Vinay Mahishale

Prevalence of Smoking and Its Impact on Treatment Outcomes in Newly Diagnosed Pulmonary Tuberculosis Patients: A Hospital-Based Prospective Study

There is growing evidence that tobacco smoking is an important risk factor for tuberculosis (TB). India, with a population of 1.26 billion, has the highest number of both TB patients and smokers. The convergence of these two important health hazards is likely severely affecting Indias TB control programs. This study was carried out to determine the prevalence of smoking in newly diagnosed pulmonary TB patients and the impact of smoking on disease outcomes in a tertiary care hospital. All patients newly diagnosed with pulmonary TB as per the Revised National Tuberculosis Program of India (RNTCP) 2013 criteria were enrolled in the study. On the basis of their self-reported smoking status, the participants were classified as never smokers, current smokers, and ex-smokers. Patients were started on anti-TB treatment and were followed for 2 years. Among the 2350 subjects (1,758 males and 592 females), 1,593 patients (67.78%) were never smokers. Current and ex-smokers numbered 757 (32.21%), of which 751 (31.95%) were males and 6 (0.26%) were females. Smoking was associated with more extensive lung disease, lung cavitation, and positive sputum smear and culture results at baseline. In both current smokers and ex-smokers, sputum smears and cultures were significantly more likely to remain positive after 2 months of treatment. Ex-smokers and current smokers had significantly high rates of defaults, treatment failures, and relapses. The prevalence of smoking is very high in TB patients. Tobacco smoking is associated with a considerably increased risk of advanced and more severe disease in the form of lung cavitations, positive sputum smear and culture results, and slower smear and culture conversion after initiation of treatment. Smoking has a great negative effect on treatment completion, cure rates, and relapse rates in patients with pulmonary TB.

Ageing world: Health care challenges

The world population reached 7 billion in 2012, which is 6 billion more than in 1800. This remarkable population growth is the result of several factors like advances in the medical, technological and public health systems resulting in the control and treatment of communicable diseases, the control of pandemics, the end of large-scale wars, improvements in living conditions and the revolutions in the field of agriculture. Because of all these factors, there has been a considerable improvement in the life expectancy of human beings. There is also an alarming reduction in fertility rates. The combination of declining fertility rate and augmented life expectancies has led to a change in the demographics of the population with the strata of older individuals growing faster than the younger individuals. The aging of populations is poised to become the next global public health challenge. Advances in medicine and socioeconomic development have substantially reduced mortality and morbidity rates due to infectious conditions and, to some extent, non-communicable diseases. These demographic and epidemiological changes, coupled with rapid urbanization, modernization, globalization, and accompanying changes in risk factors and lifestyles, have increased the prominence of chronic non-infective conditions. Health systems need to find effective strategies to extend health care and to respond to the needs of older adults. This review highlights the pathophysiology of aging, biological and physiological changes, impact of aging on health, epidemiological transitions, multi-morbidity in elderly and challenges for health care system.

Endobronchial pulmonary mucormycosis diagnosed by fiberoptic bronchoscope: A rare case report

Pulmonary mucormycosis is relatively uncommon, but a life-threatening infection affecting mostly individuals with diabetes mellitus, hematological malignancies, chronic renal failure, posttransplantation and other immunocompromised states. Mucormycosis of the lung has a wide range of clinical and radiological manifestations. Very few cases of pulmonary mucormycosis presenting as a fungal ball, cavity resembling tuberculosis, nonresolving, and recurrent pneumonia in patients with diabetes mellitus or other immunosuppressive conditions, were reported from India. We report a case of pulmonary mucormycosis in an adult male patient with uncontrolled diabetes.

Glycemic control and radiographic manifestations of pulmonary tuberculosis in patients with type 2 diabetes mellitus

Background: Diabetes mellitus (DM) is a risk factor for tuberculosis (TB) and may modify its presenting features. Atypical radiologic images of pulmonary TB are common in DM. Many studies have compared the radiological manifestations of TB between patients with and without DM. Aim of the Study: To study the impact of poor glycemic control on radiographic manifestations of the newly diagnosed smear-positive pulmonary TB patients with type 2 DM. Materials and Methods: In a tertiary care hospital, 70 patients newly diagnosed with smear-positive pulmonary TB and with coexisting type 2 DM were enrolled. Glycemic control was assessed by glycosylated hemoglobin (HbA1 C ). A pretreatment chest radiograph was read independently by two qualified pulmonologists blinded to patients′ diabetic status. Films with any discordant reading were read by a third reader. Radiological lesions on chest radiograph were classified into minimal, moderately advanced and far advanced as per American Thoracic Society criteria. Results: Of 70 patients, 47 (67.1%) had their HbA1c level ΃7%. Patients with poor glycemic control (HbA1c ΃7%) were more likely to have lower lung field involvement (29.8% vs. 13.04%; P < 0.01), far advanced lesions (40% vs. 4%; P < 0.001) and cavitary disease on chest radiograph (76.6% vs. 43.4% P < 0.05). Conclusion: Poor glycemic control significantly influences radiographic manifestations of pulmonary TB in patients with DM. Uncontrolled diabetics seem to have multiple and large cavities. Also isolated lower lung field involvement is more common in uncontrolled diabetics than in optimal control patients. High index of suspicion is, therefore, required in uncontrolled diabetics when radiological patterns are atypical.

A rare case of lymphangioleiomyomatosis with recurrent pneumothorax

Lymphangioleiomyomatosis (LAM) is a rare disease of unknown etiology that traditionally affects young women of childbearing or premenopausal age. It is characterized by proliferation of atypical smooth muscle cells, preferentially along bronchovascular structures that cause progressive respiratory failure. Owing to its unusual and nonspecific presenting symptoms, patients often receive missed or delayed diagnosis. This disease occurs sporadically or in association with the genetic disease-tuberous sclerosis complex. Recurrent pneumothorax is the hallmark of LAM. We present a 16-year-old young female having recurrent pneumothorax with LAM.

Prevalence and impact of diabetes, hypertension, and cardiovascular diseases in chronic obstructive pulmonary diseases: A hospital-based cross-section study

Abstract Background: Chronic obstructive pulmonary disease (COPD) is associated with important chronic comorbid diseases, including diabetes, hypertension and cardiovascular diseases. As very limited data is available in India, the aim of the present study was to determine the relationship between COPD and the common, chronic comorbid conditions of diabetes mellitus (DM), hypertension (HTN), and cardiovascular diseases (CVD) and also to determine how these affect the clinical course of COPD. Methods: All the COPD cohorts diagnosed as per Global Initiative for Chronic Obstructive Lung Disease-2013 (GOLD-2013) criteria were screened for DM, HTN, and CVD as per stipulated national and WHO guidelines. Results: The prevalence of DM, HTN, and CVD in the 2432 COPD subjects was 25.94%, 37.25%, and 13.93%, respectively. In multivariate analyses, very severe COPD was associated with a higher risk of DM (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.2–2), HTN (OR 1.6, 95% CI 1.4–1.9), and CVD (OR 2.5, 95% CI 1.9–3.0). Conclusion: A significant relationship was found between COPD and the presence of comorbid DM, HTN, and CVD. It was also found that subjects with advanced COPD were more likely to have at least two of these conditions and hugely affect the outcome of the disease. These findings suggest that the presence of COPD could provide a rationale to look for other comorbid disease and, conversely, that the presence of DM, HTN, or CVD might be the basis for the assessment of patients for airflow limitation and COPD as the tobacco smoking and advancing age were common risk factors.

Screening of Chronic Obstructive Pulmonary Disease Patients for Pulmonary Arterial Hypertension Using Two-Dimensional Transthoracic Doppler Echocardiography in Tertiary Care Hospital in India

Background: Chronic obstructive pulmonary disease (COPD) and pulmonary arterial hypertension (PAH) are common and underdiagnosed medical conditions in India. Prevalence of these chronic diseases is high both in rural and urban areas. However, the exact prevalence of PAH in Indian COPD patients is unclear. Comorbid conditions like PAH have a great impact on the outcome of COPD in the form of severity, exacerbations, morbidity, and mortality. Right heart catheterization remains the gold standard test for diagnosis of PAH, but it is invasive and practically not feasible. Aims and objectives: The present study objective was to screen COPD patients for PAH using two-dimensional transthoracic Doppler echocardiography (ECHO) in Tertiary Care Hospital. Results: A total of 2040 patients with a confirmed diagnosis of COPD were enrolled in the study. Among these patients, 1509 were males (73.9%), 531 were females (23.06%), and 1428 were known or ex-smokers (70%). None of the females were smokers, but there was a history of biomass fuel exposure for >10 years. As per global initiative for chronic obstructive lung disease criteria, mild, moderate, severe, and very severe COPD was noted in 525,629,511, and 375 patients, respectively. When they were screened using ECHO, prevalence of PAH was 41.96% as 856 subjects had PAH. Prevalence of PAH among mild, moderate, severe, and very severe COPD was 23.8%, 34.81%, 48.53%, and 70.4%, respectively. There was a linear relationship between PAH and severity of COPD. Conclusion: PAH is very common in COPD patients in India. As the severity of COPD increased, the frequency and degree of PAH also increased. ECHO is an excellent tool for detection of PAH in COPD patients. All patients with severe to very severe COPD should be routinely screened by ECHO for PAH and with mild to moderate COPD, who have dyspnea out of proportion to their clinical condition should also be screened for PAH.

Left ventricular dysfunction and its correlates in chronic obstructive pulmonary disease patients

Background: In chronic obstructive pulmonary disease (COPD) patients, left ventricular (LV) systolic dysfunction is rare. Objectives: To evaluate the prevalence of LV systolic or diastolic dysfunction in patients with COPD. Materials and Methods: A cross-sectional study was conducted in a tertiary care hospital for a period of 2 years from January 2012 to December 2013. These patients underwent physical examination and standard two-dimensional (2D) echocardiographic views, and peak flow velocity of early diastolic filling [early filling velocity (E-Max)], peak flow velocity of late atrial filling [atrial filling velocity (A-Max)], and early flow velocity peak/late flow velocity peak [early to late (E/A)] ratio were measured according to the criteria of the American Society of Echocardiography. Statistical analysis was carried out using SPSS software. Results: A total of 102 patients diagnosed with COPD as per the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines were enrolled. Of the 102 COPD patients, the maximal A-Max increased and E-Max decreased in 76 patients (74.5%) (P < 0.001). The early flow velocity peak/late flow velocity peak (E/A) ratio also markedly decreased in these 76 patients (P < 0.001) indicating LV dysfunction. The atrial contribution to total left diastolic filling increased in patients with COPD. This was also observed in COPD patients with normal pulmonary artery pressure (PAP) (P < 0.001). Grade IV COPD (P - 0.000), the duration of illness (P < 0.001), and smoking >10 packs for years (P < 0.001) were the risk factors that were associated with the development of LV diastolic dysfunction in COPD patients. Conclusion: The prevalence of LV diastolic dysfunction was 74.5%. As the severity of COPD increased, the risk of LV diastolic dysfunction increased. The screening of severe COPD patients for LV function might improve the outcome.

Electronic cigarette: A boon or bane!!

Since their launch in 2004 in China, e-cigarettes, a diverse range of ba ery operated devices that vaporize nicotine for inhalation, have been purchased by millions of people. Many smokers use e-cigare es to help them quit. Sales are increasing so rapidly that some analysts predict that they will surpass cigare e sales within a decade.[5] The place of e-cigare es in tobacco control is controversial and there is a paucity of reliable data. Available research suggests that e-cigare es have the potential to assist smokers to quit or reduce smoking. Studies show that e-cigare es are capable of delivering nicotine into the bloodstream and a enuating tobacco withdrawal as eff ectively as NRT. Use of e-cigare es also simulates behavioral and sensory dimensions of smoking. However, this argument has many fundamental fl aws!

Lymphangioleiomyomatosis: A rare case report

Lymphangioleiomyomatosis (LAM) is a rare disease of unknown etiology that traditionally affects young women of child bearing or premenopausal age. It is characterized by proliferation of atypical smooth muscle cells, preferentially along bronchovascular structures that causes progressive respiratory failure. Due to its unusual and nonspecific presenting symptoms, patients often receive missed or delayed diagnosis. This disease occurs sporadically or in association with the genetic disease tuberous sclerosis complex (TSC). We present 34-year-old young premenopausal woman with LAM.