Amit Banga

Spectrum of clinical disease in a series of 135 hospitalised HIV-infected patients from north India

BackgroundLiterature on the spectrum of opportunistic disease in human immunodeficiency virus (HIV)-infected patients from developing countries is sparse. The objective of this study was to document the spectrum and determine the frequency of various opportunistic infections (OIs) and non-infectious opportunistic diseases, in hospitalised HIV-infected patients from north India.MethodsOne hundred and thirty five consecutive, HIV-infected patients (age 34 ± 10 years, females 17%) admitted to a tertiary care hospital in north India, for the evaluation and management of an OI or HIV-related disorder between January 2000 and July 2003, were studied.ResultsFever (71%) and weight loss (65%) were the commonest presenting symptoms. Heterosexual transmission was the commonest mode of HIV-acquisition. Tuberculosis (TB) was the commonest OI (71%) followed by candidiasis (39.3%), Pneumocystis jiroveci pneumonia (PCP) (7.4%), cryptococcal meningitis and cerebral toxoplasmosis (3.7% each). Most of the cases of TB were disseminated (64%). Apart from other well-recognised OIs, two patients had visceral leishmaniasis. Two cases of HIV-associated lymphoma were encountered. CD4+ cell counts were done in 109 patients. Majority of the patients (82.6%) had CD4+ counts <200 cells/μL. Fifty patients (46%) had CD4+ counts <50 cells/μL. Only 50 patients (37%) received antiretroviral therapy. Twenty one patients (16%) died during hospital stay. All but one deaths were due to TB (16 patients; 76%) and PCP (4 patients; 19%).ConclusionsA wide spectrum of disease, including both OIs and non-infectious opportunistic diseases, is seen in hospitalised HIV-infected patients from north India. Tuberculosis remains the most common OI and is the commonest cause of death in these patients.

Prediction of obstructive sleep apnea in patients presenting to a tertiary care center

The objective of this prospective observational clinical study is to derive and validate a diagnostic model for prediction of obstructive sleep apnea (OSA) in subjects presenting with non-sleep-related complaints in a tertiary care center in north India. We included 102 subjects (group I, range 31–70 years) presenting to the hospital with non-sleep-related complaints. None of the subjects had any significant comorbid illness such as respiratory or congestive cardiac failure. All subjects underwent detailed evaluation including polysomnography (PSG). Various parameters were compared between the cases (apnea–hypopnea index, AHI ≥15/h) and controls (AHI <15/h). Using multivariate logistic regression analysis, a diagnostic model for prediction of OSA was derived. Subsequently, using similar selection criteria, 104 subjects (group II, range 32–68 years) were included for validation of the newly derived diagnostic model. Body mass index [BMI; OR (95% CI), 1.14(1.1–1.2)], male gender 5.0(1.4–27.1), relative-reported snoring index (SI) 2.8(1.7–5.0), and choking index (ChI) 8.1(1.4–46.5) were significant, independent predictors of OSA. Diagnostic model was computed as % MathType!Translator!2!1!AMS LaTeX.tdl!TeX -- AMS-LaTeX!% MathType!MTEF!2!1!+-% feaaeaart1ev0aaatCvAUfeBSjuyZL2yd9gzLbvyNv2CaerbbjxAHX% garmWu51MyVXgatuuDJXwAK1uy0HwmaeHbfv3ySLgzG0uy0Hgip5wz% amrr1ngBPrwtHrhAYaqehuuDJXwAKbstHrhAGq1DVbqee0evGueE0j% xyaibaieYdf9irVeeu0dXdh9vqqj-hEeeu0xXdbba9frFj0-OqFfea% 0dXdd9vqaq-JfrVkFHe9pgea0dXdar-Jb9hs0dXdbPYxe9vr0-vr0-% vqpWqaaeaabiGaciaacaqabeaadaabauaaaOqaaiaabohacaqGJbGa% ae4BaiaabkhacaqGLbGaeyypa0ZaamWaaeaacaaIXaGaaiOlaiaaiA% dacaaIXaGaey41aq7aaeWaaeaacaqGNbGaaeyzaiaab6gacaqGKbGa% aeyzaiaabkhaaiaawIcacaGLPaaaaiaawUfacaGLDbaacqGHRaWkda% WadaqaaiaaigdacaGGUaGaaGimaiaaigdacqGHxdaTdaqadaqaaiaa% bofacaqGjbaacaGLOaGaayzkaaaacaGLBbGaayzxaaGaey4kaSYaam% WaaeaacaaIYaGaaiOlaiaaicdacaaI5aGaey41aq7aaeWaaeaacaqG% dbGaaeiAaiaabMeaaiaawIcacaGLPaaaaiaawUfacaGLDbaacqGHRa% WkdaWadaqaaiaaicdacaGGUaGaaGymaiabgEna0oaabmaabaGaaeOq% aiaab2eacaqGjbaacaGLOaGaayzkaaaacaGLBbGaayzxaaGaaiilaa% aa!775A!

Diagnostic Utility of Pleural Fluid IFN-γ in Tuberculosis Pleural Effusion

{\text{score}} = {\left[ {1.61 \times {\left( {{\text{gender}}} \right)}} \right]} + {\left[ {1.01 \times {\left( {{\text{SI}}} \right)}} \right]} + {\left[ {2.09 \times {\left( {{\text{ChI}}} \right)}} \right]} + {\left[ {0.1 \times {\left( {{\text{BMI}}} \right)}} \right]},

The natural history of lung function after lung transplantation for α(1)-antitrypsin deficiency.

where, gender: 0=female, 1=male and SI, ChI, BMI are actual values. The diagnostic model had an area under the receiver operator characteristics curve of 89.6%. A cutoff of 4.3 for the score was associated with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 91.3, 68.5, 70.5, and 92.3%, respectively. Misclassification rate with the application of the diagnostic model on group II subjects was 13.5% (14/104). Sensitivity, specificity, PPV, and NPV of the model for predicting OSA in this group were 82, 90.7, 89.1, and 84.5%, respectively. BMI, male gender, SI, and ChI are independent predictors of OSA. Diagnostic model derived from these parameters is useful for predicting presence of OSA and screening subjects for PSG.

Non-invasive ventilation for acute exacerbation of COPD with very high PaCO 2 : A randomized controlled trial

BackgroundPatients with acute exacerbation of chronic obstructive pulmonary disease (COPD) commonly require hospitalization and admission to intensive care unit (ICU). It is useful to identify patients at the time of admission who are likely to have poor outcome. This study was carried out to define the predictors of mortality in patients with acute exacerbation of COPD and to device a scoring system using the baseline physiological variables for prognosticating these patients.MethodsEighty-two patients with acute respiratory failure secondary to COPD admitted to medical ICU over a one-year period were included. Clinical and demographic profile at the time of admission to ICU including APACHE II score and Glasgow coma scale were recorded at the time of admission to ICU. In addition, acid base disorders, renal functions, liver functions and serum albumin, were recorded at the time of presentation. Primary outcome measure was hospital mortality.ResultsInvasive ventilation was required in 69 patients (84.1%). Fifty-two patients survived to hospital discharge (63.4%). APACHE II score at the time of admission to ICU {odds ratio (95 % CI): 1.32 (1.138–1.532); p < 0.001} and serum albumin (done within 24 hours of admission) {odds ratio (95 % CI): 0.114 (0.03-0.432); p = 0.001}. An equation, constructed using the adjusted odds ratio for the two parameters, had an area under the ROC curve of 91.3%. For the choice of cut-off, sensitivity, specificity, positive and negative predictive value for predicting outcome was 90%, 86.5%, 79.4% and 93.7%.ConclusionAPACHE II score at admission and SA levels with in 24 hrs after admission are independent predictors of mortality for patients with COPD admitted to ICU. The equation derived from these two parameters is useful for predicting outcome of these patients.

Lemierre's syndrome due to community-acquired meticillin-resistant Staphylococcus aureus infection and presenting with orbital cellulitis: A case report

Pleural fluid interferon-γ (IFN-γ) levels are increased in patients with tuberculosis (TB) pleural effusion. Recent studies from the west have found that estimation of pleural fluid IFN-γ levels is an excellent diagnostic strategy for these patients. The diagnostic utility of pleural effusion IFN-γ level estimation has not been evaluated in patients from developing countries, however. This work was carried out to study the diagnostic utility of IFN-γ level estimation in patients with TB pleural effusion and to define the best cutoff of IFN-γ for diagnosis TB pleural effusion. We studied 101 patients with pleural effusion. Of these, 64 were found to have a TB etiology, established by means of various conventional modalities. Measurement of pleural fluid IFN-γ levels was done by ELISA technique. The median value of pleural fluid IFN-γ levels in patients with TB (1480 pg/ml, range 3–14000 pg/ml) was significantly higher (p < 0.001) compared with the non-TB group (3 pg/ml, range 0–900 pg/ml). The receiver ope...

Hospital length of stay after lung transplantation: Independent predictors and association with early and late survival

Phase I of the International Study of Asthma and Allergies in Childhood (ISAAC) showed marked variability in the global pattern of allergic disorders. Risk factors for asthma in children from rural areas of developing countries have not been studied. The purpose of this study was to document the prevalence of asthma-associated symptoms in children residing in rural areas and to determine risk factors for its development. We studied 8470 school children, aged 6-7 years and 13-14 years, from 10 villages on the outskirts of Delhi, India, over a 6-month period. The study was performed using the Hindi translated version of Phase III of the ISAAC questionnaires. All of the questionnaires were self-reported by children and/or parents. Frequent passage of trucks through the street near home (odds ratio [OR]: 95% CI, 1.7 [1.2-2.4]), maternal smoking (OR: 95% CI, 1.5, [1.1-2.1]), paternal smoking (OR: 95% CI, 1.3 [1.0-1.8]), total number of cigarettes smoked by both parents of more than seven per day (OR: 95% CI, 1.9 [1.3-2.7]), paracetamol intake of more than once a month (OR: 95% CI, 1.9 [1.4-2.6]), and current exposure to cats (OR: 95% CI, 1.5 [1.1-1.9]) were independently associated with occurrence of recent wheezing (in the last 12 months), whereas fruit intake of more than twice a week had a protective effect (OR: 95% CI, 0.7 [0.5-0.9]). There is a significant burden of asthma-associated symptoms in children of rural areas of north India. Occurrence of wheezing among children from rural areas of Delhi is determined by a complex interplay of environmental agents that induce allergic sensitization and are proinflammatory and environmental agents that supplement the antioxidant stores.

A study of empyema thoracis and role of intrapleural streptokinase in its management

RATIONALE Lung transplantation (LT) is an established treatment for end-stage lung diseases, including chronic obstructive pulmonary disease (COPD) associated with α1-antitrypsin deficiency (AATD). OBJECTIVES We sought to compare the post-transplantation course of patients with AATD and AAT-replete COPD. METHODS Between June 1991 and January 2008, a total of 231 patients with AAT-replete COPD and 45 with AATD underwent LT at Cleveland Clinic. Data reviewed included baseline recipient, donor, and surgical data; all spirometry evaluations; acute cellular rejection (ACR) events; and survival data. Endpoints included temporal change in FEV1, severity of ACR, and survival. A longitudinal temporal decomposition model was used for analysis. MEASUREMENTS AND MAIN RESULTS Comparison of overall rates of FEV1 decline in AATD and AAT-replete patients with COPD showed no significant differences (P > 0.09). However, although the single LT patients had similar trends in FEV1 in both groups, patients with AATD with double LT declined faster (P < 0.002) than the AAT-replete patients. No differences in the frequency or severity of ACR episodes were observed (P = 0.32). Furthermore, there was no difference in early or late mortality between patients with AATD and patients with AAT-replete COPD (P > 0.09). CONCLUSIONS Although overall the post-LT FEV1 slope, severity of ACR, and survival among patients with AATD is similar to that of AAT-replete patients with COPD, patients with AATD with double LT have a faster rate of FEV1 decline. These findings support the eligibility of patients with AATD for LT, and suggest the need for additional studies to better understand the difference between single and double LT in AATD.