Role of detailed psychological evaluation and treatment in pulmonary rehabilitation programs for patients with chronic obstructive pulmonary disease

Psychological co-morbidities are common in chronic obstructive pulmonary disease (COPD) but remain overlooked. Psychosocial interventions are deemed to promote mental health and optimize management. This study aimed to determine the role of detailed psychological evaluation and treatment in the comprehensive management of COPD. COPD patients after screening with the general health questionnaire-12 (GHQ-12) for psychological co-morbidity were divided into three groups (26 patients each): i) group A [GHQ-12 score<3, received pulmonary rehabilitation (PR) and standard medical management]; ii and iii) group B and C (GHQ-12 score>3, in addition, received management by a psychiatrist and counseling by a pulmonologist, respectively). At baseline and 8 weeks of follow-up, all participants were evaluated for respiratory [forced expiratory volume in the first second (FEV1), six-minute walk distance (6-MWD), St. George's respiratory questionnaire (SGRQ), modified medical research council (mMRC) dyspnea scale], and psychological [GHQ-12, patient distress thermometer (PDT), coping strategy checklist (CSCL), World Health Organization-quality of life-brief (WHOQOL-Bref-26), and depression anxiety stress scales (DASS)] parameters. Psychological distress (GHQ-12>3) decreased significantly at follow-up, with 11.5% and 53.8% of patients having psychological distress in groups B and C, respectively, versus baseline (p<0.001). mMRC score, SGRQ score, FEV1 and 6-MWD significantly improved in all three groups. Improvement in mMRC and SGRQ was maximal in group B when compared with the other groups. PDT, CSCL, and WHO-QOL-Bref-26 scores improved significantly at follow-up in all three groups, with maximum improvement in group B, followed by group C, and then group A. The DASS score also improved maximally in group B. Patients should be screened for psychological co-morbidities using simple screening tools. PR plays an important role in improving the psychology of COPD patients. However, results are better with directed psycho-educative sessions by non-experts and best with definitive treatment by psychiatrists.

Assessment of the feasibility of 1-min sit-to-stand test in evaluating functional exercise capacity in interstitial lung disease patients

Six-min walk test (6MWT) is widely used exercise test for the evaluation of interstitial lung disease (ILD). However, the long test duration and need for long and flat surface hinder its routine use. One-min sit-to-stand test (1-STST) is devoid of such limitations, but has been scarcely evaluated. The study was conducted to evaluate the performance of 1-STST by correlating it with 6MWT in ILD patients. Stable ILD patients were prospectively enrolled. After initial spirometry, all patients performed 6MWT and 1-STST following the standard recommendations. Exercise capacity and physiological parameters (heart rate, pulse oxygen saturation, blood pressure and dyspnea [modified Borg scale]) including peripheral oxygen saturation (SpO2) were correlated after the tests using Pearson correlation, Intraclass correlation coefficient (ICC) and kappa (κ) coefficient. The results showed that the mean age of the patients (n=60) was 58.8±11.5 years (male:female=1:1). Repetitions after 1-STST showed significant correlation with 6MWT (r=0.48; P<0.001). Changes in the physiological variables were similar (P>0.05) with good consistency (ICC=0.68-0.95) between 6MWT and 1-STST. Both lowest SpO2 and difference in SpO2 also showed good agreement (ICC=0.86; 95% confidence interval [CI], 0.77-0.92 and ICC=0.68; 95% CI, 0.47-0.81 respectively) and significant correlation (r=0.76 and r=0.52, respectively). 1-STST and 6MWT were consistent in identifying patients having oxygen desaturation ≥4% (κ=0.56; 96% CI, 0.30-0.82). The results demonstrated that the performance of 1-STST was consistent with 6MWT in terms of exercise capacity and change in physiological parameters. 1-STST can be a valid alternative to 6MWT in the assessment of ILD patients, especially in peripheral health centers.

Serial evaluation of antibody titres in patients recovered from COVID-19 and their correlation with disease severity

On March 11, 2020, the World Health Organization (WHO) declared COVID-19 a pandemic. According to the findings of various studies conducted around the world, the serological response varies greatly among different populations, with the determinants of variable response still unknown, including the role of disease severity, which is thought to have a definite correlation. The purpose of this study was to assess serial SARS-CoV-2 IgG antibody response in COVID-19 patients and correlate it with disease severity. It was a longitudinal observational study in which 45 patients (age >18 yrs), were enrolled who had recovered from COVID-19 and were reporting to the post-COVID Care OPD Clinic. Patients who had been on long-term immunosuppressive therapy prior to SARS-CoV-2 infection were not eligible. All patients had not been immunized against SARS-CoV-2 and had no history of contact with recent COVID-19 cases. The patients underwent serial blood tests to determine serum IgG titers specific for SARS-CoV-2 at 30, 60, and 90 days after being diagnosed with COVID-19. Chemiluminescence was used to perform a semi-quantitative evaluation of the SARS-CoV-2 IgG antibody. At 30 days after confirmed SARS-CoV-2 infection, 98.78% had detectable serum IgG levels, and sero-reversion (loss of previously detectable antibodies) occurred in 2.5% at 60 days and 90 days. Serum IgG was found to peak at 30 days out of the three time points of measurement (30, 60, and 90 days from diagnosis). Serum IgG levels at 90 days were significantly lower than those at 30 days (p<0.0001) and 60 days (p=0.002). The current study's findings shed light on the presence and persistence of serum SARS-CoV-2-specific IgG antibodies following a natural infection. The findings point to a long-lasting immune response with increasing severity of initial COVID-19 disease.

Persistent respiratory symptoms and lung function abnormalities in recovered patients of COVID-19

Background and Objectives

COVID-19 is a disease caused by SARS-CoV-2 which belongs to a family of coronaviruses. After the acute phase of illness, the majority of the patients recover quickly but, in some cases, symptoms can persist for a variable duration, bringing into light another entity known as post-COVID syndrome. The objective was to estimate the burden of various persistent respiratory symptoms and lung function abnormalities among recovered patients of COVID-19 and also to correlate them with initial disease severity, demographic factors and comorbidities.

Methods

Eighty-five post-COVID patients were recruited as per inclusion/exclusion criteria. Detailed history taking, physical examination and spirometry were done in all patients and data were correlated with baseline disease severity.

Results

Fatigue and breathlessness were the most common symptoms followed by cough, chest pain and fever. Persistent symptoms and their severity were significantly higher in severe/moderate cases. Spirometry was abnormal in 45.88% of subjects and the most common pattern was restrictive type. It was seen that the likelihood of persistent symptoms and abnormal lung function increased significantly with the severity of COVID-19, age, comorbidities, hospital stay duration and steroid/oxygen therapy.

Conclusion

The current study estimated the burden and array of various pulmonary sequelae encountered by post-COVID patients and elicited various risk factors associated with their occurrence after recovery from active infection. Awareness of these symptoms/sequelae and their risk factors is necessary for their follow-up and timely management, as the threat of this relatively new virus has still not abated.

N-terminal PPE domain plays an integral role in extracellular transportation and stability of the immunomodulatory Rv3539 protein of the Mycobacterium tuberculosis

Multigene PE/PPE family is exclusively present in mycobacterium species. Only few selected genes of this family have been characterized till date. Rv3539 was annotated as PPE63 with conserved PPE domain at N-terminal and PE-PPE at C-terminal. An α/β hydrolase structural fold, characteristic of lipase/esterase, was present in the PE-PPE domain. To assign the biochemical function to Rv3539, the corresponding gene was cloned in pET-32a (+) as full-length, PPE, and PE-PPE domains individually, followed by expression in E. Coli C41 (DE3). All three proteins demonstrated esterase activity. However, the enzyme activity in the N-terminal PPE domain was very low. The enzyme activity of Rv3539 and PE-PPE proteins was approximately same with the pNP-C4 as optimum substrate at 40 °C and pH 8.0. The loss of enzyme activity after mutating the predicted catalytic triad (Ser296Ala, Asp369Ala, and His395Ala) found only in the PE-PPE domain, confirmed the candidature of the bioinformatically predicted active site residue. The optimal activity and thermostability of the Rv3539 protein was altered by removing the PPE domain. CD-spectroscopy analysis confirmed the role of PPE domain to the thermostability of Rv3539 by maintaining the structural integrity at higher temperatures. The presence of the N-terminal PPE domain directed the Rv3539 protein to the cell membrane/wall and the extracellular compartment. The Rv3539 protein could generate humoral response in TB patients. Therefore, results demonstrated that Rv3539 demonstrated esterase activity. PE-PPE domain of Rv3539 is functionally automated, however, N-terminus domain played a role in protein stabilization and its transportation. Both domains participated in immunomodulation.

Single nucleotide polymorphism rs2234711 of interferon gamma receptor 1 is associated with pulmonary tuberculosis in the population of North India

Interferon-gamma (IFN-γ) is a pro-inflammatory cytokine playing essential role in immunity against tuberculosis (TB). IFN-γ performs function by binding to its receptor complex, consisting of two polypeptide chains viz. IFN-γ receptor 1 (IFN-γR1) and IFN-γ receptor 2 (IFN-γR2). Structural and functional deficiencies in IFN-γR1 can make individual vulnerable to even weak mycobacterial infections. Studies from different populations of the world have reported the association of single nucleotide polymorphisms (SNPs) present in IFNGR1 gene with TB, however, there are no such studies from India. Thus, the present study was designed to analyse the association of rs2234711 (C/T), rs7749390 (C/T) and rs1327475 (C/T) SNPs of IFNGR1 with TB in the population of North India. For the present study, 263 TB patients (at zero day of anti-tuberculosis therapy) and 256 healthy controls (HCs) were recruited. The genotyping of selected SNPs was done by high-resolution melting (HRM) curve analysis. The mRNA and surface expression data of IFNGR1 was extracted from our previous study and was grouped according to the genotypes of studied SNPs. The genotype 'TT' and 'T' allele of SNP rs2234711 (C/T) were found to be associated with TB in studied population ['T' vs 'C': OR (CI) = 1.79 (1.39-2.29); p-value < 0.0001]. The haplotypes 'C-C-C' of rs2234711-rs7749390-rs1327475 confers protection, while haplotype 'T-C-C' is a risk factor for TB in studied population. It was also found that 'TT' genotype of rs2234711 in HCs is associated with lower surface expression of IFNGR1 (p-value = 0.0078). In conclusion, 'TT' genotype is associated with lower surface expression of IFNGR1 and is increasing the susceptibility to TB in North Indian population.

Cell wall and immune modulation by Rv1800 (PPE28) helps M. smegmatis to evade intracellular killing

Rv1800 is predicted as PPE family protein found in pathogenic mycobacteria only. Under acidic stress, the rv1800 gene was expressed in M. tuberculosis H37Ra. In-silico study showed lipase/esterase activity in C-terminus PE-PPE domain having pentapeptide motif with catalytic Ser-Asp-His residue. Full-length Rv1800 and C-terminus PE-PPE domain proteins showed esterase activity with pNP-C4 at the optimum temperature of 40 °C and pH 8.0. However, the N-terminus PPE domain showed no esterase activity, but involved in thermostability of Rv1800 full-length protein. M. smegmatis expressing rv1800 (MS_Rv1800) showed altered colony morphology and a significant resistance to numerous environmental stresses, antibiotics and higher lipid content. In extracellular and membrane fraction, Rv1800 protein was detected, while C terminus PE-PPE was present in cytoplasm, suggesting the role of N-terminus PPE domain in transportation of protein. MS_Rv1800 infected macrophage showed higher intracellular survival and low production of ROS, NO and expression levels of iNOS and pro-inflammatory cytokines, while induced expression of the anti-inflammatory cytokines. The Rv1800, PPE and PE-PPE showed antibody-mediated immunity in MDR-TB and PTB patients. Overall, these results confirmed the esterase activity in the C-terminus and function of N-terminus in thermostabilization and transportation; predicting the role of Rv1800 in immune/lipid modulation to support intracellular mycobacterium survival.

Prevalence of latent tuberculosis infection in household contacts of pulmonary tuberculosis, time to treat

Treatment of latent pulmonary tuberculosis (TB) in household contacts has been included in the National Tuberculosis Elimination Program to achieve the target of TB elimination by the Government of India by 2025. However, there are no clear estimates of the prevalence of latent TB among the contacts that could suggest the impact of this intervention. The study was conducted to determine the prevalence of and factors predicting latent TB among household contacts with pulmonary TB. All microbiologically confirmed pulmonary TB patients registered between January 2020 and July 2021 and their household contacts were enrolled. All contacts underwent Mantoux testing to determine the prevalence of latent TB. All symptomatic patients also underwent chest radiographs and sputum examinations to diagnose active pulmonary TB. Thereafter, different demographic and clinical factors were evaluated to find predictors of latent TB using a logistic regression model. A total of 118 pulmonary TB cases and their 330 household contacts were enrolled. The prevalence of latent TB and active TB among the contacts was found to be 26.36% and 3.03%, respectively. The female gender of index TB cases was independently associated with a high proportion of latent TB cases in the family (adjusted odds ratio 2.32; 95% confidence interval 1.07-5.05; p=0.03). Neither the higher sputum smear positivity nor the severity of the chest radiograph of index TB cases had any association with the number of contacts being diagnosed as latent TB or active TB. The results showed a significant prevalence of latent TB among household contacts with pulmonary TB. The severity of the disease in the index patient had no association with the prevalence of latent TB.

Predictive profiling of gram-negative antibiotics in CagA oncoprotein inactivation: a molecular dynamics simulation approach

Gastric cancer (GC) is the fifth most prevalent form of cancer worldwide. CagA - positive Helicobacter pylori infects more than 60% of the human population. Moreover, chronic infection of CagA-positive H. pylori can directly affect GC incidence. In the current study, we have repurposed FDA-approved antibiotics that are viable alternatives to current regimens and can potentially be used as combination therapy against the CagA of H. pylori. The 100 FDA-approved gram negative antibiotics were screened against CagA protein using the AutoDock 4.2 tool. Further, top nine compounds were selected based on higher binding affinity with CagA. The trajectory analysis of MD simulations reflected that binding of these drugs with CagA stabilizes the system. Nonetheless, atomic density map and principal component analysis also support the notion of stable binding of antibiotics to the protein. The residues ASP96, GLN100, PRO184, and THR185 of compound cefpiramide, doxycycline, delafloxacin, metacycline, oxytetracycline, and ertapenem were involved in the binding with CagA protein. These residues are crucial for the CagA that aids in entry or pathogenesis of the bacterium. The screened FDA-approved antibiotics have a potential druggability to inhibit CagA and reduce the progression of H. pylori borne diseases.

Revisiting the impact of serial therapeutic phlebotomy in polycythaemia on laboratory and clinical parameters using a fixed interval and fixed volume protocol

OBJECTIVES

Therapeutic phlebotomy allows for a controlled and gradual decrease in red cell mass leading to improved blood flow and symptomatic relief in polycythaemia. The present study was aimed to determine the impact of serial fixed volume and fixed interval therapeutic phlebotomy protocol on the laboratory and clinical parameters in patients of polycythaemia.

MATERIAL AND METHODS

This prospective longitudinal study was conducted over 18 months. The desired haematocrit for polycythemia vera and secondary polycythemia was 45% and 52% respectively. A fixed volume of 350 ml phlebotomy was performed every-three days till the achievement of desired haematocrit. Complete blood count was performed before and after each procedure and iron studies were done at the time of enrolment and after the achievement of desired haematocrit. Post-procedure symptomatic relief was assessed by a 10-point visual analogue scale (VAS).

RESULTS

Of the 29 patients enrolled in the study, 3 patients were lost to follow up and data of 26 patients was analyzed. Mean Hb declined from 17.84 ± 1.88 gdL^-1 to 14.67 ± 1.14 gdL^-1 (p < 0.001) and mean haematocrit decreased from a baseline of 57.11 ± 5.47% to 46.27 ± 3.763% (p < 0.001) upon achievement of desired haematocrit. There was a significant decline in serum iron from the baseline of 132.85 ± 94.136 μg dL^-1 to 69.41 ± 58.643 μg dL^-1 at desired haematocrit. A significant change in VAS score of almost all clinical parameters was observed. Post phlebotomy hematocrit correlated negatively with the number of procedures (p = 0.015).

CONCLUSION

Our protocol yielded rapid and marked improvement in patients of primary and secondary polycythemia with minimal adverse events and significant amelioration of clinical parameters.

Evaluating environmental quality in Rujigou coalfield, China, using analytic hierarchy process

Coal is the major fossil fuel used for power generation. Coal mining activities lead to environmental changes to a large extent, such as degradation in the quality of air, water, and soil, changes in landform, land use/land cover, and vegetation distribution. Evaluating the environmental quality is therefore essential to study the nature and impact of mining activities on the environment. The present study attempts to use the analytic hierarchy process (AHP) to assess the environmental quality of Rujigou coalfield that lacked previous such analysis. The criteria used for evaluation were selected through a literature review and extensive field survey. A photo tour of the study area shows the current ground conditions. Weights were assigned to these criteria based on expert opinions, recommendations from published literature, and field investigation. The results indicate that mining activities in the study region most significantly impact the air quality, followed by soil, water, landform, and vegetation. The knowledge of environmental quality can forewarn policymakers and mine managers about impending environmental problems and improve their ability to manage and resolve them. Moreover, the systematic methodological process described in this research can be applied to any study area with similar features to the one investigated in this paper.

P291 Aspergillosis: another force to reckon with during COVID-19 times

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

 

Objectives

Aspergillus is a ubiquitous fungus in the Indian environment. Spores are constantly circulating in hospital and community environments alike. Infections like COVID-19 which affect not only innate immune system but also lead to local immune-compromization especially in the respiratory system make the patient vulnerable to infections like Aspergillosis. Hereby, we present the prevalence of Aspergillus infection in a tertiary care center over a period of 1 year with special reference to co-infections with COVID-19 as Aspergillosis or mixed infection (Aspergillosis and Mucormycosis).

Material and Methods

All the samples which were submitted to Mycology laboratory during the time period of 1 year from January 2021 to December 2021 were included in the study. The samples were processed as per the standard mycological techniques for direct examination and culture. Those patients which had direct KOH mount positive for septate hyphae and grew Aspergillus on culture were included for the purpose of this study. Records of Aspergillosis patients who were positive for COVID-19 too were assessed to look for significant associating factors.

Results

Out of a total of 6863 samples, 66 samples came out to be positive for Aspergillus sp. Out of which, 55 were identified phenotypically as A. flavus, 3 A. fumigatus, 2 A. terreus and 1 was A. niger. In five of the strains, species could not be identified even phenotypically and were reported as Aspergillus sp. Maximum isolates (43) were from nasal and paranasal sinuses (sinus discharge, nasal tissue, nasal polyp, nasal muck, nasal crust, maxillary meatus etc) 16 were pulmonary samples (sputum, tracheal aspirate, bronchoalveolar lavage, pleural fluid, lung tissue), two were corneal scrapings, two samples were dental tissue and palatal necrosed material and two were nail samples. One sample was from a patient with ear discharge. A total of 15 patients had COVID-19 infection at the time of diagnosis or within 3 months prior. In all, 12 patients had co-infections of Aspergillus and Mucormycetes (9 being COVID positive too), and 2 patients had co-infection of Aspergillus and Candida. Records of COVID-19 patients revealed that all 12 patients with co-infection of Aspergillus and Mucormycetes were treated as per guidelines for Mucormycetes infection. Out of other three, two were confirmed CAPA as per the criteria. One patient was treated for COVID-19 infection only.

Conclusion

Mucormycosis was another infection during COVID-19 times, which was like a huge wave, sweeping all attention. Rather Aspergillus infections got shadowed by mucormycosis despite the fact that during COVID-19 times, as many as 15% of cases were found to be positive for Aspergillosis in COVID-19 positive patients, especially in ICU areas. In the times to come, it is speculated that sequelae of Aspergillus infections may be seen among COVID-19 patients. Emerging drug resistance among Aspergilli can worsen the situation further.

Investigating the environmental impacts of coal mining using remote sensing and in situ measurements in Ruqigou Coalfield, China

China is the largest producer and consumer of coal in the world. The extraction of coal is increasing intensively to meet the needs of the ever-increasing population and industries. However, coal mining has resulted in environmental changes, including deforestation, air, water, soil, and landform deterioration. This study investigates the impact of mining on the environment in Ruqigou coalfield by utilising in situ and remote sensing data. Field data collected include temperature, gas compositions, and water samples. Multi-temporal Landsat data of 1991, 2003, and 2019 were used in monitoring the impact of mining on different land covers, especially vegetation. A supervised classification was performed to assess the changes in land cover. In order to track the changes in vegetation, normalised difference vegetation index (NDVI) was employed. To study the changes in coal fire areas, thermal anomalies were extracted from the thermal infrared data using a dynamic thresholding technique. The results of in situ analyses show that water quality is unfit for domestic, industrial, and agricultural use. All the gas sampling sites emit noxious gases such as CO₂, CO, NO₂ and degrade the local air quality. The classified maps and vegetation indices show a significant decrease in vegetation. The thermal anomalies show an increase in fire areas over the years. Thus, it could be concluded that the conjunctive use of field-based measurements and remote sensing data can be a powerful tool for gaining a comprehensive understanding of the environmental impacts associated with large-scale mining.

Therapeutic efficacy of oscillating positive expiratory pressure therapy in stable chronic obstructive pulmonary disease

Background

Chronic obstructive pulmonary disease (COPD) is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airway and the lung to noxious particles or gases. Sputum production is a cardinal feature in COPD. Airway clearance techniques have been the mainstay of management. Oscillating positive expiratory pressure (OPEP) devices are handheld devices that provide a combination of positive expiratory pressure (PEP) with high frequency oscillations which involve exhaling against a resistance that is fluctuating. It encourages airflow within secretions, whereas oscillations induce vibrations within airway wall to displace secretions into airway lumen and help in expectoration.

Methods

A randomized control trial was conducted at the department of pulmonary medicine, Government Medical College & Hospital, Chandigarh, in which 50 patients with stable COPD were enrolled for one- and- half years. After taking proper history, they were subjected to spirometry, six- minute walk test, and were asked to fill the St. George's Respiratory Questionnaire (SGRQ) and COPD Assessment Test (CAT). These patients were randomized into group A (intervention group) and group B (control group), where group A was prescribed Aerobika OPEP device for daily use for a period of three months. After three months of use of device, the patients were again subjected to assessment parameters and inquired about any exacerbation within the three- month period.

Results

At the end of three months were compared with baseline results. The median change in FEV1, FVC, 6MWD from baseline in group A was significantly more as compared to group B (FEV1: P < 0.001; FVC: P < 0.001; 6MWD: P = 0.08), whereas SGRQ score showed a significant improvement in both the intervention and control groups (P < 0.001) and CAT score showed significant improvement in comparison to the control group (P < 0.001). The median change in 6MWD and CAT from baseline in group A was significantly more as compared to group B (SGRQ: P < 0.001; CAT: P < 0.001), whereas it was not significant in case of SGRQ (P = 0.233). There was no significant difference in the incidence of exacerbation in the two groups (P = 0.19). The device did not help in controlling the rate of exacerbation in the present study at three months.

Conclusion

Stable COPD patients who were given OPEP therapy as an adjunct to the standard drug therapy showed improvement in the spirometry parameters, exercise capacity and symptom burden in comparison to the drug only group.

Sex-dependent regulation of interferon-γ receptor expression in pulmonary tuberculosis

Interferon-γ (IFN-γ) is an essential pro-inflammatory cytokine against tuberculosis (TB). To initiate immune response, IFN-γ binds to its receptor complex which consists of two subunits IFN-γ receptor 1 (IFN-γR1) and IFN-γ receptor 2 (IFN-γR2). The deficiency in either receptor subunit can alter IFN-γ signalling thus influencing host susceptibility to TB. In the present study IFN-γ receptor expression at transcriptional and translational level was analysed in pulmonary TB patients from North India. A total of 46 pulmonary TB patients (at 0 day of anti-tuberculosis therapy) and 48 healthy controls (HCs) were recruited. It was found that the mRNA expression of IFN-γR1 was decreased in male TB patients (p = 0.003). The surface expression of IFN-γR1 (p = 0.0005) and IFN-γR2 (p = 0.024) was also found to be decreased in male TB patients. In conclusion, we found sex-dependent regulation of IFN-γR1 and IFN-γR2 expression in pulmonary TB patients of studied population.

Pulmonary rehabilitation: A novel adjunct in management of obstructive sleep apnea

Pulmonary rehabilitation (PR) is being used in the routine management of patients of obstructive sleep apnea (OSA) at some centers. However, the studies documenting benefits of PR in OSA lack standardization in terms of outcome measures. A study was hence planned to determine the efficacy of PR on exercise capacity, health related quality of life (HRQOL), day time sleepiness and sleep-quality of life (QOL) in patients of OSA. As a part of comprehensive therapy, patients diagnosed with OSA are managed with continuous positive airway pressure (CPAP), 8 weeks thrice weekly outpatient hospital-based PR and medical treatment at the Pulmonary Medicine Department, Government Medical College and Hospital, Chandigarh. However, some patients refuse for PR because of time constraints and travel issues. Patients with newly diagnosed OSA without co-existing respiratory disease, who agreed for the CPAP, PR and medical management were enrolled in group A. The patients who refused for PR but were ready for CPAP and medical management were enrolled in Group B; 30 patients were taken in each group. Exercise capacity, HRQOL, day time sleepiness and sleep-QOL were determined at baseline and at 8-weeks follow-up by 6-minute walk distance (6MWD), St. George's Respiratory Questionnaire (SGRQ), Epworth Sleepiness Scale (ESS) and Functional Outcomes of Sleep Questionnaire (FOSQ) and compared amongst the two groups. Four patients from group A were excluded as they did not complete PR; 26 patients from group A and 30 patients from group B were finally analyzed. At baseline, both groups were matched with respect to age, gender, apnea-hypopnea index (AHI), body mass index (BMI), FEV1%predicted, 6MWD, SGRQ, ESS and FOSQ. At follow up at 8 weeks, BMI, 6MWD, SGRQ, ESS and FOSQ improved significantly from baseline in group A (p<0.001). FEV1%predicted also improved but non significantly. In group B, FEV1%predicted, BMI, 6MWD, SGRQ, ESS and FOSQ score did not improve significantly from baseline. Mean improvement from baseline in BMI, 6MWD, SGRQ, ESS and FOSQ was significantly more in group A than group B (p<0.001, p<0.001, p=0.041, p<0.001 and p<0.001, respectively). PR, being beneficial, should be incorporated in standard management of OSA.

Association of single nucleotide polymorphisms of interferon-γ with pulmonary tuberculosis in population of Himachal Pradesh, India

Interferon-gamma (IFN-γ) plays an integral role in the host immunity against tuberculosis (TB). The gene encoding IFN-γ is polymorphic and several studies have reported the association of its genetic polymorphisms with TB in different populations of the world. The present study investigated the association of rs2069705 (C/T), rs1861494 (C/T), rs1861493 (A/G) and rs2069718 (C/T) single nucleotide polymorphisms (SNPs) of IFN-γ with pulmonary TB in a population of Himachal Pradesh, India. For present study, 210 pulmonary TB patients and 205 healthy controls (HCs) were recruited. The selected SNPs of IFN-γ were genotyped by amplification refractory mutation system-polymerase chain reaction (ARMS-PCR) and plasma IFN-γ levels were measured by ELISA. The 'T' allele of rs1861494 SNP was found to increase susceptibility to TB in the studied population (OR = 2.18, 95%CI = 1.57-3.03; p < 0.001). After stratifying the subjects on basis of sex, males with 'T' allele of rs2069718 SNP were found to be at higher risk to TB (OR = 1.55, 95%CI = 1.07-2.25; p = 0.02). We also found moderate linkage disequilibrium among the studied SNPs. The haplotypes C-T-A-T and T-T-G-T of rs2069705-rs1861494-rs1861493-rs2069718 were overrepresented in TB patients and found to increase susceptibility to TB (p = 0.012). The plasma IFN-γ levels in TB patients were around seven times higher in comparison to HCs (p < 0.0001). The HCs with genotype 'AA' of SNP rs1861493 were found with higher plasma IFN-γ levels than 'AG/GG' genotype (p = 0.023). In conclusion, the results suggest the association of rs1861494 (C/T) and rs2069718 (C/T) SNPs of IFN-γ with TB and genotype 'AA' of rs1861493 is associated with higher plasma IFN-γ levels in the population of Himachal Pradesh, India.

Radial Long Sheath Angioplasty for Proximal Severe Flow Limiting Radial Artery Spasm Utilizing the Dotter Technique

BACKGROUND

Although studies continue to demonstrate the advantages of transradial access (TRA) for neurointerventions, radial artery spasm (RAS) remains a frequent cause of TRA failure. Dotter initially described a technique to dilate areas of peripheral vascular stenosis by advancing sequentially larger catheters across the lesion over a wire. We present our institutional experience performing a modified Dotter technique utilizing long radial sheaths to dilate areas of proximal flow limiting RAS.

OBJECTIVE

To review the use of the Dotter technique for alleviating RAS in patients undergoing TRA for neurointerventions.

METHODS

A retrospective review of all patients undergoing TRA for neurointerventions at our institution from 2018-2020 was performed to identify patients with proximal flow limiting RAS. In identified patients, a modified Dotter technique was employed to dilate the stenosis. Demographic and periprocedural data were assessed to identify any adverse outcomes.

RESULTS

Four patients with severe proximal flow limiting RAS were identified. In each case, a hydrophilic long radial sheath and vascular dilator were sequentially advanced through the stenosis. In all cases, repeat angiography demonstrated improvement of the spasm and final radial angiograms demonstrated persistent improvement in caliber and regularity of the vessel. Each procedure was also completed via TRA with no periprocedural complications.

CONCLUSIONS

Our modified Dotter technique is effective in bypassing areas of severe proximal flow limiting RAS thus obviating the need for access site conversion. Additional studies are warranted to understand the implication of the angioplasty-like effects seen within the radial artery following removal of the long radial sheaths.

Role of interluekin-6 and insulin resistance as screening markers for metabolic syndrome in patients of chronic obstructive pulmonary disease. A hospital based cross-sectional study

Chronic obstructive pulmonary disease (COPD) is usually associated with a variety of extra-pulmonary manifestations. Metabolic syndrome (MetS) is one such entity that has been scarcely studied in Indian patients. Availability of a good screening marker may help in timely detection of this co morbidity in COPD patients. We conducted a cross sectional study to evaluate the prevalence of MetS among COPD patients and to evaluate the role of Interleukin-6 and insulin resistance (as measured by HOMA-IR) as screening markers for MetS in COPD. A total of 100 stable COPD patients were evaluated for MetS using US National Cholesterol Education Program Adult Treatment Panel III (2005) guidelines. Interleukin-6 and HOMA-IR (for insulin resistance) were measured and compared between COPD patients with and without MetS. ROC analysis was done to find the best cut-off value and sensitivity and specificity of both the molecules in detecting MetS. In the results, the mean age of the study cohort was 59.9+8.7yrs (males=93). Forty five COPD patients (45%) fulfilled the criteria for MetS. Patients with MetS were comparatively younger (57.9+9.5 v/s 61.6+7.8 years; p=0.037) but had longer duration of preceding COPD (9.9+2.8 v/s 6.0+2.2 years; p<0.001) as compared to those without MetS. Both IL-6 and HOMA index were statistically higher (p<0.05) in COPD-MetS patients as compared to the other group. At cutoff value of 36.3 pg/ml for IL-6 and 1.61 for HOMA index, IL-6 and HOMA-IR had sensitivity 91.1% and 82.2% respectively in detecting MetS among COPD patients. To conclude, metabolic syndrome is a common comorbidity seen in COPD patients. Interleukin-6 has a better sensitivity than HOMA-IR in screening MetS among COPD patients.

COVID-19 Reinfection: A Case Series

Coronovirus Disease 2019 (COVID-19) manifests with a varied spectrum of symptoms ranging from asymptomatic disease to Acute Respiratory Distress Syndrome (ARDS) and death. Contrary to the expectation of the herd immunity in controlling the pandemic, reinfection with COVID-19 poses a new threat in the control of the pandemic. Authors hereby have described three cases who developed COVID-19 infection for the second time after complete recovery from the first infection. All three patients were less than 50 years of age with no co-morbidities. First case developed the second infection three weeks after having recovered from the first infection whereas second and third case developed repeat infection after two and four months of recovery respectively. The severity of the repeat infection along with the duration between the two infections has been discussed in this article.

Interplay among the Variants of One Carbon Metabolism, Methylenetetrahydrofolate Reductase Polymorphisms and Lung Cancer

Introduction: Folates perform an integral task in DNA synthesis, methylationand repair. Methylenetetrahydrofolate Reductase (MTHFR) potrays a key part in the metabolism of folate and regulates the equilibrium between the various forms of folate for DNA synthesis and DNA methylation. MTHFR irrevocably transforms 5,10 methylenetetrahydrofolate to 5-methyltetrahydrofolate, the principal circulating folate and the carbon donor for remethylation processes. MTHFR is vastly polymorphic in the general population. Materials and Methods: It was a case-control study conducted during March 2010 to September 2011 in the Department of Pulmonary Medicine in collaboration with the Department of Biochemistry at Government Medical College and Hospital, Chandigarh, to see whether any association exists between the variants of one carbon metabolism, MTHFR polymorphisms (C677T and A1298C), and lung cancer. Twenty biopsy proven lung cancer patients and 20 age and sex matched cancer-free controls were selected. Results: The mean serum folate in cases was higher (12.84 ng/mL±7.527 ng/mL) as compared to controls (4.46 ng/mL±1.346 ng/mL), suggesting that high levels of serum folate are associated with lung cancer. There was no significant variance in the levels of vitamin B12 and plasma homocysteine between cases and controls. No MTHFR polymorphism C677T was seen in the blood and the bronchial biopsy samples of all cases as well as blood samples of all the controls. The MTHFR polymorphism A1298C was present in the blood as well as bronchial biopsy samples of cases as well as blood of controls. Thus, in the present study, there was no relation of this polymorphism with lung cancer. Conclusion: Polymorphisms in MTHFR may contribute to lung cancer. More research on the basis of cellular and molecular mechanisms of lung cancer is urgently needed to aid in understanding of pathogenesis of the disease.

Evaluation of spirometry as a parameter of response to chemotherapy in advanced lung cancer patients: A pilot study

Context

Spirometry is an important tool to monitor treatment response in diseases such as chronic obstructive pulmonary disease and asthma. However, there is lack of evidence to support its application to evaluate response to chemotherapy in advanced lung cancer. It might be a useful adjunct to the imaging-based response evaluation which lacks functional assessment of lungs.

Aims

The study was conducted to evaluate the change in spirometry in lung cancer patients after chemotherapy and to find its correlation with change in physical tumor size.

Subjects and Methods

Sixty-two advanced lung cancer patients who were eligible for palliative chemotherapy were enrolled. Baseline tumor size evaluation using Response Evaluation Criteria in Solid Tumor (RECIST)-based scoring system, and spirometry was done. Four cycles of double agent (platinum doublets) chemotherapy were administered, after which treatment response was evaluated. Repeat spirometry was analyzed and correlated with changes in physical tumor size.

Results

Twenty-five patients showed a response (all partial response) to four cycles of chemotherapy. Small cell carcinoma showed a better response rate than non-small cell carcinoma (78% vs. 39%). There was statistically significant improvement in forced expiratory volume in 1 (FEV₁) (P = 0.01) and forced vital capacity (P = 0.03) in responders as compared to nonresponders. Change in FEV1 showed a statistically significant correlation with the change in tumor size (RECIST score) (r = -0.34; P = 0.04).

Conclusions

Improvement in spirometry correlates with the tumor response as judged using RECIST criteria after chemotherapy. Further studies with bigger sample size are required to consolidate the results.

Factors limiting the utility of bronchoalveolar lavage in the diagnosis of COVID-19

We read with interest study by Geriet al. [1], in which the authors have demonstrated a strong agreement between negative nasopharyngeal (NPs)/nasal (Ns) swab and bronchoalveolar lavage (BAL) real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) in the diagnosis of coronavirus disease 2019 (COVID-19) among hospitalised patients. The study findings contradicted earlier reports [2] and suggested a limited utility of BAL. However, the results need to be interpreted comprehensively before drawing any conclusion.

Bronchoalveolar lavage has a specific place in the diagnosis of COVID-19. The clinical performance of BAL rRt-PCR is dynamic in nature and depends on different clinical and demographic factors.https://bit.ly/3aZUAPB

Filariasis presenting as isolated pleural effusion: A case report and mini review

Isolated pleural effusion is a rare manifestation of filariasis that mimics tuberculosis, especially in endemic regions. We describe a case of lymphocytic and exudative pleural effusion showing microfilaria on pleural fluid cytology. A retrospective review of all cases of filarial pleural effusion reported after 2000 was conducted to evaluate the association between filariasis and pleural effusion as well as to screen the features that can help in accurate detection of these patients. The analysis suggested a causal association between the parasite and the development of pleural effusion with a high sensitivity of pleural fluid cytology for diagnosis.

Psychological morbidity in interstitial lung disease: a study from India

Evaluation of mental health in chronic lung diseases like interstitial lung disease (ILD) and chronic obstructive pulmonary disease (COPD) has always been neglected and underrated. The aim of the study was to determine the psychological morbidity in patients of ILD and to determine its various socio-clinical and psychological correlates. A cross-sectional clinic based descriptive study with 50 ILD patients, 30 COPD patients and 30 healthy controls was undertaken. Psychological distress was assessed using different psychological scales, like General Health Questionnaire-12 (GHQ-12), Patient Distress Thermometer (PDT), Coping Strategy Checklist (CSCL), WHO Quality of Life-Brief-26 (WHOQOL-Bref-26) and Depression Anxiety Stress Scale (DASS). The patients with a GHQ-12 score of ≥3 were considered as experiencing psychological distress and additionally referred to consultant psychiatrist for further detailed evaluation and management. Fifty-eight percent of ILD patients and 60% of COPD patients experienced psychological distress after screening with GHQ-12; 40% of all the ILD and COPD patients were ultimately diagnosed with a psychiatric disorder, after evaluation by the psychiatrist. Patients of ILD and COPD had significantly higher scores on GHQ-12, CSCL and DASS, and significantly lower scores on WHOQOL-Bref-26 when compared with healthy controls. However, these scores, including PDT did not differ significantly between ILD and COPD patients. The scores on all these scales in the patients of ILD and COPD who were experiencing psychological distress (GHQ ≥3) were significantly poorer than those without psychological distress (GHQ<3). GHQ-12 emerged as an excellent predictor of psychological morbidity. Various other psychological scales correlated with GHQ-12 and amongst each other in both the groups experiencing psychological distress. GHQ-12 and other different scales also significantly correlated with the different clinical indicators in ILD as well as COPD patients having psychological distress. Psychological distress and poorer quality of life was present in a significant percentage of ILD patients, and was comparable to that seen in COPD. Mental health evaluation should be incorporated in the routine management of these patients. Simple, easy and brief screening tools like GHQ-12 can be of immense help.

An Experience with Delamanid in an XDR TB Case - Case Report

INTRODUCTION

Tuberculosis is an endemic infection and a serious public health problem in India. India constitutes one-fourth of the global TB population. The emerging drug resistance is a major threat to global tuberculosis care and control.

CASE REPORT

We present a case of newly diagnosed microbiologically confirmed, extremely drugresistant primary pulmonary tuberculosis which was treated with Delamanid and was found to be cured of tuberculosis.

DISCUSSION

Delamanid is a new anti-tubercular drug, which is thought to primarily inhibit the synthesis of methoxy-mycolic, and keto-mycolic acid, which are components of the mycobacterial cell wall. In our patient who was a newly diagnosed case of MDR-TB converted to XDR-TB in little course of time and we were successful in treating him with Delamanid therapy. His sputum culture conversion was achieved in 20 days. Even though the patient did not tolerate well because of the side effects of the drug, still he became microbiologically negative for tuberculosis.

CONCLUSION

Delamanid fulfills many target criteria for new TB drugs and may be particularly useful for the treatment of MDR-TB. It can be administered orally and its bactericidal properties make it suitable in regimens designed to shorten treatment duration. Clinical efficacy data, while limited, are reassuring.

Hormonal changes and reproductive health issues in females with tuberculosis

BACKGROUND/AIMS

The association between tuberculosis (TB) and female reproductive health issues usually remains unaddressed. TB is considered as one of the major causes of infertility in India. Because of the associated stigma, the suffering females do not discuss the problems they are facing. This may lead to disturbances in serum hormone levels also. Hence, a study was planned to find abnormalities in menstrual patterns and fertility in women in childbearing age, who were suffering from TB, and evaluate disturbances in serum hormone levels of LH, FSH, Prolactin and testosterone, if any. It also aimed to evaluate if hormone levels, or some early disturbances in menstrual cycle, can serve as a predictor for infertility in future lives.

MATERIALS AND METHODS

25 female patients each of child bearing age group from OPD/IPD: of pulmonary TB (PTB), extra pulmonary non genital TB (EPTB), extra pulmonary genital TB (GTB) and healthy controls were enrolled. Thus, a total of 75 patients with TB and 25 healthy controls were taken into the study. Patients were questioned for any abnormalities of menstrual cycle. If married, fertility status, total number of live children, abortions etc and previous history of any reproductive health issues was asked. Serum FSH, LH, Prolactin and testosterone levels on the 3rd day of the menstrual cycle were done. Data so obtained was tabulated and statistically analyzed.

RESULTS

TB patients (75/100) and healthy controls (25/100) were matched with respect to age, marital status and rural/urban background. Menstrual abnormalities, infertility and adverse events related to pregnancy were higher in patients with TB than healthy controls (p = 0.176, 0.571 and 0.005 respectively). TB patients had significantly higher levels of Testosterone and significantly lower levels of Prolactin than healthy controls (p=<0.001). Levels of FSH and LH were lower in TB patients than healthy controls (p = 0.428 and 0.274 respectively). On categorization into different types of TB, the sub-groups were matched with respect to rural/urban background. GTB was significantly higher in patients who were married (p = 0.020). Significantly higher GTB patients (10/25) reported menstrual abnormalities (p < 0.001). All the 3 infertile patients reported in the study belonged to GTB sub-group (p = 0.044). GTB had higher number of adverse events related to pregnancy followed by EPTB and PTB. Levels of FSH, LH, Testosterone and Prolactin in the three sub-groups of TB patients did not show any significant difference (p = 0.683, 0.817, 0.781, and 0.187). Since the total number of infertile patients in our study was only 3, relationship of menstrual abnormalities or serum hormone levels as a predictor of infertility could not be assessed.

CONCLUSION

Females suffering from TB experience significantly higher adverse events related to pregnancy than healthy controls. Menstrual abnormalities, infertility and adverse events related to pregnancy were more pronounced in females suffering from GTB than PTB/EPTB. Female patients suffering from any form of TB need to be comprehensively managed. Because of highly sensitive issues related to infertility and reproductive health in today's era, it is imperative that any future complications of the same are kept into consideration in female patients with TB.

Immune reconstitution inflammatory syndrome in non-HIV patients with tuberculosis. A case series

Tuberculosis associated Immune reconstitution inflammatory syndrome (IRIS) in a HIV negative patient can present with a multitude of clinic-radiological presentations that are often confused with drug resistance/treatment failure. Being a diagnosis of exclusion, this clinical entity is often prone to under-diagnosis. We present a series of 5 patients who presented with varied but uncommon IRIS manifestations. High index of suspicion coupled with clinical reasoning and judicious use of phenotypic and genotypic culture methods helped in their timely detection and successful treatment.

Isoniazid mono-resistant tuberculosis: Time to take it seriously

BACKGROUND/AIMS

In drug resistant tuberculosis (DRTB) suspects, rifampicin resistance has always been prioritized, hence Cartridge Based Nucleic Acid Amplification Test (CBNAAT) is recommended under Revised National Tuberculosis Control Programme (RNTCP), India. However, since it doesn't detect isoniazid resistance, rifampicin sensitive patients with unknown isoniazid status may be erroneously treated as drug sensitive TB, leading to poor treatment outcomes and emergence of multidrug resistant (MDR) TB. Hence isoniazid mono-resistance should be specifically looked for and treated as per recommendations. The objective of the present study, almost the first of its kind in India, was to evaluate the burden of isoniazid mono-resistance amongst patients diagnosed with DRTB and to study the association of different patient and disease related factors with treatment outcomes under the treatment regimen specific for isoniazid mono-resistance, started from January 1, 2017 in our state, under RNTCP.

METHODS

It was a retrospective study which scrutinized medical records of 52 isoniazid mono-resistant TB patients started on treatment under RNTCP between January 1 to December 31, 2017. Necessary information on possible patient and disease related predicting factors like gender, age, type of mutation (katG/inhA), weight band (26-45 kg/46-70 kg), total serum protein/albumin levels, previous history of anti-tubercular treatment (ATT), history of smoking, HIV status, presence of diabetes mellitus (DM), presence of anemia, occurrence of adverse drug reactions (ADR) during treatment and duration of intensive phase (IP), was retrieved. These factors were analyzed for their possible association with treatment outcomes.

RESULTS

Out of 103 DRTB patients enrolled, 50.5% (52/103) patients were diagnosed with isoniazid mono-resistance. 50/103 were MDR-TB and 1/103 were extensively-drug resistant TB (XDR-TB). Further analysis of these 52 isoniazid mono-resistant patients revealed:35 (67.3%) were males and 17 (32.7%) females. 27 (51.9%) patients were <30 years, 25 (48.1%) being ≥30 years of age. All patients were negative for HIV. 34/52 (65.4%) patients were declared cured, 15/52 were lost to follow up (LTFU) and 3/52 died (1 male, 2 females). Excluding these 3 patients who died, cure rates were significantly better in females (14/15 = 93.3%), with only 1/15 LTFU, than males (20/34 = 58.8% cure, 14/34 = 41.2% LTFU), (p = 0.019). Patients who were <30 years of age had significantly better cure rates (21/25 = 84%) with lesser LTFU's (4/25 = 16%), than those ≥30years of age (13/24 = 54.2% cure, 11/24 = 45.8% LTFU), (p = 0.032). Review of previous history of ATT revealed that 33 patients had primary isoniazid mono-resistance, 4 patients had previous history of being LTFU, 9 had recurrent TB and 3 were labeled as failure. Cure rates were significantly better in primary isoniazid mono-resistant patients (26/33 = 78.8%), than those with previous history of being LTFU(0/4), (p = 0.04). Type of mutation, weight band, total serum protein/albumin, history of smoking, presence of DM, presence of anemia, occurrence of ADR and duration of IP did not affect treatment outcomes.

CONCLUSION

Isoniazid mono-resistance formed a major chunk of DRTB, with majority of the patients detected with primary mono-resistance. Strategically framed treatment regimens for isoniazid mono-resistance under RNTCP in India are effective in a wide range of population. Still, there are high chances of LTFU/default, which needs to be addressed on priority. Male gender, age ≥30 years and being LTFU in the past are associated with poorer cure rates, hence should be paid special attention.

Polymeric Micelles of Modified Chitosan Block Copolymer as Nanocarrier for Delivery of Paclitaxel

Background:

Polymeric micelles are being used as successful nanocarriers for the delivery of diverse drug molecules due to properties like solubilization, selective targeting, P-glycoprotein inhibition, altered drug internalization route and subcellular localization etc.

Objective:

The present investigation was planned to prepare and characterize novel polymeric micelles derived from self assembly of amphiphilic chitosan-bile salt derivative (CS-mPEG-DA) as nanocarrier and evaluate their potential in delivery of an anticancer drug, paclitaxel.

Method:

Paclitaxel, a diterpenoid compound, useful in clinical treatment of several solid tumors such as ovarian cancer, breast cancer and lung cancer suffers from limitations like low aqueous solubility and bioavailability and subsequently was used as the model drug.

Results:

Paclitaxel was successfully incorporated into polymeric micelles using dialysis and emulsion method with encapsulation efficiency up to 95% having particle size in nanometer range (<200 nm). Paclitaxel loaded micelles were found to release the drug in a sustained manner up to 96 h in PBS containing 0.1% (w/v) tween 80 at 37&#176;C. The micelles powders subjected to stability studies for a period of 90 days were found to be stable at 4 &#177; 2&#176;C with respect to particle size and drug content. In vivo cytotoxicity assay confirmed that paclitaxel encapsulated in polymeric micelles showed higher cytotoxicity against cultured MCF-7 breast cancer cells than paclitaxel alone.

Conclusion:

Polymeric micellar systems derived from copolymerization of chitosan exhibit a great potential in successful delivery of poorly water soluble or low bioavailable drugs like paclitaxel.

Adenoid cystic carcinoma: A study of 19 cases of salivary and extra-salivary tumours diagnosed by fine needle aspiration cytology

BACKGROUND

Adenoid cystic carcinoma (ACC) arises at sites where seromucinous or sweat gland epithelium is present and commonly affects the salivary glands. Rarely it can occur at extra-salivary locations.

METHODS

A retrospective analysis of 19 cases of ACC diagnosed on fine needle aspiration cytology (FNAC) over a period of 15 y (2002-2016) was made.

RESULTS

Of 19 total cases, there were 10 salivary and 9 extra-salivary ACCs. Extra-salivary tumours were seen in 2 cases each in trachea, tongue and in one case each in bronchus, lung, subcutaneous tissue, maxillary antrum, and external auditory canal. The age ranged from 14-80 y (mean: 49.5 y), 10 patients were male and 9 were female. The smears were highly cellular in 11 cases, moderately cellular in 5 cases while 3 cases were paucicellular. Multilayered dense clusters, tissue fragments, dispersed cells and cup-shaped fragments were seen. Relatively uniform cells with high nuclear: cytoplasmic ratio, hyperchromatic nuclei, irregular margins, and nuclear moulding were observed. Variable sized hyaline globules, finger-like hyaline material, hyaline cylinders, and hyaline cords were noted. The cytologic diagnosis of ACC was rendered in 13 cases while in 6 cases it was one of the differential diagnosis including monomorphic adenoma, membranous variant of basal cell adenoma, adnexal tumour, polymorphous adenocarcinoma, and pleomorphic adenoma (PA).

CONCLUSIONS

Cytologists must be aware of varied locations where ACC can occur. A diagnosis of ACC must not rely exclusively on the occurrence of hyaline globules but necessitates a close scrutiny of cellular and nuclear features to avoid diagnostic pitfalls.

Germ cell tumor causing pleural effusion: A diagnostic dilemma

Straw colored pleural fluid with raised adenosine deaminase (ADA) levels in young healthy adults usually raises suspicion of tuberculosis, sometimes leading to laxity in carrying thorough physical examination and missing out some important clues with potential disastrous consequences. A 35-year-old male was diagnosed to have left pleural effusion and anti-tubercular treatment was started on the basis of straw colored, lymphocyte-predominant pleural fluid with significantly raised ADA levels. When there was no improvement after 1 month of treatment he was investigated further and found to have a mediastinal mass along with hydro-pneumothorax. Fine needle aspiration cytology (FNAC) of the mass was done twice at different centers with different reports followed by biopsy from the mass to settle the diagnosis. Histopathological examination revealed yolk sac tumor. Testicular ultrasound showed a mass with ill-defined hypoechoic areas and lobulated margins in left testis, which was missed on clinical examination. Serum lactate dehydrogenase (LDH) and alpha fetoprotein (AFP) levels were found to be elevated. Beta-human chorionic gonadotropin (β-hCG) was normal. The final diagnosis of nonseminomatous germ cell tumor with mediastinal metastasis was made. The present case underlines the importance of good clinical examination, an art which is diminishing with availability of sophisticated investigations and a thin line of difference between potentially curable and fatal diagnosis, especially in young population, where malignancy is overlooked as a differential diagnosis. Furthermore, despite all its advantages, too much reliance on FNAC may be responsible for misdiagnosis in certain cases.

Association of Adiponectin with Lung Function Impairment and Disease Severity in Chronic Obstructive Pulmonary Disease

Context:

Chronic obstructive pulmonary disease (COPD) is not only restricted to the pulmonary inflammation and airway obstruction but is also associated with comorbidities, which affect the therapeutic intervention and the quality of life and survival. Markers that can predict the systemic inflammation and a decline in the pulmonary function are of scientific interest. Adiponectin (APN) appears to be one such biomarker and can be used as a potential indicator of severity and response to treatment in patients of COPD.

Aims:

The study aims to find out the role of APN as a marker of inflammation in the pathogenesis of COPD and explore its relationship with the severity of the disease.

Settings and Design:

This was a cross-sectional study.

Subjects and Methods:

The study group consisted of 60 patients of COPD, which included 30 males admitted with acute exacerbation of COPD (AECOPD) and 30 males with stable COPD. The study group was compared with 30 healthy, age-matched males. APN was estimated by commercially available ELISA kits. Pulmonary function tests were performed on all cases and controls using standardized protocols on SPIROLAB III.

Statistical Analysis Used:

Statistical analysis was performed using Student's t-test and Pearson's correlation coefficient.

Results:

The levels of APN were found to be significantly higher in patients with COPD as compared to the controls and the levels increased with the severity of the disease were 16.10 ± 4.97 ng/ml and 11.43 ± 4.22 ng/ml, respectively, in AECOPD and COPD. A significant positive correlation was found between the levels of APN and interleukin (IL)-8 in patients of COPD, while the levels correlated negatively with percentage of forced expiratory volume in 1 s (FEV1%).

Conclusions:

The results reveal that APN is associated with the inflammatory process of COPD as suggested by its significant inverse relationship with FEV1% and positive correlation with a marker of inflammation such as IL-8. It can thus be used as a biomarker for disease severity and progression in patients of COPD, therefore aiding in risk stratification and therapeutic intervention.

Role of serum adenosine deaminase in pulmonary tuberculosis

BACKGROUND

Definitive laboratory diagnosis and confirmation of tuberculosis remains a major challenge because of lack of specificity and sensitivity of diagnostic methods especially in sputum smear negative tuberculosis. Many studies have proved the role of ADA in diagnosis of tuberculosis in effusion fluids and a decrease in ADA activity after treatment. This study was aimed to investigate the role of serum ADA level as an early diagnostic and prognostic marker for pulmonary tuberculosis (PTB).

MATERIAL AND METHODS

This was a cohort study done on patients visiting the OPD Clinics of the department of Pulmonary Medicine at GMCH, Chandigarh. 50 sputum positive and 50 sputum negative tuberculosis patients and 100 controls were recruited. Serum ADA levels were measured at the start of treatment and again after two months of treatment. Its correlation with severity of disease was seen.

RESULTS

Mean serum ADA (IU/L) was found to be 35.293±30.941 in PTB patients and 11.819±8.023 in control groups and the difference was found to be highly significant (P<0.00). Mean ADA was 31.107±29.32 in sputum positive patients, 39.478±32.22 in sputum negative and 11.819±8.0235 in control groups. No statistically significant difference was observed amongst sputum positive and sputum negative patients. The levels decreased significantly after intensive phase of treatment. At the cut off values of 14.6IU/L, serum ADA had 78% sensitivity and 76% specificity (AUC=0.801, P value<0.00) to differentiate between PTB from healthy controls.

CONCLUSION

Serum ADA levels may be used as a biomarker for diagnosis of PTB and to evaluate the response to treatment at follow up.

Modulation of Trehalose Dimycolate and Immune System by Rv0774c Protein Enhanced the Intracellular Survival of Mycobacterium smegmatis in Human Macrophages Cell Line

Mycobacterium tuberculosis Rv0774c protein was reported previously to express under stress conditions. Therefore, Rv0774c gene was cloned and expressed in Mycobacterium smegmatis, a surrogate host, to determine its role in bacterial persistence and immune modulation in natural environment. The bacterial colonies expressing Rv0774c (Ms_rv0774c) were larger, smoother, more moist, and flatter than the control ones (Ms_ve). Enhanced survival of Ms_rv0774c after treatment with streptomycin was observed when compared with control. The cell envelope of Ms_rv0774c was demonstrated to have more trehalose di-mycolate (TDM) and lesser amount of mycolylmannosylphosphorylheptaprenol (Myc-PL) in comparison to control. Higher intracellular survival rate was observed for Ms_rv0774c as compared to Ms_ve in the THP-1 cells. This could be correlated to the reduction in the levels of reactive NO and iNOS expression. Infection of macrophages with Ms_rv0774c resulted in significantly increased expression of TLR2 receptor and IL-10 cytokines. However, it lowered the production of pro-inflammatory cytokines such as IL-12, TNF-α, IFN-γ, and MCP-1 in Ms_rv0774c infected macrophages in comparison to the control and could be associated with decreased phosphorylation of p38 MAPK. Though, predicted with high antigenicity index bioinformatically, extracellular in nature and accessible to host milieu, Rv0774c was not able to generate humoral response in patient samples. Overall, the present findings indicated that Rv0774c altered the morphology and streptomycin sensitivity by altering the lipid composition of M. smegmatis as well as modulated the immune response in favor of bacterial persistence.

NEED OF IRON SUPPLEMENTATION IN GESTATIONAL DIABETES MELLITUS

Objective

Gestational diabetes mellitus (GDM) increases the foetal morbidity and mortality and there is also risk of development of type II diabetes for the mother. In pregnancy iron supplementations are given to all the females in India. Data are not available on the relationship between serum ferritin and GDM in Indian populations.

Material & Methods

Case control study was done on 90 women (30 GDM patients approx 28 weeks of gestation and 60 control subjects without GDM) referred to the tertiary care hospital at New Delhi. Ferritin was analysed by ELISA kit. They were analyzed for the correlation of ferritin with blood glucose in GDM patients.

Results

On comparison with blood glucose the levels of ferritin were statistically significantly high in GDM cases as compared to controls (p value 0.008). There was a negative correlation of ferritin with blood glucose level (r value -0.039, p value 0.794).

Discussion

Pregnancy is an equivalent of an inflammatory state and the high levels of ferritin can help in determining the need of iron supplementation given in pregnant females. Women who had high serum ferritin had the greatest risk of GDM.

Conclusion

This study suggests a possible link between elevated serum ferritin and low-grade inflammation. Further studies in larger populations are required to establish this study.

Low tracheal tumor and airway management: An anesthetic challenge

We describe a case presenting with tracheal tumor wherein a Microlaryngeal tube was advanced into the trachea distal to the tumor for primary airway control followed by cannulation of both endobronchial lumen with 5.5 mm endotracheal tubes to provide independent lung ventilation post tracheal transection using Y- connector attached to anesthesia machine. The plan was formulated to provide maximal surgical access to the trachea while providing adequate ventilation at the same time. A 32 yrs non smoker male, complaining of cough, progressive dyspnea and hemoptysis was diagnosed to have a broad based mass in the trachea on computed tomography of chest. Bronchoscopy of the upper airway confirmed presence of the mass at a distance of 9 cms from the vocal cords, obstructing the tracheal lumen by three fourth of the diameter. The patient was scheduled to undergo the resection of the mass through anterolateral thoracotomy. We recommend the use of extralong, soft, small sized microlaryngeal surgery tube in tumors proximal to carina, for securing the airway before the transection of trachea and bilateral endobronchial intubation with small sized cuffed endotracheal tubes for maintenance of ventilation after the transection of trachea in patients with mass in the lower trachea.