Assessment of Factors Responsible for Dropout to Multi Drug Therapy for Leprosy

This study was conducted over 2 years period at two leprosy centers of a Tertiary Care Service Hospitals one located in Eastern Uttar Pradesh and second in northern India to assess the factors resulting in pre-mature termination of anti-leprosy treatment in patients. A total of 124 patients, undergoing treatment for leprosy who consumed MDT for at least a month, then stopped it and thereafter reported to us for various reasons, were included. It was observed that 41.1% (51/124) patients dropped out on MDT. 33% (41/124) of the patients who stopped the medication were not formally educated. Most common disease forms observed in these patients was Borderline Lepromatous (BL) and Lepromatous Leprosy in 41.1% (51/124). 49.1% (61/124) patients completed 2-5 months of therapy with MDT prior to stopping it and 38.7% (48/124) patients reported back to us within 2-5 months after suspension of MDT. Reason for reporting in 31.4% (39/124) of these patients was development of deformities while 25% (31/124) reported due to weakness of hands and feet. 23.3% (29/124) developed lepra reaction becoming the reason for their reporting to us for review. Social stigma was the most common factor leading to termination of drug therapy against advice in 25.8% (32/124) patients, 21.7% (27/124) cited loss of occupational hours while 11.2% (14/124) patients felt there was no need to take MDT. To conclude non-compliance to multi drug therapy for leprosy is one of the major obstacles in achieving a leprosy free world and we need to look into all the personal, health care related and social factors responsible for it. Although these factors may vary depending upon the region, society, efficiency of the health care system and the individual commitment level of the patients, the need for better communication at professional and user level is apparent. Focus should be on psychological counselling, motivation of patients, their families and a receptive society to reduce the source of infection, complications and deformities which are otherwise largely preventable and adherence to treat will also prevent of emergence of resistance to MDT. Modified strategy(ies) addressing the factors as identified in this study well in time can make a difference.

Interesting and Unusual Presentation(s) of Leprosy Resulting in Delayed diagnosis

In the post elimination phase of leprosy programme, it continues to be an important health problem in India. Further various atypical forms are seen resulting in delayed diagnosis. A retrospective analysis of 2 years (January 2016 to December 2017) records of all in and out patients of leprosy cases who were treated at a service hospital in northern India was done. At this hospital a total of 97 leprosy cases were seen during the study period out of which 18 (18.5%) cases where the diagnosis was missed due to various reasons resulting in delay in initiation of MDT were included. These cases were examined to describe the clinical presentation, delay in diagnosis and its significant outcome. 61% (11/18) were males while 39% (7/18) females. 22.2% (4/97) had Histoid Hansen's disease; 22.2% (4/18) had chronic symmetrical polyarthritis, there was no hypoaesthetic or anesthetic patches or enlarged nerves in these patients and these were initially diagnosed and managed as Rheumatoid arthritis. 16.6% (3/18) had spontaneous ulceration of extremities and had no skin infiltration or thickened nerve on examination. Interestingly two of these three patients had associated hypoaethesia of extremities which was not taken into consideration for making diagnosis as no suspicion of leprosy was made, one patient in this group had developed foot drop (L) and Right ulnar claw. 16.6% (3/18) had pure neuritic leprosy while greater auricular nerve thickening was seen in 11.1% (2/18) atypical cases. 5.5% (1/18) patient had swelling of upper lip but there no lesion on face or nerve and was managed by a Dentist. Lichenoid lesions were seen in 5.5% (1/18) cases. Out of 18 atypical cases 83.3% (15/18) were in multibacillary pole while 16.6% (3/18) were in paucibacillary pole. 27.7% (5/18) each were BL and LL while 22.2% (4/18) each were Pure neuritic and Histoid Hansen's. 83.3% (15/18) patients were Bacillary positive. Grade 2 deformity developed in 22.2% (4/18) of these cases. The total duration elapsed between presenting to the primary care giver and the dermatology center where the final diagnosis was made ranged from 2 weeks to 3 years. Increase in awareness about various presentations of leprosy in post-elimination era should be emphasized to the health care physicians as well as other workers involved in detection/diagnosis of leprosy

Does buprenorphine maintenance improve the quality of life of opioid users.

Background & objectives: The quality of life (QOL) of substance abusers is known to be severely impaired. Information on impact of opioid maintenance treatment on the QOL of opioid dependent subjects though available from the developed countries, is lacking from India. This study was carried out to assess the impact of buprenorphine maintenance treatment on the quality of life (QOL) of opioid dependent subjects at nine months follow up. Methods: Based on specified inclusion criteria a total of 231 subjects were recruited from five participating centres across India. They received sublingual buprenorphine as a directly observed therapy along with brief psychosocial intervention (provided in groups of 8-10 subjects) after intake in to the study. The WHOQOL-BREF scale domain scores obtained at baseline were compared to domain scores at nine months follow up. Results: At nine months follow up, among the 64.1 per cent retained in buprenorphine maintenance, there was a significant (P<0.001) decline in opioid use from 24.9 ± 10.1 days at baseline to 1.7 ± 4.7 days at nine months follow up and improvements in score of the four WHOQOL-BREF domains (Physical, Psychological, Social relationships and Environment). Interpretation & conclusions: The results showed the beneficial effects of buprenorphine maintenance treatment in improving the QOL of opioid-dependent subjects at nine month follow up. These results point towards the need for an expanded nation-wide provision of buprenorphine maintenance treatment as a harm reduction strategy for the opioid dependent population.

Microbial forensics: An upcoming investigative discipline.

Microorganisms make good weapons and bioterorism has been known to exist since centuries. This has most recently been highlighted by the terrorist attack using anthrax in the fall of 2001 in U.S. Although such attacks of bioterrorism are few, forensic evidence to criminally prosecute the perpetrator is necessary. To strengthen defence against bio crimes, a comprehensive technological network involving various fields needs to be developed. Microbial forensics is one such new discipline combining microbiology and forensic science. It uses advanced molecular techniques like microarray analysis and DNA fingerprinting etc. to associate the source of the causative agent with a specific individual or group by measuring variations between related strains. High quality assurance and quality control standards for microbial forensics will ensure highly reliable results that will stand up in the court of law. The more precise and refined a microbial system becomes, the more proper guidelines for investigations will be defined. An integrated approach towards developing this field of microbial forensics needs to be followed, to meet the challenges of bioterrorism more effectively.

Toxicological properties of several medicinal plants from the Himalayas (India) against vectors of malaria, filariasis and dengue

The leaves of five plants namely Nyctanthes arbortistis (Oleaceae), Catharanthus roseus (Apocynaceae), Boenininghusenia albiflora (Rutaceae), Valeriana hardwickii (Valerianaceae) and Eupatorium odoratum (Asteraceae) were selected for the first time from the Garhwal region of north west Himalaya to investigation its toxicological properties against mosquito vectors of malaria, filariasis and dengue. In a laboratory study, using different polarity solvents (petroleum ether, chloroform and methanol) were tested against important larvae of malaria, filariasis and dengue vectors in India. It was observed that petroleum ether fraction of all selected plant possess good larvicidal properties than other solvent fraction. The LC50 values of isolates from Nyctanthes arbortistis (HAR-1), C. roseus (CAT-1), B. albiflora (BOA-1), V. hardwickii (SUG-1) and E. odoratum (EUP-1) against Anopheles stephensi were 185 ppm, 150 ppm, 105 ppm, 225 ppm and 135 ppm, respectively. The results therefore suggest that the fraction code BOA-1 has excellent larvicidal properties and could be incorporated as botanical insecticides against mosquito vectors with high safety to nontarget organisms. The same fraction was tested against adult vectors of malaria, filariasis and dengue, but no mortality was observed.

The co-occurrence of tobacco & alcohol in general population of metropolis Delhi.

BACKGROUND & OBJECTIVES: The association between tobacco and alcohol use behaviours has not been explored in India. This study reports on the co-occurrence of tobacco and alcohol use in a representative general population in metropolis Delhi at two points of time a year apart. METHODS: Matched data on 10,312 individuals from 2937 households above the age of 10 yr were available for survey I and survey II. Among them 5414 were males and 4898 females. The subjects were interviewed by non clinical staff using a structured proforma based on DSM III R criteria on the use of tobacco, alcohol, cannabis and opioids. RESULTS: Among women, use of only tobacco was reported. Among males, the prevalence of use of 'only tobacco', 'only alcohol' and concurrent smoking and drinking was 18.1, 3.3 and 9.6 per cent respectively. Concurrent use was higher in the age group 31-40 yr and dependence higher in the 41-50 yr age group. Both at surveys I and II current smokers had higher percentage of alcohol drinkers compared to tobacco abstainers; dependent smokers had higher percentage of dependent drinkers. The use of alcohol at survey II was higher among tobacco smokers compared to tobacco abstainers identified at survey I (OR = 5.77, 95% CI 4.3-7.7). INTERPRETATION & CONCLUSION: Our results demonstrate a positive correlation between smoking and drinking. The findings lend support to existing evidence suggesting associations between tobacco and alcohol use. Smoking proved to be a powerful predictor of alcohol use. It is suggested that professionals who treat alcoholism should pursue the cessation of smoking among their patients.

Incidence estimates of substance use disorders in a cohort from Delhi, India.

BACKGROUND & OBJECTIVES: There are no reports of incidence studies in the Indian setting on substance use disorders in the general population. This survey-resurvey carried out in metropolis Delhi estimated the incidence rates of substance use disorders. METHODS: A cross-sectional survey was carried out at two points of time with an interval of one year in a representative sample from the general population of metropolis, Delhi. The instrument was precoded, structured and based on DSM III-R operationalised criteria for use of tobacco, alcohol, cannabis and opioids (past one month). Matched data for two points of time were available for 5414 males and 4898 females. RESULTS: In the total cohort, the annual incidence rates (per 100 persons) among males for any drug use, alcohol, tobacco, cannabis and opioids were 5.9, 4.2, 4.9, 0.02 and 0.04 respectively. Among females, incidence of any drug use was 1.2/100 persons. INTERPRETATION & CONCLUSION: Results showed that males have higher incidence for both not-dependent and dependent use for all the drug categories. Females had a higher incidence of dependent tobacco use.

Pyoderma gangrenosum and urinary tract infection.

A case of pyoderma gangrenosum is reported in a 52-year-old man who had skin lesions without any association. On investigation urinary tract infection was detected. Treatment of UTI led to spontaneous healing of the lesions in short period thus avoiding the need of oral corticosteroids.

A rapid assessment study on prevalence of substance abuse disorders in metropolis Delhi.

BACKGROUND & OBJECTIVES: No studies in India have attempted to identify in the general population a 'dependent drug user' based on clinically used diagnostic criteria. This two point survey estimated the prevalence of substance use disorders and the change in the trends of drug use after a period of one year in metropolis Delhi. METHODS: A total of 72 colonies in five types of housing clusters were surveyed. The head of the household (HOH) was interviewed only for collecting information about family members (above 10 yr) on an instrument based on the DSM III R operationalised criteria. Trained non medical interviewers administered the precoded instrument to 6004 and 5599 HOH in the first and second surveys respectively. RESULTS: In the first survey, the prevalence of tobacco, alcohol, cannabis and opioids use among males was 27.6, 12.6, 0.3 and 0.4 per cent respectively. The rates were highest in resettlement clusters followed by urban villages, unauthorized, regularized and in 'others' clusters. The use rates remained unchanged during the re-survey. Dependent use (any drug) increased in the resettlement clusters only during the re-survey. INTERPRETATION & CONCLUSION: The results highlight that it is the legal drugs viz., tobacco and alcohol that could pose higher health and social consequences, both short and long term. The situation of illicit drug use (heroin) was higher in the resettlement clusters and urban villages. Need based programmes have to be evolved and executed to keep the drug dependent population stable. The rapid survey technique can be useful in developing countries like India, where resource crunch for survey research is acute. This technique is less costly, quicker to perform and can supplant traditional self-report methodologies.

Percutaneous transseptal mitral commissurotomy in pregnant women with critical mitral stenosis.

BACKGROUND: Percutaneous transseptal mitral commissurotomy has been successfully performed in selected pregnant patients with severe symptomatic mitral stenosis. Its safety and efficacy needs to be evaluated in a large number of cases. METHODS AND RESULTS: Percutaneous transseptal mitral commissurotomy was performed in 85 severely symptomatic (New York Heart Association functional class III or IV) pregnant women aged 22.7+/-4.1 years (range 18-39 years) with critical mitral stenosis at 24.8+/-4.7 weeks (range 20-34 weeks) of gestation. Percutaneous valvotomy was performed using a flow-guided Inoue balloon in all the patients. The procedure was considered successful in 80 (94%) patients. The hemodynamic mean end-diastolic gradient decreased from 26.7+/-6.8 mm Hg (range 16-35 mmHg) to 4.5+/-3.8 mmHg (range 0-14 mmHg) (p<0.001). The mean diastolic gradient decreased from 29.1+/-9.1 mmHg (range 18-38 mmHg) to 7.2+/-4.1 mmHg (range 4.1-18 mmHg) (p<0.001). The mean mitral valve area assessed by echocardiography increased from 0.75+/-0.5 cm2 (range 0.4-1.0 cm2) to 2.0+/-0.5 (range 1.0-2.7 cm2) (p<0.001). The mean fluoroscopy time was 3.6+/-3.2 minutes. The results of the mitral valvotomy were considered suboptimal in 4 patients. Mitral regurgitation increased by 1 grade in 16 patients and more than 2 grades in 2 patients. One patient developed pericardial tamponade during the procedure and was managed by catheter drainage. Percutaneous mitral valve dilatation was then successfully performed in this patient. No fetal abortion occurred after the procedure. CONCLUSIONS: The results of this study indicate that percutaneous transseptal mitral commissurotomy is a safe and effective procedure for severe symptomatic mitral stenosis in pregnancy.

Prevalence of rheumatic diseases in a rural population in western India: a WHO-ILAR COPCORD Study.

BACKGROUND: COPCORD (Community oriented program from control of rheumatic diseases) is a global initiative of the WHO/International League of Associations from Rheumatology (ILAR). The prevalence data from the first Indian COPCORD survey (Stage 1), carried out in village Bhigwan (Dist. Pune), in 1996, is presented. AIM: To study the rural prevalence of rheumatic-musculoskeletal symptoms/diseases (RMSD). METHODS: A cross-sectional survey of the village (non-randomised selection) was completed in five weeks, using validated questionnaires, served by 21 trained volunteers. 746 patients (18.2%, 95% CI: 17-1-19-4) were identified (Phase 1) from 4092 adults (response 89%), and systematically evaluated (Phase 2 and 3) by a medical team, including a rheumatologist; limited investigations were carried out and diagnosis confirmed during a planned 12 week initial follow-up. Standard clinical criteria were used for the diagnosis; point prevalence estimates (prev)/confidence interval (CI) are shown in parenthesis. RESULTS: There was a dominant distribution of 'pain at all sites' (articular/soft tissues) in the females; painful neck (9.5%), back (17.3%), and calf (8.5%) appeared significant when compared to the Bhigwan males and the Indonesian and the Chinese rural COPCORD results. 55% RMSD were due to soft tissue rheumatism (5.5%) and an ill-defined/unclassifiable symptom-related-diagnosis (7.1%). Osteoarthritis (5.8%) and inflammatory arthritis (IA) were seen in 29% and 10% patients respectively. 240 patients (5.9%) with chronic knee pains did not show any clinical evidence of OA. The prev of rheumatoid arthritis (0.5%, 95% CI: 0.3-0.7), as classified by the American College of Rheumatology, was the highest ever reported from an Asian rural COPCORD study. Though unclassifiable IA (0.9%, 95% CI: 0.6-1.1) was seen, well defined reactive arthritis, TB, leprosy and connective tissue disorders were not observed. Gout was diagnosed in five patients (0.12%). CONCLUSIONS AND DISCUSSION: The Bhigwan COPCORD survey demonstrates a significant rural spectrum of RMSD. It provides a reasonable speculation about the Indian rheumatological burden. Further, an eight year prospective study is in progress to identify new cases and risk factors, and educate people (Stages 2 and 3).

Detection of anti-nuclear antibodies from filter paper blood clots using indirect immunoenzyme technique: preliminary experience and results.

BACKGROUND: The facilities to detect antinuclear antibodies (ANA) patterns in patients with systemic rheumatic diseases/connective tissue disorders (CTD) using indirect immunofluorescence (IIF) technique (the gold standard) are sparse; the technique is technically difficult and expensive. A simpler technique, such as the indirect immunoenzyme (IIE) which uses light microscopy, ought to be evaluated for widespread use in our setting. OBJECTIVE: To study the feasibility and relevance of IIE in demonstrating ANA patterns, both from serum and filter paper blood clots (FPBC), in patients with CTD. METHODS: In this pilot study, ANA were detected from sera and FPBC of 21 patients with proven CTD using IIE; paired FPBC and serum samples were simultaneously collected in 10 patients. All samples, coded randomly, were tested by IIE and IIF, along with positive and negative controls. RESULTS: Using IIE, the results of the ANA patterns obtained from FPBC eluates and sera were similar; homogenous (SLE-6, PSS-1, RA-4), speckled (SLE-8, PSS-2, Overlap CTD-1) and centromere (PSS-1). Four SLE patients showed mixed pattern; sensitivity of IIE for lupus was hundred percent. On comparing the results with the serum IIF, the Kappa statistic of agreement was 1 (perfect) and 0.4 (fair) for FPBC-IIF and FPBC-IIE respectively; the results matched between serum IIF and FPBC-IIE in 8 of the 10 paired samples tested. CONCLUSIONS: IIE can demonstrate ANA both from sera and FPBC. This pilot study besides demonstrating positive trends for further probe also creates an awareness for such a feasible technique. However a larger sample size would be required to carry out its evaluation as an alternative to IIF and as a screening technique.

Post-infarction ischaemic mitral regurgitation: what determines the outcome.

Ischaemic mitral regurgitation is an important determinant of survival in patients with coronary artery disease. A retrospective analysis was performed to evaluate the overall outcome and its determinants in patients with ischaemic mitral regurgitation. Over a period of 10 years, 72 patients underwent operations for mitral regurgitation of ischaemic origin. Age ranged from 37 to 68 years (mean 54.6 +/- 10.4 years), and 62 (86.1%) were male. Thirteen (18%) patients had acute and 59 (82%) had chronic ischaemic mitral regurgitation. Twenty-one patients were in New York Heart Association class II, 32 in class III and 19 in class IV. Moderate to severe left ventricular dysfunction was present in 42 patients. Valve prolapse was present in 35 (48.6%) patients and restricted leaflet motion secondary to myocardial dysfunction was present in 37 (51.4%) patients. All the patients were operated using standard cardiopulmonary bypass technique. Mitral valve was replaced in 33 patients and repaired in 39. Repair included a combination of techniques: chordal transposition (n = 2), chordal shortening (n = 18), leaflet resection (n = 2), posterior collar annuloplasty (n = 35) and annuloplasty with flexible Duran's ring (n = 3). Operative mortality was 18.1 percent (13/72). Low cardiac output was the cause of death in the majority (n = 10). Acute presentation and presence of restricted leaflet motion were the significant predictors of early mortality. Follow-up ranged from 3 to 84 months (mean 41.6 +/- 10.2 months). Late mortality was 46.2 percent. Actuarial survival in operative survivors at five years was 44.4 +/- 8.8 percent. To conclude, ischaemic mitral regurgitation carries a poor early and late outcome, with left ventricular dysfunction and presence of restricted leaflet motion being important contributors to it. In addition, acute presentation also reflects greater early mortality.

Acute haemodynamic effects of nicorandil in patients with chronic severe regurgitant valvular lesions.

The haemodynamic effects of nicorandil, a new balanced vasodilator exhibiting nitrate-like as well as potassium-channel opening activity in patients with chronic severe valvular lesions have not been reported. We studied the acute effect of nicorandil on haemodynamics in 12 stable patients (6 males, 6 females; mean age 23.5 +/- 4.6 years) with chronic severe valvular regurgitation (8 mitral, 4 aortic). All patients were studied in resting, supine and fasting states. All cardioactive drugs were withdrawn five days prior to the study. Intra-arterial line was placed and thermodilution catheter was positioned in the pulmonary artery. Haemodynamic parameters recorded at baseline and at 30, 60, 90 and 120 minutes following a single oral dose of 20 mg nicorandil revealed no significant change in the heart rate while systemic pressures showed a small decline (p < 0.05). There was significant reduction in systolic, diastolic and mean pulmonary artery pressures (p < 0.001). The mean cardiac index increased from 3.16 L/min/m2 at baseline to 3.77 L/min/m2 at 60 minutes. Both the pulmonary and systemic vascular resistance indices reduced significantly, the peak fall being 18 percent and 29 percent, respectively. Maximal changes were observed at 60 to 90 minutes following administration of nicorandil. No adverse effect of nicorandil occurred during the study. We conclude that nicorandil has a favourable acute haemodynamic effect in patients with chronic severe valve regurgitation. Its long-term use in valvular lesions should be explored further.

A rapid survey on substance abuse disorders in the urban slums of New Delhi.

The results are presented of a rapid survey screening method of general population for identifying dependent and non dependent drug abusers, especially in vulnerable groups such as slum dwellers. The results showed that with the help of instrument with modified DSM III and interviewing only the heads of the households it was possible to get reliable estimates of dependence disorder in the community. This method can be of assistance to health planners for a quick assessment of the magnitude of the problem leading to better allocation of funds and developing services for the affected population. The method is an improvement on key informant technique and a full fledged survey.