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Kalra A, ThekkePurakkal AS, Rao R, Parija D, Ghule V, Lone A, Showket T, Joshi RP, Sarin S, Chadha SS. Implementation of a tuberculosis elimination project, India 2018-2019. Bull World Health Organ 2023; 101:179-190. [PMID: 36865603 PMCID: PMC9948499 DOI: 10.2471/blt.22.288277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 11/19/2022] [Accepted: 11/30/2022] [Indexed: 03/04/2023] Open
Abstract
Objective To describe the changes in tuberculosis case notifications by the private sector after implementation of the Joint Effort for Elimination of Tuberculosis project in India in 2018. Methods We retrieved data from the project recorded in India's national tuberculosis surveillance system. We analysed data on 95 project districts in six states (Andhra Pradesh, Himachal Pradesh, Karnataka, Punjab including Chandigarh, Telangana and West Bengal) to assess changes in the number of tuberculosis notifications, private provider notifiers and microbiological confirmations of cases from 2017 (baseline) to 2019. We compared case notification rates in districts where the project was implemented with the rates in districts where it was not. Findings From 2017 to 2019, tuberculosis notifications increased by 138.1% (from 44 695 to 106 404), and case notification rates more than doubled from 20 to 44 per 100 000 population. The number of private notifiers increased by over threefold, from 2912 to 9525, during this period. The number of microbiologically confirmed pulmonary and extra-pulmonary tuberculosis cases notified increased by more than two times (from 10 780 to 25 384) and nearly three times (from 1477 to 4096), respectively. The districts where the project was implemented showed a 150.3% increase in case notification rates per 100 000 population from 2017 to 2019 (from 16.8 to 41.9) while in non-project districts, this increase was only 89.8% (from 6.1 to 11.6). Conclusion The substantial increase in tuberculosis notifications demonstrate the value of the project in engaging the private sector. Scaling up these interventions is important to consolidate and extend these gains towards tuberculosis elimination.
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Affiliation(s)
- Aakshi Kalra
- FIND, Flat No. 8, 9th Floor, Vijaya Building, 17 Barakhamba Road, New Delhi110001, India
| | - Akhil S ThekkePurakkal
- FIND, Flat No. 8, 9th Floor, Vijaya Building, 17 Barakhamba Road, New Delhi110001, India
| | - Raghuram Rao
- Central TB Division, Ministry of Health and Family Welfare, New Delhi, India
| | - Debadutta Parija
- FIND, Flat No. 8, 9th Floor, Vijaya Building, 17 Barakhamba Road, New Delhi110001, India
| | - Vaibhav Ghule
- FIND, Flat No. 8, 9th Floor, Vijaya Building, 17 Barakhamba Road, New Delhi110001, India
| | - Ajaz Lone
- FIND, Flat No. 8, 9th Floor, Vijaya Building, 17 Barakhamba Road, New Delhi110001, India
| | - Tajamul Showket
- FIND, Flat No. 8, 9th Floor, Vijaya Building, 17 Barakhamba Road, New Delhi110001, India
| | - Rajendra P Joshi
- Central TB Division, Ministry of Health and Family Welfare, New Delhi, India
| | | | - Sarabjit S Chadha
- FIND, Flat No. 8, 9th Floor, Vijaya Building, 17 Barakhamba Road, New Delhi110001, India
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Singh H, Tanwar V, Kalra A, Saini A, Arora S, Govil N. Implication and utility of DAS-28 squeeze in rheumatoid arthritis: an Indian experience. Reumatismo 2022; 74. [PMID: 36101988 DOI: 10.4081/reumatismo.2022.1501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/10/2022] [Indexed: 11/22/2022] Open
Abstract
The purpose of this study was to compare and correlate disease activity score including 28 joints counts (DAS-28) Squeeze with DAS-28 and clinical disease activity index (CDAI) to assess disease activity (DA) in rheumatoid arthritis (RA) patients. A total of 100 RA patients were included in the study. All subjects were evaluated for disease activity using the DAS-28 Squeeze, DAS-28, and CDAI. Spearman’s rho (ρ) was calculated to determine the correlation between DAS-28 Squeeze, DAS-28, and CDAI. Cross-tabulation was performed to compare and calculate the kappa coefficient for the link between two indices. For each scale, Cronbach’s alpha was also calculated to test dependability. The average age of the study group was 43.9±11.3. The mean scores on the DAS-28 Squeeze, DAS-28, and CDAI were, respectively, 3.58±1.06, 5.06±1.56, and 22.81±14.92. p=0.001 indicated a significant correlation between DAS-28 Squeeze and DAS-28 (ρ=0.986) and CDAI (ρ=0.939) for DAS-28 Squeeze. There was a considerable correlation between all three measures at various DA levels. Cronbach’s alpha for DAS-28 Squeeze, DAS-28, and CDAI were respectively 0.716, 0.663, and 0.734. DAS-28 Squeeze exhibited a substantial positive association with DAS-28 and CDAI for assessing disease activity and appears to be a more useful and reliable method than DAS-28 and CDAI for monitoring disease activity in RA patients.
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Mannan S, Oga-Omenka C, Soman ThekkePurakkal A, Huria L, Kalra A, Gandhi R, Kapoor T, Gunawardena N, Raj S, Kaur M, Sassi A, Pande T, Shibu V, Sarin S, Singh Chadha S, Heitkamp P, Das J, Rao R, Pai M. Adaptations to the first wave of the COVID-19 pandemic by private sector tuberculosis care providers in India. J Clin Tuberc Other Mycobact Dis 2022; 28:100327. [PMID: 35874450 PMCID: PMC9295336 DOI: 10.1016/j.jctube.2022.100327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background India’s dominant private healthcare sector is the destination for 60–85% of initial tuberculosis care-seeking. The COVID-19 pandemic in India drastically affected TB case notifications in the first half of 2020. In this survey, we assessed the impact of the first wave of COVID-19 in India on private providers, and changes they adopted in their practice due to the pandemic. Methods The Joint Effort for Elimination of TB (JEET) is a nationwide Global Fund project implemented across 406 districts in 23 states to extend quality TB services to patients seeking care in private sector. We conducted a rapid survey of 11% (2,750) of active providers engaged under JEET’s intense Patient Provider Support Agency (PPSA) model across 15 Indian states in Q1 (February–March) of 2021. Providers were contacted in person or telephonically, and consenting participants were interviewed using a web-based survey tool. Responses from participants were elicited on their practice before COVID-19, during the 2020 lockdowns (March–April 2020) and currently (Q1 2021). Data were adjusted for survey design and non-response, and results were summarised using descriptive statistics and logistic regression. Results Of the 2,750 providers sampled, 2,011 consented and were surveyed (73 % response). Nearly 50 % were between 30 and 45 years of age, and 51 % were from Uttar Pradesh, Maharashtra and Gujarat. Seventy percent of providers reported reduced daily out-patient numbers in Q1 2021 compared to pre-COVID times. During the lockdown, 898 (40 %) of providers said their facilities were closed, while 323 (11 %) offered limited services including teleconsultation. In Q1 2021, 88 % of provider facilities were fully open, with 10 % providing adjusted services, and 4 % using teleconsultation. Only 2 % remained completely closed. Majority of the providers (92 %) reported not experiencing any delays in TB testing in Q1 2021 compared to pre-COVID times. Only 6 % reported raising costs at their clinic, mostly to cover personal protective equipment (PPE) and other infection control measures, although 60–90 % implemented various infection control measures. Thirty-three percent of TB providers were ordering COVID-19 testing, in addition to TB testing. To adapt, 82% of survey providers implemented social distancing and increased timing between appointments and 83% started conducting temperature checks, with variation by state and provider type, while 89% adopted additional sanitation measures in their facilities. Furthermore, 62% of providers started using PPE, and 13% made physical changes (air filters, isolation of patient areas) to their clinic to prevent infection. Seventy percent of providers stated that infection control measures could decrease TB transmission. Conclusion Although COVID-19 restrictions resulted in significant declines in patient turn-out at private facilities, our analysis showed that most providers were open and costs for TB care remained mostly the same in Q1 2021. As result of the COVID-19 pandemic, several positive strategies have been adapted by the private sector TB care providers. Since the subsequent COVID-19 waves were more severe or widespread, additional work is needed to assess the impact of the pandemic on the private health sector.
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Affiliation(s)
| | - Charity Oga-Omenka
- McGill International TB Centre, Montreal, Canada.,School of Public Health Sciences, University of Waterloo, Canada
| | | | - Lavanya Huria
- McGill International TB Centre, Montreal, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Canada
| | - Aakshi Kalra
- Foundation for Innovative New Diagnostics (FIND), India
| | | | | | - Nathali Gunawardena
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Canada
| | - Shekhar Raj
- Centre for Health Research and Innovation (CHRI), India
| | - Manjot Kaur
- TB PPM Learning Network, Research Institute of the McGill University Health Centre, Canada
| | - Angelina Sassi
- McGill International TB Centre, Montreal, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Canada
| | - Tripti Pande
- McGill International TB Centre, Montreal, Canada
| | | | - Sanjay Sarin
- Foundation for Innovative New Diagnostics (FIND), India
| | | | - Petra Heitkamp
- McGill International TB Centre, Montreal, Canada.,TB PPM Learning Network, Research Institute of the McGill University Health Centre, Canada
| | - Jishnu Das
- McCourt School of Public Policy, Georgetown University, Washington, DC, USA
| | - Raghuram Rao
- Central TB Division, Ministry of Health & Family Welfare, India
| | - Madhukar Pai
- McGill International TB Centre, Montreal, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Canada
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Kwiat C, Kalra A. M047 A CASE OF ANAPHYLAXIS TO IV CONTRAST MEDIA RESULTING IN CARDIAC ARREST. Ann Allergy Asthma Immunol 2021. [DOI: 10.1016/j.anai.2021.08.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abushouk A, Yunusa I, Elmehrath AO, Elmatboly AM, Saad A, Fayek SH, Abdelfattah O, Ghanem E, Isogai T, Shekhar S, Reed GW, Puri R, Kalra A, Kapadia SR. Evidence in crisis: a closer look into the quality of published systematic reviews in the cardiology literature. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.3151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Systematic reviews are usually considered as the highest level of evidence and are increasingly used in shaping cardiology policies and guidelines. However, as the rate of publishing systematic reviews increases annually, there are rising concerns regarding their quality and reporting standards.
Purpose
The current analysis provides an insight into the quality of published systematic reviews in cardiology and provides recommendations for researchers, clinicians, and stakeholders in this regard.
Methods
Using a comprehensive Medline/PubMed search, we retrieved all systematic reviews, published between 2009 and 2019 in five general cardiology journals with the highest impact factor as per the Clarivate Analytics 2019 Journal Impact Factor List (Circulation, European Heart Journal, Journal of the American College of Cardiology, Circulation Research, and JAMA Cardiology). We assessed the methodological characteristics, eligibility criteria, reporting standards, as well as review quality scores according to the AMSTAR tool.
Results
Among 352 retrieved reviews, 275 (75.3%) performed direct head-to-head analysis and 164 (46.6%) included only clinical trials. The median numbers of searched databases and included studies were 3 (IQR: 2, 3) and 13 (IQR: 7, 30). The primary outcomes were often hard clinical endpoints as mortality (39.2%) and stroke (11.9%). 64 (18.2%) registered their protocol, 208 (58.4%) used validated tools for risk of bias assessment, 177 (52.3%) assessed for publication bias, and 221 (62.8%) adhered to the PRISMA checklist. Thirty-five reviews detected significant publication bias, which was significantly associated with heterogeneity of the primary outcome. The AMSTAR quality scores were low or critically low in 71% of evaluated reviews. Further, 87 (24.7%) did not report on whether they received funding or not, 33 (9.4%) reported receiving no funding, and 232 adequately reported on their funding sources [70 (19.9%) from governmental/academic sources, 120 (34.1%) from pharmaceutical companies, and 42 (11.9%) from both sources]. analysis showed that reviews with advanced statistical analysis, those that included RCTs, adhered to the PRISMA checklist, or had higher AMSTAR quality scores had significantly higher citation metrics (p<0.05).
Conclusion
Due to the widespread low quality and poor reporting in cardiovascular systematic reviews, clinicians should be educated on the value of methodological quality in interpreting systematic review findings. In addition, academic societies and guideline writing groups should implement rigorous critical appraisal and peer review policies to improve the synthesis and utilization of systematic reviews in evidence-based cardiovascular medicine.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- A Abushouk
- Cleveland Clinic Foundation, Cleveland, United States of America
| | - I Yunusa
- Harvard T. H. Chan School of Public Health, Boston, United States of America
| | | | | | - A Saad
- Cleveland Clinic Foundation, Cleveland, United States of America
| | - S H Fayek
- Kasr Alainy school of medicine, Cairo, Egypt
| | - O Abdelfattah
- Cleveland Clinic Foundation, Cleveland, United States of America
| | - E Ghanem
- Al-Azhar University, Cairo, Egypt
| | - T Isogai
- Cleveland Clinic Foundation, Cleveland, United States of America
| | - S Shekhar
- Cleveland Clinic Foundation, Cleveland, United States of America
| | - G W Reed
- Cleveland Clinic Foundation, Cleveland, United States of America
| | - R Puri
- Cleveland Clinic Foundation, Cleveland, United States of America
| | - A Kalra
- Cleveland Clinic Foundation, Cleveland, United States of America
| | - S R Kapadia
- Cleveland Clinic Foundation, Cleveland, United States of America
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Place A, Barrett D, Cote S, Nomikos G, Song G, Bilic S, Kalra A, Sadanowicz M, O'Neil J, Iarrobino R, Kertesz N, Chyung Y. SMA - TREATMENT. Neuromuscul Disord 2021. [DOI: 10.1016/j.nmd.2021.07.302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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7
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Raizada N, McDowell A, Parija D, Sachdeva KS, Khaparde SD, Rao R, Pavani TN, Sudha S, Tyagi H, Rebecca YM, Huddart S, Salhotra VS, Nair SA, Denkinger CM, Chadha SS, Sarin S, Kalra A. Pathways to diagnosis of pediatric TB patients: A mixed methods study from India. Indian J Tuberc 2021; 68:363-373. [PMID: 34099202 DOI: 10.1016/j.ijtb.2020.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 11/11/2020] [Accepted: 12/28/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND A significant proportion of pediatric tuberculosis (TB) patients go unnotified due to the challenges in diagnosis of TB among children. The experiences of this vulnerable group while going through the TB care cascade remain largely undocumented. The aim of this study was to explore the experiences of pediatric TB patients and families along the pathway to TB diagnosis and appropriate treatment in four cities of India. METHODS The study used a mixed methods, single phased, embedded design. The primary qualitative and secondary quantitative data were collected simultaneously by interviewing families of 100 randomly selected Xpert MTB/RIF positive pediatric TB patients, under the pediatric TB project, in 4 Indian cities using a semi-structured questionnaire. The qualitative component was analyzed to deduce patterns and themes on the patient and family experiences. Descriptive statistics were used to quantify various events along the TB care pathway including various delays (patient, diagnosis and total) and number of providers visited by patients during the diagnostic process. RESULTS The median patient, diagnostic and total delays were 3 (IQR: 2,5), 39 (IQR: 23, 91) and 43 days (IQR: 28.5, 98.5), respectively. Patients visited a median of 3 (IQR: 2,4) providers before accessing Xpert MTB/RIF testing. On an average, 68.4% of physicians ordered any test most of them being irrelevant for TB diagnosis. Qualitative data showed considerable suffering for children and their families before and after TB diagnosis including serious concerns of stigma, disruption in education and social life and recurrence of the disease. CONCLUSION Our study highlights the significant physical and social distress that the children with TB and their families undergo along the TB care pathway. It also shows diagnostic delay in excess of a month during which multiple providers were met and the patients underwent several diagnostic tests, most of them being inappropriate. Efforts to make Xpert MTB/RIF testing more accessible and part of physicians' toolkit will be of considerable value to ease the complexity of TB diagnosis in children. In addition, communication strategy needs to be developed and implemented to generate awareness among general population around pediatric TB and its management.
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Affiliation(s)
- Neeraj Raizada
- Foundation for Innovative New Diagnostics, New Delhi, India
| | | | | | - K S Sachdeva
- Central TB Division, Government of India, New Delhi, India
| | | | - Raghuram Rao
- Central TB Division, Government of India, New Delhi, India
| | - T N Pavani
- Foundation for Innovative New Diagnostics, New Delhi, India
| | - S Sudha
- Foundation for Innovative New Diagnostics, New Delhi, India
| | | | - Y Mary Rebecca
- Foundation for Innovative New Diagnostics, New Delhi, India
| | | | | | | | | | | | - Sanjay Sarin
- Foundation for Innovative New Diagnostics, New Delhi, India
| | - Aakshi Kalra
- Foundation for Innovative New Diagnostics, New Delhi, India.
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Kalra A, Teixeira AL, Diniz BS. Association of Vitamin D Levels with Incident All-Cause Dementia in Longitudinal Observational Studies: A Systematic Review and Meta-analysis. J Prev Alzheimers Dis 2021; 7:14-20. [PMID: 32010921 DOI: 10.14283/jpad.2019.44] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The role of vitamin D is not only limited to bone health and pathogenesis of chronic diseases. Evidence now suggests that it is also involved in the development of various dementias and Alzheimer's disease (AD). OBJECTIVE To carry out a systematic review and meta-analysis to evaluate the association between vitamin D levels and increased risk of incident all-cause dementia in longitudinal studies. DESIGN We conducted a systematic review and meta-analysis using the electronic bibliographic databases PubMed and Scopus. SETTING Prospective cohort studies. PARTICIPANTS Community-dwelling older adults. MEASUREMENTS Vitamin D serum concentrations were categorized in three groups: normal levels (>50 nmol/L), insufficient levels (25 - 49.9 nmol/L), and deficient levels (<25 nmol/L). We performed a meta-analysis using the general inverse variance method to calculate the pooled risk of AD and all-cause dementia according to vitamin D levels. Random-effects or fixed-effect model were used to calculate the pooled risk based on the heterogeneity analysis. RESULTS Five studies were included in the meta-analysis. The pooled risk of all-cause dementia and AD was significantly higher in those with deficient serum vitamin D level compared to those with normal level (1.33, CI95% [1.15, 1.54], and 1.87, CI95% [1.03, 3.41], respectively). Those with insufficient level also had a higher pooled risk of all-cause dementia and AD, but the strength of association was less robust (1.14 CI95% [1.02, 1.27] and 1.25, CI95% [1.04 - 1.51], respectively). CONCLUSION We found a gradient effect for the risk of all-cause dementia and AD according to the vitamin D level, with higher risk in those in the deficient levels group and intermediate risk in those with insufficient levels. Our findings were limited by the relatively small number of studies included in the meta-analysis and their geographic restriction.
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Affiliation(s)
- A Kalra
- Anjani Kalra, Independent researcher (research consultant), Scharnhorststr. 07, 10115, Berlin, Germany, ,Tel: +49-15124977562
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Borovac J, Kwok C, Mohamed M, Fischman D, Savage M, Alraies C, Kalra A, Nolan J, Zaman A, Ahmed J, Bagur R, Mamas M. The predictive value of CHA2DS2-VASc score on adverse in-hospital outcomes among patients with the acute coronary syndrome and atrial fibrillation who undergo PCI. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) and having concomitant atrial fibrillation (AF) have a greater risk of adverse short- and long-term outcomes and death compared with patients in the same setting but without AF. On the other hand, the predictive value of CHA2DS2-VASc score in terms of in-hospital mortality and periprocedural adverse events following PCI among patients with ACS and AF is unknown.
Purpose
We retrospectively analyzed data of patients with the main admission diagnosis of ACS that underwent PCI and had AF during the 2004–2014 period from the large nationwide US National Inpatient Sample (NIS) database.
Methods
A CHA2DS2-VASc score was calculated for each patient and incorporated into a multivariable-adjusted logistic regression to determine its independent impact on in-hospital outcomes consisting of death, acute kidney injury (AKI), bleeding, vascular injury, and stroke/transient ischemic attack (TIA).
Results
A total of 283,890 patients with AF who underwent PCI following ACS were included in the analysis. The average reported prevalence of the AF in the whole cohort was 10.0% with a significant trend (p<0.001) of increase during the observed 10-year period. The average age of the cohort was 72.1±11 years, 63.4% were male while the median CHA2DS2-VASc score was 3 (IQR 2–4). Crude rates of adverse in-hospital outcomes were significantly higher among patient groups with higher CHA2DS2-VASc score (Table 1). Following adjustment for baseline covariates, incremental increase in CHA2DS2-VASc score was independently associated with an increased odds of in-hospital death (OR 1.20, CI 95% 1.18–1.22), periprocedural vascular injury (OR 1.18, 95% CI 1.17–1.20), bleeding (OR 1.17, 95% CI 1.16–1.18), stroke/TIA (OR 1.17, 95% CI 1.15–1.19), and AKI (OR 1.05, 95% CI 1.04–1.06) (Figure 1).
Conclusions
The CHA2DS2-VASc score provides important prognostic information in ACS patients with AF undergoing PCI and is independently associated with in-hospital death and periprocedural adverse events. Therefore, CHA2DS2-VASc score could be used as a practical and inexpensive tool for risk stratification in this population.
Figure 1
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- J.A Borovac
- Keele University, Stoke-on-Trent, United Kingdom
| | - C.S Kwok
- Keele University, Stoke-on-Trent, United Kingdom
| | - M.O Mohamed
- Keele University, Stoke-on-Trent, United Kingdom
| | - D.L Fischman
- Thomas Jefferson University Hospital, Philadelphia, United States of America
| | - M Savage
- Thomas Jefferson University Hospital, Philadelphia, United States of America
| | - C Alraies
- Detroit Medical Center, Detroit, United States of America
| | - A Kalra
- Cleveland Clinic, Cleveland, United States of America
| | - J Nolan
- Keele University, Stoke-on-Trent, United Kingdom
| | - A Zaman
- Freeman Hospital, Newcastle-Upon-Tyne, United Kingdom
| | - J Ahmed
- Freeman Hospital, Newcastle-Upon-Tyne, United Kingdom
| | - R Bagur
- Keele University, Stoke-on-Trent, United Kingdom
| | - M.A Mamas
- Keele University, Stoke-on-Trent, United Kingdom
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10
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Kalra A, Parija D, Raizada N, Sachdeva KS, Rao R, Swaminathan S, Khanna A, Chopra KK, Hanif M, Singh V, Umadevi KR, Sheladia KN, Rao R, Vasundhara N, S. A, A. R. N, Azeem A, Chhajlani V, Khurana J, Das NJ, Choudhury B, Nair SA, Mall S, Sen R, Chadha SS, Denkinger CM, Boehme C, Sarin S. Upfront Xpert MTB/RIF for diagnosis of pediatric TB-Does it work? Experience from India. PLoS One 2020; 15:e0236057. [PMID: 32756559 PMCID: PMC7406076 DOI: 10.1371/journal.pone.0236057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/27/2020] [Indexed: 01/02/2023] Open
Abstract
Background Diagnosis of TB in pediatric population poses several challenges. A novel initiative was implemented in several major cities of India aimed at providing upfront access to free-of-cost Xpert MTB/RIF to presumptive pediatric TB cases. This paper aims to describe the experience of implementing this large initiative and assess feasibility of the intervention in high TB burden settings. Methods Data were drawn from the pediatric TB project implemented in 10 major cities of India between April 2014 and March 2018. In each city, providers, both public and private, were engaged and linked with a high throughput Xpert MTB/RIF lab (established in that city) through rapid specimen transportation and electronic reporting system. Rates and proportions were estimated to describe the characteristics of this cohort. Results Of the total 94,415 presumptive pediatric TB cases tested in the project, 6,270 were diagnosed positive for MTB (6.6%) on Xpert MTB/RIF (vs 2% on smear microscopy). Among MTB positives, 545 cases were rifampicin resistant (8.7%). The median duration between collection of specimens and reporting of results was 0 days (same day) and >89% cases were initiated on treatment. Approximately 50% of the specimens tested were non-sputum. The number of providers/facilities engaged under the project increased >10-fold (from 124 in Q2’14 to 1416 in Q1’18). Conclusion This project, which was one of the largest initiatives globally among pediatric population, demonstrated the feasibility of sustaining rapid and upfront access to free-of-cost Xpert MTB/RIF testing. The project underscores the efficiency of this rapid diagnostic assay in tackling several challenges in pediatric TB diagnosis, identifies opportunities for further interventions as well as brings to light scope for effective engagement with healthcare providers. The findings have facilitated a policy decision by National TB Programme mandating the use of Xpert MTB/RIF as a primary diagnostic tool for TB diagnosis in children, which is being scaled-up.
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Affiliation(s)
- Aakshi Kalra
- Foundation for Innovative New Diagnostics, New Delhi, India
- * E-mail:
| | | | - Neeraj Raizada
- Foundation for Innovative New Diagnostics, New Delhi, India
| | - K. S. Sachdeva
- Central TB Division, Government of India, New Delhi, India
| | - Raghuram Rao
- Central TB Division, Government of India, New Delhi, India
| | | | - Ashwani Khanna
- State TB office, Govt of National Capital Territory, Delhi, India
| | | | - M. Hanif
- New Delhi TB Centre, New Delhi, India
| | - Varinder Singh
- Lady Hardinge Medical College and Assoc Kalawati Saran Children's Hospital, New Delhi, India
| | - K. R. Umadevi
- National Institute of research in Tuberculosis, Chennai, India
| | - K. N. Sheladia
- District TB Centre, Surat Municipal Corporation, Gujarat, India
| | - Rama Rao
- State TB Office, Vijayawada, Andhra Pradesh, India
| | - N. Vasundhara
- District TB Centre, Visakhapatnam, Andhra Pradesh, India
| | - Anil S.
- State TB Training and Demonstration Centre/Intermediate Reference Laboratory, Bangalore, Karnataka, India
| | - Nirmala A. R.
- State TB Training and Demonstration Centre/Intermediate Reference Laboratory, Bangalore, Karnataka, India
| | - Abdul Azeem
- State TB Training and Demonstration Centre/Intermediate Reference Laboratory, Bangalore, Karnataka, India
| | | | - Jyoti Khurana
- Intermediate Reference Laboratory, Indore, Madhya Pradesh, India
| | - N. J. Das
- Office of the Jt. Director of Health Services (TB), Directorate of Health Services, Assam, India
| | | | | | - Shalini Mall
- Foundation for Innovative New Diagnostics, New Delhi, India
| | - Rajashree Sen
- Foundation for Innovative New Diagnostics, New Delhi, India
| | | | | | | | - Sanjay Sarin
- Foundation for Innovative New Diagnostics, New Delhi, India
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Singh S, Pandey SS, Shanker K, Kalra A. Endophytes enhance the production of root alkaloids ajmalicine and serpentine by modulating the terpenoid indole alkaloid pathway in Catharanthus roseus roots. J Appl Microbiol 2020; 128:1128-1142. [PMID: 31821696 DOI: 10.1111/jam.14546] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 10/15/2019] [Accepted: 11/28/2019] [Indexed: 12/15/2022]
Abstract
AIM The aim of this study was to identify and characterize promising endophytes capable of enhancing the content of root alkaloids ajmalicine and serpentine in low alkaloid yielding genotype of Catharanthus roseus cultivar Prabal and the possible mechanisms involved. METHOD AND RESULT Of the four strains isolated from alkaloid-rich genotype of C. roseus cultivar Dhawal, endophytic strains CATDLF5 (Curvularia sp.) and CATDLF6 (Choanephora infundibulifera) enhanced serpentine content by 211·7-337·6%, while CATDRF2 (Aspergillus japonicus) and CATDS5 (Pseudomonas sp.) increased the content of ajmalicine by 123·4-203·8% in cultivar Prabal. Upregulated expression of key genes, geraniol 10-hydroxylase, tryptophan decarboxylase and strictosidine synthase involved in terpenoid indole alkaloid (TIA) biosynthetic pathway was observed in endophyte inoculated plants. Upregulated Octadecanoid-derivative Responsive Catharanthus AP2/ERF domain transcription activators like ORCA3 while, and downregulation of transcriptional repressor, ZCTs (Cys2/His2-type zinc finger protein family) enhanced the expression of genes for secondary metabolite production in endophyte-inoculated plants. CONCLUSION The present work concluded that the selected endophytes of C. roseus can enhance the ajmalicine and serpentine contents by modulating the expression of structural and regulatory genes of TIA biosynthetic pathway in root. SIGNIFICANCE AND IMPACT OF THE STUDY Endophytes can play an important role to enhance in planta content of pharmaceutically important alkaloids in C. roseus and can therefore be useful in reducing the cost of production of important alkaloids.
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Affiliation(s)
- S Singh
- Microbial Technology Division, CSIR-Central Institute of Medicinal and Aromatic Plants, Lucknow, Uttar Pradesh, India.,Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, Uttar Pradesh, India
| | - S S Pandey
- Microbial Technology Division, CSIR-Central Institute of Medicinal and Aromatic Plants, Lucknow, Uttar Pradesh, India
| | - K Shanker
- Analytical Chemistry Department, CSIR-Central Institute of Medicinal and Aromatic Plants, Lucknow, Uttar Pradesh, India
| | - A Kalra
- Microbial Technology Division, CSIR-Central Institute of Medicinal and Aromatic Plants, Lucknow, Uttar Pradesh, India.,Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, Uttar Pradesh, India
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Sarin S, Huddart S, Raizada N, Parija D, Kalra A, Rao R, Salhotra VS, Khaparde SD, Boehme C, Denkinger CM, Sohn H. Cost and operational impact of promoting upfront GeneXpert MTB/RIF test referrals for presumptive pediatric tuberculosis patients in India. PLoS One 2019; 14:e0214675. [PMID: 30933997 PMCID: PMC6443160 DOI: 10.1371/journal.pone.0214675] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 03/18/2019] [Indexed: 12/03/2022] Open
Abstract
Background Outreach and promotion programs are essential to ensuring uptake of new public health interventions and guidelines. We assessed the costs and operation dynamics of outreach and promotion efforts for up front Xpert MTB/RIF (Xpert) testing for pediatric presumptive tuberculosis (TB) patients in four major Indian cities. Methods Xpert test costs were assessed as weighted average per-test costs based on the daily workload dynamics matched by test volume specific Xpert unit cost at each study site. Costs of outreach programs to recruit health providers to refer pediatric patients for Xpert testing were assessed as cost per referral for each quarter based on total program costs and referral data. All costs were assessed in the health service provider’s perspective and expressed in 2015 USD. Results Weighted average per-test costs ranged from $14.71 to $17.81 at the four laboratories assessed. Differences between laboratories were associated with unused testing capacity and/or frequencies of overtime work to cope with increasing demand and same-day testing requirements. Outreach activities generated between 825 and 2,065 Xpert testing referrals on average each quarter across the four study sites, translating into $0.63 to $2.55 per patient referred. Overall outreach costs per referral decreased with time, stabilizing at an average cost of $1.10, and demonstrated a clear association with increased referrals. Conclusions Xpert test and outreach program costs within and across study sites were mainly driven by the dynamics of Xpert testing demand resulting from the combined outreach activities. However, these increases in demand required considerable overtime work resulting in additional costs and operational challenges at the study laboratories. Therefore, careful laboratory operational adjustment should be evaluated at target areas in parallel to the anticipated demand from the Xpert referral outreach program scale-up in other Indian regions.
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Affiliation(s)
- Sanjay Sarin
- Foundation for Innovative New Diagnostics, New Delhi, India
| | - Sophie Huddart
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- McGill International TB Centre, Montreal, Quebec, Canada
| | - Neeraj Raizada
- Foundation for Innovative New Diagnostics, New Delhi, India
| | | | - Aakshi Kalra
- Foundation for Innovative New Diagnostics, New Delhi, India
| | - Raghuram Rao
- Central TB Division, Government of India, New Delhi, India
| | | | | | | | | | - Hojoon Sohn
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
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13
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Walker BN, Rehg JM, Kalra A, Winters RM, Drews P, Dascalu J, David EO, Dascalu A. Dermoscopy diagnosis of cancerous lesions utilizing dual deep learning algorithms via visual and audio (sonification) outputs: Laboratory and prospective observational studies. EBioMedicine 2019; 40:176-183. [PMID: 30674442 PMCID: PMC6413349 DOI: 10.1016/j.ebiom.2019.01.028] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 12/23/2018] [Accepted: 01/11/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Early diagnosis of skin cancer lesions by dermoscopy, the gold standard in dermatological imaging, calls for a diagnostic upscale. The aim of the study was to improve the accuracy of dermoscopic skin cancer diagnosis through use of novel deep learning (DL) algorithms. An additional sonification-derived diagnostic layer was added to the visual classification to increase sensitivity. METHODS Two parallel studies were conducted: a laboratory retrospective study (LABS, n = 482 biopsies) and a non-interventional prospective observational study (OBS, n = 63 biopsies). A training data set of biopsy-verified reports, normal and cancerous skin lesions (n = 3954), were used to develop a DL classifier exploring visual features (System A). The outputs of the classifier were sonified, i.e. data conversion into sound (System B). Derived sound files were analyzed by a second machine learning classifier, either as raw audio (LABS, OBS) or following conversion into spectrograms (LABS) and by image analysis and human heuristics (OBS). The OBS criteria outcomes were System A specificity and System B sensitivity as raw sounds, spectrogram areas or heuristics. FINDINGS LABS employed dermoscopies, half benign half malignant, and compared the accuracy of Systems A and B. System A algorithm resulted in a ROC AUC of 0.976 (95% CI, 0.965-0.987). Secondary machine learning analysis of raw sound, FFT and Spectrogram ROC curves resulted in AUC's of 0.931 (95% CI 0.881-0.981), 0.90 (95% CI 0.838-0.963) and 0.988 (CI 95% 0.973-1.001), respectively. OBS analysis of raw sound dermoscopies by the secondary machine learning resulted in a ROC AUC of 0.819 (95% CI, 0.7956 to 0.8406). OBS image analysis of AUC for spectrograms displayed a ROC AUC of 0.808 (CI 95% 0.6945 To 0.9208). By applying a heuristic analysis of Systems A and B a sensitivity of 86% and specificity of 91% were derived in the clinical study. INTERPRETATION Adding a second stage of processing, which includes a deep learning algorithm of sonification and heuristic inspection with machine learning, significantly improves diagnostic accuracy. A combined two-stage system is expected to assist clinical decisions and de-escalate the current trend of over-diagnosis of skin cancer lesions as pathological. FUND: Bostel Technologies. Trial Registration clinicaltrials.gov Identifier: NCT03362138.
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Affiliation(s)
- B N Walker
- Sonification Lab, School of Psychology, School of Interactive Computing, Georgia Institute of Technology (Walker BN), Georgia
| | - J M Rehg
- School of Interactive Computing, Georgia Institute of Technology, Atlanta, Georgia
| | | | - R M Winters
- Institute of GT Sonification Lab, Georgia Technology, Atlanta, Georgia
| | - P Drews
- Institute for Robotics and Intelligent Machines, Georgia Institute of Technology, Atlanta, Georgia
| | - J Dascalu
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - E O David
- Department of Computer Science, Bar-Ilan University, Ramat-Gan, Israel
| | - A Dascalu
- Department of Physiology and Pharmacology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Abstract
INTRODUCTION King's College Hospital has proudly provided a one-stop neck lump clinic since 2012. These multidisciplinary clinics allow for rapid diagnoses due to in-clinic investigations. In April 2013, ultrasound-guided core needle biopsies were introduced as an alternative/adjunct to fine-needle aspiration cytology and open biopsies for obtaining histological diagnoses. The aim of the study was to assess the impact of core needle biopsies on the diagnosis of neck lumps compared with fine-needle aspiration cytology and open biopsies between April 2015 and May 2016. MATERIALS AND METHODS Data were collected prospectively between April 2015 and May 2016 and analysed for numbers of fine-needle aspiration cytology, core needle biopsies and open biopsies performed and diagnoses made. RESULTS A total of 190 patients were seen on the clinic; 51 had fine-needle aspiration cytology and 19 procedures gave a diagnosis. Of the remainder of these patients, 21 went on to have a core needle biopsy and 12 biopsies gave a diagnosis. An additional eight patients only had a core needle biopsy, of which five biopsies gave a diagnosis. Of the ten patients who had an open biopsy, four had a previous fine-needle aspiration cytology and core needle biopsy, three only a core needle biopsy, two had neither and one had fine-needle aspiration cytology. CONCLUSION The introduction of core needle biopsies has reduced the number of open biopsies performed. With increasing acceptance of this minimally invasive technique, core needle biopsies appear to be forming the key diagnostic investigation in patients with neck lumps.
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Affiliation(s)
- A Kalra
- Department of Oral and Maxillofacial Surgery, King's College Hospital , London , UK
| | - G-M Prucher
- Department of Oral and Maxillofacial Surgery, King's College Hospital , London , UK
| | - S Hodges
- Department of Oral and Maxillofacial Surgery, King's College Hospital , London , UK
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Raizada N, Khaparde SD, Rao R, Kalra A, Sarin S, Salhotra VS, Swaminathan S, Khanna A, Chopra KK, Hanif M, Singh V, Umadevi KR, Nair SA, Huddart S, Tripathi R, Surya Prakash CH, Saha BK, Denkinger CM, Boehme C. Upfront Xpert MTB/RIF testing on various specimen types for presumptive infant TB cases for early and appropriate treatment initiation. PLoS One 2018; 13:e0202085. [PMID: 30161142 PMCID: PMC6116934 DOI: 10.1371/journal.pone.0202085] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 07/29/2018] [Indexed: 11/18/2022] Open
Abstract
Background Diagnosis of tuberculosis (TB) in infants is challenging due to non-specific clinical presentations of the disease in this age-group and low sensitivity of widely available TB diagnostic tools, which in turn delays prompt access to TB treatment. Upfront access to Xpert/MTB RIF (Xpert) testing, a highly sensitive and specific rapid diagnostic tool, could potentially address some of these challenges. Under the current project, we assessed the utility and feasibility of applying upfront Xpert for diagnosis of tuberculosis in infants, including for testing of non-sputum specimens. Methods A high throughput lab was established in each of the four project cities, and linked to various health care providers across the city, through rapid specimen transportation and electronic reporting linkages. Free Xpert testing was offered to all infant (<2 years of age) presumptive TB cases (both pulmonary and extra-pulmonary) seeking care at public and private health facilities. Results A total of 7,994 presumptive infant TB cases were enrolled in the project from April 2014 to October 2016, detecting 465 (5.8%, CI: 5.3–6.4) TB cases. The majority (93.9%; CI: 93.4–94.4) of patient specimens were non-sputum and TB positivity was higher amongst non-sputum specimens. Further, a high proportion (5.6% CI 3.8–8.1) of infant TB cases were found to be rifampicin resistant. Covering large cities with a single lab per city over more than two years, the project demonstrated the feasibility of same-day diagnosis with upfront Xpert testing. This in turn led to prompt treatment initiation, with a two-day median turnaround time to treatment initiation. Case mortality observed in the project cohort of diagnosed TB cases was 11.0% (CI 8.4–14.1), the majority of which was pre- or early treatment mortality, in spite of prompt access to treatment for most diagnosed cases. Conclusion The current project demonstrated the feasibility of applying rapid and upfront Xpert testing for presumptive infant TB cases. Rapid TB diagnosis in turn facilitates prompt and appropriate treatment initiation. Further, levels of rifampicin resistance observed in infants TB cases highlight the additional benefit of upfront resistance testing. However, high rates of early case mortality, in spite of prompt diagnosis and treatment initiation, highlight the need for further research in infant patient pathways for overall improvement in TB care for infant populations.
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Affiliation(s)
- Neeraj Raizada
- Foundation for Innovative New Diagnostics, New Delhi, India
| | | | - Raghuram Rao
- Central TB Division, Government of India, New Delhi, India
| | - Aakshi Kalra
- Foundation for Innovative New Diagnostics, New Delhi, India
| | - Sanjay Sarin
- Foundation for Innovative New Diagnostics, New Delhi, India
| | | | | | | | | | - M. Hanif
- New Delhi TB Centre, New Delhi, India
| | - Varinder Singh
- Lady Hardinge Medical College and assoc Kalawati Saran Children's Hospital, New Delhi, India
| | - K. R. Umadevi
- National Institute of research in Tuberculosis, Chennai, India
| | | | | | | | | | - B. K. Saha
- Intermediate Reference Laboratory, Kolkata, India
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McDowell A, Raizada N, Khaparde SD, Rao R, Sarin S, Kalra A, Salhotra VS, Nair SA, Boehme C, Denkinger CM. "Before Xpert I only had my expertise": A qualitative study on the utilization and effects of Xpert technology among pediatricians in 4 Indian cities. PLoS One 2018; 13:e0193656. [PMID: 29547642 PMCID: PMC5856339 DOI: 10.1371/journal.pone.0193656] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 02/15/2018] [Indexed: 11/21/2022] Open
Abstract
Background Diagnosing tuberculosis (TB) in children presents considerable challenges. Upfront testing on Xpert® MTB/RIF (‘Xpert’)—a rapid molecular assay with high sensitivity and specificity—for pediatric presumptive TB patients, as recommended by India’s Revised National Tuberculosis Control Program (RNTCP), can pave the way for early TB diagnosis. As part of an ongoing project implemented by Foundation for Innovative New Diagnostics (FIND) dedicated to providing upfront free-of-cost (FOC) Xpert testing to children seeking care in the public and private sectors, a qualitative assessment was designed to understand how national guidelines on TB diagnosis and Xpert technology have been integrated into the pediatric TB care practices of different health providers. Methods We conducted semi-structured interviews with a sample of health providers from public and private sectors engaged in the ongoing pediatric project in 4 major cities of India. Providers were sampled from intervention data based on sector of practice, number of Xpert referrals, and TB detection rates amongst referrals. A total of 55 providers were interviewed with different levels of FOC Xpert testing uptake. Data were transcribed and analyzed inductively by a medical anthropologist using thematic content analysis and narrative analysis. Results It was observed that despite guidance from RNTCP on the use of Xpert and significant efforts by FIND and state authorities to disseminate these guidelines, there was notable diversity in their implementation by different health care providers. Xpert, apart from being utilized as intended, i.e. as a first diagnostic test for children, was utilized variably–as an initial screening test (to rule out TB), confirmatory test (once TB diagnosis is established based on antibiotic trial or clinically) and/or only for drug susceptibility testing after TB diagnosis was confirmed. Most providers who used Xpert frequently reported that Xpert was an important tool for managing pediatric TB cases, by reducing the proportion of cases diagnosed only on clinical suspicion and by providing upfront information on drug resistance, which is seldom suspected in children. Despite non-standard use, these results showed that Xpert access helped raise awareness, aided in antibiotic stewardship, and reduced dependence on clinical diagnosis among those who diagnose and treat TB in children. Conclusion Access to free and rapid Xpert testing for all presumptive pediatric TB patients has had multiple positive effects on pediatricians’ diagnosis and treatment of TB. It has important effects on speed of diagnosis, empirical treatment, and awareness of drug resistance among TB treatment naive children. In addition, our study shows that access to public sector Xpert machines may be an important way to encourage Public-Private integration and facilitate the movement of patients from the private to public sector for anti-TB treatment. Despite availability of rapid and free Xpert testing, our study showed an alarming diversity of Xpert utilization strategies across different providers who may be moving toward suggested practice over time. The degree of diversity in TB diagnostic approaches in children reported here highlights the urgent need for concerted efforts to place Xpert early in diagnostic algorithms to positively impact the pediatric TB care pathway. A positive change in diagnostic algorithms may be possible with continued advocacy, time, and increased access.
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Affiliation(s)
- Andrew McDowell
- Institut National de la Santé et Recherché Medical, Paris, France
- Harvard Medical School Center for Global Health Delivery, Dubai, United Arab Emirates
| | - Neeraj Raizada
- Foundation for Innovative New Diagnostics, New Delhi, India
| | | | - Raghuram Rao
- Central TB Division, Government of India, New Delhi, India
| | - Sanjay Sarin
- Foundation for Innovative New Diagnostics, New Delhi, India
| | - Aakshi Kalra
- Foundation for Innovative New Diagnostics, New Delhi, India
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Raizada N, Khaparde SD, Swaminathan S, Sarin S, Salhotra VS, Kalra A, Khanna A, Chopra KK, Hanif M, Umadevi KR, Hissar S, Nair SA, Prakash CHS, Saha BK, Rao R, Denkinger C, Boehme C. Catalysing progressive uptake of newer diagnostics by health care providers through outreach and education in four major cities of India. PLoS One 2018; 13:e0193341. [PMID: 29509803 PMCID: PMC5839557 DOI: 10.1371/journal.pone.0193341] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 02/08/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Unlike in adults, diagnosis of TB can be challenging in children, as signs and symptoms of paediatric TB can be very non-specific and similar to other common childhood chest infections, which may lead to under or delayed diagnosis of TB disease. In spite of the increasing availability of rapid high-sensitivity diagnostics in public and private sectors, majority of paediatric TB cases are empirically diagnosed, without laboratory confirmation. To address these diagnostic challenges, World Health Organization (WHO) has recommended upfront Xpert MTB/RIF (Xpert) testing for the diagnosis of TB in paediatric presumptive pulmonary and extra-pulmonary TB (EPTB) cases. However, in spite of the increasing availability of rapid high-sensitivity diagnostics, a significant gap exists in its application with Xpert being rarely used as an upfront diagnostic among patients presumed to have TB. Under an ongoing paediatric project since April 2014, which provided free-of-cost upfront Xpert testing, several low-cost outreach and education interventions were undertaken to increase the diagnostic uptake by different providers catering to the paediatric population, thereby increasing adherence to global guidance. METHODS Providers catering to paediatric population in the project cities were systematically mapped and contacted using different outreach strategies. The focus of outreach efforts was to increase provider literacy and increase their awareness of the availability of free rapid diagnostic services with the goal of changing their diagnostic approaches. RESULTS From April 2014 to June 2016, more than 5,700 providers/facilities were mapped and 3,670 of them were approached. The number of providers/facilities engaged under the project increased more than 10-fold (43 in April, 2014 to 466 in June, 2016), with significant increase in project uptake, both from public and private sector. Overall 42,238 paediatric presumptive TB cases were enrolled in the project, across the four cities. Over the project period, quarterly diagnostic uptake and paediatric TB cases detection rates increased more than two-fold. TB detection rates were similar in patients from public and private sectors. CONCLUSIONS Ongoing efforts in scaling up new rapid diagnostics involves significant investments. These efforts need to be complemented with proactive provider engagement to ensure provider-literacy and awareness, for maximizing impact of this scale-up. The current project demonstrated the usefulness of outreach and education interventions for the effective uptake of newer diagnostics.
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Affiliation(s)
- Neeraj Raizada
- Foundation for Innovative New Diagnostics, New Delhi, India
| | | | | | - Sanjay Sarin
- Foundation for Innovative New Diagnostics, New Delhi, India
| | | | - Aakshi Kalra
- Foundation for Innovative New Diagnostics, New Delhi, India
- * E-mail:
| | | | | | - M. Hanif
- New Delhi TB Centre, New Delhi, India
| | - K. R. Umadevi
- National Institute for research in Tuberculosis, Chennai, India
| | - Syed Hissar
- National Institute for research in Tuberculosis, Chennai, India
| | | | | | - B. K. Saha
- Intermediate Reference Laboratory, Kolkata, India
| | - Raghuram Rao
- Central TB Division, Government of India, New Delhi, India
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Raizada N, Khaparde SD, Salhotra VS, Rao R, Kalra A, Swaminathan S, Khanna A, Chopra KK, Hanif M, Singh V, Umadevi KR, Nair SA, Huddart S, Prakash CHS, Mall S, Singh P, Saha BK, Denkinger CM, Boehme C, Sarin S. Accelerating access to quality TB care for pediatric TB cases through better diagnostic strategy in four major cities of India. PLoS One 2018; 13:e0193194. [PMID: 29489887 PMCID: PMC5830996 DOI: 10.1371/journal.pone.0193194] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 02/06/2018] [Indexed: 11/25/2022] Open
Abstract
Background Diagnosis of TB in children is challenging, and is largely based on positive history of contact with a TB case, clinical and radiological findings, often without microbiological confirmation. Diagnostic efforts are also undermined by challenges in specimen collection and the limited availability of high sensitivity, rapid diagnostic tests that can be applied with a quick turnaround time. The current project was undertaken in four major cities of India to address TB diagnostic challenges in pediatric population, by offering free of cost Xpert testing to pediatric presumptive TB cases, thereby paving the way for better TB care. Methods A high throughput lab was established in each of the four project cities, and linked to various health care providers across the city through rapid specimen transportation and electronic reporting linkages. Free Xpert testing was offered to all pediatric (0–14 years) presumptive TB cases (both pulmonary and extra-pulmonary) seeking care at public and private health facilities. Results The current project enrolled 42,238 pediatric presumptive TB cases from April, 2014 to June, 2016. A total of 3,340 (7.91%, CI 7.65–8.17) bacteriologically confirmed TB cases were detected, of which 295 (8.83%, CI 7.9–9.86) were rifampicin-resistant. The level of rifampicin resistance in the project cohort was high. Overall Xpert yielded a high proportion of valid results and TB detection rates were more than three-fold higher than smear microscopy. The project provided same-day testing and early availability of results led to rapid treatment initiation and success rates and very low rates of treatment failure and loss to follow-up. Conclusion The current project demonstrated the feasibility of rolling out rapid and upfront Xpert testing for pediatric presumptive TB cases through a single Xpert lab per city in an efficient manner. Rapid turnaround testing time facilitated prompt and appropriate treatment initiation. These results suggest that the upfront Xpert assay is a promising solution to address TB diagnosis in children. The high levels of rifampicin resistance detected in presumptive pediatric TB patients tested under the project are a major cause of concern from a public health perspective which underscores the need to further prioritize upfront Xpert access to this vulnerable population.
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Affiliation(s)
- Neeraj Raizada
- Foundation for Innovative New Diagnostics, New Delhi, India
| | | | | | - Raghuram Rao
- Central TB Division, Government of India, New Delhi, India
| | - Aakshi Kalra
- Foundation for Innovative New Diagnostics, New Delhi, India
| | | | | | | | - M. Hanif
- New Delhi TB Centre, New Delhi, India
| | - Varinder Singh
- Lady Hardinge Medical College and assoc Kalawati Saran Children’s Hospital, New Delhi, India
| | - K. R. Umadevi
- National Institute of research in Tuberculosis, Chennai, India
| | | | | | | | - Shalini Mall
- Foundation for Innovative New Diagnostics, New Delhi, India
| | - Pooja Singh
- Foundation for Innovative New Diagnostics, New Delhi, India
| | - B. K. Saha
- Intermediate Reference Laboratory, Kolkata, India
| | | | | | - Sanjay Sarin
- Foundation for Innovative New Diagnostics, New Delhi, India
- * E-mail:
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Kalra A, Hussain A, Bowley R, Prucher G, Hodges S. The Role of Core Needle Biopsies in the Management of Neck Lumps. Int J Surg 2017. [DOI: 10.1016/j.ijsu.2017.08.264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Affiliation(s)
- A. Kalra
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram, Institute of Economic Growth, Delhi University, New Delhi, India
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Rudra S, Kalra A, Kumar A, Joe W. Utilization of alternative systems of medicine as health care services in India: Evidence on AYUSH care from NSS 2014. PLoS One 2017; 12:e0176916. [PMID: 28472197 PMCID: PMC5417584 DOI: 10.1371/journal.pone.0176916] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 04/19/2017] [Indexed: 11/21/2022] Open
Abstract
AYUSH, an acronym for Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-Rigpa and Homeopathy represents the alternative systems of medicine recognized by the Government of India. Understanding the patterns of utilization of AYUSH care has been important for various reasons including an increased focus on its mainstreaming and integration with biomedicine-based health care system. Based on a nationally representative health survey 2014, we present an analysis to understand utilization of AYUSH care across socioeconomic and demographic groups in India. Overall, 6.9% of all patients seeking outpatient care in the reference period of last two weeks have used AYUSH services without any significant differentials across rural and urban India. Importantly, public health facilities play a key role in provisioning of AYUSH care in rural areas with higher utilization in Chhattisgarh, Kerala and West Bengal. Use of AYUSH among middle-income households is lower when compared with poorer and richer households. We also find that low-income households display a greater tendency for AYUSH self-medication. AYUSH care utilization is higher among patients with chronic diseases and also for treating skin-related and musculo-skeletal ailments. Although the overall share of AYUSH prescription drugs in total medical expenditure is only about 6% but the average expenditure for drugs on AYUSH and allopathy did not differ hugely. The discussion compares our estimates and findings with other studies and also highlights major policy issues around mainstreaming of AYUSH care.
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Affiliation(s)
- Shalini Rudra
- Associate Fellow, Observer Research Foundation, New Delhi, India
| | - Aakshi Kalra
- Population Research Centre, Institute of Economic Growth, Delhi University North Campus, Delhi, India
| | - Abhishek Kumar
- Population Research Centre, Institute of Economic Growth, Delhi University North Campus, Delhi, India
| | - William Joe
- Population Research Centre, Institute of Economic Growth, Delhi University North Campus, Delhi, India
- * E-mail:
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Barnawal D, Pandey S, Bharti N, Pandey A, Ray T, Singh S, Chanotiya C, Kalra A. ACC deaminase-containing plant growth-promoting rhizobacteria protect Papaver somniferum
from downy mildew. J Appl Microbiol 2017; 122:1286-1298. [DOI: 10.1111/jam.13417] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 01/27/2017] [Accepted: 02/07/2017] [Indexed: 11/30/2022]
Affiliation(s)
- D. Barnawal
- Microbial Technology Department; CSIR-Central Institute of Medicinal and Aromatic Plants; Lucknow Uttar Pradesh India
| | - S.S. Pandey
- Microbial Technology Department; CSIR-Central Institute of Medicinal and Aromatic Plants; Lucknow Uttar Pradesh India
| | - N. Bharti
- Microbial Technology Department; CSIR-Central Institute of Medicinal and Aromatic Plants; Lucknow Uttar Pradesh India
| | - A. Pandey
- Microbial Technology Department; CSIR-Central Institute of Medicinal and Aromatic Plants; Lucknow Uttar Pradesh India
| | - T. Ray
- Microbial Technology Department; CSIR-Central Institute of Medicinal and Aromatic Plants; Lucknow Uttar Pradesh India
| | - S. Singh
- Microbial Technology Department; CSIR-Central Institute of Medicinal and Aromatic Plants; Lucknow Uttar Pradesh India
| | - C.S. Chanotiya
- Central Instrument Facility; CSIR-Central Institute of Medicinal and Aromatic Plants; Lucknow Uttar Pradesh India
| | - A. Kalra
- Microbial Technology Department; CSIR-Central Institute of Medicinal and Aromatic Plants; Lucknow Uttar Pradesh India
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Affiliation(s)
- A Kapila
- East Tennessee State University, Johnson City, Tennessee, USA
| | - A Kalra
- East Tennessee State University, Johnson City, Tennessee, USA
| | - L Chhabra
- University of Connecticut, Hartford, Connecticut, USA
| | - R Murthy
- Gastroenterology, James H Quillen VA Medical Center, Johnson City, Tennessee, USA
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Kalra A. The basics of Kaplan–Meier estimate. J Pract Cardiovasc Sci 2016. [DOI: 10.4103/2395-5414.201381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Maji D, Singh M, Wasnik K, Chanotiya C, Kalra A. The role of a novel fungal strain Trichoderma atroviride
RVF3 in improving humic acid content in mature compost and vermicompost via ligninolytic and celluloxylanolytic activities. J Appl Microbiol 2015; 119:1584-96. [DOI: 10.1111/jam.12954] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 08/26/2015] [Accepted: 09/11/2015] [Indexed: 11/27/2022]
Affiliation(s)
- D. Maji
- Microbial Technology Department; CSIR-Central Institute of Medicinal and Aromatic Plants; Lucknow Uttar Pradesh India
| | - M. Singh
- Central Instrument Facility; CSIR-Central Institute of Medicinal and Aromatic Plants; Lucknow Uttar Pradesh India
| | - K. Wasnik
- Microbial Technology Department; CSIR-Central Institute of Medicinal and Aromatic Plants; Lucknow Uttar Pradesh India
| | - C.S. Chanotiya
- Central Instrument Facility; CSIR-Central Institute of Medicinal and Aromatic Plants; Lucknow Uttar Pradesh India
| | - A. Kalra
- Microbial Technology Department; CSIR-Central Institute of Medicinal and Aromatic Plants; Lucknow Uttar Pradesh India
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Rajaram S, Desai N, Kalra A, Gajera M, Cavanaugh S, Brampton W, Young D, Harvey S, Rowan K. TROMBÓLISIS PREHOSPITALARIA VERSUS INTRAHOSPITALARIA PARA EL INFARTO DE MIOCARDIO CON ELEVACIÓN DEL ST. Revista Médica Clínica Las Condes 2015. [DOI: 10.1016/j.rmclc.2015.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Pokharel Y, Hira R, Kalra A, Shore S, Kerkar P, Kumar G, Risch S, Vicera V, Oetgen W, Turakhia M, Glusenkamp N, Virani S. Guideline recommended medication use among systolic heart failure patients in India: Insights from the American college of cardiology practice innovation and clinical excellence (PINNACLE)® India Registry. Indian Heart J 2014. [DOI: 10.1016/j.ihj.2014.10.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Singh H, Sukhija G, Tanwar V, Talapatra P, Kaur P, Arora S, Kalra A. Evaluation of functional disability and its correlation with disease activity in rheumatoid arthritis. Indian Journal of Rheumatology 2014. [DOI: 10.1016/j.injr.2014.10.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Singh H, Sukhija G, Kaur P, Tanwar V, Talapatra P, Arora S, Kalra A. To study the correlation of anxiety and depression with disease activity in patients of rheumatoid arthritis (RA). Indian Journal of Rheumatology 2014. [DOI: 10.1016/j.injr.2014.10.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Singh H, Tanwar V, Sukhija G, Kaur P, Talapatra P, Kalra A, Arora S. Evaluation of rheumatoid arthritis disease activity index ⊟5 (RADAI-5) for follow up of disease activity in RA. Indian Journal of Rheumatology 2014. [DOI: 10.1016/j.injr.2014.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Abstract
Burden of Influenza is significantly higher in developing countries as compared to developed countries, but the data on the disease burden is less well defined in most of the developing countries including India, and consequently, constraints evolving strategies for prioritization of measures to prevent and control it. The swine flu or A(H1N1) pandemic is on the wane but the virus continues to circulate causing sporadic outbreaks even in 2013. The A(H1N1)pdm09 has replaced the previous circulating seasonal A (H1N1) virus and acquired the status of a seasonal virus. Limited influenza activity is usually seen throughout the year in India with a clear peaking during the rainy season. The rainy season in the country lasts from June to August in all the regions except Tamil Nadu where it occurs from October to December. IAP recommends the ideal time for offering influenza vaccines is just before the onset of rainy season. The efficacy/effectiveness data of trivalent inactivated influenza vaccines are also presented in different age groups and different categories of individuals. The IAP maintains its earlier recommendations of using the current trivalent inactivated influenza vaccine in all children with risk factors but not as a universal measure. IAP has now prioritized different target groups for influenza vaccination based on contribution of the group to the overall influenza burden, disease severity, and vaccine effectiveness in different age groups and categories. The current trivalent inactivated influenza vaccines incorporate the 2009 pandemic strain also, hence avert the need of a separate A (H1N1) vaccine. IAP stresses the need of more refined surveillance; large scale studies on effectiveness of seasonal influenza vaccines in Indian children, and more effective, properly matched, higher-valent influenza vaccines.
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Affiliation(s)
- V M Vashishtha
- Advisory Committee on Vaccines and Immunization Practices, Indian Academy of Pediatrics. Correspondence to: Dr Vipin M Vashishtha, Convener, IAP Advisory Committee on Vaccines and Immunization Practices (ACVIP), Mangla Hospital and Research Center, Shakti Chowk, Bijnor, Uttar Pradesh, 246701, India.
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Kalra A, Seth S. Redirecting stem cell therapy. Natl Med J India 2014; 27:17-18. [PMID: 25403118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Aakshi Kalra
- Department of Cardiology Cardiothoracic Centre All India Institute of Medical Sciences New Delhi
| | - Sandeep Seth
- Department of Cardiology Cardiothoracic Centre All India Institute of Medical Sciences New Delhi
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Premalatha K, Kalra A. Molecular phylogenetic identification of endophytic fungi isolated from resinous and healthy wood of Aquilaria malaccensis, a red listed and highly exploited medicinal tree. FUNGAL ECOL 2013. [DOI: 10.1016/j.funeco.2013.01.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Arora N, Kalra A, Kausar H, Ghosh TK, Majumdar A. Primitive neuroectodermal tumour of uterine cervix - a diagnostic and therapeutic dilemma. J OBSTET GYNAECOL 2013; 32:711-3. [PMID: 22943734 DOI: 10.3109/01443615.2012.689028] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- N Arora
- Department of Obstetrics and Gynaecology, ESI Post Graduate Institute of Medical Science and Research, Joka, India.
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Curley M, Kalra A, Fulgham A, Xiao D, Allen J, Wainszelbaum M, Garcia G, Kubasek W, MacBeath G. 141 MM-121, an Anti-ErbB3 Antibody, Inhibits PI3K/AKT Signaling and Viability in Platinum-resistant Ovarian Cells and in Primary Ascites Derived From Chemo-resistant Ovarian Cancer Patients. Eur J Cancer 2012. [DOI: 10.1016/s0959-8049(12)71939-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kalra A, Abouzgheib W, Gajera M, Palaniswamy C, Puri N, Dellinger RP. Excessive dynamic airway collapse for the internist: new nomenclature or different entity? Postgrad Med J 2011; 87:482-6. [DOI: 10.1136/pgmj.2010.111948] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Chawla SP, Chua VS, Mohan V, Alzwahereh K, Kalra A, Quon D, Gordon EM, Hall FL. Phase I/II study of targeted gene delivery in vivo—intravenous infusions of Rexin-G—demonstrate significant biologic activity by FDG PET-CT without toxicity in patients with progressive chemo-resistant sarcoma, breast cancer and pancreatic cancer. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.14509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Mohan V, Chawla T, Alzwahereh K, Jeong W, Kita KY, Chua VS, Kalra A, Rana GS, Chawla SP. Updated results of Phase II study of trabectedin (ET-743) in pretreated patients with advanced/metastatic soft tissue sarcoma from a single institute. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.21506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
Rhodococcus equi, a Gram positive organism, is a cause of infections in immunocompromised individuals. In humans, it mainly causes disease in those infected with human immunodeficiency virus (HIV), and generally presents as chronic pulmonary infection. It may also cause intracranial infections, which manifest as brain abscesses. This report describes a case of rhodococcus brain and pulmonary infection in a patient who did not have HIV or another disorder of cell mediated immunity. He was treated with intravenous imipenem, vancomycin, and rifampin for eight weeks and recovered from the infection.
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Affiliation(s)
- M Kamboj
- Department of Internal Medicine, Michigan State University College of Human Medicine, East Lansing, MI 48824, USA
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Mallavarapu GR, Ramesh S, Mengi N, Kalra A. Chemical Composition of the Essential Oil ofPlectranthus melissoidesBenth. Journal of Essential Oil Research 2005. [DOI: 10.1080/10412905.2005.9698895] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Kalra A, Urban MO, Sluka KA. Blockade of opioid receptors in rostral ventral medulla prevents antihyperalgesia produced by transcutaneous electrical nerve stimulation (TENS). J Pharmacol Exp Ther 2001; 298:257-63. [PMID: 11408550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023] Open
Abstract
Although transcutaneous electrical nerve stimulation (TENS) is used extensively in inflammatory joint conditions such as arthritis, the underlying mechanisms are unclear. This study aims to demonstrate an opiate-mediated activation of descending inhibitory pathways from the rostral ventral medulla (RVM) in the antihyperalgesia produced by low- (4 Hz) or high-frequency (100 Hz) TENS. Paw withdrawal latency to radiant heat, as an index of secondary hyperalgesia, was recorded before and after knee joint inflammation (induced by intra-articular injection of 3% kaolin and carrageenan) and after TENS/no TENS coadministered with naloxone (20 microg/1 microl), naltrindole (5 microg/1 microl), or vehicle (1 microl) microinjected into the RVM. The selectivity of naloxone and naltrindole doses was tested against the mu-opioid receptor agonist [D-Ala2,N-Me-Phe4,Gly-ol5]-enkephalin (DAMGO) (20 ng, 1 microl) and the delta2-opioid receptor agonist deltorphin (5 microg, 1 microl) in the RVM. Naloxone microinjection into the RVM blocks the antihyperalgesia produced by low frequency (p < 0.001), but not that produced by high-frequency TENS (p > 0.05). In contrast, naltrindole injection into the RVM blocks the antihyperalgesia produced by high-frequency (p < 0.05), but not low-frequency (p > 0.05) TENS. The analgesia produced by DAMGO and deltorphin is selectively blocked by naloxone (p < 0.05) and naltrindole (p < 0.05), respectively. Thus, the dose of naloxone and naltrindole used in the current study blocks mu- and delta-opioid receptors, respectively. Hence, low-frequency and high-frequency TENS produces antihyperalgesia by activation of mu- and delta-opioid receptors, respectively, in the RVM.
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MESH Headings
- Analgesics, Opioid/pharmacology
- Animals
- Enkephalin, Ala(2)-MePhe(4)-Gly(5)-/pharmacology
- Hot Temperature
- Hyperalgesia/chemically induced
- Hyperalgesia/therapy
- Male
- Medulla Oblongata/drug effects
- Medulla Oblongata/physiology
- Naloxone/pharmacology
- Naltrexone/analogs & derivatives
- Naltrexone/pharmacology
- Narcotic Antagonists/pharmacology
- Oligopeptides/pharmacology
- Pain Measurement/drug effects
- Rats
- Rats, Sprague-Dawley
- Receptors, Opioid/drug effects
- Receptors, Opioid/physiology
- Receptors, Opioid, delta/drug effects
- Receptors, Opioid, delta/physiology
- Receptors, Opioid, mu/drug effects
- Receptors, Opioid, mu/physiology
- Transcutaneous Electric Nerve Stimulation
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Affiliation(s)
- A Kalra
- Physical Therapy Graduate Program, College of Medicine, University of Iowa, Iowa City, Iowa 52242, USA
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Abstract
This study characterizes an animal model of persistent mechanical hyperalgesia induced by repeated intramuscular injections of low pH saline. Saline at pH 4, 5, 6, or 7.2 was injected twice, 2 to 10 days apart, into the gastrocnemius muscle of rats. To quantify hyperalgesia, paw withdrawal latency to radiant heat (heat hyperalgesia) and withdrawal threshold to mechanical stimuli (mechanical hyperalgesia) were measured. Two unilateral injections of low pH saline, 5 days apart, caused a pH-dependent bilateral mechanical, but not heat, hyperalgesia that lasted 30 days. Injections given 2 and 5 days apart produced a significantly greater mechanical hyperalgesia than injections given 10 days apart. Lidocaine injection into the gastrocnemius muscle or unilateral dorsal rhizotomy, 24 h after the second injection (pH 4), had no effect on the contralateral mechanical hyperalgesia. Minimal histopathology was observed in the injected muscle, and changes were similar between groups injected with pH 4 and pH 7.2. Thus, this new model of widespread, chronic muscle-induced pain is unrelated to tissue damage and is not maintained by continued primary afferent input from the site of injury.
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Affiliation(s)
- K A Sluka
- Physical Therapy Graduate Program, 2600 Steindler Bldg., University of Iowa, Iowa City, Iowa 52242, USA.
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Abstract
The prevalence of left ventricular (LV) thrombus after acute myocardial infarction (AMI) has been reported high at 20-60%. Current reperfusion therapies such as thrombolysis have shown a trend toward reducing the incidence of LV thrombosis. However, the prevalence of LV thrombus after primary percutaneous coronary intervention (PCI) for AMI has not been systematically studied. At Massachusetts General Hospital 71 consecutive patients who underwent primary PCI for acute ST elevation MI were reviewed for the prevalence of LV thrombus evaluated by echocardiography. Echocardiography was performed within 5 days of infarction. PCI was successful in all patients. The time delay from symptom onset to intervention was 191 minutes. Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow was achieved in more than 80% of cases. Only 3 patients (4%) had echocardiographic evidence of LV thrombus. All 3 patients had anterior infarctions. The incidence among patients with anterior MI was 10% (3 of 30 patients). The prevalence of LV thrombus in patients treated with primary PCI for AMI is low (4%).
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Affiliation(s)
- A Kalra
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA
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Kalra A, Mahapatra GK, Dhalla D. Unusual presentation of mandibular extraoral sinus in a fourteen year old girl: a case report. J Indian Soc Pedod Prev Dent 2000; 18:111-4. [PMID: 11324200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
A case of fourteen year old healthy girl with complaint of a discharging sinus on the lower right side of face is reported. All teeth were vital and there was no evidence of periodontitis. There was no history of extraction of a tooth. Total leucocyte count, differential leucocyte count, fasting blood sugar, chest x-ray and routine urine examination were within normal limits. Actinomycosis and scrofuloderma which simulate such a condition were ruled out by culture study. The intraoral periapical x-ray of mandibular molar showed questionable periapical changes at the time of presentation. But definite osteolysis was observed in the repeat radiograph after three months. It was decided to extract the second molar and curette the sinus tract. The extraction proved to be difficult. On examination of the extracted tooth, it was found that the mandibular second molar and second premolar were fused together. The radiograph of the tooth taken after extraction showed confluence of the premolar pulp with the periodontal membrane. On follow up, the lesion was found to heal satisfactorily.
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Affiliation(s)
- A Kalra
- Dept. of Pedodontics, University College of Medical Sciences & Guru Teg Bahadur Hospital, Delhi
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Abstract
OBJECTIVE To compare angiographic and clinical outcomes of patients with acute myocardial infarction (AMI) who underwent primary percutaneous coronary intervention (PCI) versus rescue PCI following failed thrombolysis. BACKGROUND Patients presenting with AMI are treated either with primary PCI or with thrombolysis. When thrombolysis fails, rescue PCI is performed. METHODS AND RESULTS We compared the outcome of 105 consecutive patients with AMI who underwent either primary PCI (60 patients) or rescue PCI (45 patients) between January 1997 and January 1999. The patients were followed for up to 6 months. Time delay to reperfusion was significantly longer in the rescue PCI group (354 vs. 189 min; p < 0.001). The majority of patients received a stent (93%). Glycoprotein (GP) IIb/IIIa inhibitors were used in 53% of patients in the primary PCI group and in 22% in the rescue group. TIMI grade 3 flow was achieved in 93.3% of patients in the primary PCI group and in 88.8% in the rescue group (p = 0.08). Post-procedure ejection fraction was 53% in the primary PCI group and 47% in the rescue group (p = 0.014). A composite endpoint of death, recurrent MI, repeat PCI, coronary artery bypass grafting (CABG) and recurrent angina at 6 months occurred in 35% of the patients in the primary PCI group and 26.7% in the rescue group (p = 0.36). CONCLUSION Despite a significant delay to reperfusion and a lower immediate post-procedure ejection fraction, the clinical outcome of patients treated with rescue PCI following failed thrombolysis appears to be similar to that of patients treated with primary PCI at 6 months.
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Affiliation(s)
- G Gimelli
- Cardiology Division, Massachusetts General Hospital, Boston 02114, USA
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