Asthma Insights and Management in India: Lessons Learnt from the Asia Pacific - Asthma Insights and Management (AP-AIM) Study.

BACKGROUND: Despite a better understanding of the pathophysiology of asthma, presence of reliable diagnostic tools, availability of a wide array of effective and affordable inhaled drugs and simplified national and international asthma management guidelines, asthma remains poorly managed in India. OBJECTIVE: The Asia-Pacific Asthma Insight and Management (AP-AIM) study was aimed at understanding the characteristics of asthma, current management, level of asthma control and its impact on quality of life across Australia, China, Hong Kong, India, Malaysia, Singapore, South Korea, Taiwan and Thailand. This paper describes the results of asthma management issues in India in detail and provides a unique insight into asthma in India. METHODOLOGY: The AP-AIM India study was conducted in eight urban cities in India, viz: Ajmer, Delhi, Kolkata, Rourkela, Chennai, Mangalore, Mumbai and Rajkot from February to July 2011. Face-to-face interviews were conducted in adult asthmatics and parents of asthmatic children between the ages of 12 and 17 years with a confirmed diagnosis or a treatment history of 1 year for asthma. RESULTS: Four hundred asthmatics (M:F::1:1.273), with a mean age of 50 ± 17.8 years, from across India were studied. 91% of the asthmatics in India perceived their asthma to be under control, however, none of the asthmatics had controlled asthma by objective measures. Asthmatics in India believed that their asthma was under control if they have up to 2 emergency doctor visits a year. The quality of life of these patients was significantly affected with 93% school/work absenteeism and a loss of 50% productivity. Seventy-five percent of the asthmatics have never had a lung function test. The common triggers for asthmatics in India were dust (49%) and air pollution (49%), while only 5% reported of pollen as triggers. Eighty-nine percent of Indian asthmatics reported an average use of oral steroids 10.5 times a year. Only 36% and 50% of Indian asthmatics used controller and rescue inhalers with a majority preferring the oral route of asthma medication. CONCLUSIONS: This study has clearly highlighted the fact that asthma management in India remains very poor, with a significant proportion of patients experiencing bothersome symptoms and worsened quality of life. There is a need for an urgent review of this situation and initiate active measures at local as well as national levels to improve asthma care in India.

Insights, attitudes and perceptions about asthma and its treatment: findings from a multinational survey of patients from 8 Asia-Pacific countries and Hong Kong.

BACKGROUND AND OBJECTIVE: The Asthma Insight and Management (AIM) survey was conducted in North America, Europe, the Asia-Pacific region and Latin America to characterize patients' insights, attitudes and perceptions about their asthma and its treatment. We report findings from the Asia-Pacific survey. METHODS: Asthma patients (≥12 years) from Australia, China, Hong Kong, India, Malaysia, Singapore, South Korea, Taiwan and Thailand were surveyed. Patients answered 53 questions exploring general health, diagnosis/history, symptoms, exacerbations, patient burden, disease management, medications/treatments and patient's attitudes. The Global Initiative for Asthma guidelines were used to assess asthma control. The survey was conducted by random digit telephone dialling (Australia, China and Hong Kong) or by random face-to-face interviews (India, Malaysia, Singapore, South Korea, Taiwan and Thailand). RESULTS: There were 80 761 households screened. Data from 3630 patients were collected. Wide disparity existed between objective measures of control and patient perception. Reported exacerbations during the previous year ranged from 19% (Hong Kong) to 67% (India). Reported unscheduled urgent/emergency visits to a doctor's office/hospital/clinic in the previous year ranged from 15% (Hong Kong) to 46% (Taiwan). Patients who reported having controlled asthma in the previous month ranged from 27% (South Korea) to 84% (Taiwan). Substantial functional and emotional limitations due to asthma were identified by 13% (South Korea) to 78% (India) of patients. CONCLUSIONS: Asthma has a profound impact on patients' well-being despite the availability of effective treatments and evidence-based management guidelines. Substantial differences across the surveyed countries exist, suggesting unmet, country-specific cultural and educational needs. A large proportion of asthma patients overestimate their level of control.

A severe case of haemodynamic instability during anidulafungin administration.

WHAT IS KNOWN AND OBJECTIVE: Anidulafugin is an echinocandin used for the treatment of candida infections in non-neutropenic adults. Echinocandins show few drug-drug interactions and are usually well tolerated. We report a case of acute hypotension, bradycardia and haemodynamic instability with consecutive cardiopulmonary resuscitation during anidulafungin administration. CASE SUMMARY: A 41-year-old man ICU patient received anidulafungin for a suspected Candida glabrata infection. During the first administration of the drug, he developed acute haemodynamic instability with hypotension and bradycardia. The infusion was discontinued immediately and cardiopulmonary resuscitation was performed successfully. The patient regained haemodynamic stability. WHAT IS NEW AND CONCLUSION: To the authors' knowledge, this is the first report of a life-threatening adverse event due to haemodynamic instability during anidulafungin administration. Cardiac toxicity associated with echinocandins has been described. Further studies seem to be mandatory to investigate this potential risk.

Asylums: the historical perspective before, during, and after.

Extensive institutionalisation of people with mental disorders has a brief history lasting just 150 years. Yet asylums feature prominently in modern perceptions of psychiatry's development, on a mental map drawn in sharp contrasts between humanity and barbarity, knowledge and ignorance, and good and bad practice. This Review seeks to nuance the standard narrative of asylums by considering the voices and views of those who were in them at different historical timepoints. The arguments are to caution against dismissing inpatient care outright as simply fundamentally misconceived, and to show the ideological background to many structures and changes, which might superficially seem merely clinical and instrumental. The aim of this Review is to bring out what current mental health systems can learn from an evidence-based analysis of asylums' actual successes and failures in the past.

Prevalence of primary multidrug resistance to anti-tuberculosis drugs in Pakistan.

SETTING: Pakistan ranks sixth in the world in terms of tuberculosis (TB) burden, with a World Health Organization estimated incidence of 181 per 100000, or 286000 new cases annually. Hospital-based data indicate a significant problem of multidrug-resistant TB (MDR-TB) in the country and highlight the need to assess its extent at community level. In this cross-sectional study, sputum samples from 742 untreated newly diagnosed pulmonary TB patients from all over the country were used. OBJECTIVE: To assess the prevalence of primary drug resistance in Pakistan. RESULTS: Of 672 culture-positive patients, 76 (11.3%) showed resistance to one or more drugs. Resistance to streptomycin (10 microg/ml) was found in 36 (5.4%) patients, isoniazid (INH) (1 microg/ml) in 51 (7.6%), rifampicin (RMP) (5 microg/ml) in 15 (2.2%), ethambutol (10 microg/ml) in 12 (1.8%) and pyrazinamide in 22 (3.3%) samples. Forty-six (6.8%) of the isolates tested were resistant to a single drug, 10 (1.5%) to two drugs, 12 (1.8%) to three drugs, and 6 (0.9%) to four drugs, while 2 (0.3%) isolates were resistant to all five first-line agents. Primary MDR-TB was 1.8% (n=12) (INH 1 microg/ml, RMP 5 microg/ml). CONCLUSION: The results of this study show a prevalence of primary MDR-TB in Pakistan of <2%, which needs to be addressed through an effective DOTS strategy.

Giant primary mesenteric liposarcoma: a rare case report.

Primary mesenteric liposarcoma is a rare malignant tumor of mesenchymal origin. These tumors are often found to be of substantial size upon first clinical presentation. We report a case of primary mesenteric liposarcoma in a 55 year old man who underwent laparotomy for the clinical/radiological impression of a mesenteric cyst. FNAC was inconclusive due to suboptimal cellularity. On laparotomy there were 2 masses (diameter- 19 and 14 cms) weighing approximately 8.5 kilograms together. Histopathology showed features of atypical lipomatous tumor / well differentiated liposarcoma (ALT/WDLS) with mixed histological pattern (e.g. lipoma like, sclerosing and myxoid areas) varying from area to area. Prognosis of ALT/WD liposarcoma depends upon its anatomic location and most aggressive histological subtype. This case is being presented because of its huge dimensions, rarity of the site and mixed histological pattern.

Further characterization studies of the alpha-amylase protein inhibitor of gel electrophoretic mobility 0.19 from the wheat kernel.

A highly purified amylase protein inhibitor from the kernels of hexaplois wheat, designated 0.19 according to its gel electrophoretic mobility, has been characterized according to its circular dichroism spectra determined at different pH values and in the presence or absence of dissociating and reducing agents. The 0.19 albumin has also been characterized according to the specificity with which it inhibits 21 alpha-amylases from different origins and according to its sensitivity to a number of chemical and enzymatic treatments of its inhibitory action on human saliva and Tenebrio molitor L. larval midgut alpha-amylases. Inhibitory activity of 0.19 toward human saliva amylase significantly increased when the inhibitor was incubated with the enzyme before the addition of starch, but it was not affected by the preincubation of 0.19 with starch. Maltose reversed the inhibition of human saliva by 0.19 and showed some inhibitory activity toward the enzyme. However, maltose concentrations that only slightly affected amylase activity were very effective in restoring the amylase activity inhibited by 0.19. The inhibitory action of 0.19 on human saliva and T. molitor L. amylases were equally resistant to trypsin and thermal treatments, but 0.19 was readily inactivated by incubation with pepsin or by reduction of disulfide bonds. The inhibition of the mammalian amylase by 0.19 was adversely affected by a treatment with CNBr (1:100 ratio of methionine residues to CNBr) whereas the inhibition of the insect amylase was not. As shown by circular dichroism measurements in the far ultraviolet, 0.19 is a protein with about 50% of ordered structure. Significant and largely reversible changes have been observed in the aromatic CD spectrum of 0.19 at alkaline pH values or in the presence of sodium dodecyl sulfate. These changes, which were associated with a partial loss of inhibitory activity, indicate that ionizable tyrosine groups contribute significantly to the ellipticity bands of 0.19 in the near ultraviolet.

Inhibition of amylases from different origins by albumins from the wheat kernel.

The amylase activity of water extracts from 18 insect species, from 23 marine species and from 17 different species of birds and mammals was determined quantitatively. The inhibition of amylase in these extracts by three albumin fractions from the mature wheat kernel, which had been separated according to their molecular weights (60 000, 24 000 and 12 500 D), was determined as well. The inhibition activity of the three albumin fractions toward amylases extracted from a number of cereal species or from immature and germinating wheat kernel was also tested. The extracts from insects that are destructive of wheat grain and stored wheat products showed much higher amylase activities as compared to the other insect species that do not attack wheat and wheat products. On the basis of the effectiveness with which the three albumin fractions inhibit their activities, the amylase preparations tested were divided into susceptible, partially susceptible and resistent. Susceptible amylases, inhibited by any of the three albumin fractions, were found mainly in insects that attack wheat and in marine species. Partially susceptible amylases, inhibited by only one or two of the three albumin fractions, were present in a few avain and mammalian species including man. Resistent amylases were largely distributed in cereal, avian and mammalian species as well as in insect species that do not usually attack wheat grain or wheat flour products. At no stage of development, wheat alpha-amylase was inhibited by the albumin fractions from the mature kernel. The 12 500 dalton albumin fraction was the most effective in inhibiting insect amylases, but it was inactive toward avian and mammalian amylases. The 24 000 dalton albumin fraction was the most effective in inhibiting amylases from marine avian and mammalian species and inhibited as much as 33 amylases over 66 different amylases tested. It is suggested that protein inhibitors of amylase contributed to natural selection of polyploid wheats by giving some insect resistence to such wheats, even though some insect species were able to overcome this biochemical defense toa large degree by producing higher amylase activities.

Medical interns knowledge of TB in Pakistan.

Of 460 interns from five Pakistani teaching hospitals surveyed, only 22% correctly identified the estimated number of new TB cases in Pakistan. The majority (96%) knew that droplet infection was the usual mode of transmission. Only 38% considered sputum smears for acid-fast bacilli as the best test for diagnosis of pulmonary TB and 43.5% for follow-up during TB treatment. The recommended four-drug anti-TB regimen was prescribed by 56.5% in the initiation phase and the recommended two-drug combination in the continuation phase by 52%. Most interns (82%) were unable to identify a single component of directly observed treatment short course (DOTS) strategy. Our study reflects poor awareness of and low compliance to the World Health Organization/National Tuberculosis Programme guidelines among interns. For effective control of TB, immediate action to improve undergraduate and continuing medical education is essential, with special emphasis on national guidelines.

Humoral immune responses to Plasmodium falciparum antigens in children and adults living in a hypoendemic area of Punjab (Pakistan).

We have investigated the prevalence and the levels of antibodies reactive with repeat sequences in Plasmodium falciparum asexual blood-stage Pf155/ring-infected erythrocyte surface antigen (RESA), Pf332 antigen, and the circumsporozoite (CS) protein in 532 children and adults residing in a hypoendemic area in the Punjab (Pakistan). We show here that the levels of antibodies reactive with synthetic peptides corresponding to repeat sequences in these antigens increased gradually with age. However, the prevalence and levels of antibodies reactive with the peptides were quite low as compared with the high prevalence of such antibodies in donors from areas holoendemic and hyperendemic for malaria. The levels of Ag332 (2-12)2-reactive antibodies in individual sera as well as in the study population as a whole correlated well with the levels of antibodies to the Pf155/RESA peptide (EENV)6. However, there was no correlation between anti-(EENV)6 and anti-Ag332 (2-12)2 antibody levels and malaria parasitemia. There was a significant negative correlation between anti-(NANP)6-reactive antibodies and the parasite rate, suggesting that a heavy load of blood-stage parasites may be one factor that exerts an immunosuppressive effect on the antibody response to the sporozoites.

Effect of chilling on the gravitropic response of 'Poinsett 76' cucumber (Cucumis sativus L.) radicles.

Germinating 'Poinsett 76' cucumber (Cucumis sativus) seeds are chilling sensitive, and subsequent radicle elongation is inhibited by exposure to nonfreezing temperatures below 10 degrees C. Reorienting germinated seeds with 5-mm-long radicles from a vertical to a horizontal position induced gravitropic curvature within 2 hours at 10 to 25 degrees C without significantly affecting the rate of radicle elongation. However, neither elongation nor curvature occurred in similar seeds held at 2.5 or 5 degrees C. Chilling seeds with 5-mm-long radicles at 2.5 degrees C for 18 hours significantly reduced the subsequent rate of radicle elongation at 25 degrees C by 47% compared with nonchilled control, while gravitropic curvature was reduced by only 34%. After 36 hours of recovery at 25 degrees C, the difference was even more pronounced; elongation was reduced by 26% while curvature was reduced by only 6%. Clearly, gravitropic curvature was less chilling sensitive than radicle elongation, despite the fact that differential elongation of cells in the radicle are needed to produce curvature. Exposing seeds with 5-mm-long radicles to a heat shock of 45 degrees C for 4 to 10 minutes significantly diminished the chilling-induced reduction in radicle elongation and gravitropic curvature.

Level of asthma control and health care utilization in Asia-Pacific countries.

BACKGROUND: Data on the impact of asthma in many countries in the Asia-Pacific region is limited. This study investigated whether partly- and uncontrolled asthma were associated with increased medication use/healthcare utilization and productivity loss among a population of asthma patients from nine Asia-Pacific countries. METHODS: We used cross-sectional data from 3630 asthma patients ≥12 years from the 2011 Asia-Pacific Asthma Insights and Management (AP-AIM) survey. Using Global Initiative for Asthma (GINA) guidelines, patients were categorized as having well-controlled, partly- controlled, or uncontrolled asthma. Chi-square tests were used to assess the relation of degree of asthma control with utilization of asthma medications, health services, productivity, and mood. RESULTS: Overall, 7.6% of the patients surveyed had asthma that was well-controlled, with the highest proportions in Singapore (14%) and the lowest in India (0%) and China (2%). Patients whose asthma was not well-controlled reported greater use of asthma medications, more emergency healthcare visits or hospitalizations for their asthma, and more interference of their mood due to asthma. They also reported significant decreases in productivity due to asthma. CONCLUSIONS: Patients who did not have well-controlled asthma had greater utilization rates of asthma medications and healthcare services and were more likely to report missing multiple days of work/school compared to patients whose asthma was well-controlled. These associations suggest that emphasis on improving asthma control could have dramatic effects on patient well-being and utilization of healthcare resources.

Diversidade e usos de plantas medicinais nos quintais da comunidade de São João da Várzea em Mossoró RN / Diversity and uses of medicinal plants in homegardens at the community São João da Varzea, Mossoró RN

RESUMO Nos quintais do nordeste brasileiro são mantidas tradicionalmente diversas espécies vegetais para o tratamento de doenças. O objetivo do presente trabalho foi realizar um levantamento das espécies medicinais em quintais na Comunidade de São João da Várzea, Mossoró, Rio Grande do Norte, Brasil. Participaram do estudo 22 informantes e foram aplicadas para a coleta de dados técnicas de observação direta e participante, turnê guiada, lista livre e entrevistas semiestruturadas. Verificou-se a presença de 57 espécies pertencentes a 37 famílias botânicas. As espécies com maior frequência de ocorrência foram goiabeira (Psidium guajavaL.) e coqueiro (Cocos nucifera L.), presentes em 59% e 55% dos quintais, respectivamente. Para estas espécies houve maior índice de concordância de uso (CUPc de 61,5% e 92,3%). Foram citadas 67 patologias e o maior número de plantas medicinais foi indicado para o tratamento de gripe, disenteria, inflamações e como cicatrizante de ferimentos. O principal modo de administração foi por via oral, na forma de decocção (58%) e as folhas foram as partes mais usadas (32,6%). Os quintais são sistemas que atuam como uma estratégia de uso mais sustentável dos recursos medicinais por conservarem também as espécies nativas. As espécies medicinais mais frequentes nos quintais são arvores frutífero-alimentícias importantes para a renda familiar. A gripe e desinteria são os principais agravos de saúde tratados com espécies medicinais pela comunidade. Ziziphus joazeiro Mart., Citrus X limonia (L.) Osbeck, Punica granatum L., Cocos nucifera L. e Psidium guajava L. são espécies que merecem maiores estudos farmacológicos.

ABSTRACT Traditionally, at homegardens in the northeastern of Brazil, several plant species are employed for the treatment of diseases. The aim of this study was to research the species of medicinal use in homegardens of São João da Varzea, Mossoró, Rio Grande do Norte, Brazil. 22 homegardens were studied through the techniques of direct and participant observations , guided tours, free list and semi structured interviews. We verified the presence of 57 botanical species belonging to 37 families. The two species with the highest frequency of occurrence were the guava (Psidium guajava L.) and the coconut (Cocos nucifera L.), present in 59% and 55% of the homegardens, respectively. For these species there was more agreement of use (CUPc 61.5% and 92.3%). 67 diseases, including influenza and dysentery were the most common ones mentioned during the interviews. The main mode of administration was orally, in the form of decoction (58%), and the leaves were the most employed component (32.6%). Homegardens are systems that act as a more sustainable use of medicinal resources strategy since they conserve native species. The most common medicinal plants in the homegardens are the fruitful-food trees, important to the family income. The flu and the dysentery are the main health problems treated with medicinal plants by the community. The Ziziphus joazeiro Mart., Citrus X limonia (L.) Osbeck, Punica granatum L., Cocos nucifera L. and Psidium guajava L. are species that deserve further pharmacological studies.

Plasmodium falciparum histidine-rich protein 2-based immunocapture diagnostic assay for malaria: cross-reactivity with rheumatoid factors.

Recently introduced rapid nonmicroscopic immunocapture assays for the diagnosis of malaria infection are being evaluated for their sensitivity and specificity in various epidemiological settings. A Plasmodium falciparum histidine-rich protein 2 (PfHRP-2)-based assay (ICT) and a Plasmodium-specific lactate dehydrogenase test (OptiMAL) were evaluated for their specificities in different groups of patients who tested negative for malaria infection by microscopy. The patients were selected from different disease groups: rheumatoid arthritis, hepatitis C, toxoplasmosis, schistosomiasis, and hydatid disease. One hundred thirty-three of the 225 patients were positive for rheumatoid factor. Thirty-five of the 133 (26%) rheumatoid factor-positive patients gave a false-positive reaction with the ICT assay, but only 4 of these gave false-positive reactions with the OptiMAL test. Thirty-three of the 35 false-positive specimens became negative when repeat tested with the ICT assay after absorbing out the rheumatoid factor activity. Our study shows that the PfHRP-2-based ICT assay gave a false-positive reaction in 26% of the patients who had rheumatoid factors, but were negative for malaria by microscopy.

Piracetam for the treatment of sickle cell disease in children- a double blind test.

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