) respectively, while weight loss and loss of libido had the least score, (0.10 ±0.33) and (0.19 ±0.55) respectively. Item on suicidal ideation was significantly correlated with age (p=0.038) and BDI score (< 0.001). Conclusion Depression is common among the nursing students in Nepal; which may also be related to the multitude of stressors they experience during their studentship.

4-aminoquinazoline analogs: a novel class of anticancer agents.

4-Aminoquinazoline analogs have been identified as a new class of cancer chemotherapeutic agents with significant therapeutic efficacy against solid tumors. They are potent and highly selective inhibitors of tyrosine kinase (TK) and epidermal growth factor receptor (EGFR). Till date various 4-aminoquinazoline analogs have been synthesized and evaluated for anticancer activity. This review is an attempt to compile the medicinal chemistry of various synthesized 4-aminoquinazoline analogs.

Performance of light-emitting diode fluorescence microscope for diagnosis of tuberculosis.

BACKGROUND: Fluorescence microscopy (FM) over the years has shown the potential for increasing the performance of microscopy. The present study was aimed to access the performance of the LED microscope for the detection of acid fast bacilli in a tuberculosis (TB) endemic country. METHODS: The study was conducted at a National Reference Laboratory (NRL) in New Delhi, India. Sputum samples were collected from suspected TB patients. Each sample was processed with Auramine O and ZN methods. Auramine O stained smears were evaluated using two different excitatory light sources (MVP and LED); and ZN stained smears were examined under light microscope. The mean time required to read the smears with different modalities was recorded. Bacterial cultures provided the reference standard. RESULTS: A total of 200 patients were included in this study. Sensitivity and specificity for the LED assessment, MVP assessment and light microscopy were 83.1% and 82.4%, 78.5% and 87.5% and 81.6% and 83.5%, respectively. Mean reading time was approximately three times faster than ZN microscopy. The mean time to read a negative smear was 2min with fluorescence microscopy and 5min with light microscopy with time savings of 60%. CONCLUSION: Although the use of LED-FM only marginally increased sensitivity, the considerable time saving ability combined with very good acceptance and ease of use makes it a reliable alternative to other conventional methods available.

Clinical evaluation of Veerataru (Dichrostachys cinerea Linn.) in the management of Mootrakruchchhra (Dysuria).

Veerataru is quoted to be effective in various conditions of Mootravaha Srotodushti such as Mootrakruchchhra (Dysuria), Mootraghata (Anuria), Ashmari (Urinary calculi), Sharkara (Concretions) etc., by various Acharyas. Mootrakruchchhra (Dysuria) is a disease of Basti (Bladder). It comes under Mootraapravruttijanyavyadhi, where Kruchchhrata (Shoola -Pain and Daha-Burning) during mootra pravrutti is the chief symptom. As per modern view, dysuria is a leading feature of lower or mid urinary tract infection. Antibiotics have their own limitations due to re-infections and recurrence even after long-term therapy, due to development of resistance of the microorganisms to the drugs. By considering all the above facts and to fulfill the lacuna about the absence of scientific data of Veerataru, the present research work had been taken up especially to evaluate its efficacy on Mootrakruchchhra (Dysuria). Patients suffering from Mootrakruchchhra (Dysuria) were selected and divided into two groups, i.e. Group A received Kwatha (decoction) of Veerataru-Dichrostachys cinerea Linn. (Trial drug) and Group B received Kwatha of Punarnava-Boerhaavia diffusa Linn. (Standard control) respectively. The effects of therapy were assessed by a specially prepared clinical research proforma. The result showed better symptomatic relief in Group A, i.e. trial drug as compared to Group B, i.e. standard control group.

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.

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 first 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 (LJ) 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 (18.48%) 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.

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 MDR-TB 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.

A study of gender differentials in the prevalence of tuberculosis based on NFHS-2 and NFHS-3 data.

BACKGROUND: Worldwide, the case notification rate of tuberculosis has been reported to be higher for men than women. In India also, the prevalence of TB is higher among males as compared to females but it is important to study the trend of gender gap in the prevalence of tuberculosis over the years. OBJECTIVE: To examine the trend in gender gap in the prevalence of TB over the years. MATERIALS AND METHODS: The unit level data of NFHS-2 (1998-99) and NFHS-3 (2005-06) has been utilized. Gender gap in the prevalence of TB has been estimated for the two rounds of the surveys. The delta (Δ), the difference in gender gap in two surveys, has been estimated and decomposed by background characteristics such as place of residence(urban/rural), religion (Hindus/Muslims/others), caste(SC/ST/OBC/others) and standard of living(SLI) (low/medium/high) categories. MAIN FINDINGS: Overall, the prevalence of TB has remained almost same in the two surveys [432/lakh in NFHS-2 and 418/lakh in NFHJS-3; Z=1.19, P=0.275. The gender gap has increased to 217/lakh in NFHS-3 in comparison to 145 per lakh in NFHS-2. The increase in gender gap is significantly higher in rural areas [of 98 per lakh;167/ lakh in NFHS-2 vs 265/lakh in NFHS-3; P<0.05] as compared to corresponding increase in urban areas [of 30 per lakh; 88/ lakh in NFHS-2 vs118/ lakh in NFHS-3, P>0.05]. The increase in delta (D) (difference in gender gap in two surveys) is accounted for as 88% by the rural areas and 12% by the urban areas. CONCLUSION: The increase in gender gap in the prevalence of TB is more in rural areas as compared to urban areas. The increase in rural areas is mainly contributed by Hindus, SC and ST and low and medium SLI categories and in urban areas, the contribution is mainly by Hindus, other castes and high SLI categories.

Clinical profile and treatment outcome of tuberculous lymphadenitis in children using DOTS strategy.

BACKGROUND: Extra pulmonary TB (EPTB) including tuberculous lymphadenitis is becoming more common probably due to human immuno deficiency virus (HIV) co-infection. While children do experience a high TB related morbidity and mortality, management of TB in children is challenging. The present study was designed to study the treatment outcome of DOTS strategy for pediatric tuberculous lymphadenitis. OBJECTIVE: To study the efficacy of DOTS strategy for pediatric lymphhnode tuberculosis. METHODS: Retrospective analysis of 669 children of lymphnode tuberculosis treated with DOTS strategy over 9 1/2 years. RESULTS: Mean age was 9.8 years with significantly more girls (61.3%) than boys (38.7%) {chi2=34.08, P<0.001 (S)}. Most of the patients were in the age group of 11-14 years (48.0%) followed by 6-10 years (34.5%) and 0-5 years (17.5%) respectively. Cervical tuberculous lymphadenitis (88.2%) was the commonest form for all ages followed by axillary lymphadenitis in 3.3%. TB of other sites was seen in only 57 (8.5%) cases. Out of total 622 (93%) cases of lymphnode TB where fine needle aspiration and/or excisional biopsy was done, it was positive (84.2%) and negative (15.6%) respectively for AFB/cytology, while it could not be done in 47 patients due to inaccessible sites. Category I, II and III was started on 15.4%, 7.5% and 77.1% patients respectively. Overall, treatment completion rate was 94.9% and the default rate was 2.2% with a failure rate of 2.5%. Death rate was 0.3%. CONCLUSION: The study confirms the efficacy of DOTS strategy for pediatric TB lymphadenitis.

Psychiatric illness in the paediatric population presenting to a psychiatry clinic in a tertiary care centre.

BACKGROUND: A variety of psychiatric manifestations can be seen in children below the age of 18 years. Such cases rarely present directly to psychiatric care. METHODS: Retrospective study in Tertiary care hospital . The study population included all the patients of paediatric age group presenting to Psychiatry Outpatient Department of Dhulikhel Hospital directly or referred by a paediatrician or other specialists from October 2008 to October 2010. RESULTS: Among the paediatric population evaluated in the psychiatry clinic for two years from October 2008 to October 2010 (N = 168), 66.7% were in the age group 15-18 years {mean = 14.77 (± 2.99)}, 71.4% were female and 42.3% belonged to Brahmin cast. The highest number of (15%) patients was seen during the month of August 2010. Six months analysis of the psychiatric illnesses of the patients from April 2010 up to October 2010 (n = 80) showed dissociative disorder (15%), and seizure disorder (15%) to be the most common diagnoses, followed by depressive disorder and intentional self harm (ISH) (13.8% each). 15% of patients were found to be treated by magico-religious means, with the majority of patients (66.7%) diagnosed as having dissociative disorder. CONCLUSION: The majority of the paediatric population presenting to a psychiatry clinic were in the age group 15-18 years and of female sex. Dissociative disorder was the most common diagnosis followed by depressive disorders. The majority of patients with dissociative disorder had previously been treated by magico-religious means.

A comparative study on growth pattern of Langali (Gloriosa superba Linn.) under wild and cultivated conditions.

Langali (Gloriosa superba Linn.), obtained from wild habitat and by experimental cultivation under three groups, viz., control, cultivated as per the modern agricultural guidelines and as per the norms of Vriksha-ayurveda was compared and analyzed. Methods of Vriksha-ayurveda give good result in the case of Langali in terms of yield. Failure of control groups both in seed and tuber batches denotes that this plant needs some treatment for vegetative propagation under artificial conditions. Ayurveda group may be considered as a better one in the assessment of reproduction capacity in terms of yield of seeds.

A comparative study of efficacy of Tugaksheeree [Curcuma angustifolia Roxb. and Maranta arundinacea Linn.] in management of Amlapitta.

Amlapitta is a disease caused by increase of Amla Guna of Pitta. Starch obtained from the rhizomes of two plants viz., Curcuma angustifolia Roxb. (Fam. Zingiberaceae) and Maranta arundinacea Linn. (Fam. Marantaceae) are used as Tugaksheeree. In the present clinical study, the efficacy of Tugaksheeree was studied on 67 patients of Amlapitta. A 0 total of 84 patients suffering from Amlapitta were selected from the O.P.D. and I.P.D. sections in the department of Dravyaguna, I.P.G.T. and R.A., Hospital, Jamnagar, and were randomly divided into two groups. Thirty four patients completed the treatment course in Group I, and 33 patients completed the treatment course in Group II. The efficacy of drug Tugaksheeree was studied through internal administration of the starches of C. angustifolia Roxb. (Fam. Zingiberaceae) in Group I and M. arundinacea Linn. (Fam. Marantaceae) in Group II with the dose of 4 g TID with water for 30 days. Both the drugs were found highly effective in treating Amlapitta. They significantly relieved the cardinal symptoms viz., Avipaka, Tikta-amlodgara, Daha, Shoola, Chhardi and the associated symptoms viz., Aruchi, Gaurava, Udaradhmana, Antrakujana, Vit bheda, Shiroruja, Angasada, and Trit. Statistically significant increase in body weight was noticed in both the groups. This may be because the drugs corrected the Agni and acted as Brihmana and Dhatupushtikara. Both the drugs did not produce any side effects. Therefore, both these drugs (C. angustifolia Roxb. and M. arundinacea Linn.) can be used as substitutes for each other.

Clinical profile and treatment outcome of tubercular pleurisy in pediatric age group using DOTS strategy.

BACKGROUND: A significant proportion of global tuberculosis (TB) caseload is contributed by children. Management of pediatric TB especially EPTB is challenging. The present study was designed to study demographic, clinical profile and treatment outcome of DOTS strategy for pediatric tubercular pleurisy. AIM: To study the efficacy of DOTS strategy. METHODS: Retrospective analysis of 106 TB pleurisy children treated with DOTS. RESULTS: Mean age was 10.8 years (median age 12.2 years) with more females (51.9%) than males (48.1%) chi1(2) = 0.15; P = 0.698 (NS). In the age group of 0-5, 6-10 and 11-14 years, there were 15.1%, 30.2% and 54.7% patients respectively. Fever was the commonest symptom (98.1%) followed by cough (77.4%) and chest pain (55.7%). History of contact could be elicited only in 2/3rd of cases unilateral effusion (61.3%) was commonest, followed by empyema (22.6%), massive effusion and broncho-pleural fistula each in 13.2% cases respectively. Bilateral effusion was seen in 3.8% cases only. Conventional methods (mantoux, radiograph, ultrasound, pleural aspiration) and minimal invasive surgical techniques, percutaneous pleural biopsy were done to arrive at the diagnosis. Diagnosis was made by X-ray Chest in 92.5%, exudative pleural fluid (100%) predominantly lymphocytic in 85.8%, positive AFB smear and culture in 4.7 and 5.7% cases respectively. Category I, II and III was started on 35.9%, 2.8% and 61.3% patients respectively. Overall treatment completion rate was 94.3%, 4.7% default rate, 0.9% failure rate and no deaths. CONCLUSION: The study confirms early detection by simple tests and ensuring complete treatment using DOTS strategy.

The DOTS strategy for treatment of paediatric pulmonary tuberculosis in South Delhi, India.

SETTING: Paediatric Pulmonology Department, TB Institute, New Delhi, India. OBJECTIVE: To evaluate the outcome of the DOTS strategy for paediatric pulmonary tuberculosis (TB). DESIGN: Retrospective analysis of 1098 children. RESULTS: The mean age of the children included in the study was 11.2 years, with more females (61.7%) than males (38.3%). In the 0-5, 6-10 and 11-14 year age groups, the percentage of patients was respectively 18.3%, 26.6% and 55.1%. Patients were registered as new cases (87.7%), relapses (1.9%), failures (1.0%), defaulters (5.0%), transferred in (0.9%) and others (3.5%). Of the total number of cases, 414 were smear-positive and 404 smear-negative, while sputum status was not known for 280 patients. Sputum positivity increased with age. Category I, II and III regimens were started by respectively 50.6%, 10.5% and 38.9% patients. The cure rate was 92.4% (302/327) for new and 92% (80/87) for retreatment cases (chi(2)(1) = 0.02, P = 0.901), but the treatment completion rate was significantly higher for new cases (97%, 636/656) than retreatment cases (53.6%, 15/28) (chi(2)(1) = 100.8, P < 0.001). The overall success rate was 95.4% and 82.6% for new and retreatment cases, respectively (chi(2)(1) = 30.35, P < 0.001). Overall, the rates for default, failure and death in the study were respectively 3%, 1.9% and 1%. CONCLUSION: DOTS appears to be a highly efficacious treatment strategy.

Combretastatin a-4 analogs as anticancer agents.

Combretastatin A-4 (CA-4) is one of the most potent antimitotic and antiangiogenic agents of natural origin. It has displayed potent antitumor effect in a wide variety of preclinical tumor models. Till date various CA-4 analogs have been synthesized and evaluated for anticancer activity. This review is an attempt to compile the medicinal chemistry of various synthesized CA-4 analogs.

Adherence to tuberculosis treatment: lessons from the urban setting of Delhi, India.

The Revised National Tuberculosis Control Programme (RNTCP), which incorporated the WHO DOTS strategy was introduced in India in the mid-1990s. An operational research project was conducted between 1996 and 1998 to assess the needs and perspectives of patients and providers in two chest clinics in Delhi, Moti Nagar and Nehru Nagar, during the introduction of the new strategy. This paper reports on the findings of the project, concentrating on information collected from 40 in-depth interviews with patient defaulters and from non-participant observations in clinics and directly observed treatment centres. In Moti Nagar chest clinic, 117 of 1786 (6.5%) patients and 195 of 1890 (10%) patients in Nehru Nagar left care before their treatment was complete. It was argued that the reasons for default stem from a poor correlation between patient and programme needs and priorities, and from particular characteristics of the disease and its treatment. Patient needs that were not met by the health system included convenient clinic timings, arrangements for the provision for treatment in the event of a family emergency and provision for complicated cases like alcoholics. The problems facing the provider were poor interpersonal communication with the health staff, lack of attention and support at the clinic, difficulty for patients to re-enter the system if they missed treatment and, in certain areas, long distances to the clinic. Problems related to diseases were inability of the staff to deal with drug side-effects, and patients' conception of equating well-being with cure. Simple, practical measures could improve the provision of tuberculosis (TB) treatment: more flexible hours, allowances for poor patients to reach the clinics and training health care staff for respectful communication and monitoring drug side-effects. The findings indicate a need to rethink the label of 'defaulter' often given to the patients. The important areas for future operational research is also highlighted.

TB control, poverty, and vulnerability in Delhi, India.

The Revised National Tuberculosis Control Programme (RNTCP), based on the World Health Organization's DOTS strategy,* was introduced in India in the mid-1990s. This paper reports the findings from operational research studies in two pilot sites in New Delhi from 1996 to 1998. A variety of operational research methods were used, including semi-structured interviews, focus group discussions, non-participant observations and collection of data from the tuberculosis registers. The cure rates for the clinics were 71 and 75% with a default rate of 6 and 11%, respectively. An important finding was that health workers screened patients to determine their ability to conform to the direct observation of treatment element of the RNTCP. If the health worker was confident that the patient would comply and/or be easy to trace in the community in the event of 'default', they were provided with short-course treatment under the RNTCP. Other patients, largely those who were in absolute poverty, socially marginalized, itinerant labourers, poorly integrated in the city, were put on standard tuberculosis (TB) treatment as for the previous National TB Programme. The programme was evidently excluding the most vulnerable from the best available care. These findings demonstrate the potential dangers of target-driven programmes where there is an absence of support to both frontline health workers and patients. The paper also highlights the importance of operations research in helping to identify problems within TB programmes.