Exome sequencing of extreme clopidogrel response phenotypes identifies B4GALT2 as a determinant of on-treatment platelet reactivity

Interindividual variability in platelet aggregation is common among patients treated with clopidogrel and both high on-treatment platelet reactivity (HTPR) and low on-treatment platelet reactivity (LTPR) increase risks for adverse clinical outcomes. CYP2C19 influences clopidogrel response but only accounts for ∼12% of the variability in platelet reactivity. To identify novel variants implicated in on-treatment platelet reactivity, patients with coronary artery disease (CAD) with extreme pharmacodynamic responses to clopidogrel and wild-type CYP2C19 were subjected to exome sequencing. Candidate variants that clustered in the LTPR subgroup subsequently were genotyped across the discovery cohort (n = 636). Importantly, carriers of B4GALT2 c.909C>T had lower on-treatment P2Y12 reaction units (PRUs; P = 0.0077) and residual platelet aggregation (P = 0.0008) compared with noncarriers, which remained significant after adjusting for CYP2C19 and other clinical variables in both the discovery (P = 0.0298) and replication (n = 160; PRU: P = 0.0001) cohorts. B4GALT2 is a platelet-expressed galactosyltransferase, indicating that B4GALT2 c.909C>T may influence clopidogrel sensitivity through atypical cell-surface glycoprotein processing and platelet adhesion.

Aetiology, outcomes & predictors of mortality in acute respiratory distress syndrome from a tertiary care centre in north India

BACKGROUND & OBJECTIVES

Acute respiratory distress syndrome (ARDS) is a common disorder in critically ill patients and is associated with high mortality. There is a paucity of literature on this condition from developing countries. This prospective observational study was designed to find out the aetiology, outcomes and predictors of mortality in ARDS.

METHODS

Sixty four consecutive patients who satisfied American-European Consensus Conference (AECC) definition of ARDS from medical Intensive Care Unit (ICU) of a tertiary care centre in New Delhi, India, were enrolled in the study. Demographic, biochemical and ventilatory variables were recorded for each patient. Baseline measurements of serum interleukin (IL)-1β, IL-6, tumour necrosis factor-alpha (TNF-α), procalcitonin (PCT) and high sensitivity C-reactive protein (hsCRP) were performed.

RESULTS

Common causes of ARDS included pneumonia [44/64 (68.7%)], malaria [9/64 (14.1%)] and sepsis [8/64 (12.5%]. Eight of the 64 (12.5%) patients had ARDS due to viral pneumonia. The 28-day mortality was 36/64 (56.2%).Independent predictors of mortality included non-pulmonary organ failure, [Hazard ratio (HR) 7.65; 95% CI 0.98-59.7, P=0.05], Simplified Acute Physiology Score (SAPS-II) [HR 2.36; 95% CI 1.14-4.85, P=0.02] and peak pressure (P peak ) [HR 1.13; 95% CI 1.00-1.30, P = 0.04] at admission.

INTERPRETATION & CONCLUSIONS

Bacterial and viral pneumonia, malaria and tuberculosis resulted in ARDS in a considerable number of patients. Independent predictors of mortality included non-pulmonary organ failure, SAPS II score and P peak at baseline. Elevated levels of biomarkers such as TNF-α, PCT and hsCRP at admission might help in identifying patients at a higher risk of mortality.

Chronic Tubulo-interstitial Pyelonephritis with Retroperitoneal Fibrosis

A large proportion of patients with retroperitoneal fibrosis (RPF) have been labelled as having idiopathic RPF historically. Recent reports of a subset of these patients having a fibro-inflammatory condition with characteristic histology and good response to therapy has helped in renewed understanding of an old disease. A 40 year old man presented with vague abdominal discomfort of 5 months duration. Ultrasound examination revealed soft tissue thickening with calcification over lower abdominal aorta. CT scan characterized the lesion as a retroperitoneal mass encasing the aorta with an associated lesion in upper pole of left kidney. A laparoscopic surgery and biopsy of the mass lesions were performed. It was reported as chronic tubulo-interstitial disease with retroperitoneal fibrosis. In the post-operative period, patient developed fever with weight loss. An 18F-FDG PET-CT done revealed FDG-avid retroperitoneal mass lesion. Serum IgG-4 levels were elevated and review of biopsy revealed features of IgG4 related disease. Patient had good response to treatment with steroids and azathioprine.

The Influence of Chelating Agent on the Structural and Magnetic Properties of CoFe2O4, Nanoparticles

We have studied the influence of chelating agents (glycerin and sucrose) on the structural and magnetic properties of cobalt ferrite (CoFe2O4) nanoparticles synthesized via co-precipitation method. The Rietveld refinements from X-ray diffraction patterns confirm that all samples are single phase identified in a cubic crystalline system belonging to the space group Fd-3m. Besides, we have verified that the addition of chelating agents produces a decreasing in the particles average size from 14(2) to 5(1) nm. Magnetization measurements as a function of temperature show a decrease in the blocking temperature (T(B)) to sample obtained with addition of sucrose. A superparamagnetic behavior at room temperature was observed by magnetic measurements as function of field in the sample with 0.020 mol/L of sucrose. The results show that character chelating of sucrose reduces the coalescence effect and magnetic interaction in the CoFe2O4 nanoparticles. These results suggest that sucrose could be an alternative to control the structural and magnetic properties of other oxides nanoparticles.

Pulmonary Cryptococcoma Masquerading as Lung Cancer

We report a case of pulmonary cryptococcoma, in an adult with recently detected diabetes, mimicking as lung cancer. A 45-year-old gentleman with past history of pulmonary tuberculosis presented with fever, cough with expectoration, pleuritic chest pain and hemoptysis. Chest radiograph and computed tomography revealed right lower lobe mass which significantly enhanced on contrast administration. Ultrasound guided biopsy was done which on histopathological examination showed non-necrotizing granulomas with narrow-based budding yeast cells suggestive of cryptococcosis. Detailed work-up for dissemination of infection was negative. A dramatic response to anti-fungal treatment was observed and the patient is doing fine on follow-up.

Cavitary Lung Lesions in a Difficult-To-Treat Asthma Patient

We describe an interesting case of severe asthma who was not showing satisfactory response to standard treatment. Investigations revealed him to be suffering from allergic bronchopulmonary aspergillosis (ABPA). After starting systemic steroids he showed marked improvement initially only to have recurrent symptoms within a year. He was investigated further and found to have chronic pulmonary aspergillosis in the form of chronic cavitary pulmonary aspergillosis (CCPA) and aspergilloma as also the presence of selective IgA deficiency.

Miliary tuberculosis: A new look at an old foe

Miliary tuberculosis (TB), is a fatal form of disseminated TB characterized by tiny tubercles evident on gross pathology similar to innumerable millet seeds in size and appearance. Global HIV/AIDS pandemic and increasing use of immunosuppressive drugs have altered the epidemiology of miliary TB. Keeping in mind its protean manifestations, clinicians should have a low threshold for suspecting miliary TB. Careful physical examination should focus on identifying organ system involvement early, particularly TB meningitis, as this has therapeutic significance. Fundus examination for detecting choroid tubercles can help in early diagnosis as their presence is pathognomonic of miliary TB. Imaging modalities help in recognizing the miliary pattern, define the extent of organ system involvement and facilitate image guided fine-needle aspiration cytology or biopsy from various organ sites. Sputum or BAL fluid examination, pleural, pericardial, peritoneal fluid and cerebrospinal fluid studies, fine needle aspiration cytology or biopsy of the lymph nodes, needle biopsy of the liver, bone marrow aspiration and biopsy, testing of body fluids must be carried out. GeneXpert MTB/RIF, line probe assay, mycobacterial culture and drug-susceptibility testing must be carried out as appropriate and feasible. Treatment of miliary TB should be started at the earliest as this can be life saving. Response to first-line anti-TB drugs is good. Screening and monitoring for complications like acute respiratory distress syndrome (ARDS), adverse drug reactions like drug-induced liver injury, drug-drug interactions, especially in patients co-infected with HIV/AIDS, are warranted. Sparse data are available from randomized controlled trials regarding optimum regimen and duration of anti-TB treatment.

From QTL to variety-harnessing the benefits of QTLs for drought, flood and salt tolerance in mega rice varieties of India through a multi-institutional network

Rice is a staple cereal of India cultivated in about 43.5Mha area but with relatively low average productivity. Abiotic factors like drought, flood and salinity affect rice production adversely in more than 50% of this area. Breeding rice varieties with inbuilt tolerance to these stresses offers an economically viable and sustainable option to improve rice productivity. Availability of high quality reference genome sequence of rice, knowledge of exact position of genes/QTLs governing tolerance to abiotic stresses and availability of DNA markers linked to these traits has opened up opportunities for breeders to transfer the favorable alleles into widely grown rice varieties through marker-assisted backcross breeding (MABB). A large multi-institutional project, "From QTL to variety: marker-assisted breeding of abiotic stress tolerant rice varieties with major QTLs for drought, submergence and salt tolerance" was initiated in 2010 with funding support from Department of Biotechnology, Government of India, in collaboration with International Rice Research Institute, Philippines. The main focus of this project is to improve rice productivity in the fragile ecosystems of eastern, northeastern and southern part of the country, which bear the brunt of one or the other abiotic stresses frequently. Seven consistent QTLs for grain yield under drought, namely, qDTY1.1, qDTY2.1, qDTY2.2, qDTY3.1, qDTY3.2, qDTY9.1 and qDTY12.1 are being transferred into submergence tolerant versions of three high yielding mega rice varieties, Swarna-Sub1, Samba Mahsuri-Sub1 and IR 64-Sub1. To address the problem of complete submergence due to flash floods in the major river basins, the Sub1 gene is being transferred into ten highly popular locally adapted rice varieties namely, ADT 39, ADT 46, Bahadur, HUR 105, MTU 1075, Pooja, Pratikshya, Rajendra Mahsuri, Ranjit, and Sarjoo 52. Further, to address the problem of soil salinity, Saltol, a major QTL for salt tolerance is being transferred into seven popular locally adapted rice varieties, namely, ADT 45, CR 1009, Gayatri, MTU 1010, PR 114, Pusa 44 and Sarjoo 52. Genotypic background selection is being done after BC2F2 stage using an in-house designed 50K SNP chip on a set of twenty lines for each combination, identified with phenotypic similarity in the field to the recipient parent. Near-isogenic lines with more than 90% similarity to the recipient parent are now in advanced generation field trials. These climate smart varieties are expected to improve rice productivity in the adverse ecologies and contribute to the farmer's livelihood.

Evaluation of statin prescriptions in type 2 diabetes: India Heart Watch-2

BACKGROUND

Contemporary treatment guidelines advise statin use in all patients with diabetes for reducing coronary risk. Use of statins in patients with type 2 diabetes has not been reported from India.

METHODS

We performed a multisite (n=9) registry-based study among internists (n=3), diabetologists (n=3), and endocrinologists (n=3) across India to determine prescriptions of statins in patients with type 2 diabetes. Demographic and clinical details were obtained and prescriptions were audited for various medications with a focus on statins. Details of type of statin and dosage form (low, moderate, and high) were obtained. Patients were divided into categories based on presence of cardiovascular risk into low (no risk factors, n=1506), medium (≥1 risk factor, n=5425), and high (with vascular disease, n=1769). Descriptive statistics are presented.

RESULTS

Prescription details were available in 8699 (men 5292, women 3407). Statins were prescribed in 55.2% and fibrates in 9.2%. Statin prescription was significantly greater among diabetologists (64.4%) compared with internists (n=53.3%) and endocrinologists (46.8%; p<0.001). Atorvastatin was prescribed in 74.1%, rosuvastatin in 29.2%, and others in 3.0%. Statin prescriptions were lower in women (52.1%) versus men (57.2%; p<0.001) and in patients aged <40 years (34.3%), versus those aged 40-49 (49.7%), 50-59 (60.1%), and ≥60 years (62.2%; p<0.001). Low-dose statins were prescribed in 1.9%, moderate dose in 85.4%, and high dose in 12.7%. Statin prescriptions were greater in the high-risk group (58.0%) compared with those in the medium-risk (53.8%) and low-risk (56.8%) groups (p <0.001). High-dose statin prescriptions were similar in the high-risk (14.5%), medium-risk (11.8%), and low-risk (13.5%) groups (p=0.31).

CONCLUSIONS

Statins are prescribed in only half of the clinic-based patients in India with type 2 diabetes. Prescription of high-dose statins is very low.

Phytoremediation potential of some halophytic species for soil salinity

Phytoremediation potential of six halophytic species i.e. Suaeda nudiflora, Suaeda fruticosa, Portulaca oleracea, Atriplex lentiformis, Parkinsonia aculeata and Xanthium strumarium was assessed under screen house conditions. Plants were raised at 8.0, 12.0, 16.0, and 20.0 dSm(-1) of chloride-dominated salinity. The control plants were irrigated with canal water. Sampling was done at vegetative stage (60-75 DAS). About 95 percent seed germination occurred up to 12 dSm(-1) and thereafter declined slightly. Mean plant height and dry weight plant(-1) were significantly decreased from 48.71 to 32.44 cm and from 1.73 to 0.61g plant(-1) respectively upon salinization. Na(+)/K(+) ratio (0.87 to 2.72), Na(+)/ Ca(2+) + Mg(2+) (0.48 to 1.54) and Cl(-)/SO4(2-) (0.94 to 5.04) ratio showed increasing trend. Salinity susceptibility index was found minimum in Suaeda fruticosa (0.72) and maximum in Parkinsonia aculeata (1.17). Total ionic content also declined and magnitude of decline varied from 8.51 to 18.91% at 8 dSm(-1) and 1.85 to 7.12% at 20 dSm(-1) of salinity. On the basis of phytoremediation potential Suaeda fruticosa (1170.02 mg plant(-1)), Atriplex lentiformis (777.87 mg plant(-1)) were the best salt hyperaccumulator plants whereas Xanthium strumarium (349.61 mg plant(-1)) and Parkinsonia aculeata (310.59 mg plant(-1)) were the least hyperaccumulator plants.

Chicken sperm transcriptome profiling by microarray analysis

It has been confirmed that mammalian sperm contain thousands of functional RNAs, and some of them have vital roles in fertilization and early embryonic development. Therefore, we attempted to characterize transcriptome of the sperm of fertile chickens using microarray analysis. Spermatozoal RNA was pooled from 10 fertile males and used for RNA preparation. Prior to performing the microarray, RNA quality was assessed using a bioanalyzer, and gDNA and somatic cell RNA contamination was assessed by CD4 and PTPRC gene amplification. The chicken sperm transcriptome was cross-examined by analysing sperm and testes RNA on a 4 × 44K chicken array, and results were verified by RT-PCR. Microarray analysis identified 21,639 predominantly nuclear-encoded transcripts in chicken sperm. The majority (66.55%) of the sperm transcripts were shared with the testes, while surprisingly, 33.45% transcripts were detected (raw signal intensity greater than 50) only in the sperm and not in the testes. The greatest proportion of up-regulated transcripts were responsible for signal transduction (63.20%) followed by embryonic development (56.76%) and cell structure (56.25%). Of the 20 most abundant transcripts, 18 remain uncharacterized, whereas the least abundant genes were mostly associated with the ribosome. These findings lay a foundation for more detailed investigations on sperm RNAs in chickens to identify sperm-based biomarkers for fertility.

Assessment of premature atherosclerosis in systemic lupus erythematosus patients with and without nephritis

BACKGROUND

Risk of subclinical atherosclerosis is increased in patients with systemic lupus erythematosus (SLE). We correlated carotid intima media thickness (CIMT) and endothelial dysfunction through flow-mediated dilation (FMD) in SLE patients with the SLE Disease Activity Index (SLEDAI).

METHODS

This single-centre cross-sectional study recruited 100 consenting SLE outpatients (ACR 1997 criteria) out of which 50 had nephritis, with disease duration of ≥2 years for SLE and ≥6 months for lupus nephritis. We measured baseline laboratory levels, CIMT and FMD (after brachial BP cuff inflation up to 200 mmHg for five minutes), and calculated SLEDAI.

RESULTS

Mean age was 29.88 ± 6.53 years; 95/100 were female. CIMT showed positive correlation (p = 0.037; rho = 0.209), and FMD showed inverse correlation with patient's age (p = 0.011; rho = -0.252). CIMT and FMD were more deranged in patients aged ≥25 years (p < 0.05). CIMT was not significantly different between SLE patients with and without nephritis (p > 0.05), whereas SLEDAI and FMD were more deranged in nephritis patients (p < 0.05). In patients without nephritis, FMD showed significant inverse correlation with disease duration (p = 0.043; rho = -0.288) and urine albumin (p = 0.045; rho = -0.285). In nephritis patients, the correlation between age of the patient was significantly positive with CIMT (p = 0.001; rho = 0.441) and significantly inverse with FMD (p = 0.028; rho = -0.312).

CONCLUSION

SLE patients with nephritis are at a higher risk to develop arterial stiffening, leading to early end-organ damage. Early aggressive treatment may prevent endothelial dysfunction. FMD using vascular ultrasonography on the brachial artery represents a non-invasive, repeatable and useful method for the assessment of endothelial dysfunction.

APOBEC3H polymorphisms and susceptibility to HIV-1 infection in an Indian population

Human APOBEC3H (A3H) is a member of APOBEC cytidine deaminase family intensively constraining the HIV-1 replication. A3H is known to be polymorphic with different protein stability and anti-HIV-1 activity in vitro. We recently reported that A3H haplotypes composed of two functional polymorphisms, rs139292 (N15del) and rs139297 (G105R), were associated with the susceptibility to HIV-1 infection in Japanese. To confirm the association of A3H and HIV-1 infection in another ethnic group, a total of 241 HIV-1-infected Indian individuals and ethnic-matched 286 healthy controls were analyzed for the A3H polymorphisms. The frequency of 15del allele was high in the HIV-1-infected subjects as compared with the controls (0.477 vs 0.402, odds ratio (OR)=1.36, P=0.014). Haplotype analysis showed that the frequencies of 15del-105R was high (0.475 vs 0.400, OR=1.36, permutation P=0.037) in the HIV-1-infected subjects, confirming the association of A3H polymorphisms with the susceptibility to HIV-1 infection.

Variation of Stable Carbon and Nitrogen Isotopic Composition of PM10 at Urban Sites of Indo Gangetic Plain (IGP) of India

This paper presents the variation of elemental concentrations of total carbon (TC), total nitrogen (TN) and isotopic ratios of δ13C and δ15N along with δ13OC and OC of PM10 mass over Delhi, Varanasi and Kolkata of the Indo Gangetic Plain (IGP), India. For Delhi, the average concentrations of TC and TN of PM10 were 53.0±33.6 and 14.9±10.8 µg m(-3), whereas δ13C and δ15N of PM10 were -25.5±0.5 and 9.6±2.8‰, respectively. For Varanasi, the average values of δ13C and δ15N of PM10 were -25.4±0.8 and 6.8±2.4‰, respectively. For Kolkata, TC and TN values for PM10 ranged from 9.1-98.2 to 1.4-25.9 µg m(-3), respectively with average values of 32.6±24.9 and 9.3±8.2 µg m(-3), respectively. The average concentrations of δ13C and δ15N were -26.0±0.4 and 7.4±2.7‰, respectively over Kolkata with ranges of -26.6 to -24.9‰ and 2.8±11.5‰, respectively. The isotopic analysis revealed that biomass burning, vehicular emission and secondary inorganic aerosols were likely sources of PM10 mass over IGP, India.

Prevalence and severity of asthma among Indian school children aged between 6 and 14 years: associations with parental smoking and traffic pollution

OBJECTIVE

Phase three of the International Study of Asthma and Allergy in Children (ISAAC) was carried out at various sites in India. The prevalence of asthma symptoms in school children and the effect of environmental tobacco smoke and traffic pollution on the occurrence of asthma were analysed.

METHODS

Two groups of school children, aged 6-7 yr and 13-14 yr, participated according to the ISAAC protocol. Schools were randomly selected and responses to the ISAAC questionnaire were recorded.

RESULTS

The prevalence of asthma was 5.35% in the 6-7 yr age group and 6.05% in the 13-14 yr age group. The odds ratios (ORs) for the risk of asthma in children with exposure to mild, moderate and heavy traffic pollution compared with minimal traffic pollution were 1.63 (95% CI: 1.43, 1.85), 1.71 (95% CI: 1.49, 1.96) and 1.53 (95% CI: 1.31, 1.78), respectively, in the younger group. Similarly, in the older group, they were 1.19 (95% CI: 1.04, 1.36), 1.51 (95% CI: 1.31, 1.75) and 1.51 (95% CI: 1.29, 1.76). Asthma was associated with maternal smoking [6-7 yr group: OR = 2.72 (2.05, 3.6); 13-14 yr group: OR = 2.14 (1.72, 2.66)] and paternal smoking [6-7 yr group: OR = 1.9 (1.70, 2.11); 13-14 yr group: OR = 1.21 (1.09, 1.34)].

CONCLUSIONS

The prevalence of asthma was lower in the 6-7 than the 13-14 yr age group. Environmental tobacco smoke and traffic pollution were the factors most strongly associated with asthma in Indian children.

Evaluating the Diagnostic Accuracy of Xpert MTB/RIF Assay in Pulmonary Tuberculosis

Pulmonary tuberculosis still remains a major communicable disease worldwide. In 2013, 9 million people developed TB and 1.5 million people died from the disease. India constitutes 24% of the total TB burden. Early detection of TB cases is the key to successful treatment and reduction of disease transmission. Xpert MTB/RIF, an automated cartridge-based molecular technique detects Mycobacterium tuberculosis and rifampicin resistance within two hours has been endorsed by WHO for rapid diagnosis of TB. Our study is the first study from India with a large sample size to evaluate the performance of Xpert MTB/RIF assay in PTB samples. The test showed an overall sensitivity and specificity of 95.7% (430/449) and 99.3% (984/990) respectively. In smear negative-culture positive cases, the test had a sensitivity of 77.7%. The sensitivity and specificity for detecting rifampicin resistance was 94.5% and 97.7% respectively with respect to culture as reference standard. However, after resolving the discrepant samples with gene sequencing, the sensitivity and specificity rose to 99.0% and 99.3% respectively. Hence, while solid culture still forms the foundation of TB diagnosis, Xpert MTB/RIF proposes to be a strong first line diagnostic tool for pulmonary TB cases.

Post-treatment and reuse of secondary effluents using natural ltreatment systems: the Indian practices

Paper summarizes the results of India-wide survey of natural treatment systems (NTSs) for wastewater treatment and reuse. The quality of treated wastewater from different types of NTSs was analyzed for various physico-chemical and bacteriological parameters, and needs for post-treatment were identified. Currently, about 1838 million liters per day (MLD) of wastewater is being treated using NTSs, of which the contributions of polishing ponds, waste stabilization ponds, duckweed ponds, constructed wetlands, and Karnal technology were found to be 53.39, 45.15, 0.13, 0.55, and 0.78%, respectively. Among the NTSs studied, constructed wetland was found most efficient in removal of pollutants including nitrogen, phosphorus, total coliform, and fecal coliform in the range of 76, 61, 99.956, and 99.923%, respectively. Of all types of NTSs, only constructed wetland was found to meet the total coliform count requirements (<1000 per 100 ml). Of all the 108 NTSs in operation, 23 systems are producing treated effluents for irrigation; effluents from 48 systems are being discharged into river or lake, and remaining 38 systems have not found any designated use of treated effluent. The chlorination was the only post-treatment, which is being practiced at only three wastewater treatment facilities. During post-treatment, 1-2 ppm of chlorine is applied to the secondary effluent irrespective of its quality. The treated effluents from different NTSs contain fecal bacteria in the magnitude of 10(3) to 10(5), which may cause the severe health impacts through contamination of groundwater as well as surface water resources.

Modified PISAPED Criteria in Combination with Ventilation Scintigraphic Finding for Predicting Acute Pulmonary Embolism

This prospective clinical study aimed at assessing three pulmonary scintigraphic algorithms to detect acute pulmonary embolism (PE): Lung ventilation/perfusion (V/Q) scintigraphy along with modified prospective investigation of pulmonary embolism diagnosis (PIOPED) criteria; lung perfusion scintigraphy along with prospective investigative study of acute pulmonary embolism diagnosis (PISAPED) criteria; and lung perfusion scan in combination with ventilation scan, along with modified PISAPED criteria, which were newly developed. Patients with suspicion of PE were eligible for this study if they had no abnormal chest x-ray. Their diagnostic workup included a clinical assessment, a pulmonary V/Q scintigraphy, and CT pulmonary angiography (CTPA), as well as a clinical outcome assessment over a period of 24 weeks. Referred to the final clinical diagnosis of patients, the sensitivity and specificity of each algorithm were evaluated. The diagnostic performance of each algorithm by the area under the maximum likelihood fitted receiver operating characteristic (ROC) curve was determined. With respect to the PISAPED criteria, the sensitivity was 60.8% and specificity was 87.3%. No patient was classified into nondiagnostic category. The PIOPED criteria showed that the sensitivity was 95.0% and specificity was 88.2%, while 57.4% of the patients were in nondiagnostic category. The areas under the ROC curve constructed from the PISAPED criteria results and the modified PIOPED criteria results were 0.734 and 0.859 (P < 0.01), respectively. The modified PISAPED criteria demonstrated that the sensitivity was 83.8% and specificity was 89.1%. No patient was classified into nondiagnostic category. The area under the ROC curve constructed from modified PISAPED criteria was 0.864 (P < 0.01). Perfusion scans used with ventilation scans and modified PISAPED criteria may increase the diagnostic accuracy of pulmonary scintigraphy for acute PE, compared with the two major algorithms.

Laryngeal Leishmaniasis with Extra-pulmonary Tuberculosis

Clinical presentations of Leishmania infection include visceral (most common form), cutaneous, mucocutaneous, mucosal and post-kala-azar dermal leishmaniasis. Mucosal form of leishmaniasis mostly involves oral and nasal mucosa. Rarely, laryngeal and pharyngeal mucosa may also be involved. Its concomitant presence with tuberculosis (TB), a disease rampant in India, is uncommon. Here we are reporting a case of isolated laryngeal leishmaniasis associated with extra-pulmonary tuberculosis (EPTB), with approach to diagnosis and treatment in a tropical resource-limited setting.

Intermittent Directly Observed Therapy for Abdominal Tuberculosis: A Multicenter Randomized Controlled Trial Comparing 6 Months Versus 9 Months of Therapy

BACKGROUND

The duration of treatment of gastrointestinal tuberculosis continues to be a matter of debate. The World Health Organization advocates intermittent directly observed short-course therapy (DOTs), but there is a lack of data of its efficacy in abdominal tuberculosis. We therefore conducted a multicenter randomized controlled trial to compare 6 months and 9 months of antituberculosis therapy using DOTs.

METHODS

One hundred ninety-seven patients with abdominal tuberculosis (gastrointestinal, 154; peritoneal, 40; mixed, 3) were randomized to receive 6 months (n = 104) or 9 months (n = 93) of antituberculosis therapy using intermittent directly observed therapy. Patients were followed up 1 year after completion of treatment to assess recurrence. Patients were evaluated for primary endpoint (complete clinical response, partial response, and no response) and secondary endpoint (recurrence of the disease at the end of 1 year of follow-up).

RESULTS

Baseline characteristics were similar between the 2 randomized groups. There was no difference between the 6-month group and 9-month group in the complete clinical response rate on per-protocol analysis (91.5% vs 90.8%; P = .88) or intent-to-treat analysis (75% vs 75.8%; P = .89). Only 1 patient in the 9-month group and no patients in the 6-month group had recurrence of disease. Side effects occurred in 21 (21.3%) and 16 (18.2%) patients in the 6-month and 9-month groups, respectively.

CONCLUSIONS

There was no difference in efficacy of antituberculosis therapy delivered for either 6 months or 9 months in either gastrointestinal or peritoneal tuberculosis, confirming the efficacy of intermittent directly observed therapy.

CLINICAL TRIALS REGISTRATION

NCT01124929.

Consensus and evidence-based Indian initiative on obstructive sleep apnea guidelines 2014 (first edition)

Obstructive sleep apnea (OSA) and obstructive sleep apnea syndrome (OSAS) are subsets of sleep-disordered breathing. Awareness about OSA and its consequences among the general public as well as the majority of primary care physicians across India is poor. This necessitated the development of the Indian initiative on obstructive sleep apnea (INOSA) guidelines under the auspices of Department of Health Research, Ministry of Health and Family Welfare, Government of India. OSA is the occurrence of an average five or more episodes of obstructive respiratory events per hour of sleep with either sleep-related symptoms or co-morbidities or ≥15 such episodes without any sleep-related symptoms or co-morbidities. OSAS is defined as OSA associated with daytime symptoms, most often excessive sleepiness. Patients undergoing routine health check-up with snoring, daytime sleepiness, obesity, hypertension, motor vehicular accidents, and high-risk cases should undergo a comprehensive sleep evaluation. Medical examiners evaluating drivers, air pilots, railway drivers, and heavy machinery workers should be educated about OSA and should comprehensively evaluate applicants for OSA. Those suspected to have OSA on comprehensive sleep evaluation should be referred for a sleep study. Supervised overnight polysomnography is the “gold standard” for evaluation of OSA. Positive airway pressure (PAP) therapy is the mainstay of treatment of OSA. Oral appliances (OA) are indicated for use in patients with mild to moderate OSA who prefer OA to PAP, or who do not respond to PAP or who fail treatment attempts with PAP or behavioral measures. Surgical treatment is recommended in patients who have failed or are intolerant to PAP therapy.