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   Table of Contents - Current issue
September-October 2019
Volume 36 | Issue 5
Page Nos. 373-471

Online since Friday, August 23, 2019

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Drug-resistant tuberculosis: Progress towards shorter and safer regimens Highly accessed article p. 373
Kavitha Saravu, Madhukar Pai
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Impact of biomass fuel exposure from traditional stoves on lung functions in adult women of a rural Indian village p. 376
Utkarsha Pathak, Rohit Kumar, Tejas M Suri, JC Suri, NC Gupta, Sharmishtha Pathak
Introduction: Exposure to biomass fuel (BMF) from traditional cookstoves inflicts an enormous burden of morbidities in women across the developing world. This study aims to assess the lung function and its association with the indoor air pollutants generated using BMF. Materials and Methods: This cross-sectional study including 310 women was conducted in a rural village of India. Households were divided into two groups based on the cooking fuel, the BMF group and the liquefied petroleum gas (LPG) group. Information on respiratory symptoms and socioeconomic status was obtained using a standard questionnaire. Indoor air concentration for PM10and PM2.5was measured during cooking hours. Pulmonary function tests (PFTs) were conducted for the women inhabitants. Results: On comparing the two groups, the concentration of PM10(890.26 ± 59.59 vs. 148.66 ± 31.97) μg/m3 and PM2.5(728.90 ± 50.20 vs. 99.76 ± 41.80) μg/m3 (P < 0.01) were higher in the group using BMF. The respiratory symptoms such as wheezing, dyspnea, chronic cough, and nocturnal cough, were significantly more common in the group using BMF. A significant difference was seen in the lung function indices between the two groups. A significant negative correlation of respiratory indices with duration of exposure and the particulate matter (PM) values suggested a greater decline on lung function among women exposed to increased concentrations of PM. On comparing participants with normal and abnormal PFT, it was seen that the use of BMF (odds ratio [OR] 8.01; 95% confidence interval [CI] 4.80, 13.36, P < 0.001) and the duration of exposure to BMF (OR 1.16; 95% CI 1.13, 1.20., P < 0.001) increased the odds of having an abnormal PFT. Conclusions: This study shows a high prevalence of respiratory symptoms and an abnormal pulmonary function in women exposed to BMF.
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Treatment outcome of multidrug-resistant tuberculosis with modified DOTS-plus strategy: A 2 years' experience p. 384
Abhijeet Singh, Rajendra Prasad, Ram Awadh Singh Kushwaha, Rahul Srivastava, Belur Hosmane Giridhar, Viswesvaran Balasubramanian, Amita Jain
Background: Multidrug-resistant tuberculosis (MDR-TB) is a global health problem with notoriously difficult and challenging treatment. This study determined treatment outcome in patients of MDR-TB with modified DOTS-Plus strategy. Methods: Ninety-eight consecutive MDR-TB patients treated with standardized regimen according to modified DOTS-Plus strategy aligned to the existing national DOTS-Plus guidelines with relevant modifications proposed by Chennai consensus were analyzed prospectively. Treatment included monthly follow-up with clinical, radiological, and bacteriological assessment (sputum smear advised monthly till conversion then quarterly; culture for Mycobacterium tuberculosis at 0, 4, 6, 12, 18, and 24 months), ensuring adherence, intense health education, and monitoring of adverse events (AEs). Patients' outcome was considered as cure when at least two of the last three cultures (all three or last two) were negative and as failure when the same were positive. Results: Favorable and unfavorable outcomes in this cohort were reported to be 71/98 (72.4%) and 27/98 (27.6%) (failure – 10 [10.2%], default – 7 [7.1%], and expiry – 10 [10.2%]), respectively. Sputum smear and culture conversion rate were 75/81 (92.5%) and 71/81 (87.7%), respectively. Major AEs were experienced in only 17.4% of patients. Conclusions: MDR-TB can be cured successfully with modified DOTS-Plus strategy and requires much effort from both the patients and health-care workers. It can be an alternative model for treating MDR-TB patients in private sector.
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Serum inflammatory markers and nutritional status in patients with stable chronic obstructive pulmonary disease p. 393
Sneh Arora, Karan Madan, Anant Mohan, Mani Kalaivani, Randeep Guleria
Background: Chronic obstructive pulmonary disease (COPD) is a systemic inflammatory disease. We investigated whether serum inflammatory markers, C-reactive protein (CRP), leptin, and nutritional status (assessed by measurement of serum levels of prealbumin and anthropometry) correlated with COPD severity. Materials and Methods: One-hundred and two COPD patients (mean age 56.94 ± 10.95 years) were recruited and classified into severity categories based on the GOLD guidelines. Serum concentrations of CRP, prealbumin, and leptin were measured. Anthropometry included body mass index (BMI), mid-upper arm circumference (MUAC), and sum of four skinfold thicknesses (triceps, biceps, suprailiac, and subscapular). Results: Twenty-one patients had moderate, 44 had severe, and 37 had very severe COPD. Levels of CRP (mg/dl) (mean ± standard error [SE]) in moderate, severe, and very severe COPD were 0.60 ± 0.096, 2.16 ± 0.39, and 4.15 ± 0.463, respectively. Levels of prealbumin (mg/dl) (mean ± SE) in moderate, severe, and very severe COPD were 15.7 3 ± 0.92, 10.95 ± 0.85, and 11.15 ± 0.79 mg/dl, respectively. Levels of leptin (ng/ml) (mean ± SE) in moderate, severe, and very severe COPD were 13.81 ± 3.88, 8.45 ± 2.25, and 4.40 ± 1.06, respectively. BMI values in the three groups were 23.44 ± 1.16 kg/m2, 20.33 ± 0.62 kg/m2, and 18.86 ± 0.52 kg/m2, respectively. Sum of four skinfold thickness and MUAC was significantly reduced in very severe group as compared to moderate and severe group. Very severe COPD patients had a significantly lower leptin, BMI, and 6-min walk test. Serum CRP was significantly higher in very severe COPD. Conclusion: Patients with increasing severity of COPD had a significantly greater serum inflammatory marker level and poorer nutritional status.
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Underutilization of potential donors for lung transplantation at a tertiary care center in North India p. 399
Kuruswamy Thurai Prasad, Inderpaul Singh Sehgal, Sahajal Dhooria, Valliappan Muthu, Ritesh Agarwal, Digambar Behera, Ashutosh Nath Aggarwal
Objective: Lung transplantation is infrequently performed in India due to several constraints, and whether the poor lung transplantation rates in India are due to a lack of eligible lung donors is unclear. In this study, we explored the availability of donors for lung transplantation. Materials and Methods: This was a retrospective analysis of all brain-dead participants who underwent assessment of eligibility for lung donation between August 2015 and June 2018. All participants underwent a detailed clinical evaluation that included history, physical examination, arterial blood gas analysis, chest radiograph, and bronchoscopy. The final eligibility for lung donation was assessed using the existing “ideal” criteria and the less stringent “extended” criteria. Results: A total of 55 brain-dead participants (41 [74.5%] males) were assessed for eligibility for lung donation. The mean (standard deviation [SD]) age of the participants was 38.4 (17.2) years. The mean (SD) duration of prior invasive mechanical ventilation at the time of assessment was 4 (3.1) days, with a mean (SD) partial pressure of arterial oxygen: inspired oxygen fraction ratio (PaO2:FiO2) of 326.6 (153.5). The proportion of participants who were found suitable for lung donation was 16 (29.1%) and 35 (63.6%) on employing the ideal and the extended criteria, respectively. Inadequate oxygenation status, abnormal chest radiograph, and sepsis were the most common reasons for excluding participants using either criteria. Despite the availability of adequate lung donors, only one lung transplantation could be performed. Conclusion: Even with the most stringent criteria for lung assessment, nearly one-third of the brain-dead participants had lungs suitable for lung transplantation. Lack of eligible lung donors is not a reason for the poor lung transplantation rates in India.
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The effects of obesity on pulmonary function in adults with asthma p. 404
Ümüs Özbey, Uçar Uçar, Aliye Gamze Çalis
Objective: While the effects of obesity on asthma are unclear, an increased body mass index (BMI) is known to enhance the symptoms and severity of asthma and to impair asthma control. The present study evaluates the effects of nutritional habits and obesity on pulmonary function and asthma control in individuals with asthma. Methods: This cross-sectional study included 60 obese respondents and 60 respondents with normal body weight, who were referred to pulmonology clinics over a period of 2 months. The anthropometric measurements and macro–micro nutrient consumption records of the patients in both groups were obtained, and the two groups were compared in terms of pulmonary function and asthma control test (ACT) scores. Results: The mean age of the normal weight and obese respondents was 39.55 ± 11.0 and 45.1 ± 10.3 years, respectively. The ACT scores of the respondents decreased significantly with increasing BMI, waist circumference (WC), and waist–hip ratio (WHR) measurements (P < 0.05). The obese respondents had a lower mean forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), midexpiratory flow (MEF) between 25% and 75% of the maximal expiration (MEF25–75), MEF75, MEF50, MEF25, and FEV1/FVC values when compared to the respondents with normal weight (P < 0.05). The total energy and carbohydrate intake was higher in the obese respondents, while their total protein intake was lower when compared to the normal weight respondents (P < 0.05), and a significant positive correlation was found between the omega 3 intake and ACT scores of the respondents (P < 0.05). Conclusions: Pulmonary functions and ACT scores decrease with increasing BMI, WC, and WHR. Obese respondents with asthma should be referred to diet clinics to improve their asthma symptoms.
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Coexistence of allergic rhinitis and asthma in Indian patients: The CARAS survey p. 411
Vikram Jaggi, Alpa Dalal, BR Ramesh, Sharad Tikkiwal, Anil Chaudhry, Nisha Kothari, Meena Lopez, Jaideep Gogtay
Context: Asthma patients often suffer from concomitant allergic rhinitis (AR). However, there is paucity of such data from India. Aims: This questionnaire-based survey evaluated the coexistence of AR in Indian asthmatics, and examined the inter-relationship between the two disease conditions. Subjects and Methods: This survey conducted in ten cities across India, aimed to generate information on exposure to risk factors, history of atopy, the severity of asthma, and treatment regimen in patients with physician-diagnosed asthma. Results: Data were obtained from 1161 asthma patients (mean age [±standard deviation]: 40.41 [±17.05] years). Prevalence of coexisting AR was found to be 65.24%, with the highest prevalence (80%) in the southern regions of India. Sneezing (71.78%) followed by watery, runny nose (63.59%) were the most common AR symptoms. Majority (72.32%) of the patients had seasonal AR. Coexistence of AR and asthma was significantly associated with the presence of personal and family history of atopy (odds ratio 2.53 and 1.51 respectively; both P < 0.005). Passive smoking, exposure to biomass fuel, and the presence of pets and animals at home were also significantly (P < 0.005) associated with AR-asthma coexistence. Prevalence of AR was found to increase with increasing asthma severity. The usage of oral steroids was significantly higher in patients with coexistent AR-asthma. Sixty-six percent of the patients with coexistent AR-asthma were prescribed intranasal corticosteroids. Conclusions: The results of the Coexistence of Allergic Rhinitis and ASthma (CARAS) survey highlight the high prevalence of concomitant AR in Indian patients with asthma, and reinforce the need for early diagnosis and guideline-based management of AR in patients with asthma.
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Quadriceps strength in patients with chronic obstructive pulmonary disease p. 417
Swati Shah, Bhushan Darekar, Sundeep Salvi, Arun Kowale
Background: Skeletal muscle dysfunction is well known in chronic obstructive pulmonary disease (COPD). The muscle strength is altered in various muscles variedly. Lower-limb muscle strength is very important for walking distance. Reduced lower-limb strength can affect the physical quality of life. Objectives: The aim of the study was to assess and compare the quadriceps strength in COPD patients and age-matched healthy controls and to study the correlation between lung function parameters and the quadriceps strength in patients with COPD. Methodology: Thirty nonsmoker male patients; thirty nonsmoker female patients with COPD; and sixty age-, BMI-, and gender-matched healthy controls were studied. Quadriceps muscle strength was measured using a quadriceps dynamometer. Forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEF 25–75, and peak expiratory flow rate were measured using Helios 702 Spirometer. The quadriceps muscle strength between the two groups was compared using the unpaired Student's t-test. Correlations between FVC and FEV1with muscle strength were analyzed using the Pearson's coefficient. Results: The mean unilateral and bilateral quadriceps strength in both male and female COPD patients was significantly lesser than the healthy controls (P < 0.05). There was a significant positive correlation between muscle strength and FVC and muscle strength and FEV1in patients with COPD. Conclusion: The study shows that there is quadriceps weakness in COPD patients, and pulmonary functions have a direct impact on skeletal muscle strength. Identifying those patients who have reduced strength will allow early interventions targeted at improving the quality of life of the patient.
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Pidotimod: In-depth review of current evidence Highly accessed article p. 422
Ashok Mahashur, PK Thomas, Parthiv Mehta, Kundan Nivangune, Snehal Muchhala, Rishi Jain
Pidotimod, an immunostimulant, is researched for over two decades. Current evidence indicates its utility in a variety of indications in children as well as in adults. Its immunostimulant activity has been firmly established in the management of recurrent respiratory infections in children with or without asthma. Compared to standard of care alone, addition of pidotimod to standard of care significantly prevents the recurrences and reduces the severity and duration of acute episodes, ultimately resulting in reduced visits to pediatric clinics and lower absenteeism at school. In adults, pidotimod is effective in the prevention and treatment of acute infectious exacerbations of chronic bronchitis and chronic obstructive pulmonary disease (COPD). Further, it has been evaluated in indications such as pneumonia, hand–food–mouth disease, bronchiectasis, and chronic idiopathic urticaria. From a total of 32 studies conducted in child (24 studies) and adult (8 studies) population, this in-depth review discusses the current evidence of pidotimod. With further exploration, the immunostimulant activity of pidotimod might be extended to different immunological disorders.
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Transbronchial lung cryobiopsy for the diagnosis of lepidic-predominant lung adenocarcinoma p. 434
Vikas Pathak, Christine Zhou
Lung cancer is one of the most common malignancies globally with lung adenocarcinoma as the most common type of lung cancer. With new classification of lung cancers in 2011, it has become pertinent that adequate tissue is obtained for the diagnosis and subtyping of lung adenocarcinoma particularly for prognostication. Transbronchial cryobiopsy is a minimally invasive procedure which helps obtain adequate tissue and avoid surgical lung biopsy.
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Primary pleural liposarcoma: A rare entity p. 438
Nidhi Prabhakar, Kim Vaiphei, Vikarn Vishwajeet, Eniyavel Ramamoorthy, Ujjwal Gorsi, Sahajal Dhooria, Rakesh Kapoor, MS Sandhu
Primary pleural liposarcoma (PPL) is a rare malignant tumor of the pleura. The diagnosis of PPL may be suspected on chest imaging based on radiologic features such as large pleural mass showing areas of fat with or without calcification. Herein, we present the case of a 32-year-old male whose contrast-enhanced computed tomography scan of the chest revealed a large, heterogeneous, hypodense, right pleural-based mass with small areas of fat and calcification within it. An ultrasound-guided biopsy was performed, which confirmed the diagnosis of a myxoid variant of pleural liposarcoma.
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Radiological appearance of primary laryngotracheal amyloidosis p. 441
Bharat Hosur, Vivek Gupta, Kirti Gupta, Jaimanti Bakshi
Primary laryngotracheal amyloidosis is a rare entity and can present with a very nonspecific symptom such as hoarseness of voice. We present one such case highlighting the radiological appearance with follow-up imaging so that one can identify computed tomography features of this rare entity if other clinical and histological conditions are met.
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Antifibrotics in India p. 445
Raja Dhar
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Rare cause of pulmonary consolidation in a malignancy case p. 447
Priyanka Singh, Vasu Vardhan, Manu Chopra, Ankit Mathur
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A young male with left hilar mass p. 449
Tarun Krishna Boppana, Saurabh Mittal, Karan Madan, Anant Mohan
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Utility of bedside lung ultrasound for assessment of lung recruitment in a case of acute respiratory distress syndrome p. 451
Abhijeet Singh, Ayush Gupta, Manas Kamal Sen, Jagdish Chander Suri, Shibdas Chakrabarti, Dipak Bhattacharya
Lung recruitment maneuvers are rescue measures commonly used to improve oxygenation in severely hypoxemic patients with acute respiratory distress syndrome (ARDS), who fail to improve on standard treatment. After recruitment, appropriate level of positive end-expiratory pressure (PEEP) is applied to prevent alveolar de-recruitment during expiration. Computed tomography scan of thorax and quasi-static pressure-volume curves have played a pivotal role are important in the assessment of recruitment, but they have several limitations. Lung ultrasound (LUS), which is now easily available in nearly every Intensive Care Unit, could be an attractive alternative method for assessing lung recruitment. It is noninvasive, easily repeatable and is devoid of radiation hazards. We are presenting a case of 24-year-old female patient with moderate ARDS in whom bedside LUS was successfully used into assessing lung recruitment as well as into determining the appropriate level of PEEP.
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Endoscopic ultrasound fine-needle aspiration with an echobronchoscope (EUS-B-FNA) from a difficult-to-access paraspinal lesion p. 457
Animesh Ray, Siddharth R Jain, Anubhav Narwal, Sanjeev Sinha
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Empyema caused by Myroides odoratimimus in a patient with liver abscess p. 459
Ashoka Mahapatra, Prasanta R Mohapatra, Snigdharani Choudhury, Nerbadyswari Deep
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A rare complication during endobronchial ultrasound-guided transbronchial needle aspiration: Needle assembly malfunction p. 461
Manoj K Goel, Ajay Kumar, Gargi Maitra
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Triple horror: A rare case of triple metachronous malignancy p. 463
Rituparna Biswas, Subhash Gupta, KP Haresh, Sandeep Mathur, Anirban Halder, GK Rath
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Use of nintedanib in patients with idiopathic pulmonary fibrosis: Initial Indian experience p. 465
Jai B Mullerpattan, Sana H Porwal, Trina A Sarkar, Haresh D Wagh, Zarir F Udwadia
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Multiple Benign Metastasizing Leiomyoma of the uterus in lung and retroperitoneum p. 466
Aysel Sunnetcioglu, Erbil Karaman, Mesut Ozgokce, Remzi Erten, Remzi Kiziltan, Ufuk Cobanoglu
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Combined pulmonary fibrosis and emphysema with lung cancer: Triple calamity p. 468
Irfan Ismail Ayub, Natraj Manimaran
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Imaging of chest infections p. 471
Parvaiz A Koul
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