Effect of delamanid on interim outcomes of bacteriological conversion amongst pediatric drug resistant tuberculosis cases in India

AIM

To determine the bacteriological conversion rate after 6 months of Delamanid (DLM) based treatment in children with drug-resistant tuberculosis (DR-TB) and determine factors associated with bacteriological conversion.

METHODS

This is a descriptive retrospective study done in children between the age of 6-17 years with DR-TB who received DLM-based therapy from October 2018 to May 2021. The drug resistance pattern of TB was detected using Xpert RIF/MTB and phenotypic drug sensitivity testing (DST) on TB-MGIT culture reports. Follow-up sputum TB MGIT culture was carried out monthly after DLM initiation for 6 months. Factors associated with sputum bacteriological conversion such as age, gender, pulmonary TB (PTB) versus disseminated TB, unilateral or bilateral lung involvement, type of DR-TB, prior treatment failure, and type of DR-TB regimen were analyzed.

RESULTS

Sixty patients received DLM of which two had extrapulmonary TB (EPTB) and sputum conversion could not be assessed. The mean age at presentation was 12.69 ± 3.03 years. Five patients (8.3%) died while on DLM treatment. On follow-up, 8 (13.7%) out of 58 patients had no sputum bacteriological conversion after 6 months of DLM initiation of which three patients were on salvage therapy; 46 (79.3%) had sputum bacteriological conversion within 6 months of DLM initiation.

CONCLUSION

Sputum bacteriological conversion rate was almost 80% at the end of 6 months of DLM-based treatment.

Live-cell three-dimensional single-molecule tracking reveals modulation of enhancer dynamics by NuRD

To understand how the nucleosome remodeling and deacetylase (NuRD) complex regulates enhancers and enhancer-promoter interactions, we have developed an approach to segment and extract key biophysical parameters from live-cell three-dimensional single-molecule trajectories. Unexpectedly, this has revealed that NuRD binds to chromatin for minutes, decompacts chromatin structure and increases enhancer dynamics. We also uncovered a rare fast-diffusing state of enhancers and found that NuRD restricts the time spent in this state. Hi-C and Cut&Run experiments revealed that NuRD modulates enhancer-promoter interactions in active chromatin, allowing them to contact each other over longer distances. Furthermore, NuRD leads to a marked redistribution of CTCF and, in particular, cohesin. We propose that NuRD promotes a decondensed chromatin environment, where enhancers and promoters can contact each other over longer distances, and where the resetting of enhancer-promoter interactions brought about by the fast decondensed chromatin motions is reduced, leading to more stable, long-lived enhancer-promoter relationships.

Hepatoprotective activity of Balsamodendron mukul extract against Paracetamol-induced liver toxicity in rats: In vivo pharmacological and toxicological evaluation

Overuse of the antipyretic agent Paracetamol (PCM) is linked to hepatotoxicity, which limits its clinical use. The goal of this investigation was to find out how well Balsamodendron mukul (B. mukul) extract protects the liver from acute PCM poisoning. B. mukul extract was procured from a standard crude drug supplier in the local market. The PCM-induced hepatotoxicity was screened in experimental animals. Animals that were treated only with excessive PCM (2g/kg) had changes in their serum biomarkers (i.e., serum glutamate oxaloacetate transaminase, serum glutamate pyruvate transaminase, alkaline phosphatase, and serum total bilirubin), oxidative stress, Tumor Necrosis Factor-α (TNF-α), and Interleukin-1 proteins. B. mukul extracts of 245μg and 332μg revealed 50% of hydroxyl radical scavenging and lipid peroxidation inhibiting, respectively, which was found to be more significant when compared to ascorbic acid treatment. The outcomes confirmed that B. mukul extract has strong antioxidant activity, which leads to the inhibition of reactive oxygen species (ROS). Treatment with B. mukul extract at doses of 300 and 600mg/kg produced a dose-dependent reduction in the PCM-induced rise of the biochemical parameters. Silymarin at 100mg/kg body weight significantly prevented such rise in the study. Finally, the findings confirmed that the B. mukul extract has more potent than silymarin and revealed higher antioxidant and hepatoprotective activity, which could consider a novel approach for the reduction of PCM-induced liver toxicity.

Simultaneous screening for COVID-19 and tuberculosis, India

Objective

To evaluate the implementation of new operational workflows for simultaneous screening of coronavirus disease 2019 (COVID-19) and tuberculosis at four high-volume COVID-19 testing centres located in tertiary hospitals in Mumbai, India.

Methods

Each centre already offering antigen-detecting rapid diagnostic tests were equipped with a rapid molecular testing platform for COVID-19 and tuberculosis, sufficient laboratory staff, and reagents and consumables for screening. Using a verbal tuberculosis questionnaire, a patient follow-up agent screened individuals visiting the COVID-19 testing centres. Presumptive tuberculosis patients were asked to provide sputum samples for rapid molecular testing. Subsequently, we reversed our operational workflow to also screen patients visiting tuberculosis outpatient departments for COVID-19, using rapid diagnostic tests.

Results

From March to December 2021, we screened 14 588 presumptive COVID-19 patients for tuberculosis, of whom 475 (3.3%) were identified as having presumptive tuberculosis. Of these, 288 (60.6%) were tested and 32 individuals (11.1%) were identified as tuberculosis positive (219 cases per 100 000 individuals screened). Of the tuberculosis-positive individuals, three had rifampicin-resistant tuberculosis. Among the remaining 187 presumptive tuberculosis cases not tested, 174 reported no symptoms at follow-up and 13 individuals either refused testing or could not be traced. Of the 671 presumptive tuberculosis cases screened for COVID-19, 17 (2.5%) were positive by antigen rapid diagnostic tests, and five (0.7%) who tested negative, later tested positive on the molecular testing platform (2483 COVID-19 cases per 100 000 individuals screened).

Conclusion

Simultaneous screening for COVID-19 and tuberculosis in India is operationally feasible and can improve real-time on-site detection of COVID-19 and tuberculosis.

Ethnicity in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the commonest gynecological endocrinopathy. Little is known about the exact etiopathogenesis and cardiometabolic mortality and morbidity in women with PCOS. PCOS is beyond the cosmetic concerns of an adolescent and fertility concerns of an adult and can cause serious unhealthy consequences in perimenopausal and postmenopausal age. This area needs to be assessed and addressed since the majority of these patients are lost to follow-up after completion of their families. Good evidence suggests that there are significant racial and ethnic differences in prevalence, insulin resistance, metabolic syndrome, hyperandrogenemia and the related cardiometabolic risk in women with PCOS.

Tuberculosis diagnosis and management in the public versus private sector: a standardised patients study in Mumbai, India

BACKGROUND

There are few rigorous studies comparing quality of tuberculosis (TB) care in public versus private sectors.

METHODS

We used standardised patients (SPs) to measure technical quality and patient experience in a sample of private and public facilities in Mumbai.

RESULTS

SPs presented a 'classic, suspected TB' scenario and a 'recurrence or drug-resistance' scenario. In the private sector, SPs completed 643 interactions. In the public sector, 164 interactions. Outcomes included indicators of correct management, medication use and client experience. Public providers used microbiological testing (typically, microscopy) more frequently, in 123 of 164 (75%; 95% CI 68% to 81%) vs 223 of 644 interactions (35%; 95% CI 31% to 38%) in the private sector. Private providers were more likely to order chest X-rays, in 556 of 639 interactions (86%; 95% CI 84% to 89%). According to national TB guidelines, we found higher proportions of correct management in the public sector (75% vs 35%; (adjusted) difference 35 percentage points (pp); 95% CI 25 to 46). If X-rays were considered acceptable for the first case but drug-susceptibility testing was required for the second case, the private sector correctly managed a slightly higher proportion of interactions (67% vs 51%; adjusted difference 16 pp; 95% CI 7 to 25). Broad-spectrum antibiotics were used in 76% (95% CI 66% to 84%) of the interactions in public hospitals, and 61% (95% CI 58% to 65%) in private facilities. Costs in the private clinics averaged rupees INR 512 (95% CI 485 to 539); public facilities charged INR 10. Private providers spent more time with patients (4.4 min vs 2.4 min; adjusted difference 2.0 min; 95% CI 1.2 to 2.9) and asked a greater share of relevant questions (29% vs 43%; adjusted difference 13.7 pp; 95% CI 8.2 to 19.3).

CONCLUSIONS

While the public providers did a better job of adhering to national TB guidelines (especially microbiological testing) and offered less expensive care, private sector providers did better on client experience.

Impact of COVID-19 vaccination on transmission risk of breakthrough infections: Lessons from adapted N95 mask sampling for emerging variants and interventions

This study used an adapted N95 mask sampling to understand the effect of COVID-19 vaccination in the context of circulating variants on infected individuals to emit the virus into the air, a key risk factor of transmission. Mask, swab, and blood samples were collected from 92 COVID-19 patients vaccinated (Covishield/COVAXIN-partial/fully) or unvaccinated between July and September 2021 during the Delta-dominated period in Mumbai. Mask/swab samples were analyzed by reverse transcription polymerase chain reaction for viral RNA. Blood was evaluated for SARS-CoV-2 anti-spike and nucleocapsid antibody responses. At <48 h of diagnosis, 93% of the patients emitted detectable viral RNA, with 40% emitting >1000 copies in 30 min (high emitters). About 8% continued to be high emitters even after 8 days of symptom onset. No significant difference was observed in emission patterns between partial, full, and unvaccinated patients. However, when vaccinated patients were stratified based on spike protein neutralization and nucleocapsid immunoglobulin G (IgG), the group with moderate/high neutralization showed a significantly lower proportion of high emitters and viral RNA copies than the group with no/low neutralization, which further reduced in the group having antinucleocapsid IgG. In conclusion, mask sampling showed that Delta infections were associated with greater virus emission in patients, which was significantly reduced only in vaccinated patients with moderate/high SARS-CoV-2 neutralization, especially with evidence of past infection. The study demonstrated that mask sampling could be useful for understanding the transmission risk of emerging variants, screening vaccine/booster candidates, and guiding control interventions.

Case-control study of vitamin D status and adult multidrug-resistant pulmonary TB

BACKGROUND: India has the highest prevalence of multidrug-resistant TB (MDR-TB) globally. Vitamin D deficiency is potentially an important risk factor for MDR-TB.METHODS: We conducted a case-control study of 90 newly diagnosed adult MDR-TB cases, 180 household controls and 82 non-household controls in Mumbai, India. Serum 25-hydroxyvitamin D (25(OH)D), anthropometry, clinical status and history, dietary data and sociodemographic data were collected from each participant. Interferon-gamma release assay (IGRA) was also performed in controls to assess latent TB. Multivariable regression was performed to estimate associations between 25(OH)D vs. case status and IGRA positivity.RESULTS: Mean participant age was 33.8 ± 12.0 years; 72.8% had 25(OH)D <20 ng/ml. Mean 25(OH)D was significantly (P < 0.05) lower in cases (12.5 ± 7.9) than both household (17.5 ± 11.2) and non-household controls (16.4 ± 9.1). In multivariable models, 25(OH)D concentration was inversely associated with MDR-TB case status among cases and household controls (OR 0.95 per 1 ng/ml, 95% CI 0.92-0.99; P = 0.015), and among cases and non-household controls (OR 0.94 per 1 ng/ml, 95% CI 0.89-1.00; P = 0.033); 53.6% of controls were IGRA-positive. 25(OH)D status was not associated with IGRA positivity.CONCLUSION: Vitamin D status was independently associated with MDR-TB case status. Research should evaluate the effectiveness of vitamin D supplementation in prevention and adjunctive treatment of MDR-TB.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Genomics of Post-Vaccination SARS-CoV-2 Infections During the Delta Dominated Second Wave of COVID-19 Pandemic, from Mumbai Metropolitan Region (MMR), India

The present study was initiated to understand the proportion of predominant variants of SARS-CoV-2 in post-vaccination infections during the Delta dominated second wave of COVID-19 in the Mumbai Metropolitan Region (MMR) in India and to understand any mutations selected in the post-vaccination infections or showing association with any patient demographics. Samples were collected (n=166) from severe/moderate/mild COVID-19 patients who were either vaccinated (COVISHIELD/COVAXIN - partial/fully vaccinated) or unvaccinated, from a city hospital and from home isolation patients in MMR. A total of 150 viral genomes were sequenced by Oxford Nanopore sequencing and the data of 136 viral genomes were analyzed for clade/lineage and for identifying mutations. The sequences belonged to three clades (21A, 21I and 21J) and their lineage was identified as either Delta (B.1.617.2) or Delta+ (B.1.617.2 + K417N) or sub-lineages of Delta variant (AY.120/AY.38/AY.99). A total of 620 mutations were identified of which 10 mutations showed an increase in trend with time (May-Oct 2021). Associations of 6 mutations (2 in spike, 3 in orf1a and 1 in nucleocapsid) were shown with milder forms of the disease and one mutation (in orf1a) with partial vaccination status. The results indicate a trend towards reduction in disease severity as the wave progressed. This article is protected by copyright. All rights reserved.

Feasibility of a "Salvage Regimen" Using Home-based Intravenous Meropenem Therapy With a Delamanid/Bedaquilline Containing Regimen in the Management of MDR/XDR Pediatric Tuberculosis

INTRODUCTION

The prevalence of multidrug resistant (MDR) tuberculosis (TB) with additional resistance to fluoroquinolones or second-line injectables (MDRFQ/SLI)/extensively drug-resistant TB (XDR-TB) in children is high in Mumbai. There are limited therapeutic options available in management of such children. Carbapenems, although approved for this indication, requires 2 to 3 daily injections, which are cumbersome. Bedaquilline (Bdq) and Delamanid (Dlm), the new antitubercular drugs still remain inaccessible to this subset of patients caused by conditional approvals. Hence, newer strategies to combat MDRFQ/SLI/XDR-TB needs to be explored.

OBJECTIVES

To study feasibility and interim outcomes of a "salvage regimen" using home-based carbapenem therapy through peripherally inserted central catheter as part of a longer (18-20 months) optimized background regimen including Dlm or Bdq or both in pediatric MDRFQ/SLI/XDR-TB patients who failed a standard MDR-TB regimen under the National Tuberculosis Elimination Programme in Mumbai, India.

DESIGN AND METHODS

Retrospective descriptive analysis study. National Tuberculosis Elimination Programme medical records of all MDRFQ/SLI/XDR-TB patients enrolled at the pediatric TB clinic at BJ Wadia Hospital for Children, Mumbai who were initiated on such "salvage regimen" during the period between April 2018 and December 2020 were retrospectively studied. Treatment outcomes and adverse events were described.

RESULTS

Of the 15 patients enrolled, mean age of the patient population was 12.53 ± 2.47 years and the female:male ratio was 13:2. Seven patients had XDR-TB while 8 patients had MDRFQ/SLI. Most common adverse event noted was dyselectrolytemia (3 patients). Catheter-related complications were reported in 5 patients and included catheter blockage, leak, and thrombosis. Sputum culture conversion was reported in all of the patients. One child mortality was reported and 2 patients were lost to follow up during study period.

CONCLUSIONS

Home-based meropenem therapy using peripherally inserted central catheter is feasible with few adverse effects. This can be a promising strategy in the management of MDRFQ/SLI/XDR-TB when an effective oral regimen cannot be otherwise constituted and needs to be explored further.

COVID-19 Serological Survey-3 Prior to Second Wave in Mumbai, India

Background:

Subsequent to serosurveys 1 and 2 for COVID-19 carried out in three wards of Mumbai in July and August 2020, Municipal Corporation of Greater Mumbai conducted serosurvey 3 in March 2021. This was to identify the extent of exposure by testing specific IgG antibodies against COVID-19.

Material and Methods:

A cross-sectional study was conducted to find the prevalence of seropositivity in Mumbai, which included 10,197 samples belonging to patients visiting public dispensaries (slum population, 6006) and private (nonslum population, 4191) laboratories of Aapli Chikitsa network for blood investigations for non-COVID illnesses. The ward-wise number of unlinked anonymous samples from 24 wards was predecided by using probability proportionate sampling. The samples were collected using quota sampling technique as per predecided sample for each ward. These samples collected from nonimmunized individuals were tested for IgG antibodies at the Molecular Biology Laboratory of Kasturba Hospital for Infectious Diseases by chemiluminescence assay (CLIA) method.

Results:

The overall seropositivity was found to be 36.3% (41.6% in slum and 28.59% in nonslum population). It was more in city wards (38.28%) followed by western suburb (36.47%) and then eastern suburb wards (34.86%), matching with the proportion of cases in these wards during the study period. There was no significant difference in seropositivity among males and females and in different age groups.

Conclusions:

Seropositivity is higher in slum areas than nonslum areas. It has reduced in slum areas and increased in nonslum areas as compared to findings of serosurveys 1 and 2. This explains the detection of a greater number of cases from nonslum areas in the second wave. The average seropositivity of 36.3% justifies the necessity of immunization on a wider scale in the city. Periodic serosurveys are required at fixed intervals to monitor the trend of infection and level of herd immunity.

TB case fatality and recurrence in a private sector cohort in Mumbai, India

BACKGROUND: Half of India´s three million TB patients are treated in the largely unregulated private sector, where quality of care is often poor. Private provider interface agencies (PPIAs) seek to improve private sector quality of care, which can be measured in terms of case fatality and recurrence rates.METHODS: We conducted a retrospective cohort survey of 4,000 private sector patients managed by the PATH PPIA between 2014 and 2017. We estimated treatment and post-treatment case-fatality ratios (CFRs) and recurrence rates. We used Cox proportional hazards models to identify predictors of fatality and recurrence. Patient loss to follow-up was adjusted for using selection weighting.RESULTS: The treatment CFR was 7.1% (95% CI 6.0-8.2). At 24 months post-treatment, the CFR was 2.4% (95% CI 1.7-3.0) and the recurrence rate was 1.9% (95% CI 1.3-2.5). Treatment fatality was associated with age (HR 1.02, 95% CI 1.02-1.03), clinical diagnosis (HR 0.61, 95% CI 0.45-0.84), treatment duration (HR 0.09, 95% CI 0.06-0.10) and adherence. Post-treatment fatality was associated with treatment duration (HR 0.87, 95% CI 0.79-0.91) and adherence.CONCLUSIONS: We found a moderate treatment phase CFR among PPIA-managed private sector patient with low rates of post-treatment fatality and recurrence. Routine monitoring of patient outcomes after treatment would strengthen PPIAs and inform future post TB interventions.

Evaluation of the Accuracy of 99DOTS, a Novel Cellphone-based Strategy for Monitoring Adherence to Tuberculosis Medications: Comparison of DigitalAdherence Data With Urine Isoniazid Testing

99DOTS is a cellphone-based strategy for monitoring tuberculosis medication adherence. In a sample of 597 Indian patients with tuberculosis, we compared 99DOTS' adherence assessments against results of urine isoniazid tests collected during unannounced home visits. 99DOTS had suboptimal accuracy for measuring adherence, partly due to poor patient engagement with 99DOTS.

Treatment outcomes of children and adolescents receiving drug-resistant TB treatment in a routine TB programme, Mumbai, India

Background

Childhood and adolescent drug-resistant TB (DR-TB) is one of the neglected infectious diseases. Limited evidence exists around programmatic outcomes of children and adolescents receiving DR-TB treatment. The study aimed to determine the final treatment outcomes, culture conversion rates and factors associated with unsuccessful treatment outcome in children and adolescents with DR-TB.

Methods

This is a descriptive study including children (0–9 years) and adolescents (10–19 years) with DR-TB were who were initiated on ambulatory based treatment between January 2017-June 2018 in Shatabdi hospital, Mumbai, India where National TB elimination programme(NTEP) Mumbai collaborates with chest physicians and Médecins Sans Frontières(MSF) in providing comprehensive care to DR-TB patients. The patients with available end-of-treatment outcomes were included. The data was censored on February 2020.

Result

A total of 268 patients were included; 16 (6%) of them were children (0–9 years). The median(min-max) age was 17(4–19) years and 192 (72%) were females. Majority (199, 74%) had pulmonary TB. Most (58%) had MDR-TB while 42% had fluoroquinolone-resistant TB. The median(IQR) duration of treatment (n = 239) was 24(10–25) months. Median(IQR) time for culture-conversion (n = 128) was 3(3–4) months. Of 268 patients, 166(62%) had successful end-of-treatment outcomes (cured-112; completed treatment-54). Children below 10 years had higher proportion of successful treatment outcomes (94% versus 60%) compared to adolescents. Patients with undernutrition [adjusted odds-ratio, aOR (95% Confidence Interval, 95%CI): 2.5 (1.3–4.8) or those with XDR-TB [aOR (95% CI): 4.3 (1.3–13.8)] had higher likelihood of having unsuccessful DR-TB treatment outcome.

Conclusion

High proportion of successful treatment outcome was reported, better than global reports. Further, the nutritional support and routine treatment follow up should be strengthened. All oral short and long regimens including systematic use of new TB drugs (Bedaquiline and Delamanid) should be rapidly scaled up in routine TB programme, especially for the paediatric and adolescent population.

COVID-19 pandemic and its positive impacts on environment: an updated review

In December, 2019 in Wuhan city of China, a novel coronavirus (SARS-CoV-2) has garnered global attention due to its rapid transmission. World Health Organization (WHO) termed the infection as Coronavirus Disease 2019 (COVID-19) after phylogenic studies with SARS-CoV. The virus causes severe respiratory infections with dry cough, high fever, body ache and fatigue. The virus is primarily transmitted among people through respiratory droplets from COVID-19 infected person. WHO declared this COVID-19 outbreak a pandemic and since February, 2020 affected countries have locked down their cities, industries and restricted the movement of their citizens to minimize the spread of the virus. In spite of the negative aspects of coronavirus on the globe, the coronavirus crises brought a positive impact on the natural environment. Countries where the movement of citizens was seized to stop the spread of coronavirus infection have experienced a noticeable decline in pollution and greenhouse gases emission. Recent research also indicated that this COVID-19-induced lockdown has reduced the environmental pollution drastically worldwide. In this review, we have discussed some important positive impacts of coronavirus on environmental quality by compiling the recently published data from research articles, NASA (National Aeronautics and Space Administration) and ESA (European Space Agency).

Protocol for a case-control study of vitamin D status, adult multidrug-resistant tuberculosis disease and tuberculosis infection in Mumbai, India

INTRODUCTION

Vitamin D status may be an important determinant of multidrug-resistant tuberculosis (MDR-TB) infection, progression to disease and treatment outcomes. Novel and potentially cost-effective therapies such as vitamin D supplementation are needed to stem the tide of TB and MDR-TB globally, particularly in India, a country that accounts for the largest fraction of the world's TB incidence and MDR-TB incidence, and where vitamin D deficiency is endemic. While vitamin D has shown some promise in the treatment of MDR-TB, its role in the context of MDR-TB infection and progression to disease is largely unknown.

METHODS AND ANALYSIS

Through a case-control study in Mumbai, India, we aim to examine associations between vitamin D status and active MDR-TB and to investigate vitamin D status and TB infection among controls. Cases are adult outpatient pulmonary patients with MDR-TB recruited from two public TB clinics. Controls are recruited from the cases' household contacts and from non-respiratory departments of the facilities where cases were recruited. Cases and controls are assessed for serum 25-hydroxyvitamin D concentration, nutrient intake, diet quality, anthropometry and other relevant clinical and sociodemographic parameters. Controls undergo additional clinical assessments to rule out active TB and laboratory assessments to determine presence of TB infection. Statistical analysis investigates associations between vitamin D status and active MDR-TB and between vitamin D status and TB infection among controls, accounting for potential confounding effects of diet, anthropometry and other covariates.

ETHICS AND DISSEMINATION

This study has been approved by Harvard T.H. Chan School of Public Health Institutional Review Board; Foundation for Medical Research Institutional Research Ethics Committee and Health Ministry's Screening Committee of the Indian Council for Medical Research. Permission was granted by the Municipal Corporation of Greater Mumbai, India, a collaborating partner on this research. Outcomes will be disseminated through publication and scientific presentation.

TRIAL REGISTRATION NUMBER

NCT04342598.

Outcomes, resource utilization and predictors of thirty day readmission in patients with heart failure with preserved ejection fraction (HFpEF): insights from the Nationwide Readmissions Database 2017

Background and aims

Nearly half of all heart failure patients have heart failure with preserved ejection fraction (HFpEF). Due to differences in pathophysiology of heart failure with preserved and reduced ejection fraction, as well as a paucity of studies, the treatment of hHFpEF remains a challenge.

We aimed to determine the rate of hospital readmission within 30 days of acute or acute on chronic HFpEF and its impact on mortality and health care utilization in the United States. We also focused on patient demographics as well as independent variables affecting readmission.

Methods

We performed a retrospective study using the Agency for Health-care Research and Quality's Health-care Cost and Utilization Project (HCUP), Nationwide Readmission Database (NRD) for the year of 2017 (data on approximately 18 million hospital stays at 2,454 hospitals in the United States). We collected data on hospital readmissions of 60,514 adults who were hospitalized for acute or acute on chronic diastolic heart failure and discharged. The primary outcome was the rate of all-cause readmission within 30 days of discharge. Secondary outcomes were reasons for readmission, readmission mortality rate, and resource use (length of stay, total hospitalization costs and charges). Independent risk factors for readmission were identified using Cox regression analysis.

Results

The 30-day rate of readmission was 21%. Only 1,175 (9.17%) of readmissions were associated with an admitting diagnosis of acute on chronic diastolic heart failure. The most common readmission diagnosis was hypertensive chronic kidney disease with heart failure (1,245; 9.7%). Readmission cases were associated with increased in-hospital mortality compared to index admission (7.9% vs 2.9%, p=0.000). Readmission was associated with a total of 81,997 hospital days. Total health care in-hospital economic burden was $206 million (in costs) and $779 million (in charges). Significant predictors of increased thirty-day readmission were Medicaid insurance (1.15, 1.05–1.27, p=0.004), higher Charlson co-morbidity score (1.08, 1.06–1.09, p=0.000), patient admitted to teaching hospital (1.09, 1.04–1.15, p=0.001) and longer stays in the hospital (1.01, 1.01–1.02, p=0.000). Residence in a small metropolitan (0.91, 0.86–0.97, p=0.003) or micropolitan area (0.83, 0.77–0.90, p=0.000), older age (0.99, 0.993–0.997, p=0.000), female sex (0.91, 0.86–0.95, p=0.000), private (0.85, 0.77–0.93, p=0.000) or no insurance (0.70, 0.53–0.93, p=0.015) were associated with lower odds of readmission. Interestingly discharges to rehabilitation had no effect on re-admission (0.67, 0.28–1.6, p=0.381).

Conclusions

In conclusion patients hospitalized for acute or acute on chronic HFpEF, we found that 21% of patients were readmitted to the hospital within 30 days of discharge. Readmissions were associated with higher mortality and resource utilization. Most readmissions were due to cardiorenal syndrome.

Funding Acknowledgement

Type of funding source: None

The myocardial phenotype of Fabry disease pre-hypertrophy and pre-detectable storage

Background

Cardiac involvement in Fabry Disease (FD) occurs prior to left ventricular hypertrophy (LVH) and is characterized by low myocardial native T1 with storage reflected by cardiovascular magnetic resonance (CMR) and ECG changes.

Objectives

We hypothesize that a pre-storage myocardial phenotype might occur even earlier, prior to T1 lowering.

Methods

FD patients and age, sex and heart rate matched healthy controls underwent same-day ECG with advanced analysis and multiparametric CMR (cines, global longitudinal strain [GLS], T1 and T2 mapping, stress perfusion [myocardial blood flow, MBF] and late gadolinium enhancement [LGE]).

Results

114 Fabry patients (46±13 years, 61% female) and 76 controls (49±15 years, 50% female) were included. In pre-LVH FD (n=72, 63%), a low T1 (n=32/72, 44%) was associated with a constellation of ECG and functional abnormalities compared to normal T1 FD patients and controls. However, pre-LVH FD with normal T1 (n=40/72, 56%) also had abnormalities compared to controls: reduced GLS (−18±2 vs −20±2%, P&lt;0.001), microvascular changes (lower MBF 2.5±0.7 vs 3.0±0.8mL/g/min, P=0.028), subtle T2 elevation (50±4 vs 48±2ms, p=0.027) and limited LGE (%LGE 0.3±1.1 vs 0%, P=0.004). ECG abnormalities included shorter P wave duration (88±12 vs 94±15ms, P=0.010) and T wave peak time (Tonset–Tpeak; 104±28 vs 115±20ms, P=0.015), resulting in a more symmetric T wave with lower T wave time ratio (Tonset–Tpeak)/(Tpeak–Tend) (1.5±0.4 vs 1.8±0.4, P&lt;0.001) compared to controls.

Conclusions

FD has a measurable myocardial phenotype pre-LVH and pre-detectable myocyte storage with microvascular dysfunction, subtly impaired GLS and altered atrial depolarization and ventricular repolarization intervals.

Proposed stages of cardiac involvement

Funding Acknowledgement

Type of funding source: None

Explaining Differences in the Acceptability of 99DOTS, a Cell Phone-Based Strategy for Monitoring Adherence to Tuberculosis Medications: Qualitative Study of Patients and Health Care Providers

Background

99DOTS is a cell phone–based strategy for monitoring tuberculosis (TB) medication adherence that has been rolled out to more than 150,000 patients in India’s public health sector. A considerable proportion of patients stop using 99DOTS during therapy.

Objective

This study aims to understand reasons for variability in the acceptance and use of 99DOTS by TB patients and health care providers (HCPs).

Methods

We conducted qualitative interviews with individuals taking TB therapy in the government program in Chennai and Vellore (HIV-coinfected patients) and Mumbai (HIV-uninfected patients) across intensive and continuation treatment phases. We conducted interviews with HCPs who provide TB care, all of whom were involved in implementing 99DOTS. Interviews were transcribed, coded using a deductive approach, and analyzed with Dedoose 8.0.35 software (SocioCultural Research Consultants, LLC). The findings of the study were interpreted using the unified theory of acceptance and use of technology, which highlights 4 constructs associated with technology acceptance: performance expectancy, effort expectancy, social influences, and facilitating conditions.

Results

We conducted 62 interviews with patients with TB, of whom 30 (48%) were HIV coinfected, and 31 interviews with HCPs. Acceptance of 99DOTS by patients was variable. Greater patient acceptance was related to perceptions of improved patient-HCP relationships from increased phone communication, TB pill-taking habit formation due to SMS text messaging reminders, and reduced need to visit health facilities (performance expectancy); improved family involvement in TB care (social influences); and from 99DOTS leading HCPs to engage positively in patients’ care through increased outreach (facilitating conditions). Lower patient acceptance was related to perceptions of reduced face-to-face contact with HCPs (performance expectancy); problems with cell phone access, literacy, cellular signal, or technology fatigue (effort expectancy); high TB- and HIV-related stigma within the family (social influences); and poor counseling in 99DOTS by HCPs or perceptions that HCPs were not acting upon adherence data (facilitating conditions). Acceptance of 99DOTS by HCPs was generally high and related to perceptions that the 99DOTS adherence dashboard and patient-related SMS text messaging alerts improve quality of care, the efficiency of care, and the patient-HCP relationship (performance expectancy); that the dashboard is easy to use (effort expectancy); and that 99DOTS leads to better coordination among HCPs (social influences). However, HCPs described suboptimal facilitating conditions, including inadequate training of HCPs in 99DOTS, unequal changes in workload, and shortages of 99DOTS medication envelopes.

Conclusions

In India’s government TB program, 99DOTS had high acceptance by HCPs but variable acceptance by patients. Although some factors contributing to suboptimal patient acceptance are modifiable, other factors such as TB- and HIV-related stigma and poor cell phone accessibility, cellular signal, and literacy are more difficult to address. Screening for these barriers may facilitate targeting of 99DOTS to patients more likely to use this technology.

Human articular cartilage mechanosensitivity is related to histological degeneration - a functional MRI study

OBJECTIVE

To investigate changes in response to sequential pressure-controlled loading and unloading in human articular cartilage of variable histological degeneration using serial T1ρ mapping.

METHOD

We obtained 42 cartilage samples of variable degeneration from the medial femoral condyles of 42 patients undergoing total knee replacement. Samples were placed in a standardized artificial knee joint within an MRI-compatible whole knee-joint compressive loading device and imaged before (δ₀), during (δ_ld1, δ_ld2, δ_ld3, δ_ld4, δ_ld5) and after (δ_rl1, δ_rl2, δ_rl3, δ_rl4, δ_rl5) pressure-controlled loading to 0.663 ± 0.021 kN (94% body weight) using serial T1ρ mapping (spin-lock multigradient echo sequence; 3.0T MRI system [Achieva, Philips]). Reference assessment included histology (Mankin scoring) and conventional biomechanics (Tangent stiffness). We dichotomized sample into intact (n = 21) and degenerative (n = 21) based on histology and analyzed data using Mann Whitney, Kruskal Wallis, one-way ANOVA tests and Spearman's correlation, respectively.

RESULTS

At δ₀, we found no significant differences between intact and degenerative samples, while the response-to-loading patterns were distinctly different. In intact samples, T1ρ increases were consistent and non-significant, while in degenerative samples, T1ρ increases were significantly higher (P = 0.004, δ0 vs δld1, δ0 vs δld3), yet undulating and variable. With unloading, T1ρ increases subsided, yet were persistently elevated beyond δ0.

CONCLUSION

Cartilage mechanosensitivity is related to histological degeneration and assessable by serial T1ρ mapping. Unloaded, T1ρ characteristics are not significantly different in intact vs degenerative cartilage, while load bearing is organized in intact cartilage and disorganized in degenerative cartilage.

Clinical, humanistic, and economic burden of osteoarthritis among noninstitutionalized adults in the United States

OBJECTIVE

To estimate the burden of osteoarthritis (OA) among noninstitutionalized adults (≥18 years of age) in the US.

DESIGN

Weighted nationally representative data from the 2015 Medical Expenditure Panel Survey were used to estimate OA prevalence in noninstitutionalized adults and compare adults with OA to those without OA for clinical (pain interference with activities [PIA], functional limitations), humanistic (health-related quality-of-life [HRQoL]) and economic outcomes (healthcare costs, wage loss). Productivity/wage loss was estimated among employed working-age adults (18-64 years). Multivariable regression analyses examined the associations between OA and outcomes.

RESULTS

In 2015, 10.5% (25.6 million) of noninstitutionalized US adults reported having any OA. Regression analyses indicated that adults with OA were significantly more likely than those without OA to report moderate (adjusted odds ratios [AOR] 1.99; 95% confidence interval [CI] 1.65-2.40] or severe PIA (AOR 2.59; 95% CI 2.21-3.04), any functional limitation (AOR 2.51; 95% CI 2.21-2.85), and poorer HRQoL on the SF-12 version 2 Physical Component Summary score (adjusted beta [standard error] -3.88 [0.357]; P < 0.001). Adjusted incremental annual total healthcare costs and lost wages among adults with OA relative to those without OA were $1778 and $189 per person, respectively, resulting in estimated national excess costs of $45 billion and $1.7 billion, respectively.

CONCLUSIONS

OA affects approximately 10% of noninstitutionalized adults in the US, resulting in substantial clinical, humanistic, and economic burdens.

P1894Serum light-chain neurofilament is associated with brain atrophy in patients with atrial fibrillation

Background and aims

There is emerging evidence that atrial fibrillation (AF) is associated with cognitive dysfunction, increased risk for dementia and reduced brain volume independent of stroke, but the underlying mechanisms of these associations remain unclear. Here, we investigated the association of serum light-chain neurofilament (sNfL), a neuroaxonal injury biomarker, with brain atrophy in AF patients.

Methods

Explorative analysis from the Swiss-AF cohort study, a multicenter prospective observationalstudy which recruited patients aged ≥45 years with documented AF (NCT02105844). In baseline blood samples, sNfL concentrations were measured in duplicates using a single-molecule array assay. Brain MRI was obtained at baseline and at two years using a standardized protocol including a 3D T1-weighted MPRAGE sequence, on which Structural Image Evaluation using Normalization of Atrophy (SIENA) with optimized parameters for brain extraction was applied to calculate the two-year percentage whole brain volume change (PBVC).

Results

We included 245 Swiss-AF patients (median age 73, 73% male). Two-year PBVC was significantly associated with baseline sNfL in linear regression, with a 0.09% whole brain volume decrease per 10 pg/ml sNfL increase (95% CI [0.05–0.13], p<0.001). This association remained significant after adjustment for age, history of stroke and other vascular risk factors.

Neurofilament and brain atrophy

Conclusion

Increasing baseline sNfL was predictive of higher two-year brain atrophy rates independent of stroke history in AF patients. This association might reflect a chronic neurodegenerative process in AF.

Acknowledgement/Funding

Swiss National Science Foundation

3225Global longitudinal strain measured using feature-tracking cardiac magnetic resonance imaging is an independent predictor of all cause mortality in patients with preserved ejection fraction

Introduction

Ejection fraction is the principal measure used clinically to assess cardiac mechanics and provides significant prognostic information. However, echocardiographic strain imaging has shown significant abnormalities of myocardial deformation can be present despite preserved ejection fraction, which maybe associated with adverse prognosis. Cardiac-Magnetic-Resonance (CMR) feature-tracking techniques now allow assessment of strain from routine cine-images, without specialized pulse sequences. Whether abnormalities of strain measured using CMR feature-tracking have prognostic value in patients with preserved ejection fraction is unknown.

Purpose

To evaluate the prognostic value of CMR feature-tracking derived global longitudinal strain (GLS) in a large multicenter population of patients with preserved ejection fraction.

Methods

Consecutive patients with preserved ejection fraction (EF ≥50%) and a clinical indication for CMR at four US medical centers were included in this study. Feature-tracking GLS was calculated from 3 long-axis-cine-views. The primary endpoint was all-cause death. Cox proportional hazards regression modeling was used to examine the independent association between GLS and death. The incremental prognostic value of GLS was assessed in nested models.

Results

Of the 1274 patients in this study, 115 died during a median follow-up of 6.2 years. By Kaplan-Meier analysis, patients with GLS ≥ median (−20%) had significantly reduced event free survival compared to those with GLS < median (log-rank p<0.001) (Figure, top panel). The continuous relationship between GLS and the hazard of death is shown in the cubic spline (Figure, lower panel). By Cox multivariable regression modeling, each 1% worsening in GLS was associated with a 23.6% increased risk-of-death after adjustment for clinical and imaging risk factors (HR=1.236 per %; p<0.001). Addition of GLS in this model resulted in significant-improvement in the global-chi-square (67 to 168; p<0.0001) and Harrel's C-statistic (0.716 to 0.825; p<0.0001).

Conclusions

CMR feature-tracking derived GLS is a powerful independent predictor of mortality in patients with preserved ejection fraction, incremental to common clinical and imaging risk factors.

P2806A novel sirolimus drug eluting stent for Small-Vessel Disease: results from en-ABL e-registry

Objective

The aim of the study was to assess the clinical outcome of Abluminus DES in patients with small vessels.

Background

Percutaneous coronary intervention (PCI) of small coronary vessel (≤2.75 mm) associated with more chances of restenosis and repeat revascularization even when drug eluting stent employed.

Methods

A total of 2,500 patients enrolled in en-ABL e-registry which is a prospective, multicentre observational post market registry. Out of 2,500 patients, 1,253 patients had small vessel (SV, ≤2.75 mm) while 1,247 had large vessel (LV, >3mm) disease. The primary endpoint was major adverse cardiac events (MACE) which is composite of cardiac death, target vessel myocardial infraction (TV-MI) and target lesion/vessel revascularization (TLR) at 1 year follow up. The secondary endpoint were stent thrombosis and MACE up to 2 years.

Results

Baseline characteristics were well matched in both groups. In the SV group had higher prevalence of diabetes as compared to large vessel 43.0% vs 25.7%. Total 1,400 lesions treated with 1,612 Abluminus DES and 1,569 lesions treated with 1,675 Abluminus DES in SV and LV groups respectively. The mean diameter of stent was 2.61±0.23 and 3.3±0.3 mm in SV and LV groups respectively. There was a significant difference in MACE in treatment groups (3.7% vs. 1.4%, p=0.004 respectively) at 1 year. No significant differences were observed between SV and LV groups in terms of death/myocardial infarction or stent thrombosis. There were increment of only one TLR and no stent thrombosis reported at 2-year follow-up.

Conclusion

This result suggests the efficacy and safety of novel Abluminus DES in small vessel disease.

A-07 The Potential Impact of Nuclear History of Micronesia in Neuropsychological Functioning

Objective

As a result of 67 nuclear tests in the Marshall Islands between 1946 and 1958, inhabitants of Micronesia exposed to radiation exhibited chronic health issues and birth defects that persist to this day. This patient’s presentation may be an example of the continued residual impact of nuclear testing in Micronesia and demonstrates the importance of historical and biological factors when considering differential diagnoses.

Method

Patient is a six-year-old Micronesian male referred for assessment of psychological functioning. He was developmentally delayed since birth, exhibited unusual facial features, and previously diagnosed with Autism Spectrum Disorder (ASD). Presenting problems included speech delays, limited attention span, difficulty coping with challenges, narrow interests, impulsivity, difficulties interacting with peers, and toileting issues (i.e., defecating on the floor). Mother immigrated to Hawaii from Micronesia in 2006 and primarily speaks Chuukese. While pregnant, mother was on medications for diabetes, hospitalized with high blood pressure, and chewed tobacco daily. Patient experienced some difficulties during the neonatal period.

Results

Average nonverbal intelligence; moderately low receptive single word vocabulary; possible somatization, tendency to withdraw, and atypical behavior; problems with functional communication and daily living activities; and learning-related problems at school. Probability of autism within the Possibly/Very Likely range. Age-inappropriate projective drawings, with indications of potential genetic or developmental dysfunction.

Conclusions

Patient was diagnosed with ASD, with accompanying language impairment. Due to family history of radiation exposure in Micronesia and prenatal concerns, a rule out of other neurodevelopmental disorders and various genetic conditions were considered.

Map, know dynamics and act; a better way to engage private health sector in TB management. A report from Mumbai, India

BACKGROUND

India, world's leading Tuberculosis burden country envisions to End-TB by optimally engaging private-sector, in-spite of several unsuccessful attempts of optimal private sector engagement. Private Provider Interface Agency (PPIA), a new initiative for private-sector engagement, studied the private-sector networking and dynamics to understand the spread, typology of providers and facilities and their relations in TB case management, which was critical to design an intervention to engage private-sector. We report the observations of this exercise for a larger readership.

METHOD

ology: It is a descriptive analysis of mapping data (quantitative) and perceived factors influencing their engagement in the PPIA network (qualitative).

RESULTS

Of 7396 doctors, 2773 chemists and 747 laboratories mapped, 3776 (51%) doctors, 353 (13%) chemists and 255 (34%) laboratories were prioritized and engaged. While allopathic doctors highly varied between wards (mean ratio 48/100,000 population; range 13-131), non-allopathic doctors were more evenly distributed (mean ratio 58/100,000 population; range 36-83). The mean ratio between non-allopathic to allopathic doctors was 1.75. Return benefit, apprehension on continuity of funding and issues of working with the Government were top three concerns of private providers during engagement. Similarly, irrational business expectations, expectation of advance financing for surety and fear of getting branded as TB clinic were three top reasons for non-engagement.

CONCLUSION

A systematic study of dynamics of existing networking, typology and spread of private providers and using this information in establishing an ecosystem of referral network for TB control activities is crucial in an effort towards optimal engagement of private health providers. Understanding the factors influencing the network dynamics helped PPIA in effective engagement of private health providers in the project.

What would it cost to scale-up private sector engagement efforts for tuberculosis care? Evidence from three pilot programs in India

BACKGROUND

Private providers dominate health care in India and provide most tuberculosis (TB) care. Yet efforts to engage private providers were viewed as unsustainably expensive. Three private provider engagement pilots were implemented in Patna, Mumbai and Mehsana in 2014 based on the recommendations in the National Strategic Plan for TB Control, 2012-17. These pilots sought to improve diagnosis and treatment of TB and increase case notifications by offering free drugs and diagnostics for patients who sought care among private providers, and monetary incentives for providers in one of the pilots. As these pilots demonstrated much higher levels of effectiveness than previously documented, we sought to understand program implementation costs and predict costs for their national scale-up.

METHODS AND FINDINGS

We developed a common cost structure across these three pilots comprising fixed and variable cost components. We conducted a retrospective, activity-based costing analysis using programmatic data and qualitative interviews with the respective program managers. We estimated the average recurring costs per TB case at different levels of program scale for the three pilots. We used these cost estimates to calculate the budget required for a national scale up of such pilots. The average cost per privately-notified TB case for Patna, Mumbai and Mehsana was estimated to be US$95, US$110 and US$50, respectively, in May 2016 when these pilots were estimated to cover 50%, 36% and 100% of the total private TB patients, respectively. For Patna and Mumbai pilots, the average cost per case at full scale, i.e. 100% coverage of private TB patients, was projected to be US$91 and US$101, respectively. In comparison, the national TB program's budget for 2015 averages out to $150 per notified TB case. The total annual additional budget for a national scale up of these pilots was estimated to be US$267 million.

CONCLUSIONS

As India seeks to eliminate TB, extensive national engagement of private providers will be required. The cost per privately-notified TB case from these pilots is comparable to that already being spent by the public sector and to the projected cost per privately-notified TB case required to achieve national scale-up of these pilots. With additional funds expected to execute against national TB elimination commitments, the scale-up costs of these operationally viable and effective private provider engagement pilots are likely to be financially viable.

Synthetic sodalite doped with silver nanoparticles: Characterization and mercury (II) removal from aqueous solutions

In this work, a novel silver nanoparticles-doped synthetic sodalitic composite was synthesized and characterized using advanced characterization methods, namely TEM-EDS, XRD, SEM, XRF, BET, zeta potential, and particle size analysis. The synthesized nanocomposite was used for the removal of Hg²⁺ from 10 ppm aqueous solutions of initial pH equal to 2. The results showed that the sodalitic nanocomposites removed up to 98.65% of Hg²⁺, which is ∼16% and 70% higher than the removal achieved by sodalite and parent coal fly ash, respectively. The findings revealed that the Hg²⁺ removal mechanism is a multifaceted mechanism that predominantly involves adsorption, precipitation and Hg-Ag amalgamation. The study of the anions effect (Cl^-, NO₃^-, C₂H₃O₂^-, and SO₄^2-) indicated that the Hg²⁺ uptake is comparatively higher when Cl^- anions co-exist with Hg²⁺ in the solution.

Women's rights in Asia and elsewhere - a fact or an illusion?

More than one-third of the world's population resides in Asia. China and India have the largest population densities and the focus of this article is on these two countries. In the seventeenth century, women were globally treated as inferior and subordinate to men. Women had to listen to their fathers, husbands, and sons, and they could not inherit business or wealth. Starting in the eighteenth century and continuing in the nineteenth century, women's rights became central to political debates in Europe which demanded human rights, leading to the Women's Rights Movement. The Feminist movement began in the twentieth century, which focused on the reproductive rights of women. In the twentieth century, various Declarations have been signed by the United Nations to offer both gender equity and equality to women in the world, but unfortunately many of them have not been put into practice in Asia. In the twenty-first century, the feminist movement is focusing more on women having the power to decide the course of their lives. We still have to overcome challenges of unequal economic opportunity, political empowerment, gender violence, and human trafficking to achieve gender equality in Asia.

Diagnostic accuracy of Xpert MTB/RIF assay in extrapulmonary tuberculosis

Introduction

The WHO endorsed Xpert Mycobacterium tuberculosis/rifampicin (MTB/RIF) assay, has been evaluated for pulmonary TB in a number of studies but very few have investigated it for extrapulmonary specimens. The present study evaluates the performance of Xpert MTB/RIF assay in the diagnosis of extrapulmonary TB (EPTB).

Aim and Objectives

The aim of the study is to determine sensitivity and specificity of Xpert MTB/RIF assay for diagnosis of EPTB and RIF resistance in comparison to culture on Lowenstein-Jensen (LJ) medium and proportion method (PM), respectively.

Materials and Methods

A total of 738 specimens from clinically suspected cases of EPTB were subjected to Ziehl-Neelsen staining, Xpert MTB/RIF assay and culture on LJ medium. PM was done on MTB isolates.

Results

The sensitivity, specificity of Xpert MTB/RIF assay for diagnosis of EPTB were 84.91% (95% confidence interval [CI] 72.41%-93.25%) and 86.72% (95% CI 83.94%-89.17%) and for RIF resistance detection were 60.00% (95% CI 32.29%-83.66%) and 94.74% (95% CI 73.97%-99.87%), respectively. Among culture-positive cases, the sensitivity of Xpert MTB/RIF assay was 94.12% in smear positive and 80.56% in smear-negative cases. Xpert MTB/RIF showed maximum sensitivity of MTB detection from lymph node specimens (100% [95% CI 54.07%-100.00%]) and other body fluids (100% [95% CI 15.81%-100.00%]).

Conclusion

The present study establishes Xpert MTB/RIF assay as a promising tool in the rapid diagnosis of EPTB and detection of RIF resistance.

Should vitamin D be routinely checked for all chronic obstructive pulmonary disease patients?

Aims and Objectives:

This study aimed to compare the vitamin D levels between chronic obstructive pulmonary disease (COPD) patients and healthy controls and to describe the correlation between vitamin D levels and lung functions.

Methods:

Fifty COPD patients (cases) and 30 healthy volunteers (controls) were recruited and their serum vitamin D level was measured together with lung function (forced vital capacity and forced expiratory volume in 1 s [FEV1]) by spirometry. vitamin D was categorized as ≤20 nmol/l: deficient, 21–50 nmol/l: inadequate, and ≥51 nmol/l as sufficient.

Results:

In this case–control cross-sectional study, lower vitamin D levels were associated with lower lung function in both cases as well as controls, the effect being more pronounced in cases. Mean FEV1 at vitamin D ≤20 nmol/l (0.98 ± 0.40 vs. controls 1.93 ± 0.24 with P = 0.006), mean FEV1 at vitamin D 21–50 nmol/l (1.55 ± 0.54 vs. 2.20 ± 0.31 with P = 0.000), and mean FEV1 at vitamin D ≥51 nmol/l (2.06 ± 0.54 vs. 2.20 ± 0.31 with P = 0.002). Moreover, the severity of predicted postbronchodilator FEV1% was also much lower among COPD cohort versus healthy volunteers (mean FEV1%: cases 47.88 ± 14.22 vs. controls 58.76 ± 15.05 with P = 0.002).

Conclusions:

Importantly, lung function in both the groups was affected by decreased vitamin D level; decrease in FEV1 was more pronounced among COPD patients compared to controls showing more expiratory airflow limitation. Vitamin D levels are associated with changes in lung function in cases of COPD as well as healthy controls. Larger studies to confirm the association in Indian context are required and routine assessment of vitamin D may be undertaken to obviate the effects of low vitmain D level on lung function.

Elevated obstructive sleep apnoea risk score is associated with poor healing of diabetic foot ulcers: a prospective cohort study

AIMS

To assess the prevalence of risk factors for obstructive sleep apnoea in people with diabetic foot ulcers and to determine whether this risk predicts diabetic foot ulcer healing.

METHODS

We studied 94 consecutive people (69% men) with diabetic foot ulcers (Type 2 diabetes, n=66, Type 1 diabetes, n=28) attending a university hospital foot unit. All participants were screened for obstructive sleep apnoea using the STOP-BANG questionnaire, with a score ≥4 identifying high risk of obstructive sleep apnoea. The primary outcome was poor diabetic foot ulcer healing, defined as diabetic foot ulcer recurrence (diabetic foot ulcers which healed and re-ulcerated in same anatomical position) and/or diabetic foot ulcer persistence (no evidence of healing on clinical examination). All participants were evaluated at 12 months.

RESULTS

Of the 94 participants, 60 (64%) had a STOP-BANG score ≥4. Over 12 months, 27 participants with a score ≥4 had poor diabetic foot ulcer healing as compared to seven with a score <4 (45% vs 20.5%; P=0.025). A STOP-BANG score ≥4 significantly increased the relative risk of poor healing more than twofold, independently of other risk factors in multivariable analyses.

CONCLUSIONS

There is a high prevalence of features and risk of obstructive sleep apnoea in people with diabetic foot ulcers. A STOP-BANG score ≥4 predicts poor diabetic foot ulcer healing. Obstructive sleep apnoea may be a potential, modifiable risk factor/treatment target to improve diabetic foot ulcer outcomes.