Screening for Lung Cancer in India: Expert Opinion Statement.

Lung cancer (LC) has the highest rate of disability-adjusted life years (DALY) of all cancers in India. A large majority of patients with LC present with advanced disease, resulting in poor survival rates. Early diagnosis can improve survival outcomes as the patients can be treated with curative intent. The National Lung Screening Trial (NLST), in 53,454 persons at high risk for LC in the US, showed a 20% (95% confidence interval of 6.8-26.7; p = 0.004) relative reduction in LC-specific mortality in the patients screened with low-dose computed tomography (LDCT) compared with chest X-ray. To date, India does not have a formal LC screening (LCS) program. As a panel of experts, we reviewed a synthesis of a targeted literature search on the burden of LC, the current status of diagnosis of LC, barriers to early diagnosis, current referral pathways, LC risk patterns, use of artificial intelligence (AI) and risk calculators for risk assessment, and a multidisciplinary team (MDT) approach to diagnosis LC. We used the existing international LCS guidelines, data from published literature, and clinical experience to depict the characteristics of the population at risk of LC in India-young age (<40 years), smoking, especially the predominance of bidi smoking (an indigenous form of tobacco smoking), exposure to biomass fuel smoke, especially in rural women, and air pollution being the prominent features. LC in India is characterized by a higher rate of driver mutations and adenocarcinomatous histology. Here, we present the expert opinion on risk-based LCS in India and discuss the challenges, facilitators, and research priorities for the effective rollout of LCS in India.

Atrial depolarization abnormalities in pulmonary sarcoidosis.

BACKGROUND: Cardiac sarcoidosis, often manifested as sudden death, can be the first manifestation of sarcoidosis. Since 12-lead electrocardiogram (ECG) is recommended as an initial screening tool for cardiac sarcoidosis, the recognition of subtle abnormalities assumes utmost significance. The objective of this study was to identify the electrocardiographic abnormalities in patients with pulmonary sarcoidosis. RESULTS: A detailed analysis of 12-lead ECGs obtained from sixty patients with histopathologically proven pulmonary sarcoidosis and no overt cardiac involvement was done. The findings were compared with those of an age-matched control group. Varying degrees of intraventricular conduction defects were common in the study group [67%], as well as the control group [57%] [P = 0.23]. There was a higher prevalence of biphasic P wave [P = 0.003] and bifid P wave [P = 0.029] in lead III and rsr' in lead aVF [P = 0.03] in the study group as compared to the control group. CONCLUSIONS: Our study demonstrates a greater prevalence of subtle ECG abnormalities in patients with pulmonary sarcoidosis as compared to patients with other forms of pulmonary disease. Atrial depolarization abnormalities were commoner in patients with pulmonary sarcoidosis.

Single Dose of Ivermectin is not Useful in Patients with Hematological Disorders and COVID-19 Illness: A Phase II B Open Labelled Randomized Controlled Trial.

Repurposed drugs may reduce morbidity and mortality in patients with hematological disorders who develop COVID-19 illness. 112 patients with predominantly hematological illnesses were randomized to receive standard of care, ivermectin 12 mg [Iv 12] or 24 mg [Iv24] for asymptomatic, mild, or moderate COVID 19 illness. Serial respiratory samples for rRT-PCR samples were sent on Day 3, 5 and 7. rRT-PCR negativity and ≥ 2 log10 reduction in viral loads on day 3, 5 and 7 were similar between the 3 treatment groups across all disease categories. Symptom progression occurred in 26 patients [21.6%] with no difference across 3 treatment groups. Twenty-two patients [18.3%] have expired while 98 [81.7%] survived. Survival rates were similar across treatment groups [controls-80.5%, Iv12-77.5%, Iv24-87.2% respectively]. Overall, poorer survival was seen with moderate illness compared to others [51.6% vs 92.1%; p = 0.000] and was the only significant risk factor identified on multivariate analysis. In this Phase II randomised trial, single dose of 12 or 24 mg of ivermectin did not reduce viral loads, prevent symptom progression, or reduce mortality in patients with predominantly haematological illnesses who develop mild to moderate COVID 19 illness.

Good survival rate, moderate overall and good respirator quality of life, near normal pulmonary functions, and good return to work despite catastrophic economic costs 6 months following recovery from Acute Respiratory Distress Syndrome.

Introduction: Long-term quality of life, return to work, economic consequences following Acute Respiratory Distress Syndrome (ARDS) are not well described in India. This study was aimed to address the question. Methods: A prospective cohort study of 109 ARDS survivors were followed up for a minimum of 6 months following discharge. Quality of life was assessed using the SF-36 questionnaire. Respiratory quality was assessed using the St Georges Respiratory Questionnaire. Time to return to work was documented. Costs-direct medical, as well as indirect were documented up to 6 months. Results: At 6 months, 6/109 (5.5%) had expired. Low energy/vitality and general heath were noted in the SF-36 scores at 6 months; overall a moderate quality of life. Pulmonary function tests had mostly normalized. Six-min walk distance was 77% of predicted. Respiratory quality of life was good. It took at the median of 111 days to go back Interquartile range (55-193.5) to work with 88% of previously employed going back to work. There were no significant differences in the severity of ARDS and any of these outcomes at 6 months. The average total cost from the societal perspective was ₹ 231,450 (standard deviation 146,430-, 387,300). There was a significant difference between the 3-ARDS severity groups and costs (P < 0.01). There were no independent predictors of return to work. Conclusion: ARDS survivors have low 6-month mortality. Pulmonary physiology and exercise capacity was mostly normal. Overall, quality of life is average was moderate, while respiratory quality of life was good. Return to work was excellent, while cost of care falls under a catastrophic heath expense.

Rare cause of paradoxical worsening of pleural effusion in a patient with tuberculosis.

A 33-year-old patient, Known case of chronic kidney disease on maintenance dialysis presented with complaints of low-grade fever and weight loss of 2 months duration. Computed tomography (CT) revealed bilateral mild pleural effusion with significant mediastinal and abdominal adenopathy. CT-guided fine-needle aspiration cytology of abdominal lymph nodes and bone marrow culture was suggestive of tuberculosis. The patient was started on four drug anti-tubercular therapy, post 6 weeks of initiation he developed new onset fever and chest X-ray revealed moderate right pleural effusion. Diagnostic thoracocentesis was suggestive of chylothorax. To the best of our knowledge, this is the first case report of chylothorax due to the paradoxical reaction in the HIV-negative tuberculous patient.

Prevalence of Hepatotoxicity From Antituberculosis Therapy: A Five-Year Experience From South India.

BACKGROUND: Antituberculosis (ATT) drug-induced liver injury (DILI) is a common and serious adverse effect of tuberculosis (TB) treatment. This retrospective study was carried out to study the prevalence of DILI among patients who had received anti-TB medications and to study some of the known risk factors responsible for causing DILI. MATERIALS AND METHODS: This longitudinal descriptive study was performed to evaluate cases of DILI with predefined criteria. Patients of all ages, diagnosed and treated for smear positive pulmonary TB from January 1, 2008 to December 31, 2012 and those who came for regular follow-up were included in the study. Multiple logistic regression analysis was performed to determine the association of different risk factors and DILI. The confounders considered were age, sex, weight, body mass index, doses of drugs (fixed or per kg), ATT regimens (daily or intermittent), and treatment categories. RESULTS: Of the 253 patients analyzed, 24 (9.48%) developed DILI. Associations of different risk factors were insignificant; including chronic alcohol consumption, hepatitis B infection, hepatitis C infection, HIV infection, and existing chronic TB. CONCLUSION: DILI was not significantly associated with known risk factors in our settings.

Disseminated Salmonella Infection Coexisting with Thymoma.

A 21-year-old boy presented with high grade fever, diffuse chest pain and exertional breathlessness of one month duration. Radiologically he had a large lobulated anterior mediastinal mass with necrotic thick enhancing septaes. Histopathology of the mass was suggestive of thymoma and culture from the necrotic aspirate yielded Salmonella typhi. The same pathogen was isolated in subsequent blood and sputum cultures. This current report describes the rare association of salmonella infection with thymoma.

Endobronchial pulmonary cryptococcosis and tuberculosis in an immunocompetent host.

Pulmonary cryptococcosis presenting as an endobronchial tumour-like growth has rarely been described. We report the case of a male patient with normal immune function who presented with a right upper lobe mass lesion. Bronchoscopy revealed a tumour-like growth that completely occluded the anterior segment of the right upper lobe bronchus. Bronchial biopsy and computed tomography-guided lung biopsy revealed Cryptococcus, and culture of lung biopsy specimen grew Cryptococcus neoformans and Mycobacterium tuberculosis. The patient responded clinically to amphotericin B, fluconazole and anti-tuberculous therapy. However, chest radiographic response was unremarkable. A presentation of pulmonary cryptococcosis and tuberculosis, along with endobronchial tumour-like growth in the same patient, is unusual and has not been previously described.

Evaluation of the diagnostic yield and safety of closed pleural biopsy in the diagnosis of pleural effusion.

AIM: To assess the diagnostic yield and safety of closed pleural biopsy in patients with pleural effusion. METHODS: In all, 48 consecutive cases of pleural effusion were evaluated with complete pleural fluid biochemical and microbiological analysis, cytology, routine bacterial and mycobacterial cultures. In all these 48 cases of pleural effusion closed pleural biopsy was done with tru-cut biopsy needle and biopsy samples were sent for histopathology and mycobacterial culture. RESULTS: Out of 48 cases, main causes of pleural effusion were Tuberculosis in 21(43.8%) cases, Malignancy in 14 (29.2%) cases, paramalignant effusion in six (12.5%) cases, Empyema in three (6.3%) cases, transudative effusion in three (6.3%) cases and parapneumonic effusion in one (1.9%) case. Diagnostic yield of closed pleural biopsy was 62.2% in cases of all exudative pleural effusion, 76.2% in cases of tubercular pleural effusion and 85.7% in cases of malignant pleural effusion. There was no incidence of post pleural biopsy pneumothorax or hemothorax, underlining the safety of pleural biopsy procedure. CONCLUSION: Closed pleural biopsy provides the highest diagnostic yield in cases of pleural tuberculosis and malignancy, the two most important causes of exudative pleural effusion. In view of low cost, easy availability and very low complication rates, it is a very important diagnostic tool in the hands of a trained pulmonary physician in India.

Endotracheal tuberculous stenosis: ventilation rescue and bronchography guided stenting.

We present the case of a 16-year-old female patient who presented with dyspnoea, cough and noisy breathing that progressed further in hospital with the development of stridor and severe respiratory compromise requiring mechanical ventilatory support. Investigations were consistent with a diagnosis of endotracheal tuberculosis with tracheal and bronchial stenosis. Despite adequate anti-tuberculous therapy and ventilation the patient had high airway pressures, low tidal volumes and hypercapnia, which prevented weaning from mechanical ventilation. Balloon dilatation and stenting of the 4.5cm long, 2.3mm diameter stenotic tracheal segment was performed under radiological guidance. The patient was weaned successfully from the ventilator post-procedure. This report illustrates the successful management of an uncommon presentation of a common disease with modern endoscopic therapy.

Idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is being more frequently diagnosed in India, due to its increased awareness, better availability of computed tomography (CT) and fiberoptic bronchoscopy. IPF has the histological appearance of usual interstitial pneumonia (UIP) on surgical lung biopsy. Recent research has given a new insight into the etiology of the disease. Clinical criteria have been specified for presumptive diagnosis of IPF and distinguishing IPF from other conditions. The conventional therapy has been steroids and immunosuppressive agents. But only a minority of patients respond to such a therapy. Immunomodulators (interferon Y1b), antioxidants (Acetyl cysteine) and antifibrotic agents (like pirfenidone) are being studied as novel therapies in this, otherwise, fatal condition. Lung transplantation is the only hope for those patients who show progressive deterioration on medical treatment. Living-donor lobar lung transplantation has been developed as a procedure for patients considered too ill to await cadaveric lung transplantation.

Strongyloidosis hyperinfection in a neutropenic host diagnosed by bronchoalveolar lavage.

Opportunistic disseminated strongyloidosis is an important cause of morbidity and mortality in immunocompromised patients. In addition to a high index of clinical suspicion, alerting the microbiologist will help in diagnosing this condition early and institute therapy. We report a 51-year-old male who developed pulmonary infiltrates during the period of chemotherapy-induced neutropenia. Strongyloidosis larvae were found on bronchoalveolar lavage fluid and stool specimens. The patient responded to treatment with albendazole.

Circulating D-dimers as a marker of disease activity in pulmonary sarcoidosis.

BACKGROUND AND AIMS: The search is on to find an easily measurable marker of disease activity in sarcoidosis. The present study was carried out to evaluate the utility of plasma D-dimer as a marker of disease activity in sarcoidosis. METHODS: Thirty newly diagnosed cases of sarcoidosis with clinical indications for treatment and an equal number of matched healthy controls were studied for the presence of D-dimers (DD) in the plasma before starting treatment with oral prednisolone and after clinical remission. Semi-quantitative estimations of DD were done using the latex agglutination slide test method (Commercial Kit - Diagnostica Stago, France) as per the manufacturer's recommendations. RESULTS: The mean age of cases and controls were 45.43 +/- 8.5 (range 34-60) and 46.16 +/- 8.07 (range 32-61) years, respectively. Of the 30 patients, nine (30%) were DD positive at baseline. The DD positive patients presented more often with dyspnoea, had radiological stage III (7 out of 9) disease and abnormal spirometry compared to patients with no detectable DD in their plasma. Of the 16 patients re-evaluated after clinical remission, eight (50%) were D-dimer positive. Two of the five patients initially DD positive had become negative and five additional patients who were negative at baseline had become positive. CONCLUSIONS: Plasma D-dimers, which were positive in 30% of untreated patients of sarcoidosis, indicate patients with significant pulmonary parenchymal involvement; but have no correlation with clinical disease remission.

Profile of repeat fiberoptic bronchoscopy.

BACKGROUND: Fiberoptic bronchoscopy (FOB) is invaluable in the diagnosis of a variety of pulmonary diseases, but in many instances the procedure has to be repeated because of an inconclusive initial FOB or for reassessment. METHODS: A retrospective analysis of all the fiberoptic bronchoscopic procedures done between September 2000 and February 2003 was performed and details of patients undergoing repeat FOB abstracted. RESULTS: Of the 2,270 bronchoscopies performed on 2114 patients, 132 procedures were repeated, yielding an over all frequency of repeat FOB of 6.34 percent. Bronchoscopy was done twice in 112 patients, thrice in 16 patients and four times in four patients. The commonest diagnosis in patients undergoing repeat bronchoscopy was bronchogenic carcinoma, followed by non-resolving pneumonia or presence of pulmonary infiltrates in immunocompromised host. The major indications for repeating FOB included obtaining specimens for pathological examination, pre and postoperative evaluation of airways, localization of site of bleeding in patients with hemoptysis, and placement of catheters for intraluminal brachytherapy. Of the 88 cases undergoing repeat bronchoscopy for diagnostic purposes, 41 (46.6%) yielded positive results, either in form of positive histology or localisation of source of hemoptysis. CONCLUSIONS: The frequency of repeat bronchoscopy was low. Commonest indication for a repeat procedure was to obtain repeat/additional diagnostic samples. A repeat procedure can yield positive results even when the initial FOB is nondiagnostic.

Indoor air pollution as a risk factor for lung cancer in women.

OBJECTIVES: Tobacco smoking is the most common risk factor for lung cancer. But a significant proportion of lung cancer occurs in non-smokers. Indoor pollution due to domestic fuels has been recently implicated as a causative agent in lung cancer especially in women. We conducted a case control study to find out the role of indoor air pollution due to domestic cooking fuels in Indian women. METHODS: In a case control study 67 women with proven lung cancer were recruited. Forty-six females having a non-malignant respiratory disease constituted the control group. The patients and controls were asked about the exposure in various cooking fuels using a questionnaire. RESULT: There were 50 (74.6%) non-smokers and 17 (25.4%) smokers among the female cancer cases (p = 0.016). Adenocarcinoma was the commonest histological type of malignancy (n = 26, 38.8%) in the whole group and was the predominant form in the nonsmoking females. Tobacco smoking was the most important risk factor for lung cancer with OR of 4.87 (95% CI 1.34-17.76). Among non-smokers out of all the cooking fuels the risk of development of lung cancer was highest for biomass fuel exposure with an odds ratio of 5.33 (95% CI 1.7-16.7). Use of mixed fuels was associated with a lesser risk (OR = 3.04, 95% CI 1.1-8.38). ). In multivariate logistic regression analysis biomass fuel exposure was still significant with OR of 3.59 (95% CI 1.07-11.97) even after adjusting for smoking and passive smoking. CONCLUSION: This study indicated that biomass fuel exposure is an important risk factor in the causation of lung cancer among women in addition of exposure to tobacco smoke.