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Drug-Sensitive Tuberculosis Mx and Prevention of MDR

Mar 30 | 3:30 PM

Multidrug-resistant tuberculosis (MDR TB) develops when an organism grows resistant to at least two of the most potent TB medications - isoniazid and rifampin. Physicians use these medications to treat the majority of people who have tuberculosis. Extensively drug-resistant tuberculosis (XDR TB), a rare manifestation of multidrug-resistant tuberculosis, causes the organism to develop resistance to isoniazid, rifampin, fluoroquinolone, and at least one of the three second-line injectables. Let's look at what extra precautions we may take to prevent drug-sensitive TB from progressing to MDR or XDR TB. Dr. Alpa Dalal will be discussing the various management approaches to curb the progression of TB live on Medflix!

[Music] so uh dear doctor metrics welcomes you here for tonight's session tonight we have the honor of having among us dr alfa dalal who's consultant chess physician dr alfa dalal currently practices at jupiter hospital at thane and mom specializes in treating obstructive airway diseases tuberculosis and sleep disorders today dr alpa will share with us her expert perspective on drug sensitive tuberculosis management and also prevention of multi-diet resistant tuberculosis thank you for joining us dr alpha we're truly thrilled to be learning from you today thank you so much for inviting me on this platform i was really very impressed the way things are being managed and so many people across the country are getting trained i think uh era has come with lot of blessings too that such kind of online training was uh never heard before thank you for your kind words ma'am without further delay mom i'm handing it over to you i'll just be starting a presentation okay so today the reason for selecting this topic so we've just celebrated world tb day on 24th of march and this world tb day is being celebrated to commemorate the rediscovery of mycobacterium tuberculosis by sir robert cox that was in 1882 now it is uh unfortunate that india remains the global leader in maximum number of tuberculosis cases and also maximum number of death uh as you all must be aware that the who has decided or has taken the challenge of ending tb by 2030 and 2035 but india has taken a challenge of uh ending this epidemic of tuberculosis five years ahead of this time that is by 2025 but the current figures are a bit distressing because even today in india we lose about 1400 patients of tuberculosis per day that means every three minutes two patients are dying of tuberculosis in fact during covet time there was a bit of setback and the notification came down the number of tv cases came down and you know the number of tb deaths actually increased first time in 16 years and and one of the reason why the tb mortality is so high in our country is that 70 percent of our patients get treated in private sector and there are also a lot of challenges in the public sector and as a result of that the unregularized treatment uh without you know being practiced without the guidelines is quite a common scenario in india and the best way to prevent this scenario is everyone who is a practicing clinician in our country and the future clinicians they must they must know the treatment of tuberculosis and the best way to prevent the drug racing tb is by treating the drug sensitivity be well so very few of you would actually end up treating mdr tb unless you end up taking pulmonology and become a chest and tb specialist and even amongst chess and tb specialists not everybody tease mdrtb so there are few who specialize in this but all of you whether you take up medicine or pulmonology or surgical branches all of you will come across cases of drug sensitive tuberculosis and i feel personally that every clinician must learn and must have the skills of treating drug sensitive tb and and that is one of the best way of you know ending the epidemic of tb in our country okay so uh let's see the global epidemiology of tuberculosis so there is been a genome sequencing analysis to indicate that mtb likely emerged about 70 000 years ago and i must say that one of the most tenacious organism and much more smarter than we humans are and they've been evolving they've been mutating and they've been continuing the epidemic of tb and more and more as the years are passing by more and more complex kind of drug resistant cases we see tb was an epidemic in europe in 16th and 17th century uh when about 20 percent of all deaths were happening because of uh tb india china indonesia and nigeria are the highest burden countries presently india pakistan and nigeria accounted for almost 50 percent of missed cases of tooth in 2015 and more than half of the global tb burden lies in india china and russia and amongst all three countries india has got the highest burden india china pakistan recorded substantial increase in the republic in resistance from 2008 to 2013 and ntb strategy by who aimed to ntb epidemic by 2035. uh and what is the impact of covet pandemic on tb the tb death row death rate rose for the first time in last 16 years india spent least on the tb drugs per patient despite having 28 percent of new cases last year and india contributed to 41 percent drop in tb notification during 2020 during the peak of the pandemic and unfortunate to say that tb killed 5 lakh 4 000 people in india in 2020 that was 13 increase over uh figures of 2019 so all of us talk about the tb scenario in the country and all of us have different uh you know thoughts about it and well all of all of us are talking about uh ending tb by 2025 or 2035 and we all focus on the result but when we say actual figures it is quite depressing to say that we are nowhere close to ending tb epidemic by 2025 or even 2035 so we all focus on the results but we don't understand why don't we get the results so why don't we reach to the goal that we are setting and this is a very wonderful management model which i learned from one of one of the graduate from iim and they use this wonderful model that they find out that why are we not reaching the results why are we not reaching the target and the answer lies in the deeper layers is that the people's behaviors and habits don't change and that is a real hard work to be done and behavior on part of the doctor's behavior on the part of the paramedical staff and behavior on the part of the patients that all these combined behaviors and habits are responsible for epidemic of tb in our country today and we must acquire enough skills and knowledge in one of the study conducted in south south india it was found that 100 100 students were asked to write a prescription of anti-tb drugs and out of 100 students only 30 percent of them could write actually a rational prescription of tuberculosis so this is how the skills and knowledge we have about treating the most killer infectious disease in our country many times we see that even in medical colleges in people doing or other residents doing medicine or doing pulmonology also do not get adequate exposure of treating uh drug sensitive as well as drug resistant tb so we must all focus on acquiring the skills and knowledge deeper than that we need to change our attitude there is an attitude you know many times private practitioners they do not want to treat tuberculosis cases and they think that is responsibility of the government program to take care of the tb epidemic but 70 percent of the patient get treated in the private sector so we must change our attitude we must take the responsibility and we must have the awareness so we have to start from within the most important thing is to have the awareness many of my colleagues who are non-physician colleagues when i talk to them they are not aware that even today tb is killing 1400 people in a day so what is the incidence of ab what is the incidence of mdrdb which are the hotspot areas so we don't have awareness about this and then we must all take responsibility so every medical doctor who is practicing in this country in our country must have adequate knowledge about treating at least the drug sensitivity we must change our attitude we must acquire skills and knowledge and just acquiring skills and knowledge is also not enough many times we take workshops and people are very happy to acquire knowledge but once they go back to their practices they do not practice it again and again and that doesn't come into their behavior and habit so once you acquire skills and knowledge you have to again and again apply this skill and knowledge so that it becomes it comes into your habit and then you will start to get the results so what are the behaviors and habits so today clinicians who are very busy practicing or many times students also they do not spend enough time and a lot of time is spent on writing the pharmacological prescriptions okay and a lot of investigations are advised and proportionately very little time in spend in taking the history in clinical evaluation so lot of unnecessary investigations are taken and a lot of medications are prescribed in fact uh one of the big reason of spreading the tb epidemic in our country so we spend lot of uh you know a lot of our time when we evaluate the patient on writing the sometimes investigations are unnecessary all writing medication so many times in fact in just this month i had five patients who presented to me who have who were having symptoms of tuberculosis and they had seen various primary care physician various physicians and they were not diagnosed to have tb and today we are going to see in the lecture that what is the standard of care of tb and how should you be evaluating the symptoms so they were giving given lot of unnecessary pharmacotherapy like symptomatic treatment for cough or fever antibiotics and the relevant investigations were not done and which resulted in delaying the diagnosis of tp so imagine patient diagnosis is delayed by four to five months that patient who is infectious goes on spreading the disease and so it's very important that we change our behavior and habits and and start to focus on doing the right thing according to the guideline so this was one very interesting study by dr lancelot pinto and he said that if you say about 100 patients are suspected or having tb symptom out of that maybe 80 percent of them would get actually investigated for tb that somebody might suspect that it is tb but if he goes to the right position he would get order a right and appropriate test otherwise a lot of unnecessary tests would get advised and then there's no guarantee that after the patient is advised to do some investigation whether whether that patient will end up getting the test done and then patient will end up getting diagnosed out of that few percentage of patient would actually get the correct prescription because the prescription may be inappropriate especially if they get treated in the private sector and out of this patient who get initiated on correct treatment many would still default and drop out and a few percentage of this patient would actually complete and get cured which means that if about 100 patients present with tb symptom it's likely that only about 10 to 15 percent of the patient would complete the treatment and get cured so you can imagine how much untreated tb patients get added to the pool of existing tb patient and that is how the transmission is being carried out in our country so let's now focus on each of this aspect so we know all the results have been already set in the goals have been set in but we have to start working on the inner layers so today during this course of the lecture you would be working on the inner layers and whenever i think majority of you are actually uh medical students but when you start to work in your internship or when you start to uh you know do your residency this knowledge will going to be help you because all of you are going to see large number of tuberculosis cases pulmonary as well as extract pulmonary cases so no matter what branch you choose but you're going to see a large number of tb cases so what behavior change we are talking about is that every clinician has to spend a lot of time on appropriate clinical evaluation history taking in history taking and clinical evaluation is most important and once you focus on history taking and give a clinical evaluation and you update your knowledge you are going to ask for very relevant investigations and you are going to appropriately diagnose your patient and once you have diagnosed the patient you would be spending adequate amount of time in educating your patient and counseling your patient and this is how you are going to give clinical results and also updating your knowledge and translating and also spending time on research and translating the research into practice so all these components are important to be uh to acquire skills of all this component and regularly practice the skills okay so i just wanted to know what is the basic uh knowledge people have about this so the gold standard for rapid diagnosis of tb whether it's smear microscopy gene expert or ab liquid culture i know if you can put in that yeah yes your doctors put in your answers in the comment section please yeah so yes somebody is put as to as the option yes a lot of our doctors absolutely option number two yeah so that's great somebody's saying option number three so remember the question is the gold standard for rapid diagnosis of tuberculosis and rapid diagnosis which you get quick result within 24 hours and absolutely most of you are right it's gene expert okay so when we talk of management of drug sensitive tb and that is the best way of preventing mdrtb and for curb for controlling the epidemic of tb we have to work on all these 12 components so first of all you have to ask the question that does the patient have tb if it's a cb whether it is pulmonary tb extra pulmonary or it's a combination or it is a disseminated tb disseminated tb is one which has more than two system involved then whether is a fresh case of tb or whether it is re-treatment then the second question must be answered whether this is drug sensitive tb or a drug resistant tb what should be the diagnostic algorithm that a clinician should follow then whether patient has any comorbidities one of the most important or most common comorbidities are tb patients have is diabetes and number of other condition like ckd or taking some immunosuppressant drugs hiv so you must investigate your patient for presence of comorbidities then what is the pre-treatment evaluation you do before you start your patient on anti-db treatment you must do some baseline investigation what is the guideline what should be the dosage what should be the regimen how long should i be giving this drug counselling is extremely important as you saw in the earlier study that almost eighty percent of the patient who get diagnosed with tb do not complete their treatment and that is why counseling is extremely important then how do you follow up your patient how do you manage your patient while the patient is taking the anti-db treatment and when do you decide to complete the treatment and most important how do you prevent and now as you are all aware that notification of every tb case is legally mandatory and you can be legally penalized if you don't report or don't notify the tb cases so who tb guideline they talk about the important component and one is screening so when do you screen the patient for presence of tb the diagnosis treatment addressing the comorbidity and the prevention so these are the five component of db management when it comes to screening you should be screening the high risk population so which is a high risk population to have tb one is hiv infection we are all aware if the patient is immunocompromised due to any reason so like patient has chronic kidney disease or patient has malignancy patient is taking steroids he has connective tissue disease or having interstitial lung disease or because of some any other condition is taking steroids or immunosuppressant patient has done organ transplant renal and liver transplants are happening quite uh commonly now and these patients are lifelong on immunosuppressant they are always susceptible for getting tb infection then people living in the slums in old age homes are minors health workers so every health worker including residents or doctors or even paramedical staff or even students we do get exposed to cases of tuberculosis uh drug sensitive as well as drug resistant tb so we are quite at high risk for developing uh tb infection and living in endemic areas like mumbai so in our city the incidence of tb is pretty high so living in city of mumbai also is a it's a high risk for developing tb and mdrtb which are the cases where mdrtb has incidence is high so if you are already exposed to mdrtb case especially at home retreatment case so person who has taken tb treatment in the past so it may be relaxed that is within two years of completing treatment a patient has got tb or while taking tb treatment patient has failed or defaulted and come back so these are so anybody who is a retreatment case is high risk for developing tb then there's some certain high risk population like doctors health care workers some slum dwellers etc somebody who's got extensive disease is more likely to have drug resistance somebody who has disseminated disease like we commonly get miliary tb with uh cnsdb now these are the cases who are called disseminated disease and they are high risk for developing drug resistance then living in high prevalence area like mumbai delhi and patients who have got comorbidities so all these are high risk for mdr db okay so this is one very interesting study which shows that what is the uh uh increased risk of patients having tb so patient who got hiv have got almost 20 to 40 percent high risk of developing active tb patients who are using dialysis they have 7 to 50 times so various studies have reported this different risk steroid treatment diabetes now under nutrition is also very high risk so many of our patients are actually undernourished and see there is 12 times higher risk of developing tb compared to a person which is normal weight or well nourished smoking is also high risk biomass fuel exposure alcohol use malignancy people having transplants copd now all this condition you can see that there is significant so now let's come back to screening now there are very specific guidelines that how your patients of patients should be screened for presence of tuberculosis in a high bundle burden country like ours when the patients have symptoms suggestive of tb the risk of having tb is pretty high and that is why these patients have to be screened so they say and one is a symptom screen and it is called w4ss which means who4 symptom screen so which are the four symptom person having fever person having cough for more than two weeks weight loss and night sweats so these are four classical symptoms of tb but these symptoms are again non-specific somebody having pneumonia would also have these four symptoms somebody having any other infection in the body would also have these four symptoms but when you treat this patient with routine medication or maybe antibiotics or some symptomatic treatment and if these symptoms remain for more than three to four weeks and for cough it is said that if more than two weeks of cough and not responding to the routine treatment then these are the patient where you must do the screening so this is about the symptom screen which also means that when you have high risk patients suppose a diabetes patient is there whose diabetes is not well controlled or a patient who has got chronic kidney disease or patient who has had organ transplant so every now and then when the patient is going to see his or her specialist or physician that physician frequently should ask for presence of these questions and when it's surprised that our patients do not come out with the symptom because they have so many other conditions happening and they are not aware just recently we had one young girl who came to the hospital with bilateral extensive tp she was just 19 years old she had been losing weight for past three four months and parents didn't realize because she'd always been a poor eater she had night sweat she had fever only when she became extremely weak and started becoming breathless the parents got to her and it was so shocking to see that in a city of mumbai where all the medical facilities are available young girl like this come with bilateral extensive lung involvement and this is this is pretty common so i think all of us must be aware of this symptom screen the second screening tool that we use is x-ray evaluation so many times uh we just patient may not present with symptom but patient who got chronic condition high risk condition we must do maybe once in a year x-ray chest and when patients have these kind of symptoms then if they are not producing sputum then x-ray is a muscle all these patients screening with exercise should be done second screening test which is very important is sputum evaluation and as all of you have said for rapid diagnosis of tb the most important test is gene expert then in hiv patient one can use c reactive protein if c reactive protein more than five then it is uh important cut off then you must investigate this patient for presence of tb because again in hiv having tb infection is very very common and now they they have come up with computer aided detection of the x-ray artificially to deal with evaluation of the x-ray chairs so that the x-ray is not missed so artificial evaluation can find out whether x-rays abnormal or normal and then once the artificial intelligence this computer-aided diagnosis picks up any x-ray abnormality then the radiologist can see so this i think would greatly help for early detection of tb now here i was talking about this young girl who presented with bilateral extensive disease this is the x-ray and very surprising that for five months she was not investigated despite of having the symptoms so what is the who recommendation for diagnosis so expert mtb riff or expert ultra both are gene expertise that is nuclear uh that is nucleic acid amplification test that is the first choice so in adults who have symptoms suggestive of tb you do spotum evaluation so school term for gene expert in children sputum but many times children don't produce sputum so you can take gastric aspirate or even nasopharyngeal secretion or even stool evaluation so a lot of studies are now coming where stool uh gene expert tests are being done and the sensitivity is pretty high in pediatric population and when patient has extra pulmonary tb say if cnstb then you do csf analysis see the csf should be sent for gene expert or pleural fluid or lymph node aspirate so all the extra pulmonary samples should also be sent for gene expert now you should also know the terminology and all the definitions about drug sensitive as well as drug resistant tb so what is dstb dstb is drug sensitive tb and a tb patient whose biological sample it may be pulmonary or extra pulmonary is sensitive to all the first line anti-tb drop then mono resistant tb now is when the uh drug when the mycobacterium is resistant to one of the first line anti-tb drug okay so it is mono resistance to isoniazid then it's called h mono resistant if it is mono resistant to repair piston it is called are mono resistant then uh the pump is in resistant tb where the patient sample is resistant to reformacion so even if it's mono resistance or a pump is in it is still treated as mdrtp then there is something called polydrug resistance where other than isoniazine and pampicine if any other drugs are resistant and it is called polyresistant and what is a multi drug resin tb mdrtb so by definition mdrtb is resistance to isoniazid and ripamp acid without resistance to other first line and second line drug then there is something called pre xdrtb that is when the person's sample is resistant to fluoroquinolone it is called pre xdrtb and when we talk of extensively drug resistant tb it is resistance to isoniazid rifampicin any additional resistance to procurement or one of the newer drugs that is bidarcolin or linazolin and when uh patients uh bacteria mycobacteria resistant to multiple drugs beyond xtr then it is called beyond xdr so these are the various terminologies that you must know now let's come to the diagnostic algorithm so how do you investigate your patient with tb and once it is confirmed with tb how do you further work up your patient so whenever you suspect or your patient to have tb the most important test to be done is sebina or gene expert now if the gene expert shows that it is repump is insensitive should you be just happy and treat this patient with first line akt no incidence of isoniazid mono resistance is also very high in our country that is why the moment you get that patient is gene expert positive and the pump is insensitive you subject this patient to first line lpa the first line lpa will tell you about isoniazid as well as repurposing now if postline lpa also shows that both the drugs are sensitive then this patient is classified as drug sensitivity and you start the patient on first line nttb drug now if your first line lpa shows that this is h resistance then you classify this patient as h resistance and you do further test second line lpa that is for uh levofloxacin and aminoglycoside and then you find out that second line lpa levoflox and aminoglycoside are sensitive then you cla treat this patient as h mono resistance okay now on the other side of the algorithm if you have a patient who comes as the pharmacist in resistance then you have to do fourth first line and lpa second line lpa and then further treat the patient so that comes under mdr but this part about the drug sensitivity i hope that is very very clear now all the extra pulmonary samples so whenever if some of you are interns and you are working with you know surgical team it's very important that all the extra pulmonary samples should be sent for gene expert ab smear ap culture first line lpa and second line lpa whenever possible because once you do a lymph node biopsy or if it's a surgical sample it is not possible to perform the test or surgery again to get the sample again with sputum you can repeat but in surgical samples you cannot repeat and that's why it's very important to send the sample for all the required tests so let's now just discuss this case after having learned so far about the screening and tests and evaluation let's let's see practically how you can apply this so 26 year old female she had cough and fever since 20 days no anorexia no weight loss uh past history of tb and pleural effusion five years back now you can see here on the x-ray you are seeing on the right side something like cavity and you can see here on the ct scan very clearly you can see the cavity so there is a cavity surrounding consolidation a lot of nodular opacity you're seeing something on the other side also so x-ray nct scan is very classical of tuberculosis now how will you manage this patient so start this patient on first line akt or because the patient has already taken treatment in the past you can give something like category two where we can give so first line ehrs is ethambutol isoniazide repampisin and pyroxenamide then category two is apart from these four drugs streptomycin our third option is to send the sputum for gene expert and wait for the result the fourth option is send a b smear a b culture for gene expert and start first line akt so which of the options you think is the right option for this patient you can put your answers in the chat box three okay anybody has a different view four okay [Music] or yeah so i think uh fourth option would probably be the correct but people who say three third option also may not be wrong because yes you have to send a gene expert rule out drug resistant wait for the results and the further test can be sent subsequently or the fourth option is also correct that you spend sends mere culture at the outset sputum for gene expert and start for the first line att but i think most probably uh the third option would be the right one because nowadays with gene experts we get result within 24 hours and within 24 hours you know whether patient has drug sensitive or drug resistant tb and a patient is not very sick it is ok to wait for 24 hours confirm that patient has drug sensitivity and then initiate the patient on appropriate treatment so this is how a gene expert report was available so sputum gene expert mtb detected and ripped resistant non-detected so fortunately she had drug sensitivity now what do you do after this so after the patient is diagnosed with drug sensitivity on gene expert what should be your next step you do the pre-treatment evaluation and start akt send for ab culture pretreatment evaluation and start akt or first line lpa pre-treatment evaluation and start akt so what would be the choice here so krishna yes absolutely right so most of you got that right pramod is saying is option two okay it should be first line lpa because that's where again you will get the results within about uh two days whether patient has just repair sensitive or patient as ionis sensitive also so option three is the right one great so this is how fortunately this patient in lpa shows that republican is also sensitive and isoniazid is also census so now you categorize this patient at drug sensitive tb and you are ready to start the patient on anti-tb treatment so like you have seen in this case when you write down the diagnosis of this phase you know already know which type of does the patient have tb is hundred percent confirmed because gene expert is showing mpb so patient has tb what tb it is pulmonary tb then second question is it's a fresh case or heat treatment this is a re-treatment cave is it drug sensitive or drug resistant so it is drug sensitive okay and have you followed the diagnostic algorithm yes you have followed the diagnostic algorithm so when you write the diagnosis what would you write this is a retreatment case of pulmonary retreatment case of drug sensitive pulmonary tb so that would be your diagnosis so this first four component of this 12 or 12 point formula have been taken care of now how do you move further so we look at the comorbidities pretreatment evaluation guideline based treatment and counseling so so why do you do pre-treatment evaluation so anytime when you start the patient on anti-tb treatment you must do pre-treatment evaluation so what is the purpose of doing pre-treatment evaluation the most important is you want to see the baseline status so you want to have the baseline lft complete blood count esr creatinine and buf1 urine routine and hiv status is a mass so every patient of tb whether it is drug sensitive or drug resistant tb must have hiv test that should be done because many times we pick up a patient who is undiagnosed to have hiv and we pick it up when we evaluate for tb every patient must have fasting blood sugar post lung blood sugar and hdmc levels done they said the incidence of tb is very high in diabetes and many times it happens that in our patient we pick up existence of diabetes first time when we evaluate them for tuberculosis and then in ladies urine pregnancy test should be done crp level will be done when the disease is extensive in patients with hiv and always baseline x-ray has to be done sometimes like in this patient we did we may also have to do a chassity scan but a chastity is not must for every patient and for patients who is having extra pulmonary tb like so cnsdb you have mri brain a patient has fine tb then you have mri spine ct scan of abdomen so depending on the site of extra pulmonary tb you do the relevant investigation and then subsequently when you are following up the patient you have to do say for a cnstb we don't get sample like we get in sputum so you do mri brain and after three months you have to repeat mri brain mri spine you do and after three months you have to repeat mri spine and see whether the patient is responding or not so why do we treat the patient with akt what is our primary aim of putting the patient on anti-tb treatment so one of the most important aim is you want to stop the transmission of disease in the community and the best way to stop the transmission of tb in the community is make your patient non-infectious that is mere negative as soon as possible so you can stop transmitting the disease so putting the patient on the right effective treatment is the best way to stop the transmission of this is in the community and it's very heartening to know that once you start the patient on right regimen within 48 hours the bacillus count starts to come down and within seven days patient's infectivity comes down significantly but in drug sensitivity usually you wait for two weeks before you allow the patient to mingle freely in the community so whenever you ask the patient to when you start the patient on drug sensitive tb treatment you ask the patient to follow all the infection control measures for at least two weeks then the second intention of starting the patient on anti-tb treatment is of course to cure the patient and it's a completely curable disease the third intention is to prevent the progression of the disease to prevent mortality and complication and that is why it is so important that you screen the patient in the initial stage like this young girl whom i just saw two weeks back florid bilateral extensive disease by the time she came to us and we could diagnose and now even if i put the patient on anti-tb treatment she may becomes mere negative and culture negative but the lung destruction which has happened is going to leave a permanent morbidity in her she'll develop pulmonary fibrosis she will develop obstructive airway disease so all these complications happen and that's why early diagnosis and early treatment is very important and to prevent death because tb can kill and that's how 1400 people are daily dying of tb in our country now you must know the dosages of the first line anti-tb drug so these dosages you must all know like you can copy this slide so in children what should be the range of isoniazid usually in children we give higher dose that's about 10 milligram and in others we give up to 500 milligram now earlier it was said that uh maximum dose of isonia that is 300 in adults and children but nowadays a lot of studies have come where we give higher dose we sometimes have patients who weigh 90 kg 100 kg and we give up to 400 500 milligram of isoniazid also and even in the pediatric kit now rifampicin in pediatrics is given 15 milligram per kg and uh in adults 10 milligram per kg pyrazine amide 35 and 25 and in ethambuto 20 and 15 milligram so a lot of new studies are showing that you may go a little higher but the maximum dose of ethambutol is 1600 should not go beyond that maximum amount of pyrus in amidos is 2 gram and isonia that we can go up to 450 to 500 and the palm basin we've gone up to 750 to 900 because closely you have to monitor the patient but now this is how you can give higher dosage in your patient then in the government program we get fixed dose combination and nowadays fixed dose combination is preferred because patient doesn't have to remember to take all the drugs separately and all the drugs are taken together so advantage is that when anti-tb drugs are taken together it's the peak of all the drugs is achieved together and that's how maximum bacterial serial effect is created and also compliance is better by reducing the pill burden this is how the medicines are available in in the government sector so this uh fixed combination each tablet has this proportion of four drug that is isoniazid is seven 25 mil it has 75 and pyroxene amide is 400 milligram and how do you give the dosage so these are the weight bands 25 to 34 25 35 to 49 50 to 64. and according to the weight band you give the number of medicine so for weight band of about 50 to 64 you give portra 65 to 75 you give five drugs and beyond 75 you give six drugs but six the tablets when you give sometimes it will become very difficult for patient to tolerate is six tablets then maximum that we have gone up to is phi tablet so the rational treatment of drug sensitive tb is the best way of stopping mdrtp now such a simple thing in a country like ours where tb is the first best or the top most infectious this is killer many people so many practicing clinician are not aware of the dosages the right combination and the duration of the treatment so these are certain principles about treatment avoid under dosage and overdose it sometimes you have this fixed formulation and you end up using these drugs for patients so sometimes this akt4 uh combi pack is very common this akd4 combi pack the pump is 450 isoniazide is 300 ethambutol is 800 and pyroxynamide is 1500 so it's so simple to remember akd4 so many times we see a 30 kg young girl is also prescribed akt4 where she gets such high dose of pyroxenamide and a 90 kg or weighing man also is prescribed akt4 because one is not aware so what happens that for a 30 kg person you use this source you create hepato toxicity patient will not tolerate medicines and patient will default 90 kg man would happily go on taking the medicine but here adequate drug levels will not be reached and the patient can develop drug resistance so this is how when you do under those and overdose you can actually create drug resistance you should never divide the dose of akt so suppose in fix those combination you have to give five drug and say i take two and half tablet in the morning and do it how to enough tablets in the night one should never do that uh follow the latest guideline for dosage and regimen it's very important avoid adding fluoroquinolone as a fib drug now all of you have to be very very aware very judiciously you must use fluoroquinolon in your practices okay because uh fluoroquinolone resistance is so common in our country because of misuse of fluoroquinolone for non-tb uh drugs and many many clinicians add fluoroquinolone as a fifth drug to the four drug combination and that is a very wrong practice and you should never add one or two drugs to a failing regimen and daily therapy is always superior to intermittent therapy so uh how do you treat the patient with first line regimen what is the treatment regimen so it is intensive phase and continuation phase so an intensive phase there are four drugs that ehrz and in uh continuation phase there are four drugs two drugs that is hnr so what is the new guideline saying the new who guidelines say that in the intensive phase one has to use the third drug also because the incidence of inh mono resistance is very high in our country so suppose you have a result of only gene expert and you haven't had the result of lpa and ap culture is not available to you and you are not aware whether patient has h resistance or no in that case or if the patient has got extensive disease then it is better to continue ethol in the continuation phase when you are not aware of the isoniazid resistor but if you are know that lpa report is showing r is also h is also sensitive like in the previous case then it is okay to omit ethambutol from the continuation and otherwise it is recommended to continue ethambutol in the continuation phase then all the patients should they be getting only six month treatment so a patient has got limited disease or patient is called just lymph node tb or pleural effusion then six month therapy is uh enough but if patient has got disseminated is like the previous x-ray of that young girl with bilateral disease and the cavitative disease then it is better to give nine month therapy and certain extra pulmonary tb like uh spine tb bone tb brain tb extensive dissaminated disease or cavitated this is where you give longer duration of treatment out of that spine bone and brain tb you give for one year for disseminated tb and for cavitative disease we give for nine months and very good news is soon we would be having uh india managed to be india app okay so next time somebody makes uh munnabai movie so instead of asking munnabai to ratto fi uh the anti-tv drug they would just ask him to manage with the manage tb india app okay so uh this uh managed to be india app is going to be very user friendly so just have to put in all the detail like age gender weight of the patient uh the pre-treatment evaluation x-ray findings and the site of the tv and that app will give you the right dosage duration and the action to be taken so i think probably this would be a great uh step towards you know preventing creation of mdrtb because if people use the app they'll end up giving the right regimen okay now after you have diagnosed the patient after you formulated the regimen you have done the pretreatment evaluation the next important component is counseling because the drug default is very common and that is one of the commonest reason driving the epidemic of tb in our country because patients come from different educational and social status and they do not understand the importance and the treatment is a long one imagine sometimes we have to take a course of antibiotic we don't even complete five days of antibiotic and this uneducated patient or many even the educated one it's a challenge to complete the treatment taking it daily for six months nine months to a year and that's why you have to spend enough time to educate your patient tell them the consequences of non-compliance that it can lead to morbidity and mortality also also counsel them about the possible side effects because a lot of side effects happen with anti-tb drop uh one simple thing like changing the color of the urine with reform patient if you don't tell your patient patient will panic sometimes they will go and consult some you know practitioner who may not guide them properly and they end up giving up treatment infection control measures are extremely important so once you put the patient on drug sensitive tb for 15 days that patient remains infectious so for 15 days he has to use mask at home a person should not be sharing his bed with anybody else and the attendants have to take all the precaution so that has to be told contact screening that's extremely important the moment you diagnose any patient with tb you must ask all the family members to have their ex screening done you also should ask presence of symptoms of all the family members and right at the beginning you counsel the patient about the follow-up visits so before you hand out your prescription of anti-tb drugs to your patient you ask yourself have i confirmed the diagnosis have i made a reasonable attempt to obtain a sample so if it's extra pulmonary tb you have to do investigation you would do invasive testing the plural aspiration sometime in lymph node tb we do bronchoscopy and ebus evaluation csf analysis abdominal tb we do abdominal lymph node biopsy so you have to make all the attempts to obtain the sample have i given the rational prescription as per the latest guideline have i definitely ruled out drug resistant tb have i counseled the patient and have addressed all the comorbidities so like the case we discussed so we did all the right investigation we found our patient as drug sensitive tb in the second test in the algorithm we found out that there was no inh resistance also we did all the pre-treatment evaluation we started the patient on the right treatment based on the uh you know the latest guidelines and following the weight band we counsel the patient about all the uh consequences of defaulting infection control and consequence side effects of the anti-tb medicines and now you have also ruled out the comorbidities and now you're giving out a prescription to the patient if you have followed all these steps it's very likely that patient is going to complete the treatment and you as a clinician have uh you know fully taken up your responsibility and then justice your responsibility of treating a patient of tuberculosis and contributing towards controlling this epidemic of tb in our country okay so we have address first eight uh components of this uh tb care now comes the follow-up monitoring and adverse drug reaction yes somebody is asked about severe hepatotoxic to first line drugs yes so we will going to talk about it briefly so why do you want to follow up and monitor the patient isn't it just enough that you've started the patient on nttp treatment so yes follow-up is extremely important because you want to monitor whether your patient is improving clinically radiologically and microbiologically and remember it's important to follow all the things patient is clinically saying yes i'm improving you don't check the x-ray and don't objectively see so that's not good if a patient is saying clinically improving the x-ray is also showing improvement but you should also confirm microbiologically that patient is becoming spear negative okay then you want to detect treatment failure and anything in any development of drug resistance and to detect adverse drug reaction and the fourth important point is which i have not mentioned here on the slide is check on the compliance it's extremely important especially our indian patients are always no such always in a state of denial and they become their own doctors and they have so many non-medical advisors who think that they have become doctors so very likely if you don't follow up your patients somewhere along the line patient may just stop the treatment so fourth important point is that you want to check the compliance so what i usually do in my practice is that after having explained to the patient about the adverse reaction uh the most important adverse reaction is hepatotoxicity okay so on the first first follow-up happens after two weeks so we ask for a patient to do sgot hgpt serum polyurethane after two weeks of initiating 90 db treatment and then then on monthly follow-up during the intensive phase so maybe two follow-ups uh at one month the interval during intensive phase and once the patient completes the intensive phase you omit uh zed or you omit ethambutol and z and then during the continuation phase it is okay to follow up the patient once in two months okay now during this follow-up what all you do so you ask for the symptom a patient has got symptom relief initial presenting symptoms and now what is the relief in the symptom check always for the compliance okay check for the weight one of the sign that patient is improving is a weight gain check the pulse so many times when patient initially has active infection patient has tachycardia and as the patient try improves the tachycardia settles in fact sometimes tachycardia is one of the parameter with which we have detected the patients have not patients have not responded and later on the sputum comes positive then check for the oxygen levels pulse weight compliance and symptom and what are the investigation that you do uh cbcs tpt bilirubin sputum ap smear and chest x-ray and ophthalmological evaluation has to be done once in three months and that's very important many times we pick up cases of octal optic neuritis even before patient develop symptoms of vision disturbance somebody say that we monitor also uric acid yes so we routinely in all patients we do not monitor but if somebody complains of arthralia then we do then we monitor uric acid all right so this is the chart of saying the monitoring how do you do it scooter smear and culture and clinical assessment now here they have uh talk of monthly follow but practically we we don't do monthly follow-up what they follow only during intensive phase and then once in two months okay okay so yeah so monitoring the treatment response sometimes now you get some surprises a patient is not adequately improving on your treatment so if your patients of on first line akt is not improving clinically or radiologically then what do you do so in the first place go back to your history and go back to initial evaluation whether it's the outset you confirmed it was drug sensitive tb or no many times if patient primarily comes to us we investigate in the right way but many times patient come to us halfway they have been investigated somewhere else and treatment is already been started and they come to us where we are no or when we don't we don't have access to the sample again so in that case when the patient is not improving you just see whether the drug sensitive tb was confirmed or not sometimes we see fall and rise phenomena which means that patient has mixed population of drug sensitive and drug resistant bacilli and drug sensitive bacilli get killed uh with your first line anti-tb treatment and then the drug resistant bacillus start to grow and that is why the importance of monitoring with microscopic evaluation microbiological values now many times patients who are living in high risk it's like people living in the slum they are being treated for drug sensitive tb but they get reinfection with drug resistance strain that's also possible sometimes patient is not improving radiologically it may be that they are developing some complication like post tb fibrosis secondary infection then space patients are presence of some second pathology so that may happen in diabetics or in hiv patients sometimes we see that they have some other secondary infection or in the beginning the diagnosis was wrong so that's also possible and patients i reside is immune reconstitution inflammatory response very commonly we see an hiv patient very commonly we see in lymph node tp patient so all this thing can happen when you see that the patient is not responding and that is why having all three components of assessment that is clinical radiological and microbiological is very important to ascertain that the patient is not responding now this is the patient uh you can see here along cavity and in the cavity there is the secondary infection fungal ball you can see here the fungal bone sometimes radiologically you may think that the patient is not responding but microbiologically when you do uh sputum evaluation a b smear a b culture comes negative so there is a secondary infection with fungus or colonization okay many times it so happened that the cavity is very thick walled or abscess is there and the anti-tb drugs don't penetrate and that's why patients don't respond or sometimes dst has been done from some unreliable lab okay or or there may be discordant dst between in vivo and in vitro and drug levels may not be achieved and patient is non-compliant so that is one of the very common reason so many time patients lie to us and when they scold them and we probe when they come out that okay they were missing out on some of the dosages or or they've been prescribed wrong dosage or inadequate blood levels of the drug so there is also therapeutic monitoring of the drugs is available only for and republican so now comes the prevention aspect and after the prevention maybe we will discuss something about the uh drug adverse reaction so now it is said that one of the important component of controlling the epidemic of tb is by focusing on the prevention because currently uh all of our clinician most of our time is occupied uh in treating this extensive drug i mean extensive tuberculosis any drug sensitive and drug resistant tb and and a lot of our time when resources get wasted into this instead of that if you think of prevention of the disease then it is it is probably the most important investment into the health care okay so what what are the factors about prevention so one important aspect is managing the risk factor so diabetes hiv ckd this is all very common again you know that india is a global leader in having maximum number of diabetes cases so all manage our diabetes well screen our diabetes patient and diet and nutrition is very important the vitamin d deficiency low hemoglobin are very very common in fact during this pandemic we have seen a very disturbing trend that we have started seeing lot of youngsters coming with tb and many of them are coming with extensive disease and when we ask take the history there are certain common factors which are finding that most of the time the youngsters are spending time in front of the screen there is hardly any physical activity no exercise no physical activity their dietary habits are very poor you have very poor nutritionally poor diet and the sleep patterns are completely disturbed they are spending a lot of time on social media or on the on laptops and sleep for about six hours or eight hours and the sleep timings are completely haywire and they skip their breakfast and because of all this and all our mental stress of being restricted lifestyle not having offline uh classes to be attended and all this together have put a severe compromise on their immunity and we've started seeing many youngsters coming with extensive disease and vitamin d deficiency is also very common because of lack of outdoor activity and exposure to sunlight so these are the factors and i would say many of our healthcare workers paramedical staff and medical students are also so having a very erratic lifestyle i think all of us have to start looking at this component we are all healthcare providers and we are going to treat our patients if we ourselves don't improve our lifestyle then we have no right to advise our patient to follow healthy lifestyle i think is a very important aspect we all should understand so uh this is about the other aspect of treatment prevention that is taking um chemopropyl access a lot of work is being done now on chemoprophylaxis and say that all the patients who are high risk to develop tb say for example household contacts of patients of uh you know prime drug sensitive or drug sensitive or drug resistant pulmonary tv then these patients have to be treated with because they are highly likely to develop active tb they said that once a patient has got latent tb infection there is a 5 to 10 percent risk that in lifetime this patient will develop active tb and in hiv patient this risk is uh 10 times more so let's say what is the algorithm for treating for giving preventive therapy so if the patient has any factors that is a household contact tb or patient having hiv infection or having any comorbidity then if the risk factor is yes then does the individual have any uh symptom of tb so once you identify that patient has high risk for developing drug sensitivity uh blatant tb infection the next important step is before you initiate chemo prophylaxis you have to be extremely uh careful and you you should rule out that patient does not already have active pb and that's why you have to do the evaluation so uh if the patient has any symptom if yes if the patient has any symptom then you investigate for presence of active tb with sputum smear gene expert or also x-ray chess if you find in this evaluation that there is no evidence of any active tb infection then you do uh tst that is one two test or the tb gold is called egratis if is positive then again you do chest x-ray look for any abnormality and if you find that there is no abnormality then you can initiate the patient on prophylaxis okay so now uh if your mantu test or tb goal test is negative and patient does not have any other high risk factors then you may decide not to treat this patient with chemoprophylaxis okay okay and if the patient does not have high risk for having a latent tb infection then you may not screen this patient ah now what are the different options for treating uh for giving chemoprophylaxis so you may give your patient daily isoniazide for either six to nine months so you give five milligram per kg in adults and children 10 milligram per kg or you can give daily deformation for three to four months again uh 10 milligram per kg uh sometimes you may give isonia then the pump is in combination usually i don't prefer because giving two drops and risking creating drug resistance i'll be worried about so i will just give one drug and there is a new regimen and which is very useful and i think soon uh people would be using this regimen that is repurposing and isonia that you just have to give once a week and all the studies have shown that maximum maximum compliance is with this once a week regimen for three months which means in 3 months you just have to use 12 dosages so this is the dose of repair pentine according to the body weight so for an adult usually the dose would be around 600 to 750 milligram and i so near there would be 15 milligram per kg around 600 to 900 milligram so isoniazid 900 and the pump is in nine repenting 900 just giving once a week so these are all the different so with this i come to the last part of the talk so this i've just discussed 10 common pitfalls for tuberculosis management so not suspecting tb and not evaluating while the standard of tb care says that early diagnosis symptom screen x-ray screen and appropriate evaluation is is the key so x-ray screen smear gene expert evaluation and symptom screen that is should be followed inadequate workup is usually done but standard of tb care says that you have to follow the diagnostic algorithm we learned about the diagnostic lot of inappropriate tests are being advice while the most important test for diagnosis is microbiological tests many people will do serological tests or cbc or esr or mantu test all these are not sensitive tests to diagnose presence of tb so the most important tests are the microbiological tests and that's gene expert so not suspecting drug resistant tb so you have to ah the patient is not responding a patient has got high risk photographers in tb you have to evaluate and diagnose early okay overuse of quinolons is another pitfall so use your quinolone very judiciously don't use it as far as possible for non to be conditioned then not addressing the comorbidities and contacts it's very commonly we just start the patient on anti-tb treatment but we don't address the comorbidities so every tb physician must know to diagnose comorbidities and treat inadequate regimen it's very unfortunate that many people do not know the latest updated guideline so you must treat according to the guideline uh not ensuring treatment adherence so counseling and follow-up is very important inadequate follow-up and monitoring many times i see some of my colleagues they initiate the patient on anti-tb treatment and then they do not follow up with blood investigation or subsequent x-rays and we don't even realize that the patient is responding or no and another pitfall is not notifying all the cases so notification of all the cases is mandatory and legally punishable office if you don't notify so having gone through the presentation i think now we can start from thing you are now well aware what is the magnitude of problem of tb in our country and you are ready to take as as a medical practitioner practicing in india every clinician has to take the responsibility their responsibility the part they have to play in uh controlling the epidemic of tb in the country we have to change our attitude be willing to learn be willing to accept your mistake upgrade your knowledge acquire the skills and knowledge go on upgrading the skills and knowledge because the science is changing so rapidly the new guidelines newer drugs new diagnostic tests are coming and whatever you learn you practice that in your however busy you may be in your clinical practice but you go on practicing this skill and slowly this becomes your habit your behavior will change and then the result will anyway comes so instead of focusing on the result and you know talking of the goal like a mantra start working on the inner layers and that's where you'll be able to give the results so as a department of pulmonary in jupiter hospital i'm proud to say that we've taken the various components starts with the clinical work but we also do teaching and training research and publication we've had about 8 papers and 120 citations and then we collaborate at national level for treating drug difficult cases and advocacy is very important aspect so with the generating right kind of uh evidence we've been able to impact the policy making and uh create the awareness so thank you so much for giving me this opportunity to talk to my young and future doctors who i'm sure are going to be helping the country in controlling the epidemic of tb thank you dr alpha i'm sure everyone agrees here that this is indeed an enlightening session thank you so much we'll take a couple of questions now ma'am dr darshan jada wishes to know please tell us about steroid indication and tuberculosis treatment so there is very few selected uh you know indications of steroid or treatment of tb so one is that when patient has got iris so immune deconstitution uh reaction so in that case we do give steroid the patient and in cns tb definitely steroid is indicated and sometimes we have to give for longer duration and in pericardial tuberculosis and sometime patient got adrenal tb then addison's disease and these patients we have to give them and the fifth uh indication is when patient develops allergic dermatitis or rashes and so or stephen johnson syndrome so then we have to give serotonin so apart from this no other cases steroids are not indicated okay thank you ma'am i hope that question answers your question dr darshan we have a lot of positive comments here we have a question from dr jithendra how to induce putin if sputum is not available can steam inhalation help will steam inhalation affect the result of gene expert or efp sphere that's an excellent question and very common question so what do we do routinely when the patient is not producing the sputum so we give them expectorant we also try a bronchodilator inhale bronchodilator so commonly protropium and uh levos albutamol combination we try the deolin inhaler or deolin rota cap and we ask the patient to start taking this bronchodilator three times in a day give them expectoration two teaspoon three times a day and then the morning when they try to collect the scooter sink takes t ventilation and then collect the sample and many times this this you know intervention helps to induce sputum and the patient is admitted in the hospital then we can use three percent normal saline via nebulization to induce sputum steam inhalation will not affect the results of gene expert and either it will affect the results of the culture okay thank you ma'am uh dr jatendra also wishes to know a difference between rifampicin and rifapentin so it's a reform icing derivative so that they are two different drugs so many times the few selected cases where a pump is in is resistant ripa pentin can still be used and it has much lesser interaction in case of hiv patient and used if a pending the reactions are i mean the drug drug interactions are lesser okay i hope that answers your question is much more effective as uh for treatment of drug sensitivity so effectivity against mycobacterium uh mycobacteria is much higher for a pump acid than department okay dr shri priya dr sunil and dr ashwini all say that this is an incredible session yeah very informative and impressive presentation and uh yes ma'am so we have a question from dr senjib status of streptomycin and management of cogs so now she said the latest guidelines have phased out injectable from treatment of drug resistant as well as drug sensitive tb so so routinely we don't use uh streptomycin so earlier we used to have category two uh treatment for patients of retreatment so that has been phased out now so very few selectives is where we have patient developing drug induced hepatitis and then we cannot use three drugs like isolate other pharmaceutical and pyrazine amides so for a short period till the time we are able to reintroduce this hepatotoxic drugs we do use streptomycin and sometimes in cases of cnstb where streptomycin has better drug penetration can be used apart from this few selected instances so septomycin is now no longer used for treatment of okay thank you mom just a couple of more questions and then we can wind up more of your time uh dr mustapha asked after drug-induced hepatitis how do you reintroduce reframing and isolate it so after drug induced hepatitis first of all you have to stop all the hepatotoxic drugs okay now a patient has got symptom of nausea and vomiting and so even if there is two times rise in the drug in the liver enzymes you're supposed to stop the drug but if patient is asymptomatic then up to five times the rise of enzymes also you can continue with the drug beyond phi times the rise you should not be so once you decide that patient has hepatotoxicity you stop isoniazid rifampicin and pyridomide so usually in my practice i start off with isoniazid first and then reform acid but if patient has more of hyperbilirubinemia then i uh usually prefer to start isoniazide if it's more of enzyme rice then i can i start with repurposing but either approach is okay none of the studies have shown that one is superior to the other so either isoniazid or rifampicin can be started so what we do is that once the liver enzymes come back to normal and that's very important you allow the liver injury to settle the liver enzyme come back to normal and say you start isoniazide after five days you again repeat the liver function test they remain settled then you introduce the next drug that is repurposing again after five days you allow the liver enzyme to remain stable and patients shouldn't develop symptoms also so apart from liver enzymes you also monitor patients symptoms and then introduce pyrazinamide so pyrus in ammar usually we start with say 500 000 and then reach up to 1500 okay thank you mom uh we have a couple of questions from dr pranab datta firstly he says very informative and impressive presentation and just a minute so a prophylactic treatment for sputum positive patient in the family so household contacts of uh we are one of the highest risk for developing uh this so so currently the latest uh tb guidelines have come new and we have not yet been the full fled practicing treatment of latent tb but i would say that if uh in a household if i have uh high risk contacts if elderly patient or pediatric below the age of five years or somebody who's use immunocompromised diabetic or taking immunosuppressant therapy then irrespective of their uh you know latent tb status i would like to treat them with uh with inh prophylaxis or uh repamp is in for four months or ideal would be isoniazid and ripcopentine for once a week for three months but before i put them on isoni i mean any of this prophylactic regimen i would like to rule out presence of active tb so i have to make enough attempt to rule out active pb and then put them on so currently my recommendation would be in the household contact high risk contact should be treated first okay thank you ma'am next question is from dr sonam how to manage a drug resistant tb patient on appropriate management is having persistent fever even after a month of anti-tubercular treatment all other causes for fever has been ruled out yes so patient with drug resin tb who continues to have fever even if the patient is on the right regimen first of all you have to be sure that patient has no additional resistance to the drug so what happened that usually we have first line lpa second line lp available and all the other drug sensitivity may not sensitivity may not be available so you have to rule that out another possibility of iris would remain so so these are the two possibilities that you have to check okay one last question mom um mom please tell us what you use as a third drug in drug-induced hepatitis if patient has streptomycin reaction then only levofloxacin it amputates should be used is it no no see levoflox and ethanol are very important in treating drug-reduced hepatitis because you can't give single drugs so three of the first line drugs are hepatotoxics isoniazid pumpisin and pyroxenamide so you have to use lymphofloxacin and ethambuton and many times we use streptomycin but if for some reason a patient has ckd or doesn't tolerate septum icing and liver enzymes are way too high and it's going to take another 15 days for me to reintroduce the other hepatotoxic drug then i use one of the second line drugs like linosolid or chlophage but i wouldn't routinely recommend it recommend their use but isonia that liverfloxacin and septomycin is what we routinely use but sometimes we have to use the second network okay thank you dr alpha thank you so much for your time we do have a couple of questions but we could direct them to you at a later time we will definitely have mom again on our platform we would love to have you again ma'am yeah dear doctors thank you for attending dr alpha thank you so much and have a good night

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dr. Alpa Dalal

Dr. Alpa Dalal

Consultant - Chest Physician, Jupiter Hospital, Thane

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dr. Alpa Dalal

Dr. Alpa Dalal

Consultant - Chest Physician, Jupiter Hospita...

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