Letters to Editor
Author’s reply Sir, We acknowledge the comments[1] regarding our article published in Lung India.[2] We agree with the author that Bhang, which consists of cannabis leaves, is not included under the purview of the Narcotic Drugs and Psychotropic Substances Act (NDPS Act), 1985, in legal terms. However, the purpose of our review was to shed light on the medicinal use of Marijuana in general. It is also to be noted that, in India, unscrupulous use of Bhang is prevalent. Bhang, exclusively in its leafy form is sparingly used, because of its frequent mixing with the other constituents of cannabis. It is also our view that Bhang should be strongly regulated due to its psychotropic effects, as discussed by the author,[1] and therefore, should be included under the NDPS Act. The various forms of cannabis are as follows: 1. Marijuana: The tetrahydrocannabinol (THC) content 0.5-5%, which further includes two preparations: • Bhang-Only dry leaves • Ganja-Leaves and flowering tops with a higher resin content 2. Hashish: Dried resin extracted from flowering tops with a THC content of 2-20% 3. Hash oil: Liquid extract that contains 15% THC 4. Sinsemilla: Non‑pollinated flowering tops from female cannabis plant, with high content of THC (20%) 5. Dutch Hemp (Netherweed), with THC concentration as high as 20% [3]
There is not much literature on Bhang and its effects among its users, so it is prudent to study this form of cannabis in more depth.
Interestingly, there has been an amendment in the NDPS act in March, 2014.[4] The amendment has broadened the objectives of the NDPS Act and promotes the medical and scientific use of narcotic drugs and psychotropic substances. This will also pave the way for more research in the field of chronic pain management and palliative care including the use of medicinal cannabis and its congeners.
Surender Kashyap, Kartikeya Kashyap1 Department of Pulmonary Medicine, Kalpana Chawla Government Medical College, Karnal, Haryana, 1Ex‑Intern, Government Medical College and Hospital, Chandigarh, India E-mail:[email protected]
REFERENCES 1. 2. 3. 4.
Balhara YPS, Mathur S. Bhang - beyond the purview of the narcotic drugs and psychotropic substances act. Lung India 2014;31:431-2. Kashyap S, Kashyap K. Medical marijuana: A panacea or scourge.Lung India 2014;31:145‑8. Aydin A, Fulton AJ. Cannabinoid Poisoning. US: Medscape; Updated on July 2013. Available from: http://emedicine.medscape.com/ article/833828‑overview. [Last accessed on 2014 Jul 13]. Narcotics and Drug Psychoactive Substances (Amendment) Act, 2014. Available from: http://www.indiacode.nic.in/acts2014/16 of 2014.pdf. [Last accessed on 2014 Jul 13].
Access this article online Quick Response Code:
Website: www.lungindia.com
Adenosine deaminase in exudative pleural effusions Sir, The report on ‘Adenosine Deaminase in Exudative Pleural Effusions’ is very interesting.[1] Mehta et al. have concluded that ‘pleural fluid adenosine deaminase (ADA) is cost‑effective and a good screening test for the diagnosis of tuberculosis (TB)’.[1] This conclusion must be carefully considered. First, the reported predictive values of the test, in the present report, are not good.[1] This finding is similar to that of a previous report by
Khow‑Ean et al.[2] As Islam et al. have noted, the test must be used along with the conventional method to get a diagnosis.[3] Khan et al. have also reported that the use of pleural fluid interferon‑gamma can provide a better diagnostic result than ADA.[4] Second, Mehta et al. have not performed any analysis for cost‑effectiveness, hence, the conclusion on cost‑effectiveness may not be possible. A good report that has considered the cost‑effectiveness analysis of using ADA is the previous report by Sharma et al.[5]
Lung India • Vol 31 • Issue 4 • Oct - Dec 2014 433
Letters to Editor
Somsri Wiwanitkit, Viroj Wiwanitkit1
4.
Bangkok, Thailand, 1Department of Medicine, University of Nis, Nis, Serbia E-mail: [email protected]
5.
REFERENCES 1. 2.
3.
Mehta AA, Gupta AS, Ahmed S, Rajesh V. Diagnostic utility of adenosine deaminase in exudative pleural effusions. Lung India 2014;31:142‑4. Khow‑Ean N, Booraphun S, Aekphachaisawat N, Sawanyawisuth K. Adenosine deaminase activity level as a tool for diagnosing tuberculouspleuraleffusion.Southeast Asian J Trop Med Public Health 2013;44:655‑9. Islam A, Hossain MA, Paul SK, Bhuiyan MR, Khan RA, Rahman MM, et al. Role of adenosine deaminase in diagnosis of tubercular pleural effusion.Mymensingh Med J 2014;23:24‑7.
Khan FY, Hamza M, Omran AH, Saleh M, Lingawi M, Alnaqdy A, et al. Diagnostic value ofpleuralfluidinterferon‑gamma and adenosine deaminase in patients with pleural tuberculosis in Qatar. Int J Gen Med 2013;6:13‑8. Sharma SK, Banga A. Pleuralfluidinterferon‑gamma and adenosine deaminase levels intuberculosis pleural effusion: A cost‑effectiveness analysis. J Clin Lab Anal 2005;19:40‑6.
Access this article online Quick Response Code:
Website: www.lungindia.com DOI: 10.4103/0970-2113.142114
Author’s reply We would like to thank Wiwanitkit et al., for their interest in our study and their valuable observations.
Asmita Anilkumar Mehta, Amit Satish Gupta, Subin Ahmed, Rajesh Venkitakrishnan
In response to the authors’ comments about the reported lower predictive value of the adenosine deaminase (ADA) test in our article,[1] we want to clarify that as per our study, ADA is a valuable test to differentiate malignancy from TB. Our study showed that only three (8%) out of 36 cases of malignant pleural effusion had ADA ≥40 U/l.
Department of Pulmonary Medicine, Amrita Institute of Medical Sciences,Kochi, Kerala, India E-mail: [email protected]
We agree with the authors’ comments that ADA must be used along with the conventional method to get a diagnosis, as suggested by Islam et al.[2] Khan et al.[3] has showed that use of the pleural fluid interferon‑gamma can provide a better diagnostic result than ADA, but at a higher cost.[3] We would also like to quote from the meta‑analysis by Greco et al., which showed that the joint sensitivity and specificity of ADA (93%) was similar to IFN‑γ (96%) and no significant difference was present in the performance of both the tests in the diagnosis of TB pleurisy.[4] We accept that we have not conducted a cost‑effectiveness analysis for our study,[1] and it is improper to state in conclusion that the ADA test is cost‑effective. Despite what has just been stated, it has been seen that the ADA test is less expensive than other invasive tests like the thoracoscopy‑guided or blind pleural biopsy.
434
REFERENCES 1. 2. 3.
4.
Mehta AA, Gupta AS, Ahmed S, Rajesh V. Diagnostic utility of adenosine deaminase in exudative pleural effusions. Lung India 2014;31:142‑4. Islam A, Hossain MA, Paul SK, Bhuiyan MR, Khan RA, Rahman MM, et al. Role of adenosine deaminase in diagnosis of tubercularpleuraleffusion. Mymensingh Med J 2014;23:24‑7. Khan FY, Hamza M, Omran AH, Saleh M, Lingawi M, Alnaqdy A, et al. Diagnostic value of pleural fluid interferon‑gamma and adenosinedeaminase in patients with pleural tuberculosis in Qatar. Int J Gen Med 2013;6:13‑8. Greco S, Girardi E, Masciangelo R, Capoccetta GB, Saltini C. Adenosine deaminase and interferon gamma measurements for the diagnosis of tuberculous pleurisy: A meta‑analysis. Int J Tuberc Lung Dis 2003;7:777‑86.
Access this article online Quick Response Code:
Website: www.lungindia.com
Lung India • Vol 31 • Issue 4 • Oct - Dec 2014
Copyright of Lung India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Author’s reply Sir, We acknowledge the comments[1] regarding our article published in Lung India.[2] We agree with the author that Bhang, which consists of cannabis leaves, is not included under the purview of the Narcotic Drugs and Psychotropic Substances Act (NDPS Act), 1985, in legal terms. However, the purpose of our review was to shed light on the medicinal use of Marijuana in general. It is also to be noted that, in India, unscrupulous use of Bhang is prevalent. Bhang, exclusively in its leafy form is sparingly used, because of its frequent mixing with the other constituents of cannabis. It is also our view that Bhang should be strongly regulated due to its psychotropic effects, as discussed by the author,[1] and therefore, should be included under the NDPS Act. The various forms of cannabis are as follows: 1. Marijuana: The tetrahydrocannabinol (THC) content 0.5-5%, which further includes two preparations: • Bhang-Only dry leaves • Ganja-Leaves and flowering tops with a higher resin content 2. Hashish: Dried resin extracted from flowering tops with a THC content of 2-20% 3. Hash oil: Liquid extract that contains 15% THC 4. Sinsemilla: Non‑pollinated flowering tops from female cannabis plant, with high content of THC (20%) 5. Dutch Hemp (Netherweed), with THC concentration as high as 20% [3]
There is not much literature on Bhang and its effects among its users, so it is prudent to study this form of cannabis in more depth.
Interestingly, there has been an amendment in the NDPS act in March, 2014.[4] The amendment has broadened the objectives of the NDPS Act and promotes the medical and scientific use of narcotic drugs and psychotropic substances. This will also pave the way for more research in the field of chronic pain management and palliative care including the use of medicinal cannabis and its congeners.
Surender Kashyap, Kartikeya Kashyap1 Department of Pulmonary Medicine, Kalpana Chawla Government Medical College, Karnal, Haryana, 1Ex‑Intern, Government Medical College and Hospital, Chandigarh, India E-mail:[email protected]
REFERENCES 1. 2. 3. 4.
Balhara YPS, Mathur S. Bhang - beyond the purview of the narcotic drugs and psychotropic substances act. Lung India 2014;31:431-2. Kashyap S, Kashyap K. Medical marijuana: A panacea or scourge.Lung India 2014;31:145‑8. Aydin A, Fulton AJ. Cannabinoid Poisoning. US: Medscape; Updated on July 2013. Available from: http://emedicine.medscape.com/ article/833828‑overview. [Last accessed on 2014 Jul 13]. Narcotics and Drug Psychoactive Substances (Amendment) Act, 2014. Available from: http://www.indiacode.nic.in/acts2014/16 of 2014.pdf. [Last accessed on 2014 Jul 13].
Access this article online Quick Response Code:
Website: www.lungindia.com
Adenosine deaminase in exudative pleural effusions Sir, The report on ‘Adenosine Deaminase in Exudative Pleural Effusions’ is very interesting.[1] Mehta et al. have concluded that ‘pleural fluid adenosine deaminase (ADA) is cost‑effective and a good screening test for the diagnosis of tuberculosis (TB)’.[1] This conclusion must be carefully considered. First, the reported predictive values of the test, in the present report, are not good.[1] This finding is similar to that of a previous report by
Khow‑Ean et al.[2] As Islam et al. have noted, the test must be used along with the conventional method to get a diagnosis.[3] Khan et al. have also reported that the use of pleural fluid interferon‑gamma can provide a better diagnostic result than ADA.[4] Second, Mehta et al. have not performed any analysis for cost‑effectiveness, hence, the conclusion on cost‑effectiveness may not be possible. A good report that has considered the cost‑effectiveness analysis of using ADA is the previous report by Sharma et al.[5]
Lung India • Vol 31 • Issue 4 • Oct - Dec 2014 433
Letters to Editor
Somsri Wiwanitkit, Viroj Wiwanitkit1
4.
Bangkok, Thailand, 1Department of Medicine, University of Nis, Nis, Serbia E-mail: [email protected]
5.
REFERENCES 1. 2.
3.
Mehta AA, Gupta AS, Ahmed S, Rajesh V. Diagnostic utility of adenosine deaminase in exudative pleural effusions. Lung India 2014;31:142‑4. Khow‑Ean N, Booraphun S, Aekphachaisawat N, Sawanyawisuth K. Adenosine deaminase activity level as a tool for diagnosing tuberculouspleuraleffusion.Southeast Asian J Trop Med Public Health 2013;44:655‑9. Islam A, Hossain MA, Paul SK, Bhuiyan MR, Khan RA, Rahman MM, et al. Role of adenosine deaminase in diagnosis of tubercular pleural effusion.Mymensingh Med J 2014;23:24‑7.
Khan FY, Hamza M, Omran AH, Saleh M, Lingawi M, Alnaqdy A, et al. Diagnostic value ofpleuralfluidinterferon‑gamma and adenosine deaminase in patients with pleural tuberculosis in Qatar. Int J Gen Med 2013;6:13‑8. Sharma SK, Banga A. Pleuralfluidinterferon‑gamma and adenosine deaminase levels intuberculosis pleural effusion: A cost‑effectiveness analysis. J Clin Lab Anal 2005;19:40‑6.
Access this article online Quick Response Code:
Website: www.lungindia.com DOI: 10.4103/0970-2113.142114
Author’s reply We would like to thank Wiwanitkit et al., for their interest in our study and their valuable observations.
Asmita Anilkumar Mehta, Amit Satish Gupta, Subin Ahmed, Rajesh Venkitakrishnan
In response to the authors’ comments about the reported lower predictive value of the adenosine deaminase (ADA) test in our article,[1] we want to clarify that as per our study, ADA is a valuable test to differentiate malignancy from TB. Our study showed that only three (8%) out of 36 cases of malignant pleural effusion had ADA ≥40 U/l.
Department of Pulmonary Medicine, Amrita Institute of Medical Sciences,Kochi, Kerala, India E-mail: [email protected]
We agree with the authors’ comments that ADA must be used along with the conventional method to get a diagnosis, as suggested by Islam et al.[2] Khan et al.[3] has showed that use of the pleural fluid interferon‑gamma can provide a better diagnostic result than ADA, but at a higher cost.[3] We would also like to quote from the meta‑analysis by Greco et al., which showed that the joint sensitivity and specificity of ADA (93%) was similar to IFN‑γ (96%) and no significant difference was present in the performance of both the tests in the diagnosis of TB pleurisy.[4] We accept that we have not conducted a cost‑effectiveness analysis for our study,[1] and it is improper to state in conclusion that the ADA test is cost‑effective. Despite what has just been stated, it has been seen that the ADA test is less expensive than other invasive tests like the thoracoscopy‑guided or blind pleural biopsy.
434
REFERENCES 1. 2. 3.
4.
Mehta AA, Gupta AS, Ahmed S, Rajesh V. Diagnostic utility of adenosine deaminase in exudative pleural effusions. Lung India 2014;31:142‑4. Islam A, Hossain MA, Paul SK, Bhuiyan MR, Khan RA, Rahman MM, et al. Role of adenosine deaminase in diagnosis of tubercularpleuraleffusion. Mymensingh Med J 2014;23:24‑7. Khan FY, Hamza M, Omran AH, Saleh M, Lingawi M, Alnaqdy A, et al. Diagnostic value of pleural fluid interferon‑gamma and adenosinedeaminase in patients with pleural tuberculosis in Qatar. Int J Gen Med 2013;6:13‑8. Greco S, Girardi E, Masciangelo R, Capoccetta GB, Saltini C. Adenosine deaminase and interferon gamma measurements for the diagnosis of tuberculous pleurisy: A meta‑analysis. Int J Tuberc Lung Dis 2003;7:777‑86.
Access this article online Quick Response Code:
Website: www.lungindia.com
Lung India • Vol 31 • Issue 4 • Oct - Dec 2014
Copyright of Lung India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
