Dexamethasone-cyclophosphamide Pulse Therapy Research Articles

A Case of Recurrent Pemphigus Foliaceus Following Noncompliance to Medication.

Pemphigus foliaceus (PF) is a rare autoimmune blistering disorder requiring consistent immunosuppressive therapy for management. A 66-year-old male with a history of PF presented with worsening blisters and erosions after discontinuing medication. The patient had flaccid bullae and erosions on the face, scalp, chest, and back. Histopathology confirmed PF. Treatment with oral prednisolone, azathioprine, and reinitiation of dexamethasone-cyclophosphamide pulse (DCP) therapy led to disease remission. This case underscores the importance of adherence to immunosuppressive therapy in PF management. It also highlights the role of affordable treatment regimens in ensuring patient compliance and successful outcomes.

Comparison of the Clinical Efficacy of Rituximab Infusion and Dexamethasone-Cyclophosphamide Pulse Therapy and Their Effect on Serum Th1, Th2, and Th17 Cytokines in Pemphigus Vulgaris–A Prospective, Nonrandomized, Comparative Pilot Study

Abstract Background: Rituximab infusion and dexamethasone-cyclophosphamide pulse (DCP) are the two most popular regimens used in pemphigus vulgaris (PV) in India. Objective: The present study compared the clinical efficacy of rituximab and DCP in Indian PV patients and their effects on serum Th1,2, and 17 cytokine levels. Materials and Methods: A total of 37 patients received DCP (Group A, n = 22) or rituximab (Group B, rheumatoid arthritis protocol (n = 15)) as per patients’ preference. They were monitored for clinical response, adverse events (AEs), changes in serum anti-desmoglein-1,3 antibody titers and Th1,2 and 17 cytokine levels at baseline and weeks 20 and 52. Results: The proportion of patients attaining disease control, remission, and relapse in groups A and B were 82% and 93%; 73% and 93%; and 27% and 50%, respectively, after a median duration of 2 months each for disease control; 4 and 4.5 months for remission; and 5 and 7 months for relapse post remission. The musculoskeletal AEs were the highest in the two groups. Significant and comparable decreases in anti-dsg1 and 3 titers from baseline to weeks 20 and 52 were observed in both groups. Th1 and Th17 cytokine levels decreased, while Th2 cytokines increased post-treatment in both groups. However, no correlation was found between change in body surface area of involvement by PV and anti-dsg titers and cytokine levels before and after therapy in both groups. Conclusion: Comparable clinical efficacy between DCP and rituximab was observed.

Dexamethasone-cyclophosphamide pulse therapy outcomes comparing pemphigus vulgaris and pemphigus foliaceus groups in a Brazilian cohort study

BackgroundDexamethasone-cyclophosphamide pulse (DCP) and dexamethasone pulse (DP) have been successfully used to treat pemphigus, but DCP/DP outcomes comparing pemphigus vulgaris (PV) and pemphigus foliaceus (PF) are scarce. ObjectiveTo compare DCP/DP outcomes in a Brazilian cohort of PV and PF patients according to demographic and clinical data. MethodsRetrospective analytical cohort study, reviewing medical charts of PV and PF patients (for DCP/DP Phases I‒IV consult Pasricha et al.16‒18). Results37 PV and 41 PF patients non responsive to usual treatments were included similarly for DCP or DP therapy. Disease duration was longer among PF before DCP/DP prescription (p < 0.001); PF required a higher number of monthly pulses to acquire remission in Phase I (median 10 and 6 pulses, respectively; p = 0.005). DCP/DP outcomes were similar in both groups: remission in 37.8% of PV and 34.1% of PF after completed DCP/DP cycles following a median of 13 months (1–56 months follow-up); failure occurred in 13.5% of PV and 14.6% of PF in Phase I; relapse in 13.5% of PV and 12.2% of PF, and dropout in 27% of PV and 24.4% of PF in Phases II to IV. Mild side effects were documented. Study limitationsThe severity of PV and PF disease was not assessed by score indexes. ConclusionsPV and PF patients presented similar DCP/DP outcomes. DCP/DP should be initiated earlier in PF patients due to the longer duration of their disease in order to decrease the number of pulses and the duration of Phase I to acquire remission.

A study on the outcome of pulse therapy in vesicobullous disorders at a tertiary care centre in Chidambaram, Tamilnadu

Introduction: With the advent of pulse therapy and adjuvant immunosuppressive drugs, the outcome and prognosis of vesicobullous disorders have been improved to a greater extent. Different regimen protocol has been tried and this descriptive study was carried out to assess the outcome of various pulse therapy regimens in vesicobullous disorder at our centre. Methods: A total of 26 vesicobullous patients were enrolled for the study. Diagnosis was made clinically and confirmed by histopathology. They received treatment with Dexamethasone-Cyclophosphamide pulse (DCP) or Dexamethasone -Azathioprine pulse (DAP) or Dexamethasone pulse (DP) therapy and were followed up for clinical remission and side effects of therapy. Results: There was a total of 26 patients comprising 69.23% females and 30.77% males and 50% were between the age group of 40-50 years. Pemphigus vulgaris was the commonest clinical type seen in 69.23%.DCP was given for 22(84.62%) patients, dexamethasone pulse in 3(11.54%) and DAP in one (3.85%). In DCP group 77.27% of patients were in Phase I and 22.73% achieved clinical remission. One patient was refractory to DCP and required rituximab infusion. Weakness, headache, vomiting and weight gain were the commonest side effects encountered in our study. Avascular necrosis of femur and reactivation of pulmonary tuberculosis were the major side effects noticed in one patient each. Conclusion: DCP therapy prove to be an excellent therapeutic regimen in case of vesicobullous disorders to attain faster recovery sparing the adverse effect of corticosteroids. DAP can be an useful therapeutic option in patients who were unmarried or in reproductive age group. Keywords: Pemphigus vulgaris, Dexamethasone-cyclophosphamide pulse. Dexamethasone-azathioprine pulse, Dexamethasone pulse

Comparative retrospective evaluation of efficacy of rituximab therapy with dexamethasone cyclophosphamide pulse therapy in patients of pemphigus vulgaris at a tertiary care hospital

Background: Popular treatment modalities for pemphigus vulgaris are dexamethasone cyclophosphamide pulse (DCP) therapy and rituximab. However, no previous studies are available which have compared the efficacy of the two modalities. Aim: This study aims to study the response of pemphigus vulgaris to DCP and rituximab therapy and to compare the efficacy and safety of the two modalities over a period of 1½ years. Materials and Methods: This was an observational retrospective study. The medical records of a total of 14 pemphigus vulgaris patients from July 2016 to July 2018 were retrieved for analysis who were treated with either DCP therapy or rituximab (7 in each group). Patients treated with any other modality except DCP/rituximab were excluded from the study. The pemphigus disease area index (PDAI) scores at baseline, 1 month, 6 months, 12 months, and 18 months were analyzed using statistical software (Stata Corp. 2013. Stata Statistical Software: Release 13. College Station, TX, Stata Corp. LP, Texas, USA). Outcome Measures: Time to achieve the end of consolidation phase, improvement in PDAI scores, adverse effects, and relapse. Results: Rituximab group achieved early remission; however, there was no statistically significant difference in the two groups in the time when they reached the end of consolidation phase. Repeated measure anova showed significant difference in PDAI scores within the two groups over time. One patient in DCP group relapsed following discontinuation of cyclophosphamide due to complications. Overall, the scoring of disease severity was markedly reduced in both the groups. Conclusion: Both DCP therapy and rituximab were found to be extremely and equally effective in inducing and maintaining remission.

Psoriasis vulgaris developing in healed pemphigus vulgaris: A rare case of epitope spread or isotopic response?

Although psoriasis and autoimmune blistering diseases are considered to be disorders with completely different etiopathogenesis, literature has documented a few cases of psoriasis associated with bullous diseases, particularly bullous pemphigoid. Here, we report the case of a 30-year-old male presenting with multiple flaccid blisters and erosions, clinically and histopathologically consistent with the diagnosis of pemphigus vulgaris. Although all these lesions resolved after two doses of dexamethasone cyclophosphamide pulse therapy, he returned 3 weeks later with multiple erythematous scaly plaques developing over the postinflammatory areas, compatible with the diagnosis of psoriasis vulgaris, which necessitated a modification in the treatment protocol. This rare case highlights the diagnostic and therapeutic challenges accompanying this unique scenario and attempts to elucidate the probable pathogenic mechanisms underlying the co-existence (simultaneous or sequential) of these two apparently unrelated dermatoses.

Managing the challenging cases of pemphigus vulgaris with modified pulse therapy: case series

&lt;p class="abstract"&gt;In pemphigus vulgaris, pulse therapy is a promising modality to achieve better therapeutic response and to minimize the side effects of daily steroids. Here we report 5 different challenging situations where we successfully managed with modification of pulse therapy. Our first case had multiple comorbidities with persistent skin infections managed with dexamethasone and cyclophosphamide pulse (DCP) and interval pulse. The second case was unmarried hypertensive male with poor DLQI managed with Azathioprine pulse therapy. The third case was uncontrolled diabetic patient with pulmonary tuberculosis managed with rituximab. The fourth case was diabetic and hypertensive was managed with one day dexamethasone cyclophosphamide pulse therapy (DCP). The fifth case was not completed family with cushingoid features managed with dexamethasone azathioprine pulse therapy (DAP). Pulse therapy is effective in controlling disease activity in pemphigus. But it can be modified in some situations according to the patient needs.&lt;/p&gt;

Modifications of pulse therapy in pemphigus: a retrospective study of 72 patients

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Pulse therapy defines as the administration of supra-pharmacologic doses of drugs in an intermittent manner to enhance the therapeutic effects and reduce the side effects. Dexamethasone-Cyclophosphamide pulse (DCP) therapy is known since 1986 but there are certain limitations due to side effects of cyclophosphamide.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A retrospective study was carried out where 72 patients of pemphigus were treated with modified pulse therapy like DCP, DAP, DMP from 2006-2016. Modifications were made in DCP therapy protocol and substitution of cyclophosphamide with either azathioprine or methotrexate in few patients.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Male to female ratio observed was 1:0.7. Majority of them belonged to age group of 31-40 years (41.66%) followed by 41-50 years (33.3%). Maximum number of patients had pemphigus vulgaris (86.1%) followed by pemphigus foliaceous (12.5%) and IgA pemphigus (1.38%). Good response was observed in patients who took pulse therapy regularly.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Modifications to the original DCP therapy protocol were found to be very effective, useful and it shortened the duration of phase I. Side effects were minimal and manageable.&lt;/p&gt;

Outcome of pulse therapy in pemphigus: A 10-year study

Background: Pemphigus is a potentially fatal autoimmune blistering disease affecting the skin and mucosa. Pulse therapy has been tried in pemphigus in India and other countries with variable results. Aims: The aim of the study was to assess the outcome of pulse therapy in pemphigus patients treated over a period of 10 years. Materials and Methods: Patients with pemphigus treated with pulse therapy from 2006 to 2016 were taken into the study. Results: A total of 122 pemphigus patients were included in the study, of which pemphigus vulgaris was diagnosed in 112 patients, pemphigus foliaceus in 9 patients, and pemphigus vegetans in 1 patient. The mean age was 37.75 ± 8.60 years, with an age range of 19–58 years. Duration of the disease ranged from 7 days to 3 years, with a mean of 6.87 ± 8.81 months. Ninety-three patients were started on dexamethasone cyclophosphamide pulse therapy and 29 on dexamethasone azathioprine pulse therapy. Thirty-three patients discontinued treatment, pulse therapy was stopped in two patients due to complications, and four patients died while on treatment. Out of the remaining 83 patients, 22 patients were in Phase I, 13 in Phase II, 7 in Phase III, and 41 in Phase IV by the end of the study. Sixty-one patients completed Phase I and were maintaining remission. Seven patients relapsed (3 in Phase II and 2 each in Phase III and IV). Ten patients completed 5 years of Phase IV and were considered cured of the disease. Generalized weakness, myalgia, headache, diabetes, and amenorrhea were the most common side effects. Conclusion: Pulse therapy was found to be effective in inducing and maintaining remission in the treatment of pemphigus. Prevention of relapses requires continuation of the treatment during Phase II and III.

Study of dexamethasone cyclophosphamide pulse therapy in systemic lupus erythematosus

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Systemic lupus erythematosus (SLE) is always a challenge to the treating dermatologists. Pulse therapy is the use of supra pharmacological doses of drugs to achieve a desired therapeutic effect. The success of dexamethasone cyclophosphamide pulse therapy (DCP) in autoimmune bullous diseases has prompted dermatologists to use DCP in SLE but very few studies are available which objectively measure the outcome of DCP therapy in SLE. The aim of our study is to study the efficacy of dexamethasone cyclophosphamide pulse in patients with SLE and to use objective scoring systems to assess efficacy.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; 20 SLE patients who satisfied the inclusion criteria were administered intravenous dexamethasone 100 mg over three days with cyclophosphamide 500 mg on day1, followed by oral cyclophosphamide 50 mg daily. In patients whom cyclophosphamide cannot be used oral azathioprine was given. Response to treatment was assessed using CLASI (cutaneous lupus area severity index), clinical evaluation of dermatological and systemic symptoms and laboratory parameters such as ANA, Anti dsDNA, ESR etc.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; All the patients showed clinical improvement with statistically significant fall in CLASI scores and anti dsDNA values. The mean duration of pulses required to achieve remission was 9 pulses. No major adverse effects were observed in any of the patients.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Dexamethasone cyclophosphamide pulse therapy is an effective and safe option in the management of patients with SLE.&lt;/p&gt;

Generalized Morphea following Radiotherapy for an Intracranial Tumor.

Morphea is a localized scleroderma variety which can be circumscribed or generalized and is characterized by sclerotic plaques developing on trunk and limbs. Surgery and radiation have been implicated as etiological factors for the development of morphea. Majority of the radiation-induced morphea cases have occurred in patients with breast cancer. The affected areas have been generally restricted to the area of radiation and nearby surrounding area in most of the reported cases. We hereby report a case of a 27-year-old male who developed radiation-induced progressive generalized morphea after getting radiotherapy for an intracranial tumor. His condition improved after dexamethasone-cyclophosphamide pulse therapy. With increased incidence of cancer worldwide and radiotherapy as a modality of treatment, it is imperative to follow the patient and look for the development of morphea which itself is a debilitating disease.

Study of Dexamethasone-Cyclophosphamide Pulse Therapy in Systemic Lupus Erythematosus in a Tertiary Care Center in Chhattisgarh

Study of Dexamethasone-Cyclophosphamide Pulse Therapy in Systemic Lupus Erythematosus in a Tertiary Care Center in Chhattisgarh

Efficacy and Safety of Dexamethasone Cyclophosphamide Pulse Therapy in the Treatment of Pemphigus - An Open Randomized Controlled Study

Abstract Background Various drugs used to treat pemphigus can cause remission, but none can provide permanent remission as relapses are common. With the introduction of DCP in pemphigus in 1984, patients started being in prolonged/permanent remission. This study was done to compare the efficacy of DCP to oral corticosteroids and cyclophosphamide in combination. Methods Patients were allocated into two treatment groups. Group A received treatment with DCP pulse regimen while group B was treated with oral corticosteroids and cyclophosphamide lasting for 4 years. Results 18 out of 20 patients in DCP group entered into remission, 1–29 months after complete stoppage of treatment. The two patients relapsed, one in phase III and another in phase IV of DCP. Both were reverted back to phase I and again treated with IV phase regimen of DCP. All the 20 patients in oral corticosteroids and cyclophosphamide group developed repeated relapses (4–6 times) during the study period. Conclusion This study shows that DCP therapy can put pemphigus into prolonged/permanent remission as compared to corticosteroid-cyclophosphamide group where relapses are frequent. Lately, some dermatologists have questioned the efficacy of DCP in treating pemphigus. However, this could be due to usage of wrong combination of drugs or short study duration.

Management of pemphigus vulgaris by dexamethasone cyclophosphamide pulse therapy: A SAIMS experience

Management of pemphigus vulgaris by dexamethasone cyclophosphamide pulse therapy: A SAIMS experience

Pemphigus vulgaris: an evidence-based treatment update.

While a variety of intervention options have been described for pemphigus vulgaris, the optimal treatment strategy has not been established. The objective of this systematic review is to assess the literature on the efficacy and safety of interventions for the treatment of pemphigus vulgaris. Five electronic databases were searched, including The Cochrane Skin Group's Specialized Register, The Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE and Latin American and Caribbean Health science Information database (LILACS). Five trial registers as well as reference lists of included RCTs were also searched. Any published randomised controlled trial (RCT) on intervention for pemphigus vulgaris was included, provided the diagnosis of pemphigus vulgaris was confirmed with appropriate clinical features, histopathology and immunofluorescence studies. Studies which included forms of pemphigus other than pemphigus vulgaris were excluded. Altogether 18 RCTs were identified including 16 distinct interventions. Included studies were assessed for patient selection, methods of randomisation, blinding, follow-up and selective reporting. Current evidence is incomplete and inconclusive. The interventions which appear promising, but will require further evaluation include adjuvant mycophenolate mofetil (MMF), azathioprine, intravenous immunoglobulins (IVIG), sulfasalazine and pentoxifylline, infliximab, epidermal growth factor and pimecrolimus. Interventions with inconclusive evidence include high (120-180 mg) versus low (45-60 mg) prednisone dosage, pulsed dexamethasone, cyclophosphamide, dexamethasone-cyclophosphamide pulse therapy (DCP), cyclosporine, dapsone, etanercept, acyclovir and tacrolimus. Our review is limited by the small number of high-quality RCTs and variety of outcome measures, precluding the performing of a meta-analysis. The optimal treatment strategy for pemphigus vulgaris remains unclear. Higher quality RCTs are required in the future to re-evaluate many interventions and to explore other unstudied interventions.

Non Comparative Study on Various Pulse Regimens (DCP, DAP and DMP) in Pemphigus: Our Experience.

Background:Pemphigus has been treated with Dexamethasone Cyclophosphamide Pulse (DCP) Therapy since 1981. Various modifications have been suggested in the original regimen. These include Dexamethasone Azathioprine Pulse (DAP) and Dexamethasone Methotrexate Pulse (DMP) therapies.Aims:To report our experience on the noncomparative study of various Pulse regimens DCP, DAP AND DMP therapies in patients with Pemphigus.Materials and Methods:The patients were put on three regimens depending upon the situation-Conventional DCP, DAP in the reproductive age group, DMP in patients who showed prolonged Phase I more than 12 months while on DCP.Results:30 patients were put on DCP therapy. The duration of phase I was on an average six months. Relapse was seen in 3 patients in phase IV. 12 patients on DAP therapy were considered. In Phase III 5 patients relapsed in phase IV four patients relapsed. Five patients were put on the DMP. Disease activity was poorly controlled and in three DMP was discontinued.Conclusion:DCP remains the most effective regimen with quickest onset of remission and continuance of remission. In DAP therapy fixation of dose of azathioprine at 50 mgs daily may be counterproductive. DMP does not fulfil the promise of a viable treatment option in recalcitrant pemphigus and this lacunae needs to be plugged.

Factors affecting the duration of phase I of dexamethasone - cyclophosphamide pulse therapy.

The introduction of dexamethasone-cyclophosphamide pulse (DCP) therapy for the pemphigus group of disorders by Pasricha has revolutionized the therapy for pemphigus. There are very few studies regarding factors affecting duration of phase I of the DCP. Our purpose was to study the relationship between various factors and duration of the phase I. A retrospective study of 98 patients of pemphigus on Dexamethasone Pulse therapy was conducted. Patients were classified according to duration of Phase 1 as those with phase I less than 6 months and those more than 6 months and analyzed for variable factors affecting duration of phase I. Disease severity in pemphigus significantly prolonged the duration of phase I of DCP. Longer duration was also observed in patients on concurrent oral steroid therapy (both statistically significant). The findings from our study help us to address patient expectations and apprehensions regarding duration of therapy. A detailed understanding of the various patient and disease related factors responsible for affecting Phase I duration will help in better management of the patient, and the disease.

Assessment of the therapeutic benefit of dexamethasone cyclophosphamide pulse versus only oral cyclophosphamide in phase II of the dexamethasone cyclophosphamide pulse therapy: A preliminary prospective randomized controlled study

Dexamethasone cyclophosphamide pulse (DCP) therapy is an established mode of treatment for pemphigus in India. To assess the therapeutic benefit of additional DCPs (phase II, consolidation phase) versus immediate oral cyclophosphamide, usually used in phase III (maintenance phase), after initial DCP therapy (phase I) and to assess which laboratory test (DIF or ELISA) will reflect the clinical relapse best. Nineteen newly recruited patients of pemphigus vulgaris (PV) received monthly DCPs in phase I and were then randomized into two groups. Group A (10 patients) received monthly DCPs for nine months and Group B (nine patients) received only oral cyclophosphamide for nine months. Direct immunofluorescence (DIF) and enzyme-linked immunosorbent assay (ELISA) were tested before starting DCP regimen, and at 0,3,6,9 months after randomization. Clinical relapse by the end of follow-up period occurred in only one patient in each group. In these cases, DIF became (again) positive before the relapse. No statistically significant difference between the two groups was found at three, six and nine months by ELISA indices and DIF grading. Although the DCP regimen is the standard therapy for pemphigus in India, we found no difference in the clinical outcome between patients receiving nine DCPs in phase II and patients shifted directly from phase I to III. Periodic testing using DIF and Dsg ELISA were found to be useful to monitor disease activity and predict a relapse. Further large scale studies are required to assess if patients can be shifted directly from phase I to III and maintained only on oral cyclophosphamide.

Paraneoplastic Pemphigus: A Paraneoplastic Autoimmune Multiorgan Syndrome or Autoimmune Multiorganopathy?

Paraneoplastic pemphigus (PNP), a clinically and immunopathologically distinct mucocutaneous blistering dermatosis, is a severe form of autoimmune multiorgan syndrome generally associated with poor therapeutic outcome and high mortality. This IgG-mediated disease is initiated by an obvious or occult lymphoproliferative disorder in most cases. Clinically severe mucositis, and polymorphic blistering skin eruptions, and histologically acantholysis, keratinocyte necrosis and interface dermatitis are its hallmark features. A 58-year-old female presented with recurrent, severe, recalcitrant stomatitis and widespread erosions/blistering lesions of one-year duration. Treatment with repeated courses of systemic corticosteroids at a peripheral center would provide temporary relief. She also had fever, productive cough, odynophagia and poor oral intake, herpes zoster ophthalmicus, pain in the abdomen, and watery diarrhea. An array of investigations revealed chronic lymphocytic leukemia (CLL), mediastinal and para-aortic lymphadenopathy, bronchiolitis obliterans, and vertebral osteoporosis/fractures. With the diagnosis of CLL-associated PNP she was managed with dexamethasone-cyclophosphamide pulse (DCP) therapy for 3 cycles initially, followed by COP regimen (cyclophosphamide, vincristine, and prednisolone) for 5 cycles. Remission is being maintained with chlorambucil and prednisolone pulse therapy once in 3 weeks with complete resolution of skin lesions and adequate control of CLL.

Pemphigus in India

Pemphigus is a chronic epidermal immunobullous disease with potentially fatal outcome. The journey of literature on pemphigus in India has come a long way in last five decades. Pemphigus in Indian patients has unique genetic, clinical, and epidemiological differences from those in the Western countries. Corticosteroids remain the mainstay of treatment for pemphigus. Dexamethasone-cyclophosphamide pulse therapy has revolutionized the management of pemphigus in India and abroad for nearly 3 decades now. Corticosteroid-based treatment, along with adjuvants, has significantly brought down the high mortality rates that had been observed in precorticosteroid era. Present day research is largely based on elucidating the pathogenesis beyond the antidesmoglein antibodies, and newer diagnostic and treatment approaches. In this article, we review various aspects of literature on pemphigus in India, on Indians abroad, or literature from other countries that are considered relevant to the topic.