A decade long experience of anti-neutrophil cytoplasmic antibody testing in a tertiary care referral center in North India: Perspective from a developing country.

Background: In a developing, tropical country like India, discontinuous power supply, high temperatures during summer, and lack of consistent cold chain and funds provide a challenging atmosphere for anti-neutrophil cytoplasmic antibody (ANCA) testing and reporting. However, a simple in-house test and testing algorithm are described here, which have been developed and tested over time. Materials and Methods: An analysis of a decade of testing and reporting of ANCA in the Department of Immunopathology in a tertiary referral health care center was performed to highlight the importance of testing for ANCA in proposed 1999 guideline recommended indications. Results: A total of 4195 ANCA tests were conducted from 2000 to 2009. Overall, 2060 (49%) requests had indications which met the 1999 guidelines, while the remaining 2135 (51%) fell outside the guidelines. A total of 350 samples (8.3%) were positive for ANCA on indirect immunofluorescence (IIF), out of which 212 were guideline recommended and 138 (3.2%) were non-guideline recommended ANCA requests; thus, 3.2% of non-small vessel ANCA associated vasculitis (non-SVAAV) conditions showed false positive results when the population was otherwise unselected. Maximum requests (1432) were for rapidly progressive renal failure/acute renal failure. Conclusions: The audit shows that compliance with guidelines for ANCA testing would decrease the number of false positive results. In-house screening for ANCA by IIF is cost-effective and must be performed at least twice on two different samples from the same patient or on two different sets of ANCA preparations in all the cases who requested ANCA testing with a proposed 1999 guideline recommended indication.

Validation of a hindi translation of mini asthma quality of life questionnaire in North Indian patients with bronchial asthma.

Background and Objective. There is little information on validated health-related quality of life (HRQoL) instruments for use in Indian patients with bronchial asthma. We attempted to validate the Hindi translation of Juniper’s mini asthma quality of life questionnaire (MiniAQLQ) in north Indian patients with bronchial asthma. Methods. Hindi translation of MiniAQLQ, and abbreviated World Health Organization quality of life questionnaire (WHOQOL-Bref), were administered to 30 patients with bronchial asthma twice at a six-week interval. Clinical and physiological data were also recorded. Psychometric properties (acceptability, validity, reliability and responsiveness) of MiniAQLQ were assessed after calculating four domain (physical, psychological, social relationships and environment), and a total score. Results. Most questionnaires were returned without missing responses. MiniAQLQ had good convergent and discriminant validity, but moderate content and construct validity. All components (except emotional function domain) met standards for internal consistency (Cronbach’s alpha coefficient >0.70), but intra-class correlation coefficients were variable. Change in MiniAQLQ scores between two assessments correlated poorly with corresponding changes in lung function. The effect sizes ranged from 0.02 to 0.34 in 11 patients whose forced expiratory volume in the first second (FEV1) changed by >200mL and >12% from baseline, and were considered small. Conclusion. The Hindi translation of MiniAQLQ is a moderately good discriminative and a relatively poor evaluative instrument to assess health related quality of life (HRQoL) in north Indian patients with bronchial asthma.

Manifestations of pulmonary tuberculosis in the elderly: a prospective observational study from north India.

BACKGROUND: There is scarcity of published literature on manifestations of pulmonary tuberculosis (PTB) among elderly patients in India. The aim of the present study was to compare the clinical, radiological and laboratory manifestations of PTB among young and elderly patients. METHODS: This prospective study involved 100 human immunodeficiency virus (HIV) negative patients with PTB. The demographic, clinical, radiological and laboratory manifestations were compared between young (n=50; under 60 years of age) and elderly (n=50; aged 60 years and above) with PTB. RESULTS: Elderly patients, in comparison to younger patients, tended to be heavier smokers and had more co-morbidities (40% vs 8%; p < 0.05). They presented more frequently with constitutional symptoms (except fever) and less frequently with respiratory symptoms. The mean duration of symptoms and rate of sputum smear-positivity for acid-fast bacilli was similar in both groups. Both the groups were similar with respect to physical examination and chest radiograph findings. Median values of erythrocyte sedimentation rate and total leukocyte count were significantly higher and lower respectively in the elderly patients. CONCLUSIONS: The presentation of PTB in elderly patients differs from that of younger patients by the predominance of constitutional rather than respiratory symptoms. A high index of suspicion is required to make a timely diagnosis of tuberculosis in the elderly.

Emergence of chronic obstructive pulmonary disease as an epidemic in India.

Chronic obstructive pulmonary disease (COPD), hitherto underdiagnosed in India, is now recognized in 4-10 per cent of adult male population of India and several other Asian countries. The Regional COPD Working Group for 12 Asia Pacific Countries and Regions used a COPD prevalence model and estimated an overall prevalence rate of 6.3 per cent with a range from 3.5 to 6.7 per cent. The smoking associations with COPD were high from most countries i.e., 2.65 in India, 2.57 in China and 2.12 in Japan. In a large, multicentric study from India, the population prevalence of COPD was 4.1 per cent of 35295 subjects with a male to female ratio of 1.56:1. Almost all forms of smoking products such as cigarettes and 'bidis' used in different States were found to be significantly associated with COPD. In non-smokers, especially women, exposures to indoor air pollution from domestic combustion of solid fuels was an important factor. More significantly the exposure to environmental tobacco smoke (ETS) was an established cause for COPD. The odds ratio for risk from ETS exposure in non-smokers (1.535) was on significant during both the childhood and the adulthood. On an average, an Indian COPD patient spent about 15 per cent of his income on smoking products and up to 30 per cent on disease management. Tobacco smoking was also the most frequent cause of chronic cor pulmonale which occurred as a long term complication of COPD both amongst men and women.

Role of simple needle aspiration in the management of pneumothorax.

OBJECTIVES: To determine the role of simple needle aspiration in the management of pneumothorax. DESIGN: All patients presenting with a pneumothorax requiring intervention were included in this prospective study. Patients who were very sick or had tension pneumothorax were treated with direct intercostal chest tube drainage (ICTD) and others were subjected to simple aspiration. The procedure was deemed successful, if after aspiration the lung expanded completely or symptoms were relieved with residual pneumothorax of less than 15% of hemithorax. In case of failed aspiration ICTD was carried out. RESULTS: Fifty-seven patients with 59 pneumothoraces were included in the study. Of these, 24 were treated with direct ICTD; 35 (12 spontaneous, 11 secondary and 12 iatrogenic pneumothoraces) were subjected to simple aspiration. Ten (83.3%) of the primary, 1 (9.6%) of the secondary and 11 (91.7%) of the iatrogenic pneumothoraces responded to simple aspiration. There were no significant complications. The pain perceived and the duration of hospital stay was significantly lesser in the simple aspiration group. CONCLUSIONS: Simple aspiration should be the initial modality of treatment for primary spontaneous and iatrogenic pneumothoraces. For secondary spontaneous pneumothorax and in conditions where pleurodesis is indicated, ICTD remains the treatment of choice.

Role of socio-economic factors in tuberculosis prevalence.

Background: There is a need to re-assess the role of generally identifiable risk factors for development of tuberculosis (e.g. old age, poverty and poor socio-economic status). The present study was designed to look into the socio-economic and demographic characteristics of patients of tuberculosis (TB) vis-à-vis those with other respiratory diseases in the area in and around Chandigarh. Setting: Chest Clinic of a tertiary care hospital. Design: Case-control study Material and Methods: Two hundred and fifty consecutive cases of TB and an equal number of patients with pulmonary diseases other than tuberculosis as controls were interviewed as per a pre-designed, structured questionnaire that inquired into several socio-economic and demographic variables besides the clinical details. Univariate and multiple logistic regression analyses were carried out to obtain odds ratios separately for each variable. Results: The mean age of patients suffering from tuberculosis was 35.56 years (SD 13.69). There were 168 men (67.2%) and 82 (32.8%) women among the cases. Persons suffering from tuberculosis were more frequently found to have the worst of the socio-economic conditions for all the variables. Odds ratio (OR) increased by 3.14 (95% CI 2.48-3.98, p<0.001) for every decrease of Rs.500/- in the income level per person per month below Rs.2000/-. Similarly, the OR increased by 3.66 (CI 2.9-4.61,p<0.001) with increasing number of persons per room. The ORs for poorer housing, toilet facilities, water supply and consumer articles were also significant. In multivariate logistic regression analysis, the age, level of education, crowding, type of housing, water supply and number of consumer articles in the household was found to be independently and significantly associated with a higher risk of TB. Conclusion: There is a significant SES-health gradient in TB prevalence; tuberculosis risk increases with lowering of socio-economic status.