Tobacco cessation outcomes in a cohort of patients attending a chest medicine outpatient clinic in Bangalore city, southern India.

Background & objectives: Nicotine dependence is a widely prevalent and harmful chronic addictive disorder. Quitting tobacco use is however, uncommon in India. We present long-term treatment outcomes of out-patient, tobacco cessation treatments from a specialty clinic setting in southern India. Methods: Patients seen in a tobacco cessation clinic were characterized for tobacco use, nicotine dependence and motivation for quitting and offered pharmacologic/non-pharmacologic treatment. They were subsequently contacted telephonically at a mean (±standard deviation) of 24 (±9.1) months to assess tobacco cessation outcome defined as ‘point prevalence of 1-month abstinence’ by self-reporting. Results: The mean age of participants was 48.0 ±14.0 yr. Tobacco use distribution was: beedis only (22%), cigarettes only (49%), beedis and cigarettes (18%), chewing only (2%), and smoking and chewing (9%). Two-thirds had high level of nicotine dependence. Of the 189 patients enrolled, only 15 per cent attended follow up clinics. Only 106 (56%) patients were successfully contacted telephonically and 83 (44%) were lost to follow up. Self-reported point prevalence abstinence was 5 per cent by ‘intent-to-treat’ analysis and 10 per cent by ‘responder’ analysis. Two clinical parameters – high level of nicotine dependence [estimated by the heaviness of smoking index (HSI)] and the absence of vascular or other chronic disease were found to be associated with successful quitting; these were however, not significant on multivariate analysis. Interpretation & conclusions: Our study has identified low quit-rates in a cohort of patients attending a hospital-based tobacco cessation clinic. In the absence of clear-cut predictors of cessation with low quit-rates, there should be continued efforts to improve cessation outcomes and identify predictors for action.

Measurement of 24 h energy expenditure in male tuberculosis patients.

BACKGROUND & OBJECTIVES: The total daily energy expenditure in patients with infectious disease is presumed to be high because of an increase in the basal metabolic rate (BMR), a reason for the weight loss observed in these patients. A reduction in daily physical activity, which may reduce the total daily energy expenditure. The aim of this study was to measure the free living total daily energy expenditure and physical activity of newly diagnosed hospitalized patients with tuberculosis using the labelled bicarbonate method. METHODS: In 6 healthy volunteers and 6 patients with newly diagnosed tuberculosis, 13C labelled bicarbonate method was used to measure free living total daily energy expenditure and physical activity. The 13C sodium bicarbonate (NaH13CO3) tracer was infused intravenously over a 48 h period and breath samples collected at regular intervals to estimate expired 13CO2. RESULTS: The patients had a 14 per cent increase in their BMR although they were not febrile at the time of measurement. However, their total daily energy expenditure was lower than that of the controls (mean value of 8.3 and 10.3 mJ/day respectively) and their physical activity level was also lower (mean 1.4 and 1.6 units respectively). INTERPRETATION & CONCLUSION: The total daily energy expenditure of afebrile patients with newly diagnosed tuberculosis is not higher than that of sedentary controls, despite an increased basal metabolic rate. It is possible that the observed weight loss in patients with tuberculosis is due to a reduced energy intake linked to anorexia associated with the disease. These findings may have relevance in nutritional treatment of chronic infections.

NK/T-cell lymphoma in AIDS.

A 42-year-old man diagnosed to be HIV positive and on highly active antiretroviral treatment (HAART), presented with double vision and gradual drooping of the left eyelid. He had left 3rd cranial nerve palsy and partial right lower-motor-neuron facial palsy. CT of the PNS revealed soft tissue filling the right maxillary sinus antruin. Further workup showed the mass to be an NK/T cell lymphoma.

Household environmental tobacco smoke exposure, respiratory symptoms and asthma in non-smoker adults: a multicentric population study from India.

BACKGROUND: Exposure to environmental tobacco smoke (ETS) is a risk factor for childhood asthma. Its association with asthma in adults is less clear. METHODS: In a multicentric population study on asthma prevalence in adults, specific enquiries were made into childhood and adulthood exposure to household ETS, and its relationship with asthma diagnosis were analysed. RESULTS: From a total of 73605 respondents, 62109 were studied after excluding current or past smokers. Overall observed prevalence of asthma was 2.0% (men 1.5%,women 2.5%, p < 0.001). Of all asthma patients, history of ETS exposure was available in 48.6 percent. Prevalence of asthma in the ETS exposed subjects was higher compared to non-exposed individuals (2.2% vs 1.9%, p < 0.05). Multiple logistic regression analysis showed a higher risk of having asthma in persons who were exposed to ETS compared to those not exposed (odds ratio [OR] 1.22, 95% CI 1.08-1.38) after adjusting for age, gender, usual residence, exposure to biomass fuels and atopy. Stratification of ETS exposure revealed that exposure during childhood and both during childhood and adulthood were significantly associated with asthma prevalence. Exposure only in adulthood was not a significant risk factor (OR 1.13, 95% CI 0.95-1.33). Persons reporting combined environmental tobacco smoke exposure from parents during childhood and spouse during adulthood had highest risk of having asthma (OR 1.69, 95% CI 1.38-2.07). Environmental tobacco smoke exposure was also significantly associated with prevalence of respiratory symptoms such as wheezing, cough and breathlessness. CONCLUSIONS: Environmental tobacco smoke exposure during childhood is an important risk factor for asthma and respiratory symptoms in non-smoking adults.

Tobacco smoking in India: prevalence, quit-rates and respiratory morbidity.

BACKGROUND: Population prevalence of tobacco smoking especially with reference to detailed habits such as the amount smoked, the smoking forms, quit-rates and relationship with demographic variables were studied at four different centres in India along with the study on epidemiology of asthma and chronic obstructive pulmonary disease. METHODS: The study population included adults of over 15 years of age selected with two-stage stratified random sample design. A specifically designed questionnaire was used for the study. RESULTS: There were 11496 (15.6%) ever smokers in the study sample of 73605 subjects. Among 37682 males, 10756 (28.5%) were ever smokers and among 35923 females, 740 (2.1%) were ever smokers. Bidi was the commonest form of smoking, more so in the rural areas. The mean number of cigarettes/bidis smoked per day was 14 (+/- 11.5) and the mean age of starting smoking was 20.5 (+/- 20.0) years. Increasing age, low socio-economic status and rural residence were important factors associated with smoking. Vigorous anti-tobacco measures under the tobacco control programmes yielded only a quit-rate of 10 percent. Nearly 14% of ever smokers had some respiratory symptoms. CONCLUSIONS: A substantial proportion of population in India has current or past smoking habit with higher prevalence among males than females. The quit-rates have been low in spite of the various anti-tobacco measures. There is a significant respiratory morbidity associated with smoking.

Prevalence and risk factors for bronchial asthma in Indian adults: a multicentre study.

BACKGROUND: There is limited information on field epidemiology of bronchial asthma in Indian adults. OBJECTIVES: To estimate prevalence of bronchial asthma in different regions of India and to define risk factors influencing disease prevalence. METHODS: A field study was conducted at Chandigarh, Delhi, Kanpur and Bangalore through a two stage stratified (urban/ rural) sampling and uniform methodology using a previously validated questionnaire. Asthma was diagnosed if the respondent answered affirmatively both to (a) whistling sound from chest, or chest tightness, or breathlessness in morning, and (b) having suffered from asthma, or having an attack of asthma in the past 12 months, or using bronchodilators. Besides demographic data, information on smoking habits, domestic cooking fuel used, atopic symptoms, and family history suggestive of asthma was also collected. Univariate and multivariate logistic regression modelling was performed to calculate odds ratio of various potential risk factors. RESULTS: Data from 73605 respondents (37682 men, 35923 women) were analysed. One or more respiratory symptoms were present in 4.3-10.5% subjects. Asthma was diagnosed in 2.28%, 1.69%, 2.05 and 3.47% respondents respectively at Chandigarh, Delhi, Kanpur and Bangalore, with overall prevalence of 2.38%. Female sex, advancing age, usual residence in urban area, lower socio-economic status, history suggestive of atopy, history of asthma in a first degree relative, and all forms of tobacco smoking were associated with significantly higher odds of having asthma. CONCLUSION: Prevalence estimates of asthma in adults in this study, although lower than several previously reported figures, point to a high overall national burden of disease.

A multicentric study on epidemiology of chronic obstructive pulmonary disease and its relationship with tobacco smoking and environmental tobacco smoke exposure.

INTRODUCTION: Population prevalence of chronic obstructive pulmonary disease (COPD) and its relationship with tobacco smoking, environmental tobacco smoke (ETS) exposure and other variables were studied in adult subjects of 35 years and above at four different centres in India. Question-items for the diagnosis of COPD were included in the questionnaire used for the field study on asthma epidemiology. METHODS: Field surveys were conducted in both the urban and the rural populations at Bangalore, Chandigarh, Delhi and Kanpur with the help of a structured and validated questionnaire for diagnosis of asthma and COPD. Separate sets of questions were used for the diagnoses of the two diseases. A two-stage stratified sample design was employed where a village or an urban locality formed the first stage unit and a household formed the second stage unit. A uniform methodology was used at all the four centres and the analyses were done at the central coordinating centre--Chandigarh. Chronic obstructive pulmonary disease, defined by chronic bronchitis (CB) criteria, was diagnosed from the presence of cough and expectoration on most of the days for at least three months in a year for two consecutive years or more. RESULTS: Chronic obstructive pulmonary disease was diagnosed in 4.1% of 35295 subjects, with a male to female ratio of 1.56:1 and a smoker to nonsmoker ratio of 2.65: 1. Prevalence among bidi and cigarette smokers was 8.2% and 5.9%, respectively. Odds ratio (OR) for COPD was higher for men, elderly individuals, lower socio-economic status and urban (or mixed) residence. Environmental tobacco smoke exposure among nonsmokers had an OR of 1.4(95% CI 1.21-1.61). Combined exposure to both ETS and solid fuel combustion had higher OR than for ETS exposure alone. CONCLUSIONS: Population prevalence of COPD is very high in India with some centre to centre differences. Smoking of both bidis and cigarettes, and ETS exposure among nonsmokers, were two important risk factors at all centres. It is important to employ uniform methodology for assessment of national burden and disease-surveillance programme.

Turpentine-induced chemical pneumonitis with broncho-pleural fistula.

Turpentine is a volatile hydrocarbon used in polishes, solvents, paints and textile industry. When hydrocarbons are aspirated into the lung, they cause chemical pneumonitis, acute respiratory distress syndrome (ARDS), and rarely pneumatoceles and pneumothorax. We report a 20-year old boy with turpentine-induced chemical pneumonitis that evolved into a bronchopleural fistula. He was treated with oxygen, steroids and intercostal tube drainage. This is the first reported case of turpentine-associated bronchopleural fistula.

Cognitive behavioural intervention in bronchial asthma.

OBJECTIVE: The aim of the present study was to find out the efficacy of cognitive behaviour therapy, as an adjunct to standard pharmacotherapy in bronchial asthma. DESIGN: An experimental design with pre- and post-therapy assessments was adopted. SETTING: The Medicine Out-patient Department of St. John's Medical College and Hospital, and Department of Clinical Psychology, NIMHANS, Bangalore. PATIENTS: Ten asthma patients who fulfilled the inclusion and exclusion criteria, matched for use of drugs, were sequentially allotted to two groups: a) experimental group, who were exposed to cognitive behaviour therapy along with standard pharmacotherapy, b) control group, who were exposed to standard pharmacotherapy alone. INTERVENTION: Cognitive behaviour therapy included 15 individual sessions consisting of asthma education, Jacobson progressive muscle relaxation (JPMR), behavioural techniques, cognitive restructuring, cognitive coping skills and behavioural counseling to significant others. MEASUREMENTS: The measures used for pre- and post-therapy assessments were--Asthma symptom checklist, asthma diary, state trait anxiety inventory-Y1 and Y2, Beck depression inventory, asthma quality of life questionnaire and peak expiratory flow rate. RESULTS: There was significant decrease in asthma symptoms, anxiety and depression; and significant increase in quality of life in the experimental group (p < 0.05) at the post-assessment. The control group did not show any significant change at the post-assessment. CONCLUSION: Cognitive behaviour therapy helps in improving the management of asthma.

Respiratory complications in postoperative patients.

OBJECTIVES: This study was conducted to see the extent of respiratory morbidity in the general surgical unit of a teritiary care teaching hospital and to look for probable factors that were responsible for them. METHODS: A prospective study was conducted over a six month period, of patients who underwent both elective and emergency surgeries. Patients were assessed pre-operatively, on the fifth post operative day and at the time of discharge for respiratory complications. RESULTS: Five hundred eighty four consecutive patients who underwent surgeries were studied. Eighty one of them (13.9%) had respiratory complications. Pneumonia was the most common complication (68%). The others included pleural effusion, empyema, pneumothorax and exacerbations of asthma and chronic obstructive pulmonary disease (COPD). One patient developed ARDS (Adult respiratory distress syndrome) and died. Patients who underwent upper abdominal surgery (both elective and emergency), those who had a stay in the surgical ICU for more than 24 hours and those who were on the ventilator for more than 24 hours had a higher incidence of respiratory complications (p < 0.001). CONCLUSION: Respiratory complications increase the morbidity in post operative patients. Pre-operative respiratory illnesses, upper abdominal surgery, ICU stay and mechanical ventilation in the post-operative period predispose patients to respiratory complications. Pre-operative respiratory assessment and treatment of any underlying respiratory disorder is necessary and may decrease the morbidity in surgical patients.

Bronchial responsiveness of non-smoking women exposed to environmental tobacco smoke or biomass fuel combustion.

We studied bronchial responsiveness (BR) in three groups of housewives with or without history of exposure to tobacco smoke or combustion of biomass fuels. Methacholine bronchoprovocation test was used to study BR. The group I subjects (60), who served as controls, were nonsmokers and had no chronic exposure to passive smoking or environmental tobacco smoke (ETS) or biomass fuels. Three of these women showed a 20 per cent FEV1 fall with a cumulative methacholine dose of 72.5 mg or less. Of 60 women in group II (ETS-exposure) and 52 in group III (biomass exposure), 26 (43.3%) and 10 (19.2%) respectively showed bronchial hyper-responsiveness (BHR). The odds ratios for BHR in groups II and III were 14.53 and 4.52 respectively. The number of hyper-responders was significantly more and the mean PD20 less in the exposed than the non-exposed groups. The occurrence of BHR in the ETS exposed group was more (P < 0.05) than the biomass combustion group. There were more hyper-responders (both groups II and III) amongst those who had an exposure index (EI) of 50 or more compared to those with EI of less than 50. We conclude that chronic cumulative exposure to both ETS and biomass combustion produces significant BHR. Further, BHR developed more often on ETS exposure, and when the exposure was present for a longer period.

Bronchoalveolar lavage--cellular characteristics in patients with idiopathic pulmonary fibrosis and sarcoidosis.

Bronchoalveolar lavage (BAL) was carried out in 30 patients of idiopathic pulmonary fibrosis (IPF), 10 patients of sarcoidosis and 10 normal subjects who served as controls. The total cell counts were higher both in the IPF (24.8 x 10(5)/ml) and sarcoidosis (19.3 x 10(5)/ml) as compared to the normal controls (9.8 x 10(5)/ml). The difference was statistically significant in both the groups (p less than 0.001 and less than 0.05 respectively). Patients with IPF showed a predominant polymorphonuclear response although the lymphocytes were also increased whereas patients of sarcoidosis had a lymphocytic response in the BAL fluid. In 6 patients with IPF the study was repeated after 6 weeks of steroid therapy and a decrease in the total cell count and polymorphonuclear cells (%) was noted.

Transbronchial lung biopsy in diffuse lung disease--a study of 28 cases.

Twenty-eight patients with diffuse lung disease underwent transbronchial lung biopsy during fibreoptic bronchoscopy. In 26 patients (93%) adequate tissue was obtained. Of these 26 biopsies specific diagnosis was possible in 20 (76%); a further 2 had non-specific inflammatory changes and a third, who was clinically normal, had normal lung. The inclusion of these cases raises the yield to 88%. The conditions most frequently seen were interstitial fibrosis (35%) and granulomatous diseases (31%). Three patients (11%) had procedure related pneumothorax; only one required a chest tube. This is a high yield, safe procedure and should be used more widely in India.