The DOTS strategy for treatment of paediatric pulmonary tuberculosis in South Delhi, India

SETTING

Paediatric Pulmonology Department, TB Institute, New Delhi, India.

OBJECTIVE

To evaluate the outcome of the DOTS strategy for paediatric pulmonary tuberculosis (TB).

DESIGN

Retrospective analysis of 1098 children.

RESULTS

The mean age of the children included in the study was 11.2 years, with more females (61.7%) than males (38.3%). In the 0-5, 6-10 and 11-14 year age groups, the percentage of patients was respectively 18.3%, 26.6% and 55.1%. Patients were registered as new cases (87.7%), relapses (1.9%), failures (1.0%), defaulters (5.0%), transferred in (0.9%) and others (3.5%). Of the total number of cases, 414 were smear-positive and 404 smear-negative, while sputum status was not known for 280 patients. Sputum positivity increased with age. Category I, II and III regimens were started by respectively 50.6%, 10.5% and 38.9% patients. The cure rate was 92.4% (302/327) for new and 92% (80/87) for retreatment cases (chi(2)(1) = 0.02, P = 0.901), but the treatment completion rate was significantly higher for new cases (97%, 636/656) than retreatment cases (53.6%, 15/28) (chi(2)(1) = 100.8, P < 0.001). The overall success rate was 95.4% and 82.6% for new and retreatment cases, respectively (chi(2)(1) = 30.35, P < 0.001). Overall, the rates for default, failure and death in the study were respectively 3%, 1.9% and 1%.

CONCLUSION

DOTS appears to be a highly efficacious treatment strategy.

Optimization of dose and fractionation of endobronchial brachytherapy with or without external radiation in the palliative management of non-small cell lung cancer: a prospective randomized study

AIMS

Endobronchial brachytherapy (EBBT) is an established modality for the palliation in advanced non-small cell lung cancer. We compared three different schedules using EBBT with or without external radiation (XRT) in this setting.

MATERIALS AND METHODS

Forty-five patients were randomized to three treatment arms. Arm A received XRT to a dose of 30 Gy/10 fr/2 weeks and two sessions of EBBT 8 Gy each. Arm B received the same XRT and a single session of EBBT 10 Gy at 1 cm. Arm C received only a single fraction of brachytherapy to a dose of 15 Gy at 1 cm without XRT. Symptomatic response rates, duration of symptom palliation, obstruction scores, quality of life outcomes and complications were assessed and compared.

RESULTS

The overall symptomatic response rates were 91% for dyspnea, 84% for cough, 94% for hemoptysis and 83% for obstructive pneumonia. There was no significant difference between the arms. The median time to symptom relapse was 4-8 months for all symptoms and the median time to symptom progression was 6-11 months. The results were comparable between groups except for hemoptysis, where a shorter palliation was seen in Arm C that achieved statistical significance (P < 0.01). Quality of life showed significant improvement, with maximum benefit in Arm A. Complication rates were low. Only one patient died of fatal hemoptysis.

CONCLUSION

EBBT is thus a safe and effective palliative tool in advanced non-small cell lung cancer, either alone or in conjunction with XRT. The difference between the treatment arms were not statistically significant in most categories, but patients treated with XRT and two endobronchial sessions of 8 Gy had the most consistent benefit in terms of all the parameters studied.

Idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is being more frequently diagnosed in India, due to its increased awareness, better availability of computed tomography (CT) and fiberoptic bronchoscopy. IPF has the histological appearance of usual interstitial pneumonia (UIP) on surgical lung biopsy. Recent research has given a new insight into the etiology of the disease. Clinical criteria have been specified for presumptive diagnosis of IPF and distinguishing IPF from other conditions. The conventional therapy has been steroids and immunosuppressive agents. But only a minority of patients respond to such a therapy. Immunomodulators (interferon Y1b), antioxidants (Acetyl cysteine) and antifibrotic agents (like pirfenidone) are being studied as novel therapies in this, otherwise, fatal condition. Lung transplantation is the only hope for those patients who show progressive deterioration on medical treatment. Living-donor lobar lung transplantation has been developed as a procedure for patients considered too ill to await cadaveric lung transplantation.

Lung and blood mononuclear cell responses of tuberculosis patients to mycobacterial proteins

The differences in specificity of human lung and peripheral lymphocytes for mycobacterial antigens (Ag) need to be evaluated in order to identify vaccine candidates against pulmonary tuberculosis (TB). Therefore, the present study examined the response to low molecular weight secretory proteins of Mycobacterium tuberculosis in bronchoalveolar lavage (BAL) and peripheral blood mononuclear cells (PBMCs) from minimal pulmonary TB and non-TB patients. Ag85A, Ag85B, culture filtrate protein (CFP)-31, CFP-22.5, CFP-21, M. tuberculosis protein-64 and an as yet uncharacterised 19 kDa protein were found to be predominantly recognised by BAL cells of TB patients on the basis of lymphocyte proliferation and significant interferon-gamma release. However, recognition of CFP-8, 6-kDa early secreted antigenic target, CFP-10, CFP-14.5, M. tuberculosis secretory protein-17 and five other as yet uncharacterised low molecular weight polypeptides was found to be high on the basis of lymphocyte proliferation at the level of PBMCs. Furthermore, BAL macrophages, and not blood monocytes, were found to produce nitric oxide (NO) in response to mycobacterial Ags. Among polypeptides predominantly recognised by BAL lymphocytes, only Ag85A and Ag85B were found to induce both NO and interleukin-12 (p40) by alveolar macrophages. In conclusion, the present results indicate heterogeneity in antigen recognition by bronchoalveolar lavage cells and peripheral mononuclear blood cells of minimal tuberculosis patients, and also suggest the utility of antigen 85 complex polypeptides for the development of a future mucosal antituberculous vaccine.

Evaluation of self-care manual in bronchial asthma

BACKGROUND

Asthma continues to be a substantial cause of morbidity. Various educational programmes have shown an increase in knowledge and self-management skills of asthmatic patients and also revealed a reduction of severe attacks, hospitalisations and days lost from work.

METHODS

A self-care manual on bronchial asthma was prepared. A total of 523 bronchial asthma patients were enrolled in the study. Out of these, 260 patients were included in the study group to whom self-care manual was provided and 263 were included in the control group to whom no specific instructions were given. After the initial interview (0 week), follow up of all the patients was carried out at two weeks, six months and at one year.

RESULTS

Out of the enrolled patients, 240 (92.31%) and 240 (91.25%), 212 (81.54%) and 210 (79.85%), and 204 (78.46%) and 194 (73.76%) patients completed the follow up at two weeks, six months and one year in the two groups, respectively. Various parameters analysed were knowledge of the patients, their symptomatology, various triggering factors which were inducing and/or precipitating symptoms, the self-care measures they adopted at the time of acute attacks and the indices of asthma morbidity during the last one year. The knowledge scores were significantly higher at all the three follow up visits (F = 633. 98, p < 0.001) as compared to the baseline in the study group patients. In both the groups, the symptom scores decreased at all the follow up visits (F = 71.78, p < 0.001 in the study group and F = 24.19, p < 0.001 in the control group). Multiple logistic regression analysis showed a significant improvement in knowledge and symptoms in the study group as compared to controls after adjusting for various confounding variables (p < 0.001). The number of patients whose symptoms were induced and/or precipitated by exposure to various triggering factors was significantly reduced in study group for all the triggers. There was a statistically significant decrease in the number of severe attacks, number of emergency visits and need of injections during last one year in both the groups, though the differences were more marked in the study group. However, there was a significant decrease in hospital admissions and absence from school/or job in the study group at one year as compared to the control group.

CONCLUSION

The self-care manual was effective in self-management of bronchial asthma.

Low dose of snake antivenom is as effective as high dose in patients with severe neurotoxic snake envenoming

The objective of this study was to evaluate the effects of two different dosage protocols on the outcome of patients with severe neurotoxic snake envenoming, using a retrospective analysis of patients admitted with a diagnosis of severe neurotoxic snake bite over a 4 year period. In the study, 55 snake bite victims requiring ventilatory support for severe neurotoxic envenoming received either 150 ml of polyvalent snake antivenom (SAV) (low dose SAV group, n = 28) or 100 ml of SAV at presentation followed by 100 ml every 6 hours until recovery of neurological manifestations (high dose group, n = 27). The median dose of SAV in the high dose group was 600 ml (range 300 to 1600). The duration of mechanical ventilation in the low dose group (median 47.5 hours; range 14 to 248) was similar to that in the high dose group (median 44 hours; range 6 to 400). The mean (SD) duration of intensive care unit stay was similar in the two groups. There were three deaths in the high dose group; two patients in the low dose group had neurological sequelae. All other patients improved, had no residual neurological deficit, and were discharged. We conclude that there is no difference between a protocol using lower doses of SAV and one with higher doses in the management of patients with severe neurotoxic snake envenoming.

Profile of repeat fiberoptic bronchoscopy

BACKGROUND

Fiberoptic bronchoscopy (FOB) is invaluable in the diagnosis of a variety of pulmonary diseases, but in many instances the procedure has to be repeated because of an inconclusive initial FOB or for reassessment.

METHODS

A retrospective analysis of all the fiberoptic bronchoscopic procedures done between September 2000 and February 2003 was performed and details of patients undergoing repeat FOB abstracted.

RESULTS

Of the 2,270 bronchoscopies performed on 2114 patients, 132 procedures were repeated, yielding an over all frequency of repeat FOB of 6.34 percent. Bronchoscopy was done twice in 112 patients, thrice in 16 patients and four times in four patients. The commonest diagnosis in patients undergoing repeat bronchoscopy was bronchogenic carcinoma, followed by non-resolving pneumonia or presence of pulmonary infiltrates in immunocompromised host. The major indications for repeating FOB included obtaining specimens for pathological examination, pre and postoperative evaluation of airways, localization of site of bleeding in patients with hemoptysis, and placement of catheters for intraluminal brachytherapy. Of the 88 cases undergoing repeat bronchoscopy for diagnostic purposes, 41 (46.6%) yielded positive results, either in form of positive histology or localisation of source of hemoptysis.

CONCLUSIONS

The frequency of repeat bronchoscopy was low. Commonest indication for a repeat procedure was to obtain repeat/additional diagnostic samples. A repeat procedure can yield positive results even when the initial FOB is nondiagnostic.

Human immune recognition-based multicomponent subunit vaccines against tuberculosis

The cell-mediated immune response, with its shift in favour of type-1 over type-2 T-helper cell immune response, is generally regarded as essential to protection against mycobacterial infections. The aim of this study was to evaluate the protective potential of two multicomponent subunit vaccines (MSV-1 and MSV-2) against tuberculosis (TB) based on human immune recognition. MSV-1 consisted of five immunodominant antigens (TB10.4, early secretory antigenic target (ESAT)-6, culture filtrate protein (CFP)-8, CFP-10 and CFP-15) selected from a group of polypeptides, which induced a predominant T-cell response in immune human subjects, whereas MSV-2 consisted of antigens (CFP-11, CFP-21, CFP-22.5, Mycobacterium tuberculosis protein (MPT)-64 and CFP-31) selected from a group of polypeptides which induced a subdominant T-cell response along with the antibody response. Both of these sets of polypeptides were extensively recognised in healthy individuals with significant interferon gamma release compared to the diseased population. In C57BL/6J mice, at the level of the lungs, the order of protective efficacy for the test vaccines was: bacille Calmette-Guerin (BCG)>MSV-2>MSV-1. The protective efficacy of MSV-1 was found to be significantly less than that of MSV-2 and BCG at the level of spleen, whereas that of MSV-2 was comparable to that of BCG. The results of this study indicate that high T-helper cell type 1 response-inducing polypeptides selected on the basis of human immune recognition do not necessarily impart protection during vaccination experiments.

Indoor air pollution as a risk factor for lung cancer in women

OBJECTIVES

Tobacco smoking is the most common risk factor for lung cancer. But a significant proportion of lung cancer occurs in non-smokers. Indoor pollution due to domestic fuels has been recently implicated as a causative agent in lung cancer especially in women. We conducted a case control study to find out the role of indoor air pollution due to domestic cooking fuels in Indian women.

METHODS

In a case control study 67 women with proven lung cancer were recruited. Forty-six females having a non-malignant respiratory disease constituted the control group. The patients and controls were asked about the exposure in various cooking fuels using a questionnaire.

RESULT

There were 50 (74.6%) non-smokers and 17 (25.4%) smokers among the female cancer cases (p = 0.016). Adenocarcinoma was the commonest histological type of malignancy (n = 26, 38.8%) in the whole group and was the predominant form in the nonsmoking females. Tobacco smoking was the most important risk factor for lung cancer with OR of 4.87 (95% CI 1.34-17.76). Among non-smokers out of all the cooking fuels the risk of development of lung cancer was highest for biomass fuel exposure with an odds ratio of 5.33 (95% CI 1.7-16.7). Use of mixed fuels was associated with a lesser risk (OR = 3.04, 95% CI 1.1-8.38). ). In multivariate logistic regression analysis biomass fuel exposure was still significant with OR of 3.59 (95% CI 1.07-11.97) even after adjusting for smoking and passive smoking.

CONCLUSION

This study indicated that biomass fuel exposure is an important risk factor in the causation of lung cancer among women in addition of exposure to tobacco smoke.

Serum surfactant protein-A levels in chronic bronchitis and its relation to smoking

BACKGROUND

Surfactant protein-A (SP-A), which is an important constituent of natural surfactant, occurs physiologically in small amounts in blood. Tobacco smoke induces increased alveolo-capillary leakage of surfactant proteins into blood and its level in blood may help in the assessment of lung injury caused by smoke. Little is known on the SP-A levels in patients with chronic obstructive pulmonary disease (COPD).

METHODS

Prospective analytical study of 30 patients with clinical diagnosis of chronic bronchitis, which was made on the basis of symptoms, signs and chest radiographic findings. Serum SP-A and serum cotinine levels were measured.

RESULTS

Out of 30 patients, 21 were smokers and nine were non-smokers. The serum SP-A level in smokers with chronic bronchitis is significantly higher than the non-smokers. The plasma cotinine levels are also high in smokers. However, there was no correlation between the serum SP-A level and plasma cotinine level (r=0.044). Serum SP-A levels were related to age in smokers (r=0.566, p<0.01) but not in non-smokers with chronic bronchitis (r=0.017, p>0.05).

CONCLUSION

The increase in SP-A level in smokers with chronic bronchitis suggests that tobacco smoking causes a chronic increase in permeability of the lung parenchyma. The SP-A, a lung-specific secretory protein, is a potential marker for non-invasive assessment of the integrity of the lung epithelium. Further studies are required to find out whether SP-A can be used as a marker for early identification of smokers who are at risk of COPD.

Tuberculosis among physicians in training

A total of 478 resident doctors working at our hospital were interviewed regarding development of tuberculosis after joining the hospital. Nine residents had developed tuberculosis, yielding an overall risk of 11.2 cases per 1000 person-years of exposure. Another 231 resident doctors newly admitted to the residency programme over a 1-year period were prospectively followed up over the next year. Four residents in this group developed tuberculosis within 1 year of joining the hospital, yielding an overall incidence of 17.3/1000. Physicians in training have a high risk of developing active tuberculosis after nosocomial transmission.

Lung cancer in India

BACKGROUND

Lung cancer is one of the commonest malignant neoplasms all over the world. It accounts for more cancer deaths than any other cancer. It is increasingly being recognized in India.

METHODS

We did a systematic review of the published studies on epidemiology, diagnosis and treatment of lung cancer in India. Literature from other countries was also reviewed.

RESULTS

With increasing prevalence of smoking, lung cancer has reached epidemic proportions in India. It has surpassed the earlier commonest form of cancer, that of oropharynx, and now is the commonest malignancy in males in many hospitals. In addition to smoking, occupational exposure to carcinogens, indoor air pollution and dietary factors have recently been implicated in the causation of lung cancer. Squamous cell carcinoma is still the commonest histological type in India in contrast to the Western countries, although adenocarcinoma is becoming more common. Molecular genetics of lung cancer has opened up new vistas of research in carcinogenesis. Various modalities for early detection through screening are being investigated. Majority of the patients have locally advanced or disseminated disease at presentation and are not candidates for surgery. Chemotherapy applied as an adjunct with radiation improves survival and the quality of life. New anticancer drugs, which have emerged during the last decade, have shown an improved efficacy-toxicity ratio.

CONCLUSIONS

In view of our large population, the burden of lung cancer will be quite enormous in India. Drastic measures aimed at discouraging people from smoking must be taken to reduce the morbidity and mortality due to lung cancer.

Development of a computer software for easy storage and analysis of fibreoptic bronchoscopy data

OBJECTIVE

To develop a simple software for management of fibreoptic bronchoscopy records.

METHODS

After identification of the specific needs at our hospital, a software was developed. A graphical interface with structured data entry related to patient information and diagnosis, bronchoscopic findings and specimens obtained, and their reports were envisaged. After initial construction, the software was tested over a four-week period. The software was put to routine use after necessary corrections, and validated over the next few months through actual data entry.

RESULTS

The software has various modules for input and modification of data, as well as for generation of reports, and can work both on stand-alone personal computers and on networks. With little practice, residents soon became adept at entering details correctly and quickly. The slightly increased time of data entry into the computer was more than made up by uniform and complete report generation. The database component was evaluated by analyzing 1000 consecutive records entered over a 14-month period, and no discrepancies were observed.

CONCLUSION

A user-friendly software providing uniform and complete data entry regarding fibreoptic bronchoscopic procedures was developed.

Ifosfamide containing regimen for non-small cell lung cancer

BACKGROUND

Combination chemotherapy has been demonstrated as one of the best active regimens in patients with non-small cell lung cancer (NSCLC).

METHODS

A total of 206 patients with advanced unresectable NSCLC stage III B or stage IV were enrolled to receive combination chemotherapy with mitomycin, ifosfamide and cisplatin. About a third of them (n=63) did not continue therapy after the first course either because of toxicity, lack of affordability, or death. The remaining 143 patients (121 males) received two or more cycles of chemotherapy.

RESULTS

Nearly half of all followed-up patients showed a partial or complete radiological response. Overall performance status (Karnofsky scale) worsened in 28 (19.6%) and improved in 44 (30.8%). While 50 patients (35%) gained weight, 65 (45.5%) lost weight during follow-up. Overall median survival was 20 weeks [95% confidence interval (CI), 16 to 24 weeks]. However, overall survival improved progressively with the number of chemotherapy cycles administered. Median survival in patients receiving at least three, four and five chemotherapy cycles was 23 (95% CI, 19-27); 27 (95% CI, 24-30) and 35 (95% CI, 28-42) weeks respectively. Survival at the end of three, six, nine and 12 months was 64.3%, 29.4%, 14.7% and 9.8%) respectively. Survival had no association with age of the patient, but was significantly correlated with baseline performance status (Pearson's correlation coefficient 0.29 p<0.01). The cost of each course of chemotherapy was a little over 100 US dollars. The side effects were minimal and acceptable, and the regimen was tolerated well by all the patients.

CONCLUSION

Ifosfamide regimen containing mitomycin and cisplatin is a chemotherapeutic combination for treating patients with advanced NSCLC.

Bronchoendoscopic involvement in patients with carcinoma of middle third of esophagus in absence of respiratory symptoms

BACKGROUND

Bronchoscopic examination has been advocated as an essential part of evaluation of patients with newly diagnosed esophageal malignancy. The present study describes the role of routine preoperative fibreoptic bronchoscopy in staging disease and assessing resectibility in patients with malignancy involving the middle third of esophagus.

METHODS

Preoperative fibreoptic bronchoscopy was performed in 125 patients with carcinoma of the middle third of esophagus. None of the patients had clinical or chest radiographic evidence of extension of disease outside the esophagus.

RESULTS

Abnormalities were detected in 33 patients (25.6%), the commonest being external compression over the posterior wall of trachea in 17 (13.6%). Other abnormalities noted were left vocal cord paresis in seven (5.6%); compression over one or both major bronchi in seven (5.6%) and over the left lower lobe bronchus in one (0.8%); infiltration of the left main bronchus in two (1.6%); and growth in trachea in four (3.2%), in left main bronchus in two (1.6%) and over cricoarytenoid area in one (0.8%) patient.

CONCLUSIONS

Tracheobronchial involvement, even in the absence of clinical or radiological features, is not uncommon in esophageal cancer. Preoperative bronchoscopy is useful to assess the extent of disease and resectibility in these patients.

Ventilatory management of respiratory failure in patients with severe Guillain-Barre syndrome

Guillain-Barre syndrome (GBS) is the commonest peripheral neuropathy causing ventilatory failure, and 10-30% patients may require respiratory support. Records of 11 adult patients of GBS in respiratory failure, admitted to the Respiratory Intensive Care Unit (RICU) of our institute for mechanical ventilation over a four-year period, were studied. Six patients received intravenous immunoglobulin. The median duration of mechanical ventilation was 38 days. Seven patients underwent tracheostomy. Four patients were ventilated for less than 2 weeks and 3 for more than 2 months each. Seven developed ventilator-associated pneumonia and/or sepsis. Three patients died in, and two shortly after discharge from RICU; all had systemic problems or complications of hospitalization.