Pub Date : 2025-04-01DOI: 10.1016/j.ijtb.2023.12.006
Hemant Deepak Shewade , Asha Frederick , Madhanraj Kalyanasundaram , Prabhadevi Ravichandran , S. Lokesh , K.V. Suma , S. Aarthi , G. Kiruthika , Joshua Chadwick , T. Daniel Rajasekar , K. Gayathri , R. Vijayaprabha , Delphina Peter Pathinathan , M. Bhavani Nivetha , Deiveegan Chidambaram , S. Kiran Pradeep , Tarun Bhatnagar , Shanmugasundaram Devika , S. Rajkumar , M. Sakthivel , Manoj V. Murhekar
Background
In 2021, India's national tuberculosis (TB) elimination programme recommended severity assessment using 16 indicators (involving clinical, laboratory and radiological assessment) for all TB patients at diagnosis. Patients with a total score more than one or emergency criteria were eligible for referral and inpatient care (called as severely ill). This guidance is yet to be implemented statewide in India. Even in ideal settings, we wanted to understand the feasibility of implementing and acting upon the findings of severity assessment using 16 indicators. Specifically, how many would be assessed and eligible for inpatient care, followed by early deaths (within two months) among those with and without severe illness.
Methods
In this cross-sectional study, for a period of one month (June 5 and July 5, 2022), we intended to comprehensively assess all adults (≥15 y) with TB (drug-sensitive) notified from eight public teaching hospitals (tertiary care facilities) in Tamil Nadu (0.1 million TB notifications per year), a southern Indian state. We also followed them up for early deaths.
Results
Among 557 notified, 399 (71.6 %) were comprehensively assessed. Among 399, a total of 246 (61.7 %) were eligible for inpatient care. Early deaths were reported in 23 (9.3 %) of those with severe illness (n = 246), when compared to one (0.7 %) in those without (n = 153).
Conclusion
Even in facilities with clinical and diagnostic capacity, only seven in ten adults were comprehensively assessed. Nearly all the early TB deaths happened among those with severe illness. In future (especially in resource constrained settings), until clinical and diagnostic capacity improves up to the primary level, and bed and staff availability increase to admit every six in ten TB patients at diagnosis, implementing and acting upon the findings of severity assessment using 16 indicators appears non-feasible.
{"title":"India's 2021 differentiated TB care guidance: Is it feasible to implement and act upon?","authors":"Hemant Deepak Shewade , Asha Frederick , Madhanraj Kalyanasundaram , Prabhadevi Ravichandran , S. Lokesh , K.V. Suma , S. Aarthi , G. Kiruthika , Joshua Chadwick , T. Daniel Rajasekar , K. Gayathri , R. Vijayaprabha , Delphina Peter Pathinathan , M. Bhavani Nivetha , Deiveegan Chidambaram , S. Kiran Pradeep , Tarun Bhatnagar , Shanmugasundaram Devika , S. Rajkumar , M. Sakthivel , Manoj V. Murhekar","doi":"10.1016/j.ijtb.2023.12.006","DOIUrl":"10.1016/j.ijtb.2023.12.006","url":null,"abstract":"<div><h3>Background</h3><div>In 2021, India's national tuberculosis (TB) elimination programme recommended severity assessment using 16 indicators (involving clinical, laboratory and radiological assessment) for all TB patients at diagnosis. Patients with a total score more than one or emergency criteria were eligible for referral and inpatient care (called as severely ill). This guidance is yet to be implemented statewide in India. Even in ideal settings, we wanted to understand the feasibility of implementing and acting upon the findings of severity assessment using 16 indicators. Specifically, how many would be assessed and eligible for inpatient care, followed by early deaths (within two months) among those with and without severe illness.</div></div><div><h3>Methods</h3><div>In this cross-sectional study, for a period of one month (June 5 and July 5, 2022), we intended to comprehensively assess all adults (≥15 y) with TB (drug-sensitive) notified from eight public teaching hospitals (tertiary care facilities) in Tamil Nadu (0.1 million TB notifications per year), a southern Indian state. We also followed them up for early deaths.</div></div><div><h3>Results</h3><div>Among 557 notified, 399 (71.6 %) were comprehensively assessed. Among 399, a total of 246 (61.7 %) were eligible for inpatient care. Early deaths were reported in 23 (9.3 %) of those with severe illness (n = 246), when compared to one (0.7 %) in those without (n = 153).</div></div><div><h3>Conclusion</h3><div>Even in facilities with clinical and diagnostic capacity, only seven in ten adults were comprehensively assessed. Nearly all the early TB deaths happened among those with severe illness. In future (especially in resource constrained settings), until clinical and diagnostic capacity improves up to the primary level, and bed and staff availability increase to admit every six in ten TB patients at diagnosis, implementing and acting upon the findings of severity assessment using 16 indicators appears non-feasible.</div></div>","PeriodicalId":39346,"journal":{"name":"Indian Journal of Tuberculosis","volume":"72 2","pages":"Pages 183-188"},"PeriodicalIF":0.0,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139190073","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Tuberculosis (TB) is an infectious disease that causes health problems and is the main cause of death in the world. TB caused by Mycobacterium Tuberculosis Bacillus can spread in the air if a patient who is sick with TB exhales coughs containing TB bacteria. One of the supporters of the success rate of TB recovery is the patient's ability to carry out independent care consisting of treatment, prevention and transmission, fulfillment of nutrition, and increasing the patient's self-confidence.
Purpose
This study aims to produce self-care guidelines based: self-care agency for TB patients with output in the form of self-care guidelines for tuberculosis patients at the Sentosa Baru Public Health Center, North Sumatra.
Method
The method of this research is action research which consists of the stages of reconnaissance, planning, acting observation, and reflecting. Data collection methods used patient knowledge questionnaires about tuberculosis self-care, Focus Group Discussions (FGD), and in-depth interviews for participants' knowledge. The participants involved in this study were 22 participants using a purposive sampling technique from October 2018 to January 2019. Data analysis used qualitative methods. Qualitative data were obtained through the results of FGDs and in-depth interviews about self-care.
Results
This study has produced self-care agency-based self-care guidelines for tuberculosis patients. This study produced three themes, namely 1) the development of self-care guidelines for TB patients, 2) the benefits of self-care guidelines for TB patients, and 3) factors in supporting self-care for TB patients.
Conclusion
The successful treatment of TB patients at the Sentosa Baru Public Health Center, North Sumatra, requires agency-based self-care guidelines to produce high tuberculosis care.
{"title":"The development of self-care guidelines based: Self-care agency in tuberculosis patients at public health center, North Sumatra","authors":"Lina Berliana Togatorop , Setiawan , Cholina Trisa Siregar","doi":"10.1016/j.ijtb.2024.01.006","DOIUrl":"10.1016/j.ijtb.2024.01.006","url":null,"abstract":"<div><h3>Background</h3><div>Tuberculosis (TB) is an infectious disease that causes health problems and is the main cause of death in the world. TB caused by Mycobacterium Tuberculosis<span><span> Bacillus can spread in the air if a patient who is sick with TB exhales </span>coughs containing TB bacteria. One of the supporters of the success rate of TB recovery is the patient's ability to carry out independent care consisting of treatment, prevention and transmission, fulfillment of nutrition, and increasing the patient's self-confidence.</span></div></div><div><h3>Purpose</h3><div>This study aims to produce self-care guidelines based: self-care agency for TB patients with output in the form of self-care guidelines for tuberculosis patients at the Sentosa Baru Public Health Center, North Sumatra.</div></div><div><h3>Method</h3><div>The method of this research is action research which consists of the stages of reconnaissance, planning, acting observation, and reflecting. Data collection methods used patient knowledge questionnaires about tuberculosis self-care, Focus Group Discussions (FGD), and in-depth interviews for participants' knowledge. The participants involved in this study were 22 participants using a purposive sampling technique from October 2018 to January 2019. Data analysis used qualitative methods. Qualitative data were obtained through the results of FGDs and in-depth interviews about self-care.</div></div><div><h3>Results</h3><div>This study has produced self-care agency-based self-care guidelines for tuberculosis patients. This study produced three themes, namely 1) the development of self-care guidelines for TB patients, 2) the benefits of self-care guidelines for TB patients, and 3) factors in supporting self-care for TB patients.</div></div><div><h3>Conclusion</h3><div><span>The successful treatment of TB patients at the Sentosa Baru Public Health Center, North Sumatra, requires agency-based self-care guidelines to produce high </span>tuberculosis care.</div></div>","PeriodicalId":39346,"journal":{"name":"Indian Journal of Tuberculosis","volume":"72 2","pages":"Pages 208-212"},"PeriodicalIF":0.0,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139393145","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-04-01DOI: 10.1016/j.ijtb.2024.01.003
Samantha Cheryl Kumar , George Ipe Vettiyal MD, DCH , Winsley Rose MD , Joy Michael MD,PHD , J Visalakshi MSc, PHD , Sathish Kumar MD, DCH
Objectives
The mainstay of treatment for pediatric rheumatological disease is disease-modifying anti-rheumatic agents which are immunosuppressive in nature and increase the susceptibility to tuberculosis. The aims and objectives were to evaluate the performance of the QuantiFERON®-TB Gold test (QFT) and Tuberculin skin test (TST) to diagnose latent tuberculosis in children receiving immunosuppressive therapy for rheumatic diseases in a tertiary hospital in South India.
Methods
This was a prospective observational study. 60 consecutive children diagnosed with various rheumatic diseases attending the Paediatric Rheumatology clinic on immunosuppressive therapy were included. The QFT and TST were performed on the same day. Data regarding the demography, diagnosis, treatment received and test results were collected and analysed.
Results
Among patients included (n = 60), two children had positive QFT and one child had positive TST. The agreement between tests was k = 0.85 and the proportion of latent tuberculosis was 5 %. All the children included were on conventional DMARDs and 3.3 % were on biological DMARDs. There was a significant decrease in the mitogen induced interferon level in children on treatment with hydroxychloroquine (p = 0.022) and a significant increase in the level in children on azathioprine (p = 0.006). Children on steroids had a lower range of mitogen-induced interferon levels.
Conclusion
QFT may be a more reliable test than TST for the detection of latent tuberculosis in children with rheumatic diseases receiving immunosuppressive treatment. The use of hydroxychloroquine and steroids might influence the mitogen-induced IFN-γ secretion and may interfere with the interpretation of the QFT test.
{"title":"Performance of the QuantiFERON- TB gold test in children receiving immunosuppressive therapy for rheumatic diseases","authors":"Samantha Cheryl Kumar , George Ipe Vettiyal MD, DCH , Winsley Rose MD , Joy Michael MD,PHD , J Visalakshi MSc, PHD , Sathish Kumar MD, DCH","doi":"10.1016/j.ijtb.2024.01.003","DOIUrl":"10.1016/j.ijtb.2024.01.003","url":null,"abstract":"<div><h3>Objectives</h3><div><span><span>The mainstay of treatment for pediatric<span> rheumatological disease is disease-modifying anti-rheumatic agents which are immunosuppressive in nature and increase the susceptibility to tuberculosis. The aims and objectives were to evaluate the performance of the QuantiFERON®-TB Gold test (QFT) and </span></span>Tuberculin<span> skin test (TST) to diagnose latent tuberculosis<span> in children receiving immunosuppressive therapy for </span></span></span>rheumatic diseases in a tertiary hospital in South India.</div></div><div><h3>Methods</h3><div><span>This was a prospective observational study. 60 consecutive children diagnosed with various rheumatic diseases attending the </span>Paediatric Rheumatology<span> clinic on immunosuppressive therapy were included. The QFT and TST were performed on the same day. Data regarding the demography, diagnosis, treatment received and test results were collected and analysed.</span></div></div><div><h3>Results</h3><div>Among patients included (n = 60), two children had positive QFT and one child had positive TST. The agreement between tests was <em>k</em><span><span><span> = 0.85 and the proportion of latent tuberculosis was 5 %. All the children included were on conventional DMARDs and 3.3 % were on biological DMARDs. There was a significant decrease in the </span>mitogen<span> induced interferon level in children on treatment with </span></span>hydroxychloroquine<span> (p = 0.022) and a significant increase in the level in children on azathioprine<span> (p = 0.006). Children on steroids had a lower range of mitogen-induced interferon levels.</span></span></span></div></div><div><h3>Conclusion</h3><div><span>QFT may be a more reliable test than TST for the detection of latent tuberculosis in children with rheumatic diseases receiving immunosuppressive treatment. The use of hydroxychloroquine and steroids might influence the mitogen-induced IFN-</span><em>γ</em> secretion and may interfere with the interpretation of the QFT test.</div></div>","PeriodicalId":39346,"journal":{"name":"Indian Journal of Tuberculosis","volume":"72 2","pages":"Pages 204-207"},"PeriodicalIF":0.0,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139393178","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-04-01DOI: 10.1016/j.ijtb.2024.03.005
Stuti Sharma , Anurag Agarwal , Ashwani Khanna
Background
Neurological involvement is one of the deadliest forms of tuberculosis especially in pediatric population.
Aim
To study the clinico-epidemiological profile of 75 cases of pediatric TB meningitis and its co-relation with CBNAAT/TRUENAT positivity.
Study design
Prospective study in children and adolescents less than 18 years in Tertiary Health care centre in New Delhi.
Subjects and methods
75 Children and adolescents less than 18 years with Probable TBM as per NTEP guidelines were enrolled. Clinical, Radiological and CSF analysis were carried out in all the patients.
Results
75 children were enrolled out of which 61% were females. The most common symptom at presentation was fever followed by loss of appetite and weight loss. Neck rigidity was present in 66% cases followed by posturing in 25% cases. 46% patients presented in Stage 2. Tuberculin skin test was positive in 16% cases and 20% patients had evidence of pulmonary TB on chest Xray. Hydrocephalous was the most common finding in neuroimaging present in 61% cases. In majority of the cases, CSF analysis revealed pleocytosis with lymphocyte predominance, low glucose and high protein values. Nucleic amplification tests (CBNAAT/TRUENAT) were positive in 33% cases and 4 out of 75 were detected to have rifampicin resistance. There was no co-relation identified between Stage at presentation, tuberculin positivity and CSF analysis with CBNAAT/TRUENAT positivity. Six patients expired within 2 weeks of presentation.
Conclusion
The diagnosis of TBM is a composite of clinical, radiological and CSF analysis parameters. Being a paucibacillary sample, the yield of TB bacilli in NAAT studies remains moderately low. Moreover, detection of TB bacilli in CBNAAT/TRUENAT is independent of the CSF cytological and biochemical profile, and is also independent of the Stage of TBM.
{"title":"Clinico-epidemiological profile of 75 cases of TB meningitis in children and adoloscents","authors":"Stuti Sharma , Anurag Agarwal , Ashwani Khanna","doi":"10.1016/j.ijtb.2024.03.005","DOIUrl":"10.1016/j.ijtb.2024.03.005","url":null,"abstract":"<div><h3>Background</h3><div>Neurological involvement is one of the deadliest forms of tuberculosis especially in pediatric population.</div></div><div><h3>Aim</h3><div>To study the clinico-epidemiological profile of 75 cases of pediatric TB meningitis and its co-relation with CBNAAT/TRUENAT positivity.</div></div><div><h3>Study design</h3><div>Prospective study in children and adolescents less than 18 years in Tertiary Health care centre in New Delhi.</div></div><div><h3>Subjects and methods</h3><div>75 Children and adolescents less than 18 years with Probable TBM as per NTEP guidelines were enrolled. Clinical, Radiological and CSF analysis were carried out in all the patients.</div></div><div><h3>Results</h3><div><span><span>75 children were enrolled out of which 61% were females. The most common symptom at presentation was fever followed by loss of appetite<span> and weight loss. Neck rigidity was present in 66% cases followed by posturing in 25% cases. 46% patients presented in Stage 2. Tuberculin skin test was positive in 16% cases and 20% patients had evidence of pulmonary TB on </span></span>chest Xray. Hydrocephalous was the most common finding in neuroimaging present in 61% cases. In majority of the cases, CSF analysis revealed </span>pleocytosis<span> with lymphocyte predominance, low glucose and high protein values. Nucleic amplification tests (CBNAAT/TRUENAT) were positive in 33% cases and 4 out of 75 were detected to have rifampicin resistance. There was no co-relation identified between Stage at presentation, tuberculin positivity and CSF analysis with CBNAAT/TRUENAT positivity. Six patients expired within 2 weeks of presentation.</span></div></div><div><h3>Conclusion</h3><div>The diagnosis of TBM is a composite of clinical, radiological and CSF analysis parameters. Being a paucibacillary sample, the yield of TB bacilli<span> in NAAT studies remains moderately low. Moreover, detection of TB bacilli in CBNAAT/TRUENAT is independent of the CSF cytological and biochemical profile, and is also independent of the Stage of TBM.</span></div></div>","PeriodicalId":39346,"journal":{"name":"Indian Journal of Tuberculosis","volume":"72 2","pages":"Pages 240-242"},"PeriodicalIF":0.0,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140269536","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
According to recent NTEP report it was estimated that in India the MDR-TB cases were 9.1/lakh population. Patients undergoing the pulmonary TB are known to cause MDR-TB due to multi drug resistance. Early identification of risk elements in Multidrug resistant-TB patients is crucial to managing and preventing the disease.
Objective
To evaluate risk variables that contribute to cause Multidrug resistant tuberculosis and to providing patient counselling to TB patients regarding risk factors.
Method
ology: A Prospective interventional study to assess the various Risk factors involved in cause of Multi drug resistance tuberculosis. This study was conducted for period of 09 months. The study is conducted with standard validated questionnaires which are prepared to assess the risk factors among Multidrug resistant-TB patients. Study site includes the tertiary care hospitals in Belagavi.
Result
Overall, 120 Multidrug resistant tuberculosis patients were recruited from the district tuberculosis centre, Belagavi District, Karnataka. India. Most patients (47.50%) were aged 25–44 years. Of the 120 MDR-TB patients, 67.50% are male and 32.5% are female. Of 120 MDR-TB patients, 7.50% are HIV positive. As part of the study, smoking (26.67%), chewing tobacco (50%), and alcohol consumption (33.33%) were found to be other major risk factors. 24.17% of patients had a family history of tuberculosis, of which 5% had contact with an infected person as a source of infection.
Conclusion
This study documented various risk variables involved in the emergence of Multidrug resistant TB. This research also highlighted the significance of pharmaceutical care in the effective management of multidrug-resistant tuberculosis (MDR-TB). This study identified risk variables that contribute to MDR-TB and helped educate tuberculosis patients about these risk factors.
{"title":"Empowering care: Unleashing pharmaceutical care to confront MDR-TB transmission risks-A prospective interventional study","authors":"Vishwa Rajakumar Byakod, Madiwalayya Shivakantayya Ganachari","doi":"10.1016/j.ijtb.2024.03.001","DOIUrl":"10.1016/j.ijtb.2024.03.001","url":null,"abstract":"<div><h3>Introduction</h3><div><span>According to recent NTEP report it was estimated that in India the MDR-TB cases were 9.1/lakh population. Patients undergoing the pulmonary TB are known to cause MDR-TB due to </span>multi drug resistance. Early identification of risk elements in Multidrug resistant-TB patients is crucial to managing and preventing the disease.</div></div><div><h3>Objective</h3><div>To evaluate risk variables that contribute to cause Multidrug resistant tuberculosis and to providing patient counselling to TB patients regarding risk factors.</div></div><div><h3>Method</h3><div>ology: A Prospective interventional study to assess the various Risk factors involved in cause of Multi drug resistance tuberculosis. This study was conducted for period of 09 months. The study is conducted with standard validated questionnaires which are prepared to assess the risk factors among Multidrug resistant-TB patients. Study site includes the tertiary care hospitals in Belagavi.</div></div><div><h3>Result</h3><div>Overall, 120 Multidrug resistant tuberculosis patients were recruited from the district tuberculosis centre, Belagavi District, Karnataka. India. Most patients (47.50%) were aged 25–44 years. Of the 120 MDR-TB patients, 67.50% are male and 32.5% are female. Of 120 MDR-TB patients, 7.50% are HIV positive. As part of the study, smoking (26.67%), chewing tobacco (50%), and alcohol consumption (33.33%) were found to be other major risk factors. 24.17% of patients had a family history of tuberculosis, of which 5% had contact with an infected person as a source of infection.</div></div><div><h3>Conclusion</h3><div>This study documented various risk variables involved in the emergence of Multidrug resistant TB. This research also highlighted the significance of pharmaceutical care in the effective management of multidrug-resistant tuberculosis (MDR-TB). This study identified risk variables that contribute to MDR-TB and helped educate tuberculosis patients about these risk factors.</div></div>","PeriodicalId":39346,"journal":{"name":"Indian Journal of Tuberculosis","volume":"72 2","pages":"Pages 233-239"},"PeriodicalIF":0.0,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140279221","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-04-01DOI: 10.1016/j.ijtb.2024.08.006
Leong Tung Ong
Recent population-based studies conducted in Asia have revealed a notable increase in the overall incidence of nontuberculous mycobacteria (NTM) infection, coinciding with a decline in tuberculosis (TB) cases. The incidence of NTM infection has exceeded that of TB in Japan, with a prevalence rate showing a substantial increase over the years. Similarly, South Korea and Taiwan have witnessed an increase of NTM infection rates, particularly in pulmonary disease. The NTM species isolation rate has increased in the past years globally. The most common NTM species isolated in Asia was Mycobacterium avium complex (MAC) at 16.5%, followed by M. abscessus at 12.2%, and M. intracellulare at 11.1 %. Furthermore, the prevalence of co-infection of NTM and TB has been explored, highlighting a prevalence of 4.2% in patients diagnosed with TB infection and 7.6% in patients diagnosed with NTM infection. Extrapulmonary NTM infection manifests in diverse form, including pleuritis, peritonitis, ocular infections, central nervous system infections, skin and soft-tissue infections, lymphadenitis, genitourinary infections, and disseminated disease. The prevalence and manifestations of these extrapulmonary manifestations varies across countries, emphasizing the complex clinical spectrum of NTM infection. Increased awareness of NTM infection, their microbiological characteristics, and co-infection with TB in Asia provide valuable insights for effective diagnosis and management. This comprehensive review enhances the understanding of NTM infection in Asia, providing insights that may differ from Western countries and could contribute to the development of public health interventions.
{"title":"Epidemiology of nontuberculous mycobacteria infection in Asia: A narrative review","authors":"Leong Tung Ong","doi":"10.1016/j.ijtb.2024.08.006","DOIUrl":"10.1016/j.ijtb.2024.08.006","url":null,"abstract":"<div><div>Recent population-based studies conducted in Asia have revealed a notable increase in the overall incidence of nontuberculous mycobacteria (NTM) infection, coinciding with a decline in tuberculosis (TB) cases. The incidence of NTM infection has exceeded that of TB in Japan, with a prevalence rate showing a substantial increase over the years. Similarly, South Korea and Taiwan have witnessed an increase of NTM infection rates, particularly in pulmonary disease. The NTM species isolation rate has increased in the past years globally. The most common NTM species isolated in Asia was <em>Mycobacterium avium</em> complex (MAC) at 16.5%, followed by M. <em>abscessus</em> at 12.2%, and M. <em>intracellulare</em> at 11.1 %. Furthermore, the prevalence of co-infection of NTM and TB has been explored, highlighting a prevalence of 4.2% in patients diagnosed with TB infection and 7.6% in patients diagnosed with NTM infection. Extrapulmonary NTM infection manifests in diverse form, including pleuritis, peritonitis, ocular infections, central nervous system infections, skin and soft-tissue infections, lymphadenitis, genitourinary infections, and disseminated disease. The prevalence and manifestations of these extrapulmonary manifestations varies across countries, emphasizing the complex clinical spectrum of NTM infection. Increased awareness of NTM infection, their microbiological characteristics, and co-infection with TB in Asia provide valuable insights for effective diagnosis and management. This comprehensive review enhances the understanding of NTM infection in Asia, providing insights that may differ from Western countries and could contribute to the development of public health interventions.</div></div>","PeriodicalId":39346,"journal":{"name":"Indian Journal of Tuberculosis","volume":"72 2","pages":"Pages 259-265"},"PeriodicalIF":0.0,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144270464","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-04-01DOI: 10.1016/j.ijtb.2024.04.004
Gauri Abhijit Oka, Prasad D. Pore, Prakash P. Doke
Background
The monetary incentive under Nikshay Poshan Yojana (NPY) for patients with tuberculosis (TB) could be wasted on purposes other than intended. We explored the uptake and ways of utilization of NPY.
Methods
Demographic, clinical, and installment-related information was retrieved from the beneficiary registers. Through telephonic interviews, knowledge about the purpose of the incentive and receipt of the same in the bank accounts was sought, with reasons for non-receipt. The avenues of expenditure were documented. Any dietary modifications after the TB diagnosis were noted, specifically regarding milk, proteins, fruits, and vegetables.
Results
Out of 1882 patients, 1863 (99%) knew their eligibility, and 1788 (95%) knew the incentive was for buying food. The median duration between diagnosis and receipt of the first installment was 1 month (IQR 1,2). Of the 988 patients claiming non-receipt of the incentive, 923 (93.4%) had not checked their bank accounts. The money was refused by 98 patients. 570/796 (71.6%) patients had bought food. 1449 (76.9%) changed their diet after the diagnosis. Most patients consumed cereals, proteins, milk, fruits, and vegetables at least thrice a week.
Conclusion
NPY awareness was almost universal. Most of the participants used it for the intended purpose and were found to make healthy dietary modifications after their TB diagnosis.
{"title":"The uptake and utilization of Nikshay Poshan Yojana: Lessons from an urban setting in India","authors":"Gauri Abhijit Oka, Prasad D. Pore, Prakash P. Doke","doi":"10.1016/j.ijtb.2024.04.004","DOIUrl":"10.1016/j.ijtb.2024.04.004","url":null,"abstract":"<div><h3>Background</h3><div>The monetary incentive under Nikshay Poshan Yojana (NPY) for patients with tuberculosis (TB) could be wasted on purposes other than intended. We explored the uptake and ways of utilization of NPY.</div></div><div><h3>Methods</h3><div>Demographic, clinical, and installment-related information was retrieved from the beneficiary registers. Through telephonic interviews, knowledge about the purpose of the incentive and receipt of the same in the bank accounts was sought, with reasons for non-receipt. The avenues of expenditure were documented. Any dietary modifications after the TB diagnosis were noted, specifically regarding milk, proteins, fruits, and vegetables.</div></div><div><h3>Results</h3><div>Out of 1882 patients, 1863 (99%) knew their eligibility, and 1788 (95%) knew the incentive was for buying food. The median duration between diagnosis and receipt of the first installment was 1 month (IQR 1,2). Of the 988 patients claiming non-receipt of the incentive, 923 (93.4%) had not checked their bank accounts. The money was refused by 98 patients. 570/796 (71.6%) patients had bought food. 1449 (76.9%) changed their diet after the diagnosis. Most patients consumed cereals, proteins, milk, fruits, and vegetables at least thrice a week.</div></div><div><h3>Conclusion</h3><div>NPY awareness was almost universal. Most of the participants used it for the intended purpose and were found to make healthy dietary modifications after their TB diagnosis.</div></div>","PeriodicalId":39346,"journal":{"name":"Indian Journal of Tuberculosis","volume":"72 2","pages":"Pages 249-252"},"PeriodicalIF":0.0,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140759288","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-04-01DOI: 10.1016/j.ijtb.2025.03.011
Amitesh Gupta , Eshutosh Chandra , Parul Mrigpuri
The intersection of diabetes mellitus (DM) and tuberculosis (TB) constitutes a significant global health challenge, marked by complex disease interactions with profound clinical and public health consequences. TB, a historically prevalent infectious disease, and DM, a rising non-communicable disease, together fuel a syndemic in which each condition exacerbates the other. DM increases susceptibility to TB by weakening immune defenses, facilitating the proliferation of Mycobacterium tuberculosis (MTB) and accelerating TB progression. Mechanistic insights reveal that hyperglycemia-driven immune dysfunction impairs both innate and adaptive immunity, with effects such as reduced T-helper cell activity, impaired macrophage and neutrophil responses, and altered cytokine profiles. These immune changes allow for easier MTB survival, lung damage, and systemic inflammation, thus worsening TB outcomes in diabetic patients. The combined burden of TB and DM disproportionately impacts vulnerable populations, particularly in resource-limited settings and developing nations where TB remains endemic, and diabetes prevalence is increasing. Population health data highlight the increasing occurrence of DM among TB patients, with studies reporting comorbidity rates as high as 45 % in some regions. Furthermore, TB worsens glycemic control in DM patients, creating a cyclical burden that complicates disease management. Evidence also highlights the role of social and demographic characteristics, including age, urban residence, and financial standing, along with behavioral factors like tobacco and alcohol use, as significant risk enhancers for TB-DM comorbidity. Screening for tuberculosis in individuals with diabetes and for diabetes in those with tuberculosis is crucial in high-burden regions to enable timely detection and intervention. Effective screening methods include clinical assessments, radiological imaging, and both rapid and conventional microbiological testing for TB, while plasma glucose and glycosylated hemoglobin (HbA1c) tests are standard for detecting diabetes. Latent tuberculosis utilizing the Mantoux tuberculin skin test or interferon-gamma release assays (IGRAs) for screening is particularly recommended for high-risk diabetic patients to help prevent the progression of the disease. These dual screening efforts are essential for reducing morbidity, mortality, and the transmission of TB among individuals with diabetes. Therapeutic strategies for TB-DM management involve tailored anti-diabetic regimens and cautious selection of anti-TB medications to avoid adverse interactions. Insulin is the preferred treatment for severe cases of diabetes in TB patients due to its anabolic properties and lack of interaction with TB medications. Oral agents like metformin are widely used in mild cases but require monitoring for renal and hepatic health. Innovative approaches and meticulous monitoring can improve TB outcomes in DM patients by achieving be
{"title":"Navigating the dual burden of diabetes mellitus and tuberculosis: A comprehensive review of clinical and public health strategies","authors":"Amitesh Gupta , Eshutosh Chandra , Parul Mrigpuri","doi":"10.1016/j.ijtb.2025.03.011","DOIUrl":"10.1016/j.ijtb.2025.03.011","url":null,"abstract":"<div><div>The intersection of diabetes mellitus (DM) and tuberculosis (TB) constitutes a significant global health challenge, marked by complex disease interactions with profound clinical and public health consequences. TB, a historically prevalent infectious disease, and DM, a rising non-communicable disease, together fuel a syndemic in which each condition exacerbates the other. DM increases susceptibility to TB by weakening immune defenses, facilitating the proliferation of <em>Mycobacterium tuberculosis</em> (MTB) and accelerating TB progression. Mechanistic insights reveal that hyperglycemia-driven immune dysfunction impairs both innate and adaptive immunity, with effects such as reduced T-helper cell activity, impaired macrophage and neutrophil responses, and altered cytokine profiles. These immune changes allow for easier MTB survival, lung damage, and systemic inflammation, thus worsening TB outcomes in diabetic patients. The combined burden of TB and DM disproportionately impacts vulnerable populations, particularly in resource-limited settings and developing nations where TB remains endemic, and diabetes prevalence is increasing. Population health data highlight the increasing occurrence of DM among TB patients, with studies reporting comorbidity rates as high as 45 % in some regions. Furthermore, TB worsens glycemic control in DM patients, creating a cyclical burden that complicates disease management. Evidence also highlights the role of social and demographic characteristics, including age, urban residence, and financial standing, along with behavioral factors like tobacco and alcohol use, as significant risk enhancers for TB-DM comorbidity. Screening for tuberculosis in individuals with diabetes and for diabetes in those with tuberculosis is crucial in high-burden regions to enable timely detection and intervention. Effective screening methods include clinical assessments, radiological imaging, and both rapid and conventional microbiological testing for TB, while plasma glucose and glycosylated hemoglobin (HbA1c) tests are standard for detecting diabetes. Latent tuberculosis utilizing the Mantoux tuberculin skin test or interferon-gamma release assays (IGRAs) for screening is particularly recommended for high-risk diabetic patients to help prevent the progression of the disease. These dual screening efforts are essential for reducing morbidity, mortality, and the transmission of TB among individuals with diabetes. Therapeutic strategies for TB-DM management involve tailored anti-diabetic regimens and cautious selection of anti-TB medications to avoid adverse interactions. Insulin is the preferred treatment for severe cases of diabetes in TB patients due to its anabolic properties and lack of interaction with TB medications. Oral agents like metformin are widely used in mild cases but require monitoring for renal and hepatic health. Innovative approaches and meticulous monitoring can improve TB outcomes in DM patients by achieving be","PeriodicalId":39346,"journal":{"name":"Indian Journal of Tuberculosis","volume":"72 2","pages":"Pages 253-258"},"PeriodicalIF":0.0,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144270463","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-04-01DOI: 10.1016/j.ijtb.2024.05.006
DrSumit Sural
<div><div>Duration of antitubercular therapy (ATT) for musculoskeletal (MSK) tuberculosis (TB) is a challenge, particularly if pain persists at the end of therapy. WHO recommends 6–9 months therapy, index TB guidelines of India recommends 12 months ATT extendable to 18 months, yet many surgeons in India continue to prescribe 18–24 months ATT in all cases of MSK TB. To address this controversy, two studies were conducted to assess the adequacy of 6 months ATT for MSK TB, the third study to evaluate results of 9–12 months of ATT and fourth study to assess residual back pain<span> in spinal TB after ATT of different duration.</span></div><div>In the 1st study (2006–09), after 6 months of ATT, all 9 cases of spinal and all 25 cases of extraspinal MSK TB had healed clinically and with a negative ciprofloxacin-labelled technetium 99 scan and among them, even as early as 3 months, 2 spinal and 4 extra-spinal cases had negative scans.</div><div>In the 2nd study (2010–2013), after 6 months ATT, Gadolinium<span> enhanced MRI scans in 50 cases of MSK TB depicted complete resolution in 6 cases (12%), partial resolution in 36 cases (72%) and no resolution in 8 cases (16%). Irrespective of the MRI findings at 6 months, in 44 clinically healed cases ATT was stopped at 6 months and they remained healed at more than 5-year follow up. In 6 cases, who had no clinical healing, ATT was prolonged in 3 patients and the category of ATT was changed in remaining 3 patients (2 spinal TB and one Hip TB).</span></div><div>In the 3rd study (2019–2022), all 51 patients of spinal TB who took 9–12 months of ATT had fever subsidence within 1–6 months (mean 3.52 months), appetite improvement within 1–7 months (mean 3.5 months) and weight gain by 1–8 months (mean 4.45 months). Intermittent back pain continued in 23/51 patients (41%) even after 2 years of stoppage of 9–11 months ATT, among them 20 patients (96.4%) had radiological bony fusion. Persistent back-pain (mean VAS 6.33) occurred in 3 cases who took 12 months ATT; 2 reported after 10 months of whom 1 was detected as MDR, 3rd patient reported after 7 years and recovered after 1 year of ATT.</div><div>In the 4th study (2020–2023), 88 of 300 MSK TB (non-resistant cases, managed non-operatively) patients responded telephonically, 48 visited the hospital and 40 patients were telephonically interviewed regarding back pain after ATT. After various duration of ATT, 6–9 months (13.6% cases); 10–12 months (26.1% cases); 13–18 months (53.4% cases) and 19–24 months (6.8% cases) all had clinically healed with no fever, loss of appetite or weight loss. Majority (45/48) of patients (93.8%) had bony healing yet back pain was present in 28 patients (31.8%); intermittent pain in 19 patients and continuous pain in nine.</div><div>Stopping ATT at 6 months may be considered in cases with complete clinical healing with normal ESR. Patients with no progressive signs of clinical healing by 6 months should be investigated for drug resistance rather
{"title":"Changing trends in duration of treatment of musculoskeletal and spinal tuberculosis- long term experience in a tertiary care teaching hospital","authors":"DrSumit Sural","doi":"10.1016/j.ijtb.2024.05.006","DOIUrl":"10.1016/j.ijtb.2024.05.006","url":null,"abstract":"<div><div>Duration of antitubercular therapy (ATT) for musculoskeletal (MSK) tuberculosis (TB) is a challenge, particularly if pain persists at the end of therapy. WHO recommends 6–9 months therapy, index TB guidelines of India recommends 12 months ATT extendable to 18 months, yet many surgeons in India continue to prescribe 18–24 months ATT in all cases of MSK TB. To address this controversy, two studies were conducted to assess the adequacy of 6 months ATT for MSK TB, the third study to evaluate results of 9–12 months of ATT and fourth study to assess residual back pain<span> in spinal TB after ATT of different duration.</span></div><div>In the 1st study (2006–09), after 6 months of ATT, all 9 cases of spinal and all 25 cases of extraspinal MSK TB had healed clinically and with a negative ciprofloxacin-labelled technetium 99 scan and among them, even as early as 3 months, 2 spinal and 4 extra-spinal cases had negative scans.</div><div>In the 2nd study (2010–2013), after 6 months ATT, Gadolinium<span> enhanced MRI scans in 50 cases of MSK TB depicted complete resolution in 6 cases (12%), partial resolution in 36 cases (72%) and no resolution in 8 cases (16%). Irrespective of the MRI findings at 6 months, in 44 clinically healed cases ATT was stopped at 6 months and they remained healed at more than 5-year follow up. In 6 cases, who had no clinical healing, ATT was prolonged in 3 patients and the category of ATT was changed in remaining 3 patients (2 spinal TB and one Hip TB).</span></div><div>In the 3rd study (2019–2022), all 51 patients of spinal TB who took 9–12 months of ATT had fever subsidence within 1–6 months (mean 3.52 months), appetite improvement within 1–7 months (mean 3.5 months) and weight gain by 1–8 months (mean 4.45 months). Intermittent back pain continued in 23/51 patients (41%) even after 2 years of stoppage of 9–11 months ATT, among them 20 patients (96.4%) had radiological bony fusion. Persistent back-pain (mean VAS 6.33) occurred in 3 cases who took 12 months ATT; 2 reported after 10 months of whom 1 was detected as MDR, 3rd patient reported after 7 years and recovered after 1 year of ATT.</div><div>In the 4th study (2020–2023), 88 of 300 MSK TB (non-resistant cases, managed non-operatively) patients responded telephonically, 48 visited the hospital and 40 patients were telephonically interviewed regarding back pain after ATT. After various duration of ATT, 6–9 months (13.6% cases); 10–12 months (26.1% cases); 13–18 months (53.4% cases) and 19–24 months (6.8% cases) all had clinically healed with no fever, loss of appetite or weight loss. Majority (45/48) of patients (93.8%) had bony healing yet back pain was present in 28 patients (31.8%); intermittent pain in 19 patients and continuous pain in nine.</div><div>Stopping ATT at 6 months may be considered in cases with complete clinical healing with normal ESR. Patients with no progressive signs of clinical healing by 6 months should be investigated for drug resistance rather","PeriodicalId":39346,"journal":{"name":"Indian Journal of Tuberculosis","volume":"72 2","pages":"Pages 266-272"},"PeriodicalIF":0.0,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141131762","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-04-01DOI: 10.1016/j.ijtb.2023.12.009
Sanjeev Khanth P E , Akhilesh Mishra , Shramana Mandal , Shalini Chawla , Bhupinder Singh Kalra
Background
Isoniazid (INH) and Rifampicin (RIF) are the common drugs causing hepatitis in patients undergoing Antitubercular therapy (ATT). This often results in discontinuation of the therapy or change in the treatment regimen. Free radical injury by drug metabolites has been postulated as cause of liver damage. The herbal extracts of Phyllanthus niruri and Andrographis paniculata possess antioxidant activity.
Methods
Hepatotoxicity was induced in Sprague Dawley rats by administering Isoniazid (100 mg/kg, po) and Rifampicin (100 mg/kg, po) combination for 14 days. Each group of rats were simultaneously treated with P. niruri (125 mg/kg, po), A. paniculata (125 mg/kg, po) and in combination of both for 14 days. Assessment of hepatotoxicity was done by evaluating serum total bilirubin, serum aspartate aminotransferase (AST), serum alanine aminotransferase (ALT), liver superoxide dismutase (SOD), liver catalase levels, and histopathological examination of liver.
Results
There was a significant reduction in the total bilirubin and SGOT levels in the groups treated with P.niruri, A.paniculata and combination of P.niruri and A.paniculata when compared with the INH and RMP treated groups (P<; 0.0001, P = 0.03, P < 0.0001) respectively. The liver SOD and Catalase enzymes were significantly deranged in the group treated with INH and RMP compared to the control animals (P < 0.0001). However, the SOD and Catalase levels were significantly elevated in the groups treated with these protective agents (P < 0.0001) when compared with INH and RMP group. Histopathological examination revealed that in the groups treated with INH and RMP, grades 1 & 2 necrosis was observed than those animals of the normal control group (p = 0.002). However, treatment with P.niruri and A.paniculata extracts showed no signs of necrosis on comparing with the INH and RMP group (p = 0.002).
Conclusion
Extracts of P. niruri and A. paniculata both in monotherapy and combination has hepatoprotective action against the hepatotoxicity induced by Isoniazid and Rifampicin.
{"title":"Hepatoprotective potential of Phyllanthus niruri and Andrographis paniculata in isoniazid-rifampicin induced hepatotoxicity in rats","authors":"Sanjeev Khanth P E , Akhilesh Mishra , Shramana Mandal , Shalini Chawla , Bhupinder Singh Kalra","doi":"10.1016/j.ijtb.2023.12.009","DOIUrl":"10.1016/j.ijtb.2023.12.009","url":null,"abstract":"<div><h3>Background</h3><div><span><span>Isoniazid (INH) and Rifampicin (RIF) are the common drugs causing hepatitis in patients undergoing Antitubercular therapy (ATT). This often results in discontinuation of the therapy or change in the treatment regimen. </span>Free radical<span><span> injury by </span>drug metabolites has been postulated as cause of liver damage. The herbal extracts of </span></span><span><em>Phyllanthus niruri</em></span> and <span><em>Andrographis paniculata</em></span><span> possess antioxidant activity.</span></div></div><div><h3>Methods</h3><div><span>Hepatotoxicity was induced in Sprague Dawley rats by administering Isoniazid (100 mg/kg, po) and Rifampicin (100 mg/kg, po) combination for 14 days. Each group of rats were simultaneously treated with </span><em>P. niruri</em> (125 mg/kg, po), <em>A. paniculata</em><span><span> (125 mg/kg, po) and in combination of both for 14 days. Assessment of hepatotoxicity was done by evaluating serum total bilirubin<span><span>, serum aspartate aminotransferase (AST), serum alanine aminotransferase (ALT), liver </span>superoxide dismutase (SOD), liver </span></span>catalase levels, and histopathological examination of liver.</span></div></div><div><h3>Results</h3><div>There was a significant reduction in the total bilirubin and SGOT levels in the groups treated with <em>P.niruri, A.paniculata</em> and combination of <em>P.niruri and A.paniculata</em> when compared with the INH and RMP treated groups (P<; 0.0001, P = 0.03, P < 0.0001) respectively. The liver SOD and Catalase enzymes were significantly deranged in the group treated with INH and RMP compared to the control animals (P < 0.0001). However, the SOD and Catalase levels were significantly elevated in the groups treated with these protective agents (P < 0.0001) when compared with INH and RMP group. Histopathological examination revealed that in the groups treated with INH and RMP, grades 1 & 2 necrosis was observed than those animals of the normal control group (p = 0.002). However, treatment with <em>P.niruri</em> and <em>A.paniculata</em> extracts showed no signs of necrosis on comparing with the INH and RMP group (p = 0.002).</div></div><div><h3>Conclusion</h3><div>Extracts of <em>P. niruri</em> and <em>A. paniculata</em><span> both in monotherapy and combination has hepatoprotective action against the hepatotoxicity induced by Isoniazid and Rifampicin.</span></div></div>","PeriodicalId":39346,"journal":{"name":"Indian Journal of Tuberculosis","volume":"72 2","pages":"Pages 189-193"},"PeriodicalIF":0.0,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139195309","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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