Strategies for primary HPV test-based cervical cancer screening programme in resource-limited settings in India: Results from a quasi-experimental pragmatic implementation trial.

BACKGROUND: In order for low and middle income countries (LMIC) to transition to Human Papilloma Virus (HPV) test based cervical cancer screening, a greater understanding of how to implement these evidence based interventions (EBI) among vulnerable populations is needed. This paper documents outcomes of an implementation research on HPV screening among women from tribal, rural, urban slum settings in India. METHODS: A mixed-method, pragmatic, quasi-experimental trial design was used. HPV screening on self-collected cervical samples was offered to women aged 30-60 years. Implementation strategies were 1) Assessment of contextual factors using both qualitative and quantitative methods like key informant interviews (KII), focus group discussions (FGDs), pre-post population sample surveys, capacity assessment of participating departments 2) enhancing provider capacity through training workshops, access to HPV testing facility, colposcopy, thermal ablation/cryotherapy at the primary health care centers 3) community engagement, counselling for self-sampling and triage process by frontline health care workers (HCWs). Outcomes were assessed using the RE-AIM (Reach, Effectiveness, adoption, implementation, maintenance) framework. RESULTS: Screening rate in 8 months' of study was 31.0%, 26.7%, 32.9%, prevalence of oncogenic HPV was 12.1%, 3.1%, 5.5%, compliance to triage was 53.6%, 45.5%, 84.6% in tribal, urban slum, rural sites respectively. Pre-cancer among triage compliant HPV positive women was 13.6% in tribal, 4% in rural and 0% among urban slum women. Unique challenges faced in the tribal setting led to programme adaptations like increasing honoraria of community health workers for late-evening work and recalling HPV positive women for colposcopy by nurses, thermal ablation by gynaecologist at the outreach camp site. CONCLUSIONS: Self-collection of samples combined with HCW led community engagement activities, flexible triage processes and strengthening of health system showed an acceptable screening rate and better compliance to triage, highlighting the importance of identifying the barriers and developing strategies suitable for the setting. TRIAL REGISTRATION: CTRI/2021/09/036130.

A systematic review of the theory of planned behaviour interventions for chronic diseases in low health-literacy settings.

Background: Due to their chronicity, prolonged morbidity, and high mortality, chronic respiratory diseases (CRDs) pose a huge burden of disease globally, primarily among low- and middle-income countries. Most of these diseases can be controlled by early diagnosis and treatment, correct practice of medications, regular follow-up, and avoidance of risk factors, which involves a change in health behaviour among patients. The theory of planned behaviour (TPB) has been proven to be effective and has been used increasingly as a behavioural framework for designing and evaluating behaviour change interventions, although most such studies were on affluent populations and from the global north. We aimed to collate evidence of TPB-based behavioural interventions in low health literacy settings for its effectiveness and feasibility by conducting a systematic review (SR). Methods: We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines in conducting and reporting this study. We selected interventional studies using at least two constructs of TPB for behaviour change in chronic disease patients and conducted in LMICs, used the PICO framework, and exported the retrieved studies through the Endnote software. We evaluated the studies using the Risk of Bias (RoB) 2 and Risk of Bias in Non-randomised Studies - of Interventions (ROBINS-I) tools. Results: We retrieved and reviewed the titles and abstracts 4281 titles and abstracts, identifying 186 articles for further detailed screening. Eleven studies met the criteria for a standardised independent full-text screening by two authors and four were selected for narrative synthesis. All studies were from urban settings, with established feasibility and fidelity; all interventions were effective in changing health behaviour and TPB constructs and provided structured education to participants in the intervention group (either face-to-face and through group education). Three studies had some concerns/moderate risk of bias and one had high risk of bias. Conclusions: All studies demonstrated effectiveness, feasibility, and fidelity of TPB interventions in LMIC settings, although most were of moderate quality. Further studies should gather definitive evidence and prove their feasibility and utility in LMICs. Registration: PROSPERO CRD42018104890.

Theory of planned behaviour-based interventions in chronic diseases among low health-literacy population: protocol for a systematic review.

BACKGROUND: Health behaviour can change outcomes in both healthy and unhealthy populations and are particularly useful in promoting compliance to treatment and maintaining fidelity to care seeking and follow-up options in chronic diseases. Interventions to change health behaviour based on psychological theory are more often successful than those without any underlying theory. The theory of planned behaviour (TPB) is one such psychological theory which had been found to predict human behaviour with respect to disease prevention and when applied to interventions can change the outcomes of diseases. Most of the research evidence of TPB-based interventions have been from developed world. Evidence is required whether TPB-based interventions can be applied and works in low-resource, low health-literacy settings of low- and middle-income countries (LMICs). METHODS: The protocol has been developed as per PRISMA-P guidelines and incorporates PICO (population, intervention, comparison, outcomes) framework for describing the methodology. Population above 18 years of age and having any chronic disease (as defined for this systematic review) will be selected, while any health or educational intervention based on constructs of TPB will be included. Comparison will be with non-TPB-based interventions or treatment as usual without any intervention, and the primary outcome will be the behaviour change effected by the TPB-based intervention. Intervention studies will be considered, and relevant databases like MEDLINE, Embase, Cochrane Library and ProQuest will be explored. Data extraction will done in a standardised form, and risk-of-bias assessment will be done using the Cochrane Collaboration's tools for such assessment. Narrative synthesis of the selected studies will be done to draw the conclusions, and meta-analysis will be done to calculate the effect estimates with I-squared statistics to describe the heterogeneity. DISCUSSION: This systematic review will provide new evidence on fidelity and effectiveness of the TPB-based interventions among chronic disease patients from low health literacy, resource-poor background. It will inform of how to plan and use such interventions to change health behaviour in chronic disease patients, particularly in LMIC settings. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018104890 .

The groundwater arsenic contamination in the Bengal Basin-A review in brief.

The presence of arsenic in the groundwater of the densely-populated Bengal Basin evolved as a mass-poisoning agent and is a reason for the misery of millions of people living here. High-level arsenic was detected in the shallow aquifer-tube wells of the basin in the late-20th century. The redox conditions and the biogeochemical activities in the shallow aquifers support the existence of arsenic in its most toxic +3 state. The shallow aquifers are constructed by the Holocene reduced grey sands, having a lesser capacity to hold the arsenic brought from the Himalayas by the Ganga-Brahmaputra-Meghna river system. Among several other hypotheses, the reductive dissolution of arsenic bearing Fe-oxyhydroxides coupled with the microbial activities in the organic-matter-rich Holocene grey sands is believed to be the primary reason for releasing arsenic in groundwater of basinal shallow aquifers. The deep aquifers below the late Pleistocene aquifers and the Palaeo-interfluvial aquifers capped by the last glacial maximum Palaeosol generally contain arsenic-free or low-arsenic water. Ingress of arsenic into the deep aquifers from the shallow aquifers was considered to have been caused by extensive non-domestic pumping. However, studies have found that extensive pumping is unlikely to contaminate the deep aquifer water with higher levels of arsenic within decadal time scales. Irrigation-pumping may produce hydraulic barriers between the shallow and deep aquifer-groundwater and distributes arsenic in the topsoil by flushing. Significant disparities have been observed among the Bengal basinal groundwater arsenic concentrations. However, abrupt spatial variation in groundwater arsenic concentrations has been a key feature of the basin.

Predictors for detecting chronic respiratory diseases in community surveys: A pilot cross-sectional survey in four South and South East Asian low- and middle-income countries.

BACKGROUND: Our previous scoping review revealed limitations and inconsistencies in population surveys of chronic respiratory disease. Informed by this review, we piloted a cross-sectional survey of adults in four South/South-East Asian low-and middle-income countries (LMICs) to assess survey feasibility and identify variables that predicted asthma or chronic obstructive pulmonary disease (COPD). METHODS: We administered relevant translations of the BOLD-1 questionnaire with additional questions from ECRHS-II, performed spirometry and arranged specialist clinical review for a sub-group to confirm the diagnosis. Using random sampling, we piloted a community-based survey at five sites in four LMICs and noted any practical barriers to conducting the survey. Three clinicians independently used information from questionnaires, spirometry and specialist reviews, and reached consensus on a clinical diagnosis. We used lasso regression to identify variables that predicted the clinical diagnoses and attempted to develop an algorithm for detecting asthma and COPD. RESULTS: Of 508 participants, 55.9% reported one or more chronic respiratory symptoms. The prevalence of asthma was 16.3%; COPD 4.5%; and 'other chronic respiratory disease' 3.0%. Based on consensus categorisation (n = 483 complete records), "Wheezing in last 12 months" and "Waking up with a feeling of tightness" were the strongest predictors for asthma. For COPD, age and spirometry results were the strongest predictors. Practical challenges included logistics (participant recruitment; researcher safety); misinterpretation of questions due to local dialects; and assuring quality spirometry in the field. CONCLUSION: Detecting asthma in population surveys relies on symptoms and history. In contrast, spirometry and age were the best predictors of COPD. Logistical, language and spirometry-related challenges need to be addressed.

Comparative spectroscopic analysis, performance and emissions evaluation of Madhuca longifolia and Jatropha curcas produced biodiesel.

In order to fulfil the growing need to replace fossil fuels, investigations exploring the production of biodiesel from agricultural biomass have gained attention. In this study, biodiesels were produced from Madhuca longifolia and Jatropha curcas by means of pre-treatment followed by a two-step acid-base homogeneous catalyst method. These biodiesels were blended with diesel at different percentages. The efficacy of the process was examined using various characterization methods while the efficiency of the produced biodiesels was examined by their engine performance and emission tests. Both Madhuca and Jatropha-based biodiesels exhibited physiochemical properties like that of diesel. Biodiesels were produced by pre-treating with orthophosphoric acid and toluene. The second step involves acid esterification, followed by base transesterification. Raman spectra exhibited C=O stretching at 1725 cm-1 indicating conversion of Madhuca and Jatropha oil into biodiesel. Fourier transform infrared spectroscopy showed a strong presence of fatty acid profile and triglyceride ester linkage at 1744 cm-1. Ultraviolet-visible (UV) spectra confirmed the presence of conjugated dienes in the extracted biodiesels. UV absorbance at 320 nm decreased linearly with blend percentage. 1H and 13C nuclear magnetic resonance (NMR) confirmed the presence of methyl ester moiety at 3.6 δ (ppm) and methoxy carbon at 51.2 δ in biodiesel, distinguishing it from diesel. In the engine performance tests, the variations of brake specific fuel consumption, exhaust gas temperature and brake thermal efficiency versus brake power were studied. The emission tests of different blends were done in terms of carbon monoxide, nitrous oxide and unburnt hydrocarbon. The Jatropha biodiesel exhibited lower mean brake specific fuel consumption, exhaust gas temperature, emitted less carbon monoxide and unburnt hydrocarbon than Madhuca biodiesel. The average decrease in brake thermal efficiency was more in Jatropha biodiesel than Madhuca biodiesel. The present work uses for the first time treatment of ortho phosphoric acid and toluene to produce biodiesel followed by a two-step homogeneous acid-base catalyst method, drastically reducing free fatty acid value.

Development of an educational intervention to reduce the burden of adult chronic lung disease in rural India: Inputs from a qualitative study.

BACKGROUND: Chronic respiratory diseases (CRDs) are major causes of mortality and morbidity worldwide with a substantial burden of the disease being borne by the low and middle income countries (LMICs). Interventions to change health behaviour which aim to improve the quality of life and reduce disease burden due to CRD require knowledge of the problem and factors influencing such behaviour. Our study sought to appreciate the lived experiences of people with CRD, their understanding of the disease and its risk factors, and usual practice of health behaviour in a rural low-literate community in southern India. METHODS: Qualitative data were collected between September and December 2018 through eight focus group discussions (FGDs), five in-depth interviews and four key-informant interviews from patients and community members. Community engagement was undertaken prior to the study and all interviews and discussions were recorded with permission. Inductive coding was used to thematically analyse the results. RESULTS: Major themes included understanding of chronic lung disease, health behaviours, lived experiences with the disease and social norms, attitudes and other factors influencing health behaviour. DISCUSSION: Poor understanding of CRDs and their risk factors affect health seeking behaviour and/or health practices. Stigma associated with the disease and related health behaviours (e.g. inhaler use) creates emotional challenges and mental health problems, besides influencing health behaviour. However barriers can be circumvented by increasing community awareness; communication and connection with the community through community based health care providers can turn challenges into opportunities for better health care.

Identification of potential strategic sites for city planning based on water quality through GIS-AHP-integrated model.

Freshwater is one of the most important resources for the ecosystem's sustenance and any nation's development. However, clean water bodies are exploited to cater to urban societies' growing demands and economic expansion. This has led to the scarcity of clean water on the planet since the last decade, which is a crucial environmental concern in the present time. Therefore, proper water quality assessment and better management plan integrated with city planning have become an essential need of the hour to combat the clean water stress problem. This study aims to frame a model to identify the potential sites suitable for water use and document an effective development plan for a highly industrialized, populated, planned, and critically polluted city. The potential strategic sites were identified based on the impact of water quality on factors such as human health and economy, which are directly linked to drinking, irrigation, fisheries, as well as industrial production. The relative importance of each criterion (weightage) was estimated using the analytical hierarchy process (AHP). The physico-chemical parameters of groundwater and surface water of the strategic locations were analyzed to calculate multi-purpose water quality index (WQI) and Ryznar suitability index (RSI). These indices were interpolated through a geospatial tool and reclassified using a scoring system to a uniform scale. These thematic maps were weighted overlaid through the GIS model builder tool in GIS interface to develop suitability maps through developed potential site index (PSI) of the ground as well as surface water. The final suitability maps were used to identify the potential strategic sites for various uses such as drinking, fishery, irrigation, and industries, which can be considered by the planners for improvising the city planning. Various management practices were also drawn through these maps, which will safeguard human health as well as the environment.

Left atrial appendage occlusion for ischemic stroke prevention in patients with non-valvular atrial fibrillation: clinical expert opinion and consensus statement for the Asian-Pacific region.

PURPOSE: To develop a consensus statement for left atrial appendage occlusion (LAAO) in Asian-Pacific patients with non-valvular atrial fibrillation (NVAF) at risk of ischemic stroke. The need for such a region-specific consensus was indicated by the relative paucity of clinical evidence for LAAO and oral anticoagulation therapy obtained in Asian-Pacific populations and the specific stroke and bleeding characteristics of this population. METHODS: Consensus was developed by discussion and evaluation of available evidence and expert opinions during a 2-day meeting attended by clinical experts from the Asian-Pacific regions. RESULTS: The consensus statement arrived at provides recommendations based on available evidence and expert opinions regarding LAAO in Asian-Pacific patients. Gaps in the evidence and other areas requiring further research were identified. CONCLUSION: LAAO is an alternative device-based therapy in carefully selected patients with NVAF at risk of ischemic stroke. However, evidence for LAAO is primarily obtained from Caucasian populations, and data on LAAO in Asian-Pacific patients are scarce. While the present consensus statement addresses several therapy-related aspects based on careful interpretation of available evidence and expert opinions, other areas require additional evidence derived from Asian-Pacific populations.

Evaluation of the performance of zirconia-multiwalled carbon nanotube nanoheterostructures in adsorbing As(III) from potable water from the perspective of physical chemistry and chemical physics with a special emphasis on approximate site energy distribution.

In this study, the performance of zirconia-multiwalled carbon-nanotube nanoheterostructure in adsorbing the highly toxic water-contaminant As(III) from water has been probed from the perspective of physical chemistry and chemical physics. The adsorbent found extremely efficient in adsorbing As(III) from potable water. Moreover, its ability to oxidize As(III) to As(V) in the aqueous solution has been evinced by the XPS studies. The values of the maximum adsorption capacities (qm) depend on the isotherm studied and in this study, no wonder different values of qm are obtained for different adsorption isotherms. The thermodynamic studies advocate the exothermic and spontaneous nature of the adsorption process. Calculation on density functional theory (DFT) also suggested the exothermic nature of the adsorption process. DFT calculation further revealed the role of the Zr-O and Zr-OH bridges in binding As(III) species on the zirconia surface. However, this study finds an adverse effect of visible light-irradiation on the adsorption process. Furthermore, this study propounds an approach to estimate the maximum solubility of As(III) in water combining the Cerofolini's condensation-approximation and Polanyi adsorption potential. Detailed analysis on the approximate adsorption site energy distribution (f(E*)) further finds an inconsistency in the formula used to estimate qm using f(E*), which underestimates qm. The inconsistency, for the very first time, has successfully been resolved by modifying the heterogeneity related parameter in f(E*).

Groundwater quality assessment in an industrial hotspot through interdisciplinary techniques.

Dependency on groundwater has increased due to unprecedented growth of industries as well as settlements. Therefore, assessment of groundwater quality to determine its impact on human and environment has become essential. The major objective of this study was to frame a methodology for complete assessment of groundwater quality in a highly industrialized area comprising of iron, steel, fertilizer, cement, chemical, heavy machinery manufacturing, thermal power, coal mining, and allied industries. Physico-chemical parameters of water samples were analyzed from strategic locations during pre- and post-monsoon seasons. The primary analysis through the water quality index showed 50% of the sampling locations in pre-monsoon and 65% in post-monsoon seasons have very poor quality. Hence, the health risk calculated through hazard index indicates that the water is unsafe for drinking. Chemical indices such as sodium percentage, sodium adsorption ratio, residual sodium carbonate, permeability index, and magnesium hazard suggest that the water can be used for irrigation. High corrosivity ratio at 90% sampling locations specifies its unsuitability for use in industrial production. Factor analysis and other statistical methods justified that the pollution of groundwater was attributed to geogenic, as well as anthropogenic, activities. This research demonstrates the usefulness of interdisciplinary techniques for complete assessment of groundwater quality and representation of complex data set into a presentable and understandable form for proper communication with public, regulatory authorities, as well as policy makers, responsible for water management.

Efficient Enrichment of Gene-Modified Primary T Cells via CCR5-Targeted Integration of Mutant Dihydrofolate Reductase.

Targeted gene therapy strategies utilizing homology-driven repair (HDR) allow for greater control over transgene integration site, copy number, and expression-significant advantages over traditional vector-mediated gene therapy with random genome integration. However, the relatively low efficiency of HDR-based strategies limits their clinical application. Here, we used HDR to knock in a mutant dihydrofolate reductase (mDHFR) selection gene at the gene-edited CCR5 locus in primary human CD4+ T cells and selected for mDHFR-modified cells in the presence of methotrexate (MTX). Cells were transfected with CCR5-megaTAL nuclease mRNA and transduced with adeno-associated virus containing an mDHFR donor template flanked by CCR5 homology arms, leading to up to 40% targeted gene insertion. Clinically relevant concentrations of MTX led to a greater than 5-fold enrichment for mDHFR-modified cells, which maintained a diverse TCR repertoire over the course of expansion and drug selection. Our results demonstrate that mDHFR/MTX-based selection can be used to enrich for gene-modified T cells ex vivo, paving the way for analogous approaches to increase the percentage of HIV-resistant, autologous CD4+ T cells infused into HIV+ patients, and/or for in vivo selection of gene-edited T cells for the treatment of cancer.

Suitability Assessment of Surface Water Quality with Reference to Drinking, Irrigation and Fish Culture: A Human Health Risk Perspective.

A multi-purpose Water Quality Index (WQI) was developed to assess the suitability of surface water for drinking, fish-culture, as well as irrigation in Durgapur industrial city, India. WQI was calculated for 48 sampling locations, where 2.08%, 4.17% and 22.91% of the sampling locations have excellent water quality (WQI: 0-25) and 20.83%, 33.33% and 34.35% have good quality (WQI: 25-50), which represents its suitability for drinking, irrigation, and fish-culture respectively. Further, health risk was evaluated by Hazard Index (HI), which reflected that the population were prone to risk on oral ingestion [HI (female): 1.52; HI (male): 1.29], while safe for dermal contact (HI < 1). Potent toxic pollutants like Co, F, Mn, NO3 were identified to cause health hazards. The pollutants were attributed to rock-weathering, industries, agriculture and municipal sources, was investigated by factor analysis. This novel assessment technique with integration of geographical information system affirmed its effectiveness and easiness to evaluate water quality for multiple uses in any area.

Mobile technology and cancer screening: Lessons from rural India.

BACKGROUND: Rates of cervical and oral cancer in India are unacceptably high. Survival from these cancers is poor, largely due to late presentation and a lack of early diagnosis and screening programmes. Mobile Health ('mHealth') shows promise as a means of supporting screening activity, particularly in rural and remote communities where the required information infrastructure is lacking. METHODS: We developed a mHealth prototype and ran training sessions in its use. We then implemented our mHealth-supported screening intervention in 3 sites serving poor, low-health-literacy communities: RUHSA (where cervical screening programmes were already established), Mungeli (Chhattisgarh) and Padhar (Madhya Pradesh). Screening was delivered by community health workers (CHWs - 10 from RUHSA, 8 from Mungeli and 7 from Padhar), supported by nurses (2 in Mungeli and Padhar, 5 in RUHSA): cervical screening was by VIA; oral cancer screening was by mouth inspection with illumination. Our evaluation comprised an analysis of uptake in response to screening and follow-up invitations, complemented by qualitative data from 8 key informant interviews and 2 focus groups. RESULTS: 8686 people were screened through the mHealth intervention - the majority (98%) for oral cancer. Positivity rates were 28% for cervical screening (of whom 37% attended for follow-up) and 5% for oral cancer screening (of whom 31% attended for follow-up). The mHealth prototype was very acceptable to CHWs, who felt it made the task of screening more reliable. A number of barriers to screening and follow-up in test-positive individuals were identified. Use of the mHealth prototype has had a positive effect on the social standing of the CHWs delivering the interventions. CONCLUSIONS: mHealth approaches can support cancer screening in poor rural communities with low levels of health literacy. However, they are not sufficient to overcome the range of social, cultural and financial barriers to screening and follow-up. Approaches which combine mHealth with extensive community education, tailored to levels of health literacy in the target population, and well-defined diagnostic and treatment pathways are the most likely to achieve a good response in these communities.

Role of intestinal dysfunction in the nutritional compromise seen in human immunodeficiency virus-infected adults in rural India.

Human immunodeficiency virus (HIV) disease progression is often marked by significant weight loss with or without chronic diarrhoea. We studied the extent of intestinal dysfunction using a D-xylose absorption test and association with nutritional compromise as measured by body mass index (BMI) and serum antioxidants levels in HIV-infected individuals through a cross-sectional survey of 45 ART naïve, HIV-positive and 45, age-socioeconomic status matched negative controls in a rural population in India. More than 40% of HIV-positive and HIV-negative participants had intestinal dysfunction (42.2% vs. 44.4%). However an increasing gradient of low D-xylose absorption was noted with decreasing CD4 counts (32%, 50% and 58.3% among those with >350, 200-350 and <200 cells/mm3, respectively). Multivariate analysis revealed a significant association between intestinal dysfunction and low BMI (P = 0.03) independent of HIV infection and calorie intake per day (P = 0.02). Weight loss in HIV-infected individuals should be investigated for intestinal dysfunction especially in low resource settings.

Efficient Modification of the CCR5 Locus in Primary Human T Cells With megaTAL Nuclease Establishes HIV-1 Resistance.

A naturally occurring 32-base pair deletion of the HIV-1 co-receptor CCR5 has demonstrated protection against HIV infection of human CD4+ T cells. Recent genetic engineering approaches using engineered nucleases to disrupt the gene and mimic this mutation show promise for HIV therapy. We developed a megaTAL nuclease targeting the third extracellular loop of CCR5 that we delivered to primary human T cells by mRNA transfection. The CCR5 megaTAL nuclease established resistance to HIV in cell lines and disrupted the expression of CCR5 on primary human CD4+ T cells with a high efficiency, achieving up to 80% modification of the locus in primary cells as measured by molecular analysis. Gene-modified cells engrafted at levels equivalent to unmodified cells when transplanted into immunodeficient mice. Furthermore, genetically modified CD4+ cells were preferentially expanded during HIV-1 infection in vivo in an immunodeficient mouse model. Our results demonstrate the feasibility of targeting CCR5 in primary T cells using an engineered megaTAL nuclease, and the potential to use gene-modified cells to reconstitute a patient's immune system and provide protection from HIV infection.

Dobutamine Stress Echocardiography - Need for a Better Gold Standard?

INTRODUCTION: Dobutamine stress echocardiography (DSE) has come a long way as establishing itself as a feasible, safe, effective, relatively cheaper non-invasive technique to detect population suffering from coronary artery disease (CAD) and following up patients post revascuralization. Besides these DSE is commonly used to diagnose low gradient, low flow true severe aortic stenosis (AS); differentiating it from pseudo- AS and to follow up patients with dilated cardiomyopathy (DCMP). Various non-invasive techniques have different sensitivity and specificity to accurately judge a viable myocardium and to accurately detect the improvement in regional wall motion abnormality (RWMA) post-revascularization, leading to an overall increase in left ventricular ejection fraction (LVEF). The comparison of various modalities, role of DSE in intermediate coronary lesions (75%) and other important uses and controversies surrounding DSE are discussed; suggesting the incremental value of DSE as a indispensable and versatile a diagnostic technique.