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Malnutrition and tuberculosis are both problems of considerable magnitude in most of the underdeveloped regions of the world. These two problems tend to interact with each other. Tuberculosis mortality rates in different economic groups in a community tend to vary inversely with their economic levels. Similarly, nutritional status is significantly lower in patients with active tuberculosis compared with healthy controls. Malnutrition can lead to secondary immunodeficiency that increases the host's susceptibility to infection. In patients with tuberculosis, it leads to reduction in appetite, nutrient malabsorption, micronutrient malabsorption, and altered metabolism leading to wasting. Both, protein-energy malnutrition and micronutrients deficiencies increase the risk of tuberculosis. It has been found that malnourished tuberculosis patients have delayed recovery and higher mortality rates than well-nourished patients. Nutritional status of patients improves during tuberculosis chemotherapy. High prevalence of human immunodeficiency (HIV) infection in the underdeveloped countries further aggravates the problem of malnutrition and tuberculosis. Effect of malnutrition on childhood tuberculosis and tuberculin skin test are other important considerations. Nutritional supplementation may represent a novel approach for fast recovery in tuberculosis patients. In addition, raising nutritional status of population may prove to be an effective measure to control tuberculosis in underdeveloped areas of world.

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Pulmonary hypertension is a serious and unrelenting pulmonary vascular disorder that affects the functional quality of patients and significantly decreases their life span. If diagnosed early, with the number of new therapeutic options that are available, a better quality of life can be provided for a protracted length of time. It is likely that the available treatment will change the natural course of the disease and perhaps prolong survival. As symptoms are often subtle in the early stages of the disease it is imperative that physicians are aware of the manifestations of this condition. A thorough investigation of patients suspected of this condition is essential so that appropriate treatment can be initiated promptly. The routine workup of a patient suspected to have pulmonary hypertension could easily be carried out in any well-equipped peripheral hospital in many affluent and advanced countries. However, it must be mentioned that in some less advanced countries the necessary work up can only be done in major teaching hospitals. Both pulmonologists and cardiologists should be aware of the pathophysiology of pulmonary arterial hypertension, the workup and the treatment options that are available. Patients with refractory pulmonary hypertension should be referred to these research centers for enrolment into any ongoing drug trials as well as for evaluation for heart−lung, single lung, or double lung transplantation. This paper is primarily aimed at pulmonologists and cardiologists taking care of these patients. Unless indicated otherwise this paper mainly deals with WHO group 1 pulmonary hypertension which is designated pulmonary arterial hypertension. Extensive review of the literature spanning the last 30 years was made through Medline using titles such as primary pulmonary hypertension, pulmonary arterial hypertension, secondary pulmonary hypertension, and pulmonary vascular diseases.

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The aim of our study was to obtain comprehensive insight into the bacteriological and clinical profile of community-acquired pneumonia requiring hospitalization. The patient population consisted of 100 patients admitted with the diagnosis of community-acquired pneumonia (CAP), as defined by British Thoracic society, from December 1998 to Dec 2000, at the Sher- i-Kashmir institute of Medical Sciences Soura, Srinagar, India. Gram negative organisms were the commonest cause (19/29), followed by gram positive (10/29). In 71 cases no etiological cause was obtained. Pseudomonas aeruginosa was the commonest pathogen (10/29), followed by Staphylococcus aureus (7/29), Escherichia coli (6/29), Klebsiella spp. (3/29), Streptococcus pyogenes (1/29), Streptococcus pneumoniae (1/29) and Acinetobacter spp. (1/29). Sputum was the most common etiological source of organism isolation (26) followed by blood (6), pleural fluid (3), and pus culture (1). Maximum number of patients presented with cough (99%), fever (95%), tachycardia (92%), pleuritic chest pain (75%), sputum production (65%) and leucocytosis (43%). The commonest predisposing factors were smoking (65%), COPD (57%), structural lung disease (21%), diabetes mellitus (13%), and decreased level of consciousness following seizure (eight per cent) and chronic alcoholism (one per cent). Fourteen patients, of whom, nine were males and five females, died. Staphylococcus aureus was the causative organism in four, Pseudomonas in two, Klebsiella in one, and no organism was isolated in seven cases. The factors predicting mortality at admission were - age over 62 years, history of COPD or smoking, hypotension, altered sensorium, respiratory failure, leucocytosis, and s0 taphylococcus pneumonia and undetermined etiology. The overall rate of identification of microbial etiology of community-acquired pneumonia was 29%, which is very low, and if serological tests for legionella, mycoplasma and viruses are performed the diagnostic yield would definitely be better. This emphasizes the need for further studies (including the serological tests for Legionella, mycoplasma and viruses) to identify the microbial etiology of CAP.

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Spontaneous pneumomediastinum (SPM) is an uncommon, self-limiting condition resulting from alveolar rupture in young adults. There are asthma, illicit drug use, and activities triggering a Valsalva maneuver as causes of developing SPM. We report two patients who were diagnosed with SPM in the absence of known predisposing factors and without any clinical sign of subcutaneous emphysema of the neck, the most common physical finding on presentation. Both of them developed dysphagia after swallowing a peach seed and boned rib of pork, respectively. SPM was suspected after performing lateral neck X-ray, and the diagnosis of SPM was confirmed by chest CT. These cases showed the importance of performing the lateral neck X-ray to screen SPM in patients with dysphagia.

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Mycoplasma pneumonia is a common respiratory pathogen that produces diseases of varied severity ranging from mild upper respiratory tract infection to severe atypical pneumonia. Apart from respiratory tract infections, this organism is also responsible for producing a wide spectrum of non-pulmonary manifestations including neurological, hepatic, cardiac diseases, hemolytic anemia, polyarthritis and erythema multiforme. This review focuses on molecular taxonomy, biological characteristics, epidemiology, clinical presentation, radiology and various laboratory tools in diagnosis, differential diagnosis, treatment and prevention of mycoplasma pneumonia.

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Background: The prevalence of chronic obstructive pulmonary disease (COPD) is increasing in India and there is a need to study the prevalence of COPD, particularly in the rural areas, which may be most affected due to their lifestyle. Materials and Methods: First stage: Validation of the questionnaire-105 consecutive patients underwent administration of the structured questionnaire and spirometry was used as a gold standard for the diagnosis of COPD. Second stage: Adults above 40 years (n = 900) in two villages of Mysore district were administered with the validated questionnaire, Knowledge and Attitude questionnaire and Fagerstorm questionnaire, to assess nicotine dependency. Results: The questionnaire was found to have a sensitivity of 62.5% and specificity of 87.6% to diagnose COPD. Of the total 900 adults surveyed (Males: 453, Females: 447), the total prevalence of COPD was 7.1%. Males had a higher prevalence (11.1%) compared to females (4.5%). The prevalence of smoking was very high among men at 71.9% and all the women were nonsmokers. The prevalence of COPD was 14.7% in smokers, 19.3% had mild to moderate nicotine dependency and 12.8% were highly dependent. Of the women exposed to regular biomass fuels, the prevalence of COPD was 3.9%, which increased to 4.8% on addition of regular passive smoking. In smoking, male gender and age were significantly associated with COPD ( P < 0.05). Conclusion: The structured questionnaire is a useful tool for the screening of COPD in field studies. Smoking and biomass fuel exposure are important risk factors for COPD.

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Background: Lung cancer has been found to be the second commonest cancer according to a hospital-based data from Kashmir, India. However, no incidence studies are available. Objective: To ascertain the incidence of lung cancer in Kashmir. Materials and Methods: All newly histologically diagnosed cases of lung cancer seen in various hospital and private laboratories of the Kashmir valley were registered over a period of two years (January 1, 2004 to December 31, 2005). Also included were patients attending the various oncological service areas of the institute and those diagnosed from any other laboratory outside the state. The incidence rate was calculated using the January 2005 population as the reference population estimated using the census-based projected populations. Results: Four hundred and sixty-two incident cases of lung cancer were seen during the study period. The crude incidence rate, age standardized (world) and truncated age adjusted (40-69 years, world) incidence rates for lung cancer per 100 000 population were 4.01, 6.48 and 15.28 respectively (males 6.55, 10.09 and 23.94 respectively and females 1.19, 2.14 and 4.65). The age adjusted rates for males in district Srinagar was 19.34 per 100 000. One hundred and fifty nine (69.8%) of the 221 had a history of Hukkah smoking. Conclusions: Even though Kashmir as a whole is a low incidence area for lung cancer (ASR of < 15), Srinagar district has the highest incidence of lung cancer among the males in Kashmir. The data presented is assumed to be the closest approximation to a population-based data registry and the geographical incidence maps of ICMR need appropriate updating

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To systematically review the role of corticosteroids in prevention of acute respiratory distress syndrome (ARDS) in high-risk patients, and in treatment of established ARDS. Primary articles were identified by English-language Pubmed/MEDLINE, Cochrane central register of controlled trials, and Cochrane systemic review database search (1960-June 2009) using the MeSH headings: ARDS, adult respiratory distress syndrome, ARDS, corticosteroids, and methylprednisolone (MP). The identified studies were reviewed and information regarding role of corticosteroids in prevention and treatment of ARDS was evaluated. Nine trials have evaluated the role of corticosteroid drugs in management of ARDS at various stages. Of the 9, 4 trials evaluated role of corticosteroids in prevention of ARDS, while other 5 trials were focused on treatment after variable periods of onset of ARDS. Trials with preventive corticosteroids, mostly using high doses of MP, showed negative results with patients in treatment arm, showing higher mortality and rate of ARDS development. While trials of corticosteroids in early ARDS showed variable results, somewhat, favoring use of these agents to reduce associated morbidities. In late stage of ARDS, these drugs have no benefits and are associated with adverse outcome. Use of corticosteroids in patients with early ARDS showed equivocal results in decreasing mortality; however, there is evidence that these drugs reduce organ dysfunction score, lung injury score, ventilator requirement, and intensive care unit stay. However, most of these trials are small, having a significant heterogeneity regarding study design, etiology of ARDS, and dosage of corticosteroids. Further research involving large-scale trials on relatively homogeneous cohort is necessary to establish the role of corticosteroids for this condition.

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Acute exacerbations in chronic onstructive pulmonary disease (COPD) are common and systemic steroids play an important role in the management of these cases along with the bronchodilators. Nebulized budesonide is being used in the acute attacks of bronchial asthma either in children or in adults. But the role of nebulized steroids in acute exacerbation of COPD is not much studied in the literature. In this clinical review we have evaluated the role of nebulized corticosteroids in the management of acute exacerbation of COPD (AECOPD). Through Medline, Pubmed and Embase we analyzed the various studies that has been done to study the role of nebulized corticosteroids in the management of acute exacerbation of COPD. The key words used for the search criteria were: acute exacerbation, COPD, nebulized corticosteroids, budesonide, fluticasone. Only eight studies were found which had evaluated the role of nebulized corticosteroids in acute exacerbations of COPD. All these studies had used nebulized budesonide in AECOPD in different dosages, and had been compared with both either parental or oral steroids, and standard bronchodilator therapy. All the studies had found the clinical efficacy of nebulized budesonide to be of similar extent to that of either parental or oral steroids in AECOPD. Side effects profile of nebulized budesonide was minimal and acceptable as compared to systemic steroids. Nebulized budesonide may be an alternative to parental/oral prednisolone in the treatment of acute exacerbations of COPD but further studies should be done to evaluate its long-term impact on clinical outcomes after an initial episode of COPD exacerbation.

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Plasmodium (P.) vivax malaria is rarely associated with severe complications like acute respiratory distress syndrome (ARDS). We report three cases of ARDS, which occurred as a complication of vivax malaria, from the city of Kolkata. A middle aged man who developed ARDS along with hepatic and renal dysfunction on the day 7 after completion of antimalarial treatment; a 36-year-old man who developed ARDS on the day 5 after completion of antimalarial treatment and a 15-year-old boy who developed ARDS on day 2, before starting anti-malarial drug. In all cases, vivax malaria was diagnosed by peripheral blood film (PBF) examination. Associated falciparum infection was excluded by repeated PBF examination, and by negative P. falciparum malaria antigen tests. In all cases, ARDS was diagnosed by the presence of hypoxia with PaO ₂ / FiO ₂ ratio < 200 and bilateral pulmonary infiltration, and by excluding cardiac disease by echocardiography. All cases typically had dramatic onset of ARDS, and required immediate (within hour of onset of dyspnea) institution of mechanical ventilation with high positive end expiratory pressure. All three cases recovered completely, and early ventilator support was life-saving.

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Study objective : To study the value of adenosine deaminase level in tuber­cular pleural effusion. Design: A hospital based observational study. Setting : Out and In patients service of department of Tuberculosis & Chest Diseases, MLN Medical College Allahabad. Patients : 50 consecutive patients of pleural effusion, who were above the age of 12 years, were studied. RESULTS: Pleural fluid adenosine deaminase was more than 36 IU/L (36 to 229.7 IU/L) in tubercular pleural effusion (34 patients). In case of malignancy no. of patients was 08 and pleural fluid adenosine deaminase was more than 18.5 IU/L (18.5 to 87.6 IU/L). While in one case of hypoprotenemiea pleural fluid adenosine deaminase was 8.21 IU/L. If 36 IU/L is taken as cut of limit the sensitiv­ity and specificity of ADA for tuberculosis is 100 % and 77.7 %. More than 100 IU/L was exclusively seen in tubercular pleural effusion. Conclusion: ADA > 100IU/L was observed in TB only.

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Objective: The World health organization (WHO) has accepted Keith Edward scoring system for the diagnosis of childhood tuberculosis (TB). In the present study, we evaluated this scoring system. Methods and Results: We included 53 children with confirmed TB involving different organs, admitted in NB Medical College, during two years period as cases; and 50 randomly selected, age, sex, and organ matched confirmed non-TB cases as controls. We noticed 15.1% false negative and 22% false positive results in our study, and the scoring system had 84.9% sensitivity, 78% specificity, and 80.36% positive predictive value. Likelihood ratio positive (LR+) was 3.86, likelihood ratio negative (LR-) was 0.19, and overall agreement was 81.55%. We observed that Keith Edward scoring system was less effective in children suffering from non-TB chronic diseases (false positive rate: 45.5%). We found no significant difference in nutritional status between study and control groups (P = 0.65). We noticed that more than 15-mm indurations for tuberculin test were specific for TB in children. Conclusion: We concluded that Keith Edward scoring system is good for public health purpose, but there is a scope for improvement, and further study is required for this purpose.

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Objective: To study skin sensitivity to various allergens in patients of nasobronchial allergy. Materials and Methods: 2880 skin prick tests with 60 allergens were performed in 48 patients of nasobronchial allergy. Results: Most common offending allergens were insects (21.2%), followed by dusts (12.0%), pollens (7.8%), animal dander (3.1%), and fungi (1.3%). The common insect antigen were locust female (33.3%) followed by locust male (25%), grasshopper (20.8%), cricket (16.7%), cockroach female (16.7%) and cockroach male (14.6%). Common dust allergens were house dust, wheat dust, cotton mill and paper dust. Among pollens, Amaranthus spinosus, Argemone mexicana, Adhatoda vasica, Ailanthus and Cannabis were found to be common allergens. In animal danders common offending allergens were cow dander and dog dander. Among fungi Aspergillus fumigatus, Aspergillus flavus, Alternaria teneis and Fusarium sodani were common allergens. Patients of bronchial asthma had associated allergic rhinitis in 80% cases. Conclusion: Common allergens in patients of nasobronchial allergy were identified. The data may prove useful in of allergen avoidance and immunotherapy in these patients.

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Nowadays, endobronchial tuberculosis is of rare occurrence. This article presents three such cases. All of them presented as unresolved pneumonia with collapse-consolidation in chest X-ray. All the three patients were sputum smear negative for acid fast bacilli. Diagnosis was possible only with fiberoptic bronchoscopy and bronchial biopsy.

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Elongated uvula is relatively an uncommon condition. Upper airway obstruction is often a missed complication of such a rare condition. Clinical presentations of upper airway obstruction often mimic asthma. Hence it is very easily mis-diagnosed as asthma. Spirometry offers a very simple test to diagnose upper airway obstruction very early and easily. Once diagnosed, the management of elongated uvula, almost exclusively, is surgical excision leading to total cure. Here is a case report of such a rare condition.

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Cleidocranial dysplasia is a rare autosomal dominant condition with generalized dysplasia of bone, characterized by delayed closer of cranial sutures, hypoplastic or aplastic clavicles, short stature, dental abnormalities and a variety of other skeletal abnormalities. We present a seven-year-old female child presenting with classical features of cleidocranial dysplasia.

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Background: Thoracic empyema is a disease of significant morbidity and mortality, especially in the developing world where tuberculosis remains a common cause. Clinical outcomes in tuberculous empyema are complicated by the presence of concomitant fibrocavitary parenchymal disease and frequent bronchopleural fistulae. We performed a prospective study over a one-and-a-half-year period with the objective of comparing the clinical profiles and outcomes of patients with tuberculous and nontuberculous empyema. Materials and Methods: A prospective study of adult cases of nonsurgical thoracic empyema admitted in a tertiary care hospital in eastern India was performed over a period of 18 months. A comparative analysis of clinical characteristics, treatment modalities, and outcomes of patients with tuberculous and nontuberculous empyema was carried out. Results: Seventy-five cases of empyema were seen during the study period, of which 46 (61.3%) were of nontuberculous etiology while tuberculosis constituted 29 (38.7%) cases. Among the nontuberculous empyema patients, Staphylococcus aureus (11, 23.93%) was the most frequent pathogen isolated, followed by Gram-negative bacilli. Tuberculous empyema was more frequent in younger population compared to nontuberculous empyema (mean age of 32.7 years vs. 46.5 years). Duration of illness and mean duration of chest tube drainage were longer (48.7 vs. 23.2 days) in patients with tuberculous empyema. Also the presence of parenchymal lesions and bronchopleural fistula often requiring surgical drainage procedures was more in tuberculous empyema patients. Conclusion: Tuberculous empyema remains a common cause of empyema thoracis in a country like India. Tuberculous empyema differs from nontuberculous empyema in the age profile, clinical presentation, management issues, and has a significantly poorer outcome.

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Objective: To obtain reference values for FEV ₁ , FVC, FEV ₁ % and PEFR among children aged 8-14 years in south Gujarat region of India. Materials and Methods: This cross-sectional study was conducted among 655 normal healthy school children (408 boys and 247 girls) of Surat city aged 8 to 14 years studying in V to VII standard during November 2007 to April 2008. Height, weight, body surface area were measured. All included children were tested in a sitting position with the head straight after taking written consent from parents. Spirometry was done using the spirometer "Spirolab II" MIR 010. Spirometer used in the study facilitates the total valuation of lung function including forced vital capacity (FVC), forced expiratory volume in one second (FEV ₁ ), forced expiratory volume ratio in one second (FEV ₁ %) and peak expiratory flow rate (PEFR). Results: FVC, FEV ₁ and PEFR were found to be statistically significant in the study groups. For FVC and FEV ₁ , highest correlation was found with age in girls and height in boys. For FEV ₁ %, significant negative correlation was found with age and height in both sexes, but positive correlation was found with surface area. Similarly, PEFR showed highest correlation with surface area in boys and girls. Conclusion: Variables such as FVC, FEV ₁ and PEFR show good positive correlation with height, age and body surface area in both sexes. There is a need to have regional values for the prediction of normal spirometric parameters in a country like India with considerable diversity.

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Background: Allergic bronchopulmonary mycosis (ABPM) is a clinical syndrome associated with immune sensitivity to various fungi notably Aspergillus spp. that colonize the airways of asthmatics. Early diagnosis and treatment with systemic corticosteroids is the key in preventing the progression of the disease to irreversible lung fibrosis. Aims: To study the occurrence of ABPM among asthma patients with fungal sensitization attending a chest clinic of a tertiary hospital of eastern India. The clinico-radiological and aetiological profiles are also described. Materials and Methods: All consecutive patients with asthma presenting to the chest clinic over a period of one year were screened for cutaneous hypersensitivity to 12 common fungal antigens. The skin test positive cases were further evaluated for ABPM using standard criteria. Results: One hundred and twenty-six asthma patients were screened using twelve common fungal antigens; forty patients (31.74%) were found to be skin test positive, and ABPM was diagnosed in ten patients (7.93%). Of the 10 cases of ABPM, nine cases were those of allergic bronchopulmonary aspergillosis (ABPA) and one case was identified as caused by sensitization to Penicillium spp. A majority of the cases of ABPM had advanced disease and had significantly lower FEV1 compared to non-ABPM skin test positive asthmatics. Central bronchiectasis on high resolution CT scan was the most sensitive and specific among the diagnostic parameters. Conclusion: There is a significant prevalence of ABPM in asthma patients attending our hospital and this reinforces the need to screen asthma patients for fungal sensitisation. This will help in early diagnosis and prevention of irreversible lung damage.

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Objectives: To study the effect of unsupported upper limb and lower limb exercise training and their combined influence on the exercise performance and health-related quality of life in COPD patients. Materials and Methods: Thirty patients were randomly assigned to one of the three groups, through block randomization. Of the three groups, group A received upper limb training, group B received lower limb training, and group C received both upper and lower limb training. Patients in group A, B, and C underwent exercise training five times a week for four weeks. The outcome measures used in the study were unsupported upper limb endurance test (UULEX), Six-Minute Walk Test (6-MWT), and a Chronic Respiratory Questionnaire. Statistical analysis was performed with analysis of variance, Wilcoxon scale, and a Kruskal Wallis one way ANOVA test, and a P value of .05 was used in the study. Conclusion: The combined upper limb and lower limb training group showed a significant improvement in the exercise performance and health-related quality of life.

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