Increasing incidence of adenocarcinoma lung in India: Following the global trend.

BACKGROUND: Lung cancer is one of the most common malignant neoplasms worldwide and accounts for more deaths than any other cancer. The clinicopathological profile of lung cancer has shown marked regional and geographical variation. AIMS: We aimed to compare the demographic and pathological profile of lung cancer patients from North India with other Indian and International series. SETTING AND DESIGN: A retrospective study over a period of 5 years from January 2008 to May 2013 was conducted in the Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi. PATIENTS AND METHODS: A total of 397 newly diagnosed patients with lung cancer from January 2008 to May 2013 were included in the study. The clinical, demographic, and pathological features were reviewed and compared with other major National and International reports. Data were entered and analyzed using SPSS software (SPSS Inc. Released 2009. PASW Statistics for Windows, Version 18.0. Chicago: SPSS Inc. RESULTS: A total of 397 patients (86% men, mean age 57.8 years) were studied. The ratio of men to women was 7.4. Majority of patients (78.3%) were current/previous smokers. Small cell carcinoma was diagnosed in 14.6% (58) of patients while 85.4% (339) had nonsmall cell lung carcinoma (NSCLC). Within NSCLC, the most common histology types were squamous cell carcinoma (30%), followed closely by adenocarcinoma (ADC) (28.3%) and large cell carcinoma (1.7%). Majority (87%) of the patient were staged III and IV. About 30.1% patients received anti-tubercular treatment during the current episode before a diagnosis of lung cancer was made. CONCLUSION: The clinicopathological profile of lung cancer has undergone noticeable changes over the last four decades, especially in the increase in ADC incidence and their frequent presence in smokers. Lung cancer is often mistreated as tuberculosis in the Indian subcontinent and hence continues to be diagnosed late.

Evaluation of Metered Dose Inhaler Use Technique and Response to Educational Training.

Background. Prescribing inhalers without imparting adequate education regarding proper technique of their usage may result in suboptimal clinical improvement and wastage of medication. Training interventions using a standard check-list may help improve faulty techniques and enhance drug efficacy. Methods. Patients using metered dose inhaler (MDI) were included in the study. Inhaler technique was first evaluated at baseline using a standard check-list of recommended steps (National Institute of Health guidelines; see Table) and scores were given for each step correctly performed. Those who could not perform all steps correctly were given training intervention. The patients were assigned to two methods of educational intervention; one group was trained by providing written material giving step-wise instructions while the other group was given an actual physical demonstration using a placebo device. The technique was re-evaluated and scored following each educational session, and continued till the patient achieved a full score, or for a maximum of 3 sessions, whichever occurred earlier. Median score was calculated after each session and was compared between the two groups. Each patient was followed up after two months and the re-evaluated the same way. Results. One hundred and seventeen subjects were enrolled in the study (59 in the written group and 57 in the practical demonstration group). At baseline, only 1 of the 117 subjects could perform all the steps of inhaler usage correctly. This patient was, therefore, not provided the inhaler technique education. The overall median (range) score of the whole group was 3 (range 1-8). This score rose to 6, 7 and 8 after each of the three subsequent educational intervention sessions. At one-month follow-up, the median score dropped to 7 and improved with a repeat educational session as previously done. A significant difference was observed in the median score improvement achieved in the practical demonstration group compared with the written instruction group (3.0 versus 2.0 respectively, p<0.001). Conclusions. Inhalation technique of patients improves after imparting systematic educational intervention. A practical demonstration of all the steps proved more effective than simple verbal/written advice. In view of increasing errors being committed over a period of time, repeated demonstration of the proper technique using a standard check-list significantly improves the errors committed during inhaler use.

Microsporum gypseum dermatophytosis in a patient of acquired immunodeficiency syndrome: A rare case report.

Microsporum gypseum, a geophillic dermatophyte is rarely isolated from patients with acquired immunodeficiency syndrome. We report tinea corporis due to Microsporum gypseum, an uncommon aetiological agent, in a patient with acquired immunodeficiency syndrome from our region. The clinical presentation resembled psoriasis characterised by atypical, scaly and hyperkeratotic lesions.

A case report of an uncommon phaeoid fungal infection in nasal polyposis and review of literature.

Nasal polyposis is an inflammatory condition of mucous membrane of the nose and paranasal sinuses with unknown aetiology. Massive nasal polyps can obstruct the nasal cavity causing discomfort and lowered quality of life. Thus, aetiological diagnosis is important for treatment, especially in recurrent nasal polyposis. We present a rare case of pansinusitis with bilateral ethmoidal polyps caused by an unusual phaeoid fungus Fonsecaea pedrosoi in a 65-year-old immunocompetent male from a rural background. The diagnosis was made by endoscopic nasal examination; high resolution computed tomography of the paranasal sinuses, detection of fungal hyphae in 10% potassium hydroxide wet mount and culture.

Effect of tripod position on objective parameters of respiratory function in stable chronic obstructive pulmonary disease.

Objective. To examine changes in respiratory dynamics in patients with chronic obstructive pulmonary disease (COPD) sitting leaning forward with hands supported on the knees (tripod position), a posture frequently assumed by patients in respiratory distress. Methods. Spirometry, maximal inspiratory and expiratory pressures (MIP and MEP) generated at the mouth, and diaphragmatic excursion during tidal and vital capacity maneuver breathing measured by B-mode ultrasonography were studied in 13 patients with stable COPD in sitting, supine and tripod positions. Results. Mean±SD age of patients was 52.2±6.8 years. Median disease duration was three years. There was no statistically significant difference in spirometry for sitting, supine and tripod positions (FEV1: 1.11±0.4L, 1.14±0.5L and 1.11±0.4L; p=0.99), respectively, (FEV1/FVC: 49.2±11.0, 53.7±8.5 and 48.5±11.3, p=0.37), mouth pressures (MIP: 102.9±28.9, 90.6±29.1 and 99.2±32.9 cm H2O, p=0.61 and MEP: 100.8±29.9, 100.4±34.4 and 90.6±32.6 cmH2O, p=0.74) and diaphragmatic movements during tidal (16.1±5.9, 20.1±6.8 and 16.6±6.2 mm, p=0.22) and forced breathing (33.9±11.0, 43.1±19.6 and 37.4±17.1 mm, p=0.35). Conclusion. Commonly measured indices of respiratory function were not different in the tripod compared to sitting and supine positions.

Effect of change in symptoms, respiratory status, nutritional profile and quality of life on response to treatment for advanced non-small cell lung cancer.

INTRODUCTION: Quality of life (QOL), and pulmonary and nutritional parameters are important outcome measures during treatment of lung cancer; however, the effect of chemotherapy on these factors and their relationship with clinical response is unclear. METHODS: Patients with non-small cell lung cancer (NSCLC) were evaluated for symptom profile, nutritional status (using anthropometry), pulmonary functions by spirometry and six minute walk distance (6 MWD), and QOL using the WHO-QOL Bref 26 questionnaire, before and after chemotherapy. RESULTS: Forty-four patients were studied (mean (SD) age, 55 (10) years, 75% males). The majority (98%) had stage III or IV disease and 72% were current / ex-smokers with median pack-years of 27.0 (range, 0.5-90). Some 61% had a Karnofsky Performance Scale (KPS) 70 or 80. The commonest symptoms were coughing, dyspnea, chest pain, anorexia and fever (79%, 72%, 68%, 57% and 40%, respectively). The mean (SD) 6 MWD was 322.5 (132.6) meters. The mean (SD) percentage forced vital capacity (FVC %), and forced expiratory volume in one second (FEV1 %) were 64.7 (18.8) and 57.8 (19.4), respectively. The mean (SD) QOL scores for the physical, psychological, social, and environmental domains were 52.9 (20.5), 56.1 (17.9), 64.5 (21.8), 57.1 (16.6), respectively. Fourteen patients (32%) responded to chemotherapy. Non-responders had significantly higher baseline occurrence of fever, anorexia, and weight loss, higher pack-years of smoking and poorer KPS compared to responders. Overall, chemotherapy caused significant decline in the frequency of coughing, dyspnea, chest pain, fever, anorexia, weight loss, and improvement in hemoglobin and albumin levels. There was no significant improvement in pulmonary functions, nutritional status, or QOL scores after treatment. CONCLUSIONS: Lung cancer patients have a poor QOL. Although chemotherapy provides significant symptomatic benefit, this does not translate into similar benefit in respiratory and nutritional status or QOL. Patients with constitutional symptoms, higher smoking burden, and poor KPS are less likely to respond to chemotherapy. Management of NSCLC must include strategies to improve various aspects of QOL, nutritional status and pulmonary reserve to achieve comprehensive benefit.

Derivation of a prognostic equation to predict in-hospital mortality and requirement of invasive mechanical ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease.

OBJECTIVE: Predicting in-hospital mortality and formulating a scoring system derived from predictors of mortality may aid prognostication. METHODS: One hundred and fifty-one consecutive patients admitted with a diagnosis of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) were followed to discharge or death in hospital stay. Secondary variables studied were duration of hospital stay, and need for and duration of mechanical ventilation (MV). RESULTS: Mean (SD) age of patients was 60.5 (11.4) years; 65.6% were mechanically ventilated, and 25.2% died in hospital. Independent predictors of mortality at admission were serum creatinine (odds ratio [OR] 2.1, 95% Confidence intervals [CI] 1.03 to 4.30; p = 0.04), and serum sodium (OR 0.94, 95% CI 0.90 to 0.99; p = 0.03). An equation derived [Score = 8+ (0.74 x creatinine) = (0.015 x sodium)] to predict mortality, had an area under receiver operating characteristic (ROC) curve of 73%, with a cut-off of 6.74 having sensitivity, specificity, positive and negative predictive values for predicting death of 71%, 64%, 40% and 87%, respectively. Glasgow coma scale (GCS), partial pressure of oxygen in arterial blood (PaO2) and partial pressure of carbon dioxide in arterial blood (PaCO2) at admission independently predicted need for invasive ventilation. An equation derived [Score = 2.36+(0.02 x PaO2)+(0.05 x PaCO2)-(0.47 x GCS)] to predict need for MV, had an area under ROC curve of 85%, with a cut-off of 0.54 having sensitivity, specificity, positive and negative predictive values for predicting need for MV of 82%, 81%, 89% and 70%, respectively. CONCLUSIONS: Serum creatinine and sodium at admission are independent predictors of mortality for patients admitted with AECOPD. The equation derived from these two variables is a simple and useful method for predicting outcome.

Survival in small cell lung cancer in India: prognostic utility of clinical features, laboratory parameters and response to treatment.

BACKGROUND: Predictors of survival and response to treatment in patients with small cell lung cancer (SCLC) are ill-defined and unclear. In an attempt to assess the impact of common presenting symptoms and laboratory values on survival, we undertook this retrospective review of patients with SCLC. To our knowledge, there is no study on survival in SCLC patients from the Indian subcontinent. DESIGN: Retrospective Cohort study. MATERIALS AND METHODS: All newly diagnosed small cell lung cancer cases from December 2001 through December 2004, were identified and clinical data on presenting symptoms and laboratory findings from their hospital records, noted. The influence of various pretreatment factors on survival was investigated using Kaplan-Meier plots and Cox multivariate regression model. RESULTS: 76 subjects were included (84% males, 91% smokers). 57% patients had five or more symptoms at presentation. Cumulative symptom burden was strongly associated with survival (P =0.02). Survival was also significantly related with Karnofsky performance status (KPS) (P =0.04), disease extent (P =0.03) and symptomatic response to treatment (P< 0.001). Patients with higher hemoglobin (P =0.02), serum sodium (P =0.04) and serum globulin (P =0.02), survived significantly longer. By multivariate regression analysis, hemoglobin, KPS and brain metastases, were significant predictors of survival (P =0.01, P =0.02, P< 0.01 respectively). CONCLUSION: Cumulative symptom burden, KPS, disease extent and symptomatic assessment of improvement after treatment, are useful predictors of survival. This has important clinical implications, keeping in view, the infrastructure and cost involved in more objective tests like CT scan, for evaluation of disease extent and prognosis. These findings can provide a simple basis for predicting prognosis in small cell lung cancer, especially in developing countries like ours.

Cardiac sarcoidosis: an uncommon presentation of sarcoidosis in India.

Cardiac involvement in sarcoidosis is uncommon. The manifestations of cardiac sarcoidosis are protean and vary from benign ectopics to life threatening ventricular tachycardias. High index of suspcion and early aggressive intervention is required for the diagnosis and treatment of this condition. Early diagnosis is essential since ventricular tachycardia is the most common terminal event in these patients if left untreated. Corticosteroids are needed early in these patients which along with other antiarrhythmic management strategies including intracardiac defibrillator form the backbone of treatment. We describe four patients who were diagnosed to have pulmonary and cardiac sarcoidosis. Their varied presentations highlight the difficulties that may occur in the diagnosis. Furthermore, the need for proper management is stressed, as a delay in diagnosis may be fatal.

Human pneumocystosis.

Pneumocystis is an atypical fungus causing pneumonia in immuno-compromised individuals. Though previously termed as Pneumocystis carinii, the recent taxonomy has considered human derived Pneumocystis to be a different species Pneumocystis jiroveci. The organism is the most common cause of opportunistic infections among patients with acquired immunodeficiency syndrome (AIDS) in developed countries. Incidence of Pneumocystis pneumonia or pneumocystosis in developing countries including India continues to be low. Microscopy of appropriate clinical samples has been the mainstay of diagnosis of pneumocystosis. Amplification techniques are now being evaluated for detection of P. jiroveci. This review attempts to give a recent update on P. jiroveci with special focus on epidemiology, taxonomy, current diagnostic modalities and recommended immuno-prophylaxis.

Mycoplasma pneumonia associated with rhabdomyolysis and the Guillain-Barre syndrome.

A 25-year-old housewife who presented with Mycoplasma pneumonia who developed acute respiratory distress syndrome (ARDS) and required assisted ventilation. During her hospital stay, she developed acute renal failure because of rhabdomyolysis and was put on haemodialysis. She also had difficulty in weaning from ventilator because of acute motor-sensory axonal neuropathy (AMSAN) variant of the Guillain-Barre syndrome. The patient was treated with antibiotics and corticosteroids. The patient recovered from both the complications gradually.

Unilateral pulmonary agenesis: an uncommon cause of lower zone lung opacity.

Congenital abnormalities of the lung are rare and are often misdiagnosed. We report the case of a young girl who was initially diagnosed to have pleural effusion with collapse. After detailed evaluation including computerised tomographic (CT) scan and fiberoptic bronchoscopy, a final diagnosis of unilateral pulmonary agenesis was made. This condition must be suspected in differential diagnosis in a young person presenting with features of lung collapse.

Laser bronchoscopy--current status.

The majority of patients with lung cancer have advanced disease with severe endobronchial symptoms such as cough, dyspnea, and hemoptysis for which palliation is required. Laser resection of endobronchial lesions located in the trachea, mainstem or proximal lower lobe bronchi provides significant and rapid improvement in the patient's symptoms. Neodymium:yttrium-aluminium-garnet (Nd:YAG) laser is gaining popularity due to efficient photocoagulation, good penetration and excellent hemostasis. Complications are rare and can be minimized by following standardized techniques and safety guidelines. Laser resection is equally effective with the rigid and flexible bronchoscope. The future may see combinations of laser with other palliative modalities to improve the chances of a symptom-free life for lung cancer patients.

Non small cell lung cancer (NSCLC): current status and future prospects.

The incidence of lung cancer is rising dramatically and it is now the commonest cause of mortality and morbidity not only in the industrialised countries, but in developing nations like India as well. Tobacco smoking has consistently been demonstrated to be an important aetiological factor, though lung cancer occurs in non-smokers also. In spite of great advances in radiological and molecular diagnostic techniques, the ideal screening marker for early detection of lung cancer has still not been found. Histological diagnosis and staging is essential for selecting the mode of therapy in patients with lung cancer. Stages I and II are amenable to surgery. However, advanced stage III and IV need an individualised combination of surgery, chemotherapy and radiotherapy. With a better understanding of the cellular mechanisms operating in carcinogenesis, newer target specific modalities are being developed and tested in order to stem this disease, which threatens to assume epidemic proportions.

Domestic cooking fuel and lung functions in healthy non-smoking women.

OBJECTIVE: The objective of this study was to compare the pulmonary functions in healthy non-smoking women who used either biomass or liquified petroleum gas (LPG) as their sole cooking fuel. The effects of passive smoking, ventilation, over crowding and cooking index were also taken into account. METHODOLOGY: The study was conducted over a period of two years from January 1994. One hundred healthy non-smoking women were included 50 cooked solely with biomass and 50 cooked with LPG. A standardised respiratory symptoms questionnaire was administered to all the subjects and spirometry was carried out. RESULTS: Passive smoking showed no significant difference between the two groups. No statistically significant differences was found in lung functions in the two groups except for the PEFR, which was significantly lower (P < 0.01) in women using biomass. No correlation was observed between different variables and pulmonary functions. The step-wise multivariate linear regression analysis showed no correlation between cooking fuel and the pulmonary functions. CONCLUSION: The absence of the expected adverse effects of biomass on pulmonary functions was possibly due to better ventilation in the kitchens of subjects in the biomass group compared to previous studies.

Bronchoscopy in adults at a tertiary care centre: indications and complications.

Fibreoptic bronchoscopy (FOB) helps in visualisation of the endobronchial tree. Fibreoptic bronchoscopies were done in 429 cases between January 1999 and January 2000 [322 men (75.1%) and 107 women (24.9%)]. Patients were between 12 and 89 years of age (mean+/- SD = 49 +/- 15.1 years). Of which, 196 (45.7%) had lung cancer and 233 (54.4%) had non-malignant disease [Tuberculosis (TB) 26, miliary TB 16, non-resolving pneumonia 29, atypical pneumonia 10, bronchiectasis 11, aspergillosis 12, sarcoidosis 17, interstitial lung disease (ILD) 20, haemoptysis with normal chest x-ray 13 and miscellaneous 79]. In this series of 429 patients a significant number of patients (n = 127) presented with fever (38 malignant and 89 non-malignant disease, p < 0.0001), 137 had haemoptysis (74 malignant and 63 non-malignant disease, p < 0.01), 89 had chest pain (61 malignant and 28 non-malignant disease, p < 0.0001) and 29 patients presented with complaint of anorexia (21 malignant and 8 non-malignant disease, p < 0.003). High prevalence of lung lesions in the right upper lobe [10.4% (43 of 411)] and left main bronchus [12% (49 of 411)] was observed. Left upper lobe showed 8.7% (36 patients) lesions and right middle lobe showed 5.5% (23 patients) lesions. In 143 (34.8%) patients, FOB findings were normal. Out of 407 patients, FOB was suggestive of necrotic/nodular growth in 159 patients (39.1%), infiltrative growth in 8 patients (1.9%), and extrinsic compression was found in 39 patients (9.6%). In 143 patients (35.2%) no endobronchial growth was seen. Bronchial biopsy (BB) was performed in 162 (37.8%) patients, transbronchial lung biopsy in 56 patients (13.1%), bronchial washing for cytology in 350 patients (81.5%), bronchial washing for AFB in 302 patients (70.3%), bronchial washing for culture in 67 patients (15.6%), bronchial washing for fungus in 64 patients (14.9%) and Pneumocystis carinii infection was looked for in 6 patients (1.4%). Postbronchoscopy complications were recorded as follows: Early termination of FOB due to decreased O2 saturation in 10 cases (2.4%), postbiopsy bleeding in 5 cases (1.2%), post FOB fever in 5 cases (1.2%), chest pain in 7 patients (1.7%) and pneumothorax occurred in 2 patients (0.5%). FOB performed in outpatient setting is a useful and safe modality. Most patients in whom FOB was done in the present setup had suspected lung cancer. No major complications were encountered.

Pulmonary functions in patients with type 2 diabetes mellitus & correlation with anthropometry & microvascular complications.

BACKGROUND & OBJECTIVES: The purpose of this study was to evaluate pulmonary functions including respiratory muscle strength in patients with type 2 diabetes mellitus (T2DM) and to determine their correlations with anthropometric profile, glycaemic control, and microangiopathic diabetic complications. METHODS: Twenty nine patients with T2DM and 11 healthy control subjects were divided into the following three groups; (i) T2DM patients with any or a combination of microangiopathy(ies) (retinopathy, nephropathy, and peripheral neuropathy) (group 1, n=12); (ii) T2DM patients without any complications (group 2, n = 17); and (iii) a healthy control group (group 3, n=11). All patients were assessed with anthropometry, glycosylated haemoglobin (HbA1C), and lipid profile. Pulmonary functions were measured by spirometry. Pulmonary diffusion capacity for carbon monoxide (DLco) was measured by the steady state method. The presence of diabetic nephropathy was determined by 24 h protein excretion. RESULTS: A significant reduction of DLco was observed in group 1 (P<0.001), as compared to the other groups. There were no differences among the three groups for other pulmonary functions; forced vital capacity, forced expired volume in one second, peak expiratory flow rate, and maximal static inspiratory and expiratory pressures. Significant correlations were observed between DLco and the following parameters in group 1; HbA1c (r=0.62, P<0.05), total cholesterol level (r = -0.44, P<0.05) and creatinine clearance (r=0.42, P<0.05). INTERPRETATION & CONCLUSION: The present study shows that the impairment of pulmonary diffusion capacity for carbon monoxide was common in T2DM Asian Indian patients having microangiopathy. Pathophysiologically, it could be related to glycaemic control or dyslipidaemia. Correlation of % BF with DLCo needs to be explored further.