Jagdish Chander Suri

Impact of sleep-disordered breathing on metabolic dysfunctions in patients with polycystic ovary syndrome

BACKGROUND Polycystic ovary syndrome (PCOS) is the most common endocrinological disorder among women in the reproductive age group. These women are prone to develop sleep-disordered breathing (SDB) and metabolic disorders. SDB is also associated with metabolic dysfunctions. We hypothesized that SDB is an independent risk factor contributing to metabolic dysfunctions in women with PCOS. METHODS Prospective cross-sectional study in which 50 women with PCOS and not on any treatment were selected. They were divided into two groups: Group 1 - PCOS with SDB and Group 2 - PCOS without SDB. RESULTS Thirty-three (66%) women with PCOS had SDB. Women in Group 1 had significantly higher systolic blood pressure (SBP) (P = 0.002); diastolic blood pressure (DBP) (P = 0.044); fasting blood sugar (P = 0.006), triglyceride levels (P = 0.014) and mean Ferriman-Gallwey score (P = 0.028). The HDL was significantly lower in group 1 (P = 0.006). In group 1, 42.4% of women had metabolic syndrome (P < 0.001). Excessive daytime sleepiness (EDS) was significantly higher in Group 1 (P = 0.04). Respiratory distress index significantly correlated positively with waist circumference (r = 0.551, P < 0.001), SBP (r = 0.455, P = 0.001), DBP (r = 0.387, P = 0.006), FBS (r = 0.524, P = 0.000), homeostatic model assessment (r = 0.512, P = 0.000), triglycerides (r = 0.384, P = 0.006), free testosterone (r = 0.390, P = 0.005), and negatively with HDL (r = -0.555, P < 0.001). CONCLUSION Women with PCOS and SDB had significantly increased metabolic abnormalities as well as more severe hyperandrogenism. Women with PCOS who have metabolic abnormalities or severe hyperandrogenism should undergo an overnight PSG.

Pulmonary function tests in beta thalassemia

To study pulmonary function tests (PFT) in multiple transfusion recipient thalassemics, PFTs were done for 30 thalassemics and 20 matched controls. Confirmed cases of thalassemia on regular transfusion therapy were the subject of study. Apart from history and physical examination of the thalassemics, serum ferritin estimation and spirometry were done. Parameters studied included lung volumes—functional residual capacity (FRC), forced vital capacity (FVC), residual volume (RV) and total lung capacity (TLC); and flow rates —forced expiratory volume in one second (FEV,), forced expiratory volume in 1 second/forced vital capacity (FEV,/FVC), peak expiratory flow 25–75 (PEF 25–75%) and peak expiratory flow rate (PEFR). Single breath carbon monoxide diffusing capacity (DLco) and arterial blood gas (ABG) were also analysed. The mean height and weight of thalassemics were below that of age matched controls. A restrictive abnormality in PFT was found in 86.6% cases. These patients were found to have a decrease in all the lung volumes namely FVC, FRC, RV and TLC with a proportional decrease in the flow rates, FEV1, PEF 25–75% and PEF with a normal (> 0.75) FEV1/FVC ratio. DLco was decreased in all the patients with restrictive lung disease and fall in DLco showed a good correlation (r = 0.7, P <. 001) with the severity of restrictive disease suggesting that some intrapulmonary pathology is likely to be responsible for the restrictive pattern. None of the cases had an obstructive or mixed pattern of pulmonary dysfunction. No correlation was found between severity of restrictive disease and the serum ferritin levels. A negative correlation with degree of hepatosplenomegaly was found. No correlation was found between severity of the defect and age, number of blood transfusions received and hemoglobin at the time of doing the test. To conclude, restrictive lung disease is the predominant abnormality in multi-transfused thalassemics, which is probably due to pulmonary parenchymal pathology. The abnormality of PFTs is not directly related to iron overload.

Outcome of adenotonsillectomy for children with sleep apnea

BACKGROUND AND OBJECTIVES The prevalence of obstructive sleep apnea syndrome is about 1%-4.9% in children aged 2-18 years. This is a prospective study carried out to evaluate the role of adenotonsillectomy (AT) in pediatric sleep apnea. METHODS Fifty children aged less than 15 years presenting with the chief complaints of snoring, mouth breathing, recurrent upper respiratory infections, and adenotonsillar hypertrophy were included in the study. Physical examination included body mass index (BMI) z-score, orodental and nasal examination, modified Mallampati scoring; whole-night level I polysomnography was conducted and repeated after three to six months of AT. RESULTS The mean preoperative BMI z-score was -0.76, which improved significantly to -0.15 (p < 0.001) after AT. A negative correlation was seen between respiratory distress index (RDI) and pre surgery BMI z-score. As per pre-operative RDI, OSA was classified mild in 6.7% children (31.1% as per apnea-hypopnea index [AHI]), moderate in 35.6% (31.1% as per AHI), and severe in 57.8% (37.8% as per AHI). The average RDI value reduced significantly from 16.2 ± 10.7 to 6.46 ± 4.8 (p < 0.001) and AHI from 8.5 (SD ± 5.7) to 1.3 (SD ± 1) post-operatively. Only 6.7% children could be cured with surgery, of whom none belonged to moderate or severe category. Multivariate analysis shows that initial severity of disease, modified Mallampati scores III and IV, high-arched palate, and age above eight years were associated with significant residual disease after AT. CONCLUSION AT was associated with a statistically significant change in RDI and AHI. However, complete resolution of OSA could be seen in a small percentage of patients with a mild degree of disease.

Pulmonary Cryptococcosis in HIV- sero-negative patients: case series from India.

Pulmonary cryptococcosis is likely to be misdiagnosed due to relatively non‐specific clinical and radiological features. It is more frequently associated with immuno‐suppressed conditions especially acquired immuno‐deficiency syndrome (AIDS) and pulmonary tuberculosis (PTB). Four cases of pulmonary cryptococcosis were diagnosed over a period of eleven years. All patients in this case series were human immune‐deficiency virus (HIV)‐negative. The predisposing factors in these patients were diabetes mellitus (DM), acute lymphoblastic leukaemia (ALL), post‐partum and pregnancy in one each of the patients. Relapse was seen in two cases. All the patients survived due to strict follow‐up. Pulmonary cryptococcosis is common in non‐AIDS patients and it warrants rapid diagnosis, treatment and follow‐up to prevent relapse.

Silica associated mixed connective tissue disorder in a stone crusher

Silica exposure has been implicated with the development of various connective tissue diseases. We report a case of 32-year-old stone crusher who developed silicosis with mixed connective tissue disorder (MCTD) 6 years after exposure to silica. This association of silicosis with MCTD has never been reported from the Indian subcontinent, although the problem of this pneumoconiosis remains rampant. This rare association urges us to report this case.

Sleep Pattern of Adolescents in a School in Delhi, India: Impact on their Mood and Academic Performance

ObjectivesTo examine the sleep pattern and observe differences in sleep routines, phase preferences, mood, attendance, and academic performance among different adolescent age students. Secondly, to observe the age at which sleep phase transition and changes in sleep requirement become evident.MethodsA cross-sectional study was conducted among 501 students (aged 11–15 y) of a school in Delhi, India. Students were evaluated for their sleep patterns, sleep duration, habits of napping, quality of sleep, sleepiness, depression, phase preferences by self-reported school sleep habits survey questionnaire along with school performance and attendance.ResultsSignificant differences were found in sleep pattern of students aged 11–12 y and 13–15 y. Bedtime shifted to a later time with increasing age but early morning schools kept the wake time same, leading to a decline in total sleep duration of older adolescents. Older adolescents had higher depression but poor attendance and academic performance. Prevalence of sleep deprivation increased with age, from 83.7% to 87.1% in 11–12 y to 90.5% to 92.5% in 13–15 y.ConclusionsThe study clearly identifies 12–13 y as age of transition of sleep pattern among adolescents. Though significant differences were found in the academic performance, mood and attendance among preteens and teens but no direct association was seen between academic performances and sleep pattern. A complex multifactorial association between sleep patterns, attendance, mood and academic performance which may change over days, months, or years should be explored further in a longitudinal follow up study.

Bronchoscopic resection of endobronchial inflammatory myofibroblastic tumor: A case report and systematic review of the literature

Inflammatory myofibroblastic tumour (IMT) is a rare tumour affecting the tracheo-bronchial tree in the adult population. The clinical presentation of this tumour is diverse and diagnosis can be definitively clinched by histopathological examination. Treatment of this tumour usually requires surgical resection with bronchoscopic resection being described in few cases. We describe a 32 year old male presenting with hemoptysis who was diagnosed to have IMT. Resection of the tumour was done with the help of rigid bronchoscopy. Post-resection, hemoptysis stopped and no recurrence of tumour was noted on subsequent follow-up. We also present a systematic review of literature of all the cases of tracheo-bronchial IMT treated with bronchoscopic resection and conclude it to be a useful alternative to surgery in such cases.

Diagnostic utility of endobronchial ultrasound features in differentiating malignant and benign lymph nodes

Endobronchial ultrasound (EBUS) features have been shown to be useful in predicting etiology of enlarged malignant lymph nodes. However, there is dearth of evidence especially from developing countries. We assessed the EBUS characteristics across various mediastinal and hilar lymphadenopathies. In this prospective study, all patients with mediastinal and hilar lymphadenopathy on CT Chest and who were planned for EBUS-FNA (Fine Needle Aspiration) were included. EBUS features of lymph nodes studied were shape, size, margins, echogenicity, central hilar structure (CHS), coagulation necrosis sign and colour power doppler index (CPDI). These were scored and compared between benign and malignant lymphadenopathies. A total of 86 lymph nodes in 46 patients were prospectively studied of which 23 (26.7%) were malignant, 27 (31.3%) tuberculosis and 36 (41.8%) sarcoidosis. There was significant difference between malignant and benign lymph nodes in terms of CHS [central hilar structutre] (p=0.011), margins (p=0.036) and coagulation necrosis sign (p<0.001). On comparison of features of malignancy and tuberculosis, there were significant differences in margins (p=0.016) and coagulation necrosis sign (p 0.001). However, when malignancy and sarcoidosis was compared, there were differences in echogenicity (p=0.002), CHS (p=0.009) and coagulation necrosis sign (p<0.001). Only coagulation necrosis sign was found to be highly consistent with malignant lymph nodes. The other features cannot be used to distinguish malignant from benign lymph nodes, especially in a developing country like India where tuberculosis is a common cause of mediastinal lymphadenopathy.

Pulmonary artery catheter-directed thrombolysis for intermediate high risk acute pulmonary embolism

A case of 60-year-old male with acute pulmonary embolism without hypotension but signs of right ventricular dysfunction and elevated cardiac biomarkers is reported in this study. The patient comes under intermediate high-risk category and was successfully thrombolysed with alteplase infused through pulmonary artery catheter. Catheter-directed thrombolysis (CDT) can be considered as much safer and effective alternative to systemic thrombolysis in such patients with lower risk of bleeding. This novel bedside method of pulmonary artery CDT with the advantage of no radiation exposure and real time monitoring of pulmonary artery pressures as an end-point of thrombolysis can be utilized in the near future.