Chest Medicine Department Research Articles

Frequency of Asymptomatic Deep Vein Thrombosis in Hospitalized Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD).

Acute exacerbations of chronic obstructive pulmonary disease (COPD) are always associated with high mortality. Because of the presence of some concomitant risk factors such as immobilization and bronchial superinfection, patients who are admitted for acute exacerbations of COPD are generally considered to be at moderate risk for the development of venous thromboembolism. Thromboembolism is a cause of unexplained dyspnea, exacerbations, and mortality in COPD. This study aims to determine the frequency of asymptomatic deep vein thrombosis (DVT) in patients with acute exacerbations of COPD presented at a tertiary care hospital. This is a descriptive cross-sectional study conducted at the Department of Chest Medicine, Jinnah Postgraduate Medical Center (JPMC), Karachi. A duplex ultrasound study of both lower limbs was performed by a sonologist to assess asymptomatic DVT in patients with acute exacerbations of COPD. The mean age of the sample was 59.64 ± 9.711 years. Out of 106 patients, 95 (90%) were male and 11 (10%) were female. Asymptomatic DVT was found in 16 (15%) patients with acute exacerbations of COPD. Male patients exhibited a higher incidence of DVT, with 12 cases versus four in females, a statistically significant finding (p=0.03). Additionally, DVT was significantly more prevalent among patients with restricted mobility, with all 16 cases occurring in this group (p=0.006). Age did not show a statistically significant difference in DVT occurrence between patients above and below 59 years. Deep venous thrombosis is a common occurrence in COPD exacerbations. It is a risk factor for pulmonary embolism that carries a high mortality. All patients with COPD exacerbations may need to be assessed for thromboembolic events. COPD morbidity and mortality are continually rising despite efforts to recognize new phenotypes and treatments. The cause may be the association of unrecognized and untreated thromboembolism. Prompt diagnosis and treatment with anticoagulants in COPD patients may lead to a better prognosis.

Bronchoscopic lung volume reduction by instillation of fibrinogen and thrombin in COPD patients with homogenous emphysema

BackgroundThe new endobronchial therapy called biological lung volume reduction (BioLVR) involves using a rapid polymerizing sealant to block off the most emphysematous portions of the lungs. The primary mechanism of action is resorption atelectasis, which is then followed by inflammation and remodeling of the airspace. The remodeling process will result in the formation of scars, leading to the contraction of the lung tissue. As a result, a decrease in functional lung volume is anticipated for a period of 6–8 weeks.ObjectiveAssessing the safety and effectiveness of bronchoscopic installation of (fibrinogen and thrombin) in COPD patients with homogeneous emphysema in terms of radiological, physiological, and quality of life outcomes.MethodsBetween December 2017 and December 2019, 40 COPD patients with homogeneous emphysema were studied using a fiber optic bronchoscope while they were awake but sedated. Tanta University Hospitals’ chest medicine department collaborated with the diagnostic radiology department of the Faculty of Medicine.ResultsAll the following parameters were reduced from their initial values: HRCT volumetry, RV/TLC, mMRC dyspnea scale, CAT score, 6MWT, FEV1, and the FEV1/FVC ratio at the first, third, and sixth months from the beginning (p = 0.001). One individual (0.025%) had pneumonia, whereas three individuals had COPD (0.075%). Using fibrin glue produced locally, biological lung volume reduction (Bio LVR) may be an effective treatment for advanced homogenous emphysema.ConclusionBy using locally prepared fibrin glue the biologic lung volume reduction (Bio LVR) may be a convenient method to treat advanced homogenous emphysema.

Comparison of NEWS2 and CURB65 Score in Predicting Mortality of Hospitalized patients with AECOPD

Aim: To determine the diagnostic accuracy of the NEWS2 and CURB-65 scores in predicting in-hospital mortality in patients with acute exacerbations of COPD, mortality during hospital stays is considered the gold standard. Study Design: Cross-sectional study-design. Place and duration of study: Department of Chest Medicine, JPMC, Karachi, from September 25, 2020, to January 25, 2021. Two hundred and twelve patients of both genders were included who were admitted because of acute COPD exacerbations. The National Early Warning Score 2 (NEWS2) and CURB-65 Score in the estimation and evaluation of hospital-related mortality were noted. Results: NEWS2 predicted 156(73.6%), CURB-65 predicted 72(34%) as high-risk patients, and in-hospital mortality was 39(18.4%). NEWS2 had shown sensitivity of 100%, specificity of 32.4%, diagnostic accuracy of 45%, PPV of 25.1%, and NPV of 100% as a prediction value of in-hospital mortality. CURB-65 had shown sensitivity of 76.9%, specificity of 75.7%, and diagnostic accuracy of 76%, PPV of 41.7%, and NPV of 93.6% as a prediction value of in-hospital mortality. Implication: It is recommended that individual analyses of these associated factors be performed in future studies for the formulation of novel, efficient scores that may be better predictors of mortality in AECOPD patients. Conclusion: Both of the scoring systems can be used for the purpose of AECOPD patients risk stratification as per clinicians’ preference and as the basic tools of assessment in a resource-poor country. Keywords: Acute exacerbation of COPD, NEWS2, CURB-65, In-hospital mortality

Prevalence and Antifungal Susceptibility of Candida Infections in Patients with Pulmonary Tuberculosis: A Cross-sectional Study from the Union Territory of Puducherry, India

Introduction: Pulmonary Tuberculosis (TB) is a bacterial infectious disease caused by Mycobacterium tuberculosis. Candida albicans is the most commonly isolated fungal pathogen in bronchopulmonary patients. Invasive candidiasis due to Candida species has been on the rise in recent years. However, drug sensitivity studies of C. albicans isolated from TB patients are not routinely conducted in India and other developing countries. Aim: To isolate and identify Candida albicans from patients with TB and to determine its antifungal susceptibility. Materials and Methods: This cross-sectional study was conducted on 129 patients suspected of having pulmonary TB, analysed from August 2016 to January 2018 at the Department of Chest Medicine, Aarupadai Veedu Medical College and Hospital, Puducherry, India. Sputum samples were collected and processed to identify Candida species through Gram staining, Ziehl-Neelsen staining, germ tube formation, and sugar fermentation. Antifungal resistance testing was performed using the disk diffusion method recommended by the Clinical and Laboratory Standards Institute (CLSI). The collected data were subsequently analysed using descriptive statistics and the Chi-square test to evaluate the results. Results: Candida infection was observed in 10 (7.75%) out of 129 patients with pulmonary TB. Among patients with co-infection, C. albicans was the most common, accounting for 4 (40%) cases, followed by C. krusei with 2 (20%) cases, C. tropicalis with 1 (10%) case, C. kefyr with 1 (10%) case, C. glabrata with 1 (10%) case, and C. parapsilosis with 1 (10%) case. Among the azole category, itraconazole and amphotericin B exhibited the highest sensitivity percentages against Candida. Conclusion: The current study revealed a high prevalence of coinfection between pulmonary TB and Candida spp., which may contribute to the symptoms of pulmonary lung disorders. The prevalence of Candida species could also be associated with an inadequate response to antitubercular drugs. Amphotericin B and itraconazole, two commonly used drugs in the community, are often employed as the preferred treatments for fungal infections. Early detection and treatment of this opportunistic candidiasis in patients with pulmonary TB will likely enhance outcomes for such individuals.

Prevalence of hypothyroidism in newly diagnosed patients with obstructive sleep apnea syndrome: a prospective cross-sectional study

Abstract Introduction: One of the most common presentations of OSAS is daytime sleepiness, which is also seen in patients with hypothyroidism. We hypothesized that hypothyroidism is one of contributing factors in the development of OSAS; thus, adequate management of hypothyroidism can simply help to alleviate OSAS symptoms. Aim of the Study: The aim of this study was to evaluate the prevalence of hypothyroidism in OSAS patients in our locality and to compare respiratory polysomnographic parameters of OSAS patients with hypothyroidism versus those without hypothyroidism. Patients and Methods: In a descriptive prospective cross-sectional study, our patients attending Sleep Disordered Breathing Clinic at Sleep Disordered Breathing Unit, Chest Medicine Department, Mansoura University Hospital. All patients were subjected to full history taking with stress on sleep questionnaires, pulmonary complaints, physical examination, anthropometric measures, diagnostic PSG, laboratory evaluation (serum TSH and free T4 levels), and chest radiology and echocardiography. Results: There were two groups of OSAS participants (hypothyroid and euthyroid). Hypothyroidism was evident in 12% of patients;they were classified according to AHI, 13, 15, and 60 of Euthyroid patients had mild, moderate, and severe OSAS, respectively. hypothyroid patients, 2 mild OSAS, 1 moderate OSAS and 9 severe OSAS. Epworth sleepiness scale scores were significantly higher in the hypothyroid group with a mean score of 18 ± 4.8 vs 12.47 ± 6 in the euthyroid group (P = 0.003). Different PSG parameters showed no difference between the two groups. AHI, serum TSH level, and T4 levels were positively correlated but with insignificant P values. Conclusion: Hypothyroidism is thought to be one of the key players in the development of sleep-breathing disorders. It was evident in 12% of OSAS patients; however, the a proven insignificant difference in PSG parameters in OSAS with hypothyroidism versus euthyroid group, except for affection of daytime sleepiness.

Visual outcome in suspected ocular tuberculosis and role of mantoux testing

To determine the role of mantoux test in treatment of ocular TB.Three patients who presented to the OPD with features of anterior Uveitis were examined completely, both systemically and ophthalmologically. BCVA, Color vision, Slit lamp examination, dilated fundus examination was done. Systemic investigations in pertaining to Uveitis was done(CBC, Mantoux, CXR, Serology, ESR).All patients systemically had all investigations negative (including Chest X-ray) except and strong Mantoux reaction with signs of active anterior Uveitis and Vitritis. In collaboration with the department of chest medicine, Anti tubercular treatment was commenced. Patients have recovered from the Uveitis and have improved symptomatically and clinically.Uveitis can be a presenting feature of extra pulmonary TB. Easily available and affordable Mantoux test can help in detecting TB and commencing treatment which can be sight saving. A close follow up for these patients is needed, as they have been started on ATT after testing mantoux strongly positive and should be closely monitored for any ocular toxicity due to ATT.

The Correlation of Peak Expiratory Flow Rate and Hand Dynamometry in Chronic Obstructive Pulmonary Disease Patients A Case Control study

Objectives: To determine the correlation of peak expiratory flow rate and hand dynamometry in patients with chronic obstructive pulmonary disease and to find out the differences between hand grip in cases and control group Methodology: This study was carried out in the Department of Physiology and Department of Chest Medicine, Liaquat National Hospital and Medical College between July 1st 2019 and June 30th 2020 after the approval of the research and ethical committee of the same hospital. We used purposive sampling technique. Total 100 consenting individuals were recruited that were equally divided into control group and chronic obstructive pulmonary disease group. Anthropometric measurements alongwith peak expiratory flow rate and hand dynamometry values were measured. Results: We found significant difference in hand grip strength and peak expiratory flow rate between the case and control groups, chronic obstructive pulmonary disease patients have decreased peak expiratory flow rate and handgrip strength. Weak correlation exists between peak expiratory flow rate and hand grip strength with significant p value. No relationship was found between waist hip ratio and hand grip. Also, body mass index showed a weak negative but statistically significant correlation with hand grip strength. Conclusion: In chronic obstructive pulmonary disease patients, hand grip strength is decreased and determining hand grip strength may ensures quick assessment of quality of life.

Mortality Predictors in Hospitalized Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD)

Objectives: To determine predicting factors for in-hospital outcomes in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) Methodology: A prospective cross-sectional validation study was performed in Jinnah Postgraduate Medical Center Karachi, Pakistan from 2019 to 2020 at the Chest Medicine department, a largest public tertiary care center in Karachi. All the patients with other inflammatory diseases such as malignancy, Arthritis, Inflammatory bowel diseases, connective tissue disorders, bronchiectasis (radiologically proven or history of phlegm expectoration >30 ml/day) or history of Tuberculosis were excluded. Patients with a recent history of use of antibiotic treatment or systemic steroids (prednisolone equivalent to >20 mg/day) in the preceding two months on medical record were also excluded from the study. Ethical Approval was taken from Institutional Research committee. All the patients who were presented to ER with Acute exacerbation of COPD was included in the study, AECOPD was defines Anthonisen criteria. Data was entered into SPSS version 21 for statistical analysis of the data. Results: Total 157 study participants were included into the study with predominance of male gender (n=106, 67.5%). The average age of study participants was 65.1 ± 11.41 years. Age was significantly higher among non-survivors than survivors (p=0.037). PH level at 4 hours was significantly lower in survivors (p=0.038). Heart rate (p=0.026) and respiratory rate (p=0.018) were significantly higher among non-survivors at 4 hours. Among NLR, PLR, PCO2, PO2 and HCO3, a higher sensitivity of 92.59% for NLR and lower specificity of 6.15% PCO2 was determined. None of these parameters had area under the curve significantly higher than 0.5. Multivariable logistic regression showed that age and PCO2 were independently predictors of mortality. Conclusion: The present study found that increasing age and PCO2 were significant predictors of mortality in in patients with acute exacerbation of chronic obstructive pulmonary disease. NLR has high sensitivity and low specificity in determining the mortality

Effect of mandibular advancement device in the treatment of obstructive sleep apnea

Abstract Background Obstructive sleep apnea (OSA) is a situation of repetitive and interrupted collapse of the upper airways (UAs) during sleep. The physiopathology of OSA is multifactorial. Provided that continuous positive airway pressure is the gold standard for treatment of OSA, the American Academy of Sleep Medicine in 2015 stated that mandibular advancement device (MAD) was indicated as a first-line therapy for mild OSA and a second-line therapy for moderate to severe OSA with lower BMI. Aim This study is aimed to evaluate the MAD success rate in patient with OSA and to assess improvement in sleep quality. Patients and methods This was a prospective one-group pretest–post-test quasiexperimental study carried out on 30 patients with OSA admitted to the sleep center at Chest Medicine Department of Mansoura University Hospitals through the period from February 2019 to January 2021. All patients had thorough clinical examination. The clinical assessment was scored according to the following questionnaires: the Epworth Sleepiness Scale, the Berlin questionnaire, the STOP-Bang questionnaire, and the Pittsburgh sleep quality index. Patients also had polysomnography, drug-induced sleep endoscopy, and dental volumetric computerized tomography (CT) scan. All patients were treated by MAD, and then patients began home adjustment as patients were instructed to advance the device 0.5 mm each night as tolerated. After two weeks, patients repeated PSG and CBCT to assess airway volume and airway area after treatment of OSA by the MAD. Results A total of 30 patients with OSA were included, comprising 14 males and 16 females, with a mean age of 42.9 ± 7.0 years. The types of UA obstruction were detected by both drug-induced sleep endoscopy (DISE) and dental volumetric cone-beam CT (CBCT). A total of 30 patients were studied and showed that multiple-level obstruction was the most frequent type of UA obstruction detected by both dental volumetric CBCT and DISE, representing 53.3 and 60%, respectively. Regarding polysomnographic data of the studied patients before and after treatment by MAD, there is very high significant improvement of apnea-hypopnea index among the studied patients whose were treated by MAD. Conclusion MAD has a high success rate in treatment of OSA and improves sleep quality. DISE and CBCT can be useful tools for assessing the success of MAD in the treatment of OSA.

Diagnostic Accuracy of Bronchoalveolar Lavage in Diagnosis of Ple-ural Tuberculosis among Suspected Cases of Pleural TB

Aim: To determine the accuracy of bronchoalveolar lavage in diagnosis of pleural tuberculosis among suspected cases of pleural tuberculosis using biopsy. Study design: Descriptive, cross-sectional. Place and duration of study: Department of Chest Medicine, JPMC, Karachi from 1st August 2017 to 31st January 2018. Methodology: One hundred and thirty six patients with cases of pleural tuberculosis of age 18-55 years and both genders were included. Patients with anti-tuberculosis drugs, pneumonia, tonsillitis, pharyngitis, obstructive pulmonary disease and platelet function disorders, thrombocytopenia or coagulation factors disorder were excluded. 30-50 ml of bronchoalveolar fluid was carried out through fiberoptic bronchoscopy. Three milliliters of 4% lignocaine was used as pre-medication and 3 ml of 2% lignocaine was used during bronchoscopy. Results: In BAL positive patients, 73 (true positive) had pleural tuberculosis and 9 (false positive) had no pleural tuberculosis on biopsy. Among 54, BAL negative patients, 5 (false negative) had pleural tuberculosis on biopsy whereas 49 (true negative) had no pleural tuberculosis on biopsy. Overall sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of BAL in diagnosis of pleural tuberculosis among suspected cases of pleural tuberculosis using biopsy as gold standard was 93.59%, 84.48%, 89.02%, 90.74% and 89.71% respectively. Conclusion: The diagnostic accuracy of bronchoalveolar lavage in diagnosis of pleural tuberculosis among suspected cases of pleural tuberculosis is quite high. Keywords: Pleural tuberculosis, Bronchoalveolar lavage, Sensitivity

Association of Zinc and Vitamin A with Pulmonary TB Infection and PTB-HIV CO-Infection

Objectives of Study: To assess serum zinc and vitamin A levels among patients of PTB and PTB-HIV co-infection. Study Setting: Physiology department, Chest Medicine department, HIV center and Medical Research Centre, LUMHS Jamshoro and the Institute of Chest Diseases in Kotri TB Sanatorium Hospital. Material and Methods: In this cross-sectional comparative study, patients having PTB and PTB-HIV co-infection were recruited from Chest Medicine Department and the Institute of Chest Diseases in Kotri after approval from Ethical Review Committee, LUMHS, Jamshoro. Study participants divided in two groups; one group (n=114) included diagnosed cases of PTB having no co-infection while in other group (n=9) there were patients having coinfection of PTB and HIV. The sampling method was non probability purposive. Blood samples were obtained intravenously after informed consent. Serum zinc levels were determined by zinc ELIA kit and vitamin A by vitamin A ELISA kit. Results: Mean age of study participants was 28.88 years and among them 69.11 percent were AFB positive. To find out drug resistance, gene Xpert was done that was positive in 95.93 percent of patients. Vitamin A and zinc levels were decreased in the main but furthermore they were compared between PTB and PTB-HIV coinfection. Mean of vitamin A in PTB and PTB/HIV co-infection groups were 0.07 and 0.02 respectively, (p-value=0.03 and t value=2.09) that show statistically significant difference in vitamin A levels in two groups. Mean of serum zinc in PTB and PTB/HIV co-infection groups were 2.84 and 1.14 respectively, (p-value<0.01 and t value=2.89) that show highly significant difference statistically. Conclusion: Vitamin A and zinc are significantly less in coinfected people. Keywords: Co-infection, HIV, PTB, vitamin A, Zinc

ΔSpO2/distance ratio from the six-minute walk test in evaluation of patients with chronic obstructive pulmonary disease.

The six-minute walk test (6MWT) contains two independent components: walk distance (6MWD) and oxygen saturation (SpO₂). 6MWD does not give detailed data on numerous COPD associated disorders. As oxygen desaturation plays a key role in exercise limita-tions, a few new parameters integrating oxygen desaturation during exercise along with walk distance are necessary. So, this study was conducted to assess the relationships between ΔSpO₂/distance ratio and pulmonary function test in addition to extent of pulmonary emphysema in COPD patients. 57 stable COPD patients who attended the outpatient clinic of chest medicine department. Mansoura university. were enrolled. Included patients were classified according to GOLD airflow limitation. Age, sex, and modified Medical Research Council dyspnea score (mMRC) were recorded. furthermore, every patient completed the 6MWT and underwent a pulmonary function test and a CT scan to evaluate the degree of pulmonary emphysema. ΔSpO₂/distance ratio was moderately correlated with DLCO%, FVC % and GOLD classification. However, strong correlation was found with FEV1% and RV%. mMRC was weakly correlated with ΔSpO₂/distance ratio. In addition, weak nonsignificant correlation was found between ΔSpO₂/distance ratio and extent of pulmonary emphysema as measured by HRCT volumetry. A significant moderate cor-relation was noticed between the ΔSpO₂/distance ratio and 6MWD (r = -0.5, P < 0.001). a significant strong cor-relation was observed between the ΔSpO₂/distance ratio and ΔSpO₂ (r = 0.87, P < 0.001). ΔSpO₂/distance ratio could be a simple and valuable index for the evaluation of exercise capacity in COPD individuals and might be utilized to predict severity of airway obstruction, pulmonary diffusing capacity disorder and severe hyperinflation.

The Cavity as a Lasting Abode for Tuberculous Bacilli: An Observational Study.

The aim of this study was to determine the factors associated with persistent sputum positivity at the end of 2 months of treatment in patients presenting with (drug-susceptible) pulmonary tuberculosis at a tertiary care hospital in Karachi. A cross-sectional study was conducted at the Department of Chest Medicine (Ward 12), Jinnah Postgraduate Medical Center (JPMC), Karachi, over 6 months. A sample of 73 consenting, newly diagnosed, smear-positive drug-susceptible pulmonary tuberculosis patients was studied. Demographic (age, gender, height, weight and duration of tuberculosis, BMI, socioeconomic, occupational, marital, educational and residential statuses) and clinical factors (chest X-ray extent and cavities, initial smear results, diabetic and smoking statuses) which may be associated with sputum non-conversion were entered in a proforma. Patients were followed up at 2 months of treatment with a sputum smear. Data analysis was done on SPSS (Statistical Package for Social Sciences-version 20.0). Rate of sputum positivity after 2 months of anti-tubercular drug treatment was 17.8%. None of the above-mentioned demographic and clinical factors was associated with persistence of sputum positivity except for the presence of CXR cavities, which made it 5.5 times more likely that the patient would remain smear-positive at 2 months (p = 0.035). The finding of chest radiograph cavities makes it highly likely that a pulmonary tuberculosis patient may remain infectious or have an unfavorable outcome despite taking treatment for 2 months. Clinicians and national policy-makers should thus bear in mind the implications this can have with regard to disease control and therefore pay particular attention to such patients in terms of stringent monitoring and directly observed treatment short-course (DOTS) provision.Supplementary InformationThe online version contains supplementary material available at 10.1007/s42399-021-01098-6.

Psychiatric Co-Morbidity and its Associated Risk Factors among Tuberculosis Patients

Aim: To assess psychiatric co-morbidity (i.e., depression and anxiety) and its associated risk factors among Multidrug/Rifampicin Resistant Tuberculosis (MDR/RR-TB) patients. Methods: It was an analytical cross-sectional study carried out in Department of Chest Medicine, Jinnah Post Graduate Medical Centre from February to August, 2015. Eighty diagnosed and registered patients of MDR/RR-TB, able to comprehend Urdu language, between the age range of 18 to 60 years were approached by using convenient sampling technique. Psychiatric co-morbidity i.e., depression and anxiety were assessed by using the Urdu adapted version of Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder Questionnaire (GAD – 7). Results: By applying the standard cut off score of 10 or more on PHQ-9 and GAD-7, the frequency of depression was 58 (72.5%) and for anxiety it was 53 (66.25%) out of 80 MDR/RR-TB patients. The multivariant analysis, intensive phase of TB treatment (OR = 3.02; 95% CI = 0.97-9.41) was found to be significantly associated with depression by using PHQ-9 and age group of 18 to 30 years (OR=0.156; 95% CI= 0.02-0.86), pulmonary TB (OR=6.33e+7; 95% CI=0.00-inf) and intensive phase of treatment (OR= 3.892; 95% CI=1.14-13.20) were significantly associated with anxiety by using GAD-7. Conclusion: Frequency of psychiatric co-morbidity was higher among MDR/RR-TB patients. Age group of 18 to 30 years, pulmonary TB and intensive phase of treatment were found to be the risk factors for depression and anxiety among TB patients. Psycho-social factors are strong factors in the successful treatment of tuberculosis. Early detection and proper management of psychiatric co-morbidity during the treatment of MDR-TB needs special attention. Keywords: Anxiety, Depression, Drug resistance, Multidrug resistance tuberculosis, psychiatric co-morbidity,

TO STUDY THE CLINICAL, RADIOLOGICAL AND MICROBIAL PROFILE OF PULMONARY INFECTION IN IMMUNOCOMPROMISED PATIENTS

BACKGROUND The lung is one of the most frequently involved organs in complications of immunocompromised host. Among these, pulmonary infection is the most common complication. The chest radiograph is initial diagnostic tool for detection of suspected pulmonary infection in immunocompromised. However, chest radiograph ndings are nonspecic in determining pathogens. The early use of Computed Tomography (CT) is helpful in detecting pulmonary lesions which may not be evident on routine chest radiographs. But there is overlap of CT nding in different infections. This study is therefore, designed to document the clinical, radiological &amp; microbial prole of pulmonary infection in immunocompromised patients. AIM To study the clinical, radiological and microbial prole of pulmonary infection in immunocompromised patients, and to study diagnostic yield of sputum examination, induced Sputum examination &amp; bronchoscopic BAL examination. METHODS The present prospective descriptive observational study was conducted in the Department of Chest Medicine at King Edward Memorial Hospital, Pune. It included immunocompromised patients with lower respiratory tract infection symptoms. A total number of 70 indoor &amp; OPD patient with urban &amp; rural background were included in the study. Among them 45 patients were HIV reactive group and 25 patients were having Non-HIV immunocompromised condition. All of them had pulmonary infection. The study was conducted over a period of 15 months. RESULTS Incidence of pulmonary infection was higher in age 31-40 years (28.58%). There were 51 males and 19 females. Opportunistic infections were more common in males as compared to females. Majority of immunocompromised patients were HIV reactive (64.3%) followed by of Malignancy (15.7%). Focal non homogenous opacity (37.5%) was most common radiological nding followed by consolidation with air brochogram (25%). Pulmonary Tuberculosis (40.5%) was most common opportunistic infection in immunocompromised patients followed by bacterial (30.38 %) and fungal infections (17.72%). Sputum (40.98), induced sputum examination (19.29), and Bronchoscopy with BAL (91.42%) had good diagnostic yield in diagnosis of pulmonary infection in immunocompromised patients. CONCLUSION Induced sputum had less diagnostic yield in immunocompromised patients and also it is time consuming.Early bronchoscopy with BAL remains crucial to establish the diagnosis in immunocompromised patients with pulmonary infection when the cause is infectious in nature.

Molecular profiling and utility of cell-free DNA in nonsmall carcinoma of the lung: Study in a tertiary care hospital.

Lung carcinoma accounts to the most common cause of cancer globally. Optimal management of nonsmall cell lung carcinoma (NSCLC) requires prognostic biomarkers that help in targeted therapy and identification of tumor subsets with a distinctive molecular profile that can foretell response to therapy. Quantitative analysis of circulating cell-free DNA is considered as a possible aid for lung cancer screening. The main aim of our study was detection of the clinicopathological spectrum of NSCLC, immunohistochemical (IHC) study of lung adenocarcinoma with epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), and molecular expression of EGFR mutation using Formalin fixed paraffin embedded tissue (FFPE) and cell-free DNA (cfDNA) from blood samples. It was a prospective and observational study conducted in the Department of Pathology in association with the Department of Chest Medicine in a tertiary care hospital for 18 months, done on 50 patients. Histological subtyping of lung carcinomas was done, followed by IHC analysis using P40, thyroid transcription factor (TTF1), EGFR, and ALK. Molecular analysis for EGFR mutation was done using FFPE and cfDNA from the patient's blood samples. On histological subtyping, majority (66%) of the cases were found to be adenocarcinoma. All adenocarcinoma (66%) cases show TTF1 positivity and all squamous cell carcinoma (32%) cases show P40 positivity. All the ALK-positive (6%) cases were never smokers and histologically diagnosed as adenocarcinoma. About 58% of the NSCLC cases were found to be EGFR IHC positive. Formalin-fixed paraffin tissue (FFPE) showed EGFR mutation in 32% cases, of which majority were deletion (19, 28%) and rest (4%) of the cases involving mutation in exon 21. From cfDNA, mutations were noticed in 16% of the cases where majority involved deletion 19 (12%), whereas the rest of the cases were positive for missense mutation in exon 21 of the EGFR gene (2%) and compound heterozygous mutation involving deletion 19 and missense mutation for exon 21 (2%). On correlation of EGFR mutation studies from FFPE with that of cfDNA analysis, the study was statistically significant (P = 0.000). This study reports clinicopathological, immunochemical, and molecular analysis of EGFR among NSCLC cases. EGFR mutation detection from cfDNA has its advantage of being a noninvasive technique to avoid rebiopsy in cases of the progressive disease to detect resistance to a drug and emergence of a newer mutation. Mutation detection from FFPE samples still remains the gold standard for targeted therapy using EGFR tyrosine kinase inhibitors. ALK rearrangement detection using IHC serves as an adjunct to EGFR diagnosis.

Efficacy and safety of lung biopsy via mini-thoracoscopy in interstitial lung diseases

Introduction Histopathological examination of interstitial lung diseases is important to assist diagnosis when the results of clinical assessment, laboratory investigations, high-resolution computed tomographic imaging, and pulmonary function testing do not allow making a confident diagnosis of a certain type or stage of interstitial lung disease. Patients and methods A total of 20 patients were enrolled in the study at Chest Medicine Department, Mansoura University Hospital, Mansoura, Egypt. A written informed consent for thoracoscope and tissue sampling was obtained from all patients. The patients were divided into two groups: group I underwent medical thoracoscope and group II underwent mini-thoracoscope. Results The biopsy size ranges from 3 to 9 mm, with a mean±SD of 6.2±1.4 mm in group I and 3.9±0.88 mm in group II. Fever was common in group I (50%) than group II (20%). Surgical emphysema was higher in group I, with a median (range) of 3 (2–3) and median (range) in group II was 1 (1–2). Bleeding was reported in most cases for each group, with median (range) of 1.5 (1–2) in group I and 1 (0–1) in group II. No cases were complicated with severe bleeding in both groups. Pain scoring was higher in group I with median (range) of 2 (0–3) and 1 (1–2) in group II. Only two cases in group I were complicated with persistent air leak more than or equal to 7 days. There is a statistically significant difference regarding bleeding, pain, and surgical emphysema (P=0.010, 0.044, 0.013). Diagnostic yield is 100% in both groups. Nonspecific interstitial pneumonia was the most common diagnosis in group I (40%) and in group II (60%), followed by usual interstitial pneumonia in three (30%) cases in group I and four (40%) cases in group II. The least common diagnosis is broncholites obliterans organising pneumonia (BOOP), pulmonary alveolar proteinosis (PAP), and mucoid adenocarcinoma, which were encountered in 10% each in group I. Conclusion Lung biopsy can be performed with less invasive maneuver by mini-thoracoscopy, leading to decrease complications with good diagnostics.

Comparison of DECAF (dysponea, eosinopenia, consolidation, acidaemia, and atrial fibrillation) and APACHE II (acute physiology and chronic health evaluation ii) scoring system to predict mortality among patients with acute exacerbation of chronic obstructive pulmonary disease.

To compare the diagnostic accuracy of two systems in predicting mortality among patients with acute exacerbation of chronic obstructive pulmonary disease. The cross-sectional study was conducted from November 2017 to June 2018 in the Department of Chest Medicine, Jinnah Postgraduate Medical Centre, Karachi, and comprised patients with acute exacerbation of chronic obstructive pulmonary disease. Dyspnoea-eosinopenia-consolidation-acidaemia-atrial fibrillation system was compared with acute physiology and chronic health evaluation II scoring system after mortality scores were calculated for each patient. Data was analysed using SPSS 21. Of the 210 patients, 147(70%) were males and 63(30%) were females. Overall, 59(28.1%) patients died during hospital stay. The mean dyspnoea-eosinopenia-consolidation-acidaemia-atrial fibrillation score was 2.31±0.93 while the mean acute physiology and chronic health evaluation II score was 15.8±7.2. A decision threshold of dyspnoea-eosinopenia-consolidation-acidaemia-atrial fibrillation score >2 had a sensitivity of 84.6% and specificity of 82.3% while acute physiology and chronic health evaluation II score had sensitivity of 53.9% and specificity of 76.5%. Both scoring systems were found to be good predictors of mortality, but dyspnoea-eosinopenia-consolidationacidaemia-atrial fibrillation score was a simpler and effective clinical tool.

Low Dose Theophylline and Tiotropium Rotacap as Add on Therapy in COPD Patients-Clinical Trial

Objectives: To compare the role of low dose Theophylline and Tiotropium rotacap in improving the lung functions and day to day life of patients suffering from COPD. Study Design and Setting: A Clinical trial study was conducted at Department of Pharmacology and Therapeutics, BMSI in association with Department of Chest Medicine, JPMC. Methodology: This study was planned as an open label and parallel clinical trial study. A total of 168 patients of COPD were selected for this study and only 161 patients completed the 3 months duration of the study. The enrolled patients were grouped into 2, namely A and B. Tab. Theophylline 350 mg was given to Group A in two divided doses while Tiotropium rotacap18µg through rotahaler was given to group B once a day. Results: Mean FEV1 ± SD was improved by 0.04 ± 0.02 in Theophylline therapy group while by 0.07 ± 0.01 in the Tiotropium therapy treated group and a significant difference between the changes in the two treatment groups was evident. There was a percentage improvement in PEFR of 8.9 ± 5.8 in the Theophylline therapy treated group and of 13.2 ± 4.7 in Tiotropium therapy treated group. When Tiotropium group was compared with Theophylline group for improvement in percentage change in PEFR from day 0, a significant difference was evident between the two groups. There was a significant improvement from day 0 in CAT score in Tiotropium treated groups versus Theophylline group after 3 months of therapy. Conclusion: Tiotropium rotacap was more effective as compared to low dose Theophylline in improving pulmonary functions and CAT score in patients with COPD

Comparison of High-Resolution Computed Tomography and Real-Time Reverse Transcriptase Polymerase Chain Reaction in Diagnosis of COVID-19 Pneumonia in Intensive Care Unit Population

IntroductionThe efficacy of high-resolution computed tomography (HRCT) chest in common respiratory infections is well-established; however, its use in the diagnosis of COVID-19 pneumonia is less popular. The previous studies have failed to establish the efficacy of HRCT in the diagnosis of COVID-19 pneumonia.ObjectiveThe current study aimed to assess the efficacy of HRCT as compared to a polymerase chain reaction (PCR) in diagnosing COVID-19 pneumonia in patients in our setting.MethodologyA prospective observational study was conducted at the Department of Chest Medicine, Shifa International Hospital from April 2020 to December 2020. A total of 250 patients were admitted to medical intensive care units. Findings of HRCT and PCR were documented. The accuracy of HRCT compared with PCR was assessed. Data were analyzed using SPSS version 24 (IBM Corp., Armonk, NY).ResultsCOVID-19 infection was more prevalent in male patients (62.8% vs 37.2%). The mean age was 60 years (interquartile range, IQR, 49-72). Sensitivity and specificity of HRCT segregated into typical, indeterminate, and atypical HRCT were (94.8%, 56.8%), (92.7%, 47.2%), and (91.7%, 76.8%), respectively. The positive predictive value for typical HRCT was 84.3% (p≤0.001).ConclusionWe concluded that typical HRCT findings have diagnostic utility in the diagnosis of COVID pneumonia. Similarly, a negative HRCT chest reliably excludes the possibility of COVID pneumonia. HRCT chest is a reliable alternative to RT-PCR.