Outcomes of patients with elevated pulmonary artery systolic pressure on echocardiography due to chronic lung diseases.

BACKGROUND: Pulmonary hypertension is associated with increased mortality, and lung diseases are the second most common cause of pulmonary hypertension. We aimed to evaluate the prognostic value of echocardiography in low-middle income countries where right heart catheterization is difficult to perform. METHODS: This retrospective chart review study included adult patients hospitalized from June 2012 to May 2021, with a pulmonary artery systolic pressure (PASP) of ≥35 mmHg on echocardiography. The control arm consisted of patients with similar lung diseases who did not have an elevated PASP. RESULTS: The study and control arm consisted of 128 patients each, with both groups having similar lung diseases. Obesity hypoventilation syndrome was the most common etiology of elevated PASP (28.1 %), followed by pulmonary embolism (20.3 %). The overall 1-year mortality of the study cohort, after diagnosis of elevated PASP, was 20.3 %. The control cohort with normal PASP had a 1-year mortality of 4.7 %. In the study cohort, patients with bronchiectasis had the highest cause-specific 1-year mortality (45.5 %). In the normal PASP cohort, the highest cause-specific 1-year mortality was observed in patients with interstitial lung disease (13.0 %). One-year hospital readmission was observed in 46.9 % and 33.6 % of patients in the study and control arms, respectively. On multivariate analysis, increased odds of 1-year mortality were observed in patients with elevated PASP, patients with 1-year hospital readmission, and in patients with interstitial lung disease or bronchiectasis. CONCLUSION: Elevated PASP on echocardiography may be a prognostic factor for mortality in patients with chronic lung diseases.

Non-cystic fibrosis bronchiectasis: a retrospective review of clinical, radiological, microbiological and lung function profile at a tertiary care center of low-middle income country.

Non-cystic fibrosis (non-CF) bronchiectasis has emerged as a significant respiratory disease in developing countries. Given the variation in causes and clinical characteristics across different regions, it is necessary to conduct studies in regions with limited data such as low-middle income countries (LMIC). The aim of the study was to investigate the underlying causes, clinical presentation, etiology, lung function and imaging in patients with bronchiectasis who sought treatment at a tertiary care hospital in a LMIC. We conducted retrospective observational study at the Aga Khan University, Pakistan. Adult patients diagnosed with non-CF bronchiectasis on high-resolution computed tomography scan between 2000 and 2020 were included. We evaluated the etiology, clinical characteristics, microbiology, radiology and spirometric pattern of these patients. A total of 340 patients were included with 56.5% being female and 44.7% aged over 60 years. Among them, 157 (46.2%) had experienced symptoms for 1-5 years. The most common spirometric pattern observed was obstructive impairment (58.1%). Previous tuberculosis (TB) (52.94%) was the most common etiology followed by allergic bronchopulmonary aspergillosis (7.64%). Bilateral lung involvement on HRCT scan was found in 63.2% of patients. Pseudomonas aeruginosa was the most frequently identified organism (38.75%) among 240 patients with available specimens. Patients with P. aeruginosa infections had a significantly higher number of exacerbations (p=0.016). There was a significant difference (p<0.001) in P. aeruginosa growth among different etiologies. In conclusion, post-TB bronchiectasis was the most common cause of non-CF bronchiectasis in our study population. P. aeruginosa was the predominant organism, and 63.2% of the patients exhibited bilateral lung involvement. Since P. aeruginosa growth and extensive lung involvement have been associated with poor prognosis and increased mortality risk, we recommend close follow ups of these patients to improve quality of life and survival in developing countries like Pakistan.

GRADE-ADOLOPMENT of clinical practice guidelines and creation of clinical pathways for the primary care management of chronic respiratory conditions in Pakistan.

INTRODUCTION: In Pakistan, chronic respiratory conditions contribute a large burden of morbidity and mortality. A major reason for this is the lack of availability of local evidence-based clinical practice guidelines (EBCPGs) in Pakistan, particularly at the primary care level. Thus, we developed EBCPGs and created clinical diagnosis and referral pathways for the primary care management of chronic respiratory conditions in Pakistan. METHODS: The source guidelines were selected by two local expert pulmonologists after a thorough literature review on PubMed and Google Scholar from 2010 to December 2021. The source guidelines covered idiopathic pulmonary fibrosis, asthma, chronic obstructive pulmonary disorders, and bronchiectasis. The GRADE-ADOLOPMENT process consists of three key elements: adoption (using recommendations as is or with minor changes), adaptation (effective context-specific changes to recommendations) or additions (including new recommendations to fill a gap in the EBCPG). We employed the GRADE-ADOLOPMENT process to adopt, adapt, adopt with minor changes, or exclude recommendations from a source guideline. Additional recommendations were added to the clinical pathways based on a best-evidence review process. RESULTS: 46 recommendations were excluded mainly due to the unavailability of recommended management in Pakistan and scope beyond the practice of general physicians. Clinical diagnosis and referral pathways were designed for the four chronic respiratory conditions, explicitly delineating the role of primary care practitioners in the diagnosis, basic management, and timely referral of patients. Across the four conditions, 18 recommendations were added (seven for IPF, three for bronchiectasis, four for COPD, and four for asthma). CONCLUSION: The widespread use of the newly created EBCPGs and clinical pathways in the primary healthcare system of Pakistan can help alleviate the morbidity and mortality related to chronic respiratory conditions disease in the country.

Diagnostic accuracy of different cut-off values of adenosine deaminase levels in tuberculous pleural effusion.

Objectives: To assess the diagnostic accuracy of different cut-off values of pleural fluid adenosine deaminase levels as a diagnostic method for tuberculous pleural effusion. METHODS: The prospective study was conducted from 2014 to 2016 at the Aga Khan University Hospital, Karachi, and comprised pleural fluid samples of adult patients with and without tuberculosis which were tested for adenosine deaminase levels, and divided into tuberculosis group A and non-tuberculosis group B. Sensitivity, specificity, negative predictive value and positive predictive value were calculated using different cut-offs. Data was analysed using IBM SPSS (Statistical Package for Social Sciences) version 21.0 (IBM Corp., Armonk, NY). RESULTS: Of 155 patients, 46(29.7%) had tuberculosis; 30(65.2%) males and 16(34.8%) females. Those who did not have tuberculosis were 109(70.3%); 69(63.3%) males and 40(36.7%) females. The adenosine deaminase levels were elevated in group A compared to group B (p<0.001). The cut-off of 30U/L showed the highest sensitivity (71.7%) and negative predictive value (87.4%), and a specificity of 82.6%. The cut-off of 50U/L showed the highest specificity (89.9%) with sensitivity 52.2%, and the cut-off of 40U/L showed the highest positive predictive value of 68.9% with sensitivity 67.4% and specificity 87.2%. CONCLUSIONS: Pleural fluid adenosine deaminase testing for diagnosing tuberculosis pleuritis revealed highest sensitivity and moderate specificity for cut-off value of 30U/L.

Clinical characteristics, outcomes, and factors associated with mortality in Nocardia pneumonia: 18 years' real-world data from a tertiary care hospital in Karachi, Pakistan.

BACKGROUND: Pulmonary nocardiosis is a rare pulmonary infection with high morbidity and mortality. Limited real-world data on pulmonary nocardiosis patients are available from developing countries like Pakistan. METHODS: This retrospective observational study was conducted at the Aga Khan University Hospital, Karachi, Pakistan, from August 2003 to June 2020. Demographics, immune status, underlying diseases, laboratory data, treatment, and outcomes of all nocardiosis patients were recorded in predesigned proforma. RESULTS: Sixty-six patients with smear/culture-proven pulmonary nocardiosis were identified. Most patients (83.3%) were treated with trimethoprim-sulfamethoxazole alone or in combination with other medicines. The overall mortality rate in our study was 33.3% (n = 22/66). Factors significantly associated with mortality were respiratory failure (p < 0.001), raised procalcitonin levels (p = 0.01), concomitant fungal infections (p = 0.01), concomitant TB (p = 0.03), and patients on combination therapy (p < 0.001). Respiratory failure (odds ratio [OR] 46.94 [95% confidence intervals [CI]: 5.01-439.03] p < 0.001), concomitant fungal infection (OR 17.09 [95% CI: 1.47-197.88] p- = 0.02) and patients on combination therapy (OR 6.90 [95% CI: 1.23-38.61] p = 0.02) were also identified as independent risk factors for mortality on multivariate analysis. CONCLUSIONS: This study provides essential information on the clinical characteristics and risk factors, outcomes, and factors associated with mortality for pulmonary nocardial infections.

Respiratory pathogens in patients with acute exacerbation of non-cystic fibrosis bronchiectasis from a developing country.

Bronchiectasis unrelated to cystic fibrosis (non-CF bronchiectasis) has become a major respiratory disease in developing nations. The dilated mucus filled airways promote bacterial overgrowth followed by chronic infection, bronchial inflammation, lung injury and re-infection. Accurate pathogen identification and antimicrobial susceptibility allowing appropriate treatment, in turn, may break this vicious cycle.  This study aimed to gain kowledge about the spectrum and antimicrobial spectrum of pathogen yielded from respiratory specimens in adult patients with acute exacerbation of non-cystic fibrosis (CF) bronchiectasis. This cross-sectional study was performed at the pulmonology clinics of the Aga Khan University, Karachi, Pakistan from 2016-2019. Respiratory specimens were collected from adult patients with acute exacerbation of non-CF bronchiectasis presenting in pulmonology clinics. Microbial cultures were performed using standard methodology. Susceptibility testing was performed and interpreted using Clinical Laboratory Standard Institute criteria.  A total of 345 positive cultures from 160 patients presenting with acute exacerbation were evaluated. The most frequent organisms were Pseudomonas aeruginosa (n=209) followed by Hemophilus influenzae (n=40) and Staphylococcus aureus (n=24). High rates of antimicrobial resistance were found in all these pathogens. Proportion of Pseudomonas aeruginosa strains resistant to ciprofloxacin, imipenem, ceftazidime and piperacillin-tazobactam were 27.1%, 16.8%, 14.8% and 13.1% respectively. 65% of Hemophilus influenzae strains were resistant to cotrimoxazole and ciprofloxacin and 66.7% of Staphylococcus aureus strains were resistant to methicillin. High antimicrobial resistance in non-CF bronchiectasis patients against commonly used antimicrobials is a concern and highlight need for urgent community level interventions to improve clinical outcome in these patients.

Free flap reconstruction after lower limb trauma - outcome analysis using National Surgical Quality Improvement Programme (NSQIP) parameters.

OBJECTIVE: To assess the outcomes of free flap reconstructions performed for the management of lower limb trauma. METHODS: This retrospective study was conducted at Aga Khan University Hospital (AKUH), Karachi and included data from June 2017 to May 2019 of patients who underwent free flap reconstruction as part of management of lower limb trauma. RESULTS: The mean age of the 8 adult patients was 34±11 years. Also included were two paediatric patients aged 7 and 8 years. Nine of the total 10 patients were male. Road traffic accidents were the most common mechanism of injury, occurring in 5(50%), followed by blast injuries in 3(33%). The anterolateral thigh flap was the most common type of flap used for reconstruction, done in 8(80%) patients. Flap survival rate was 90% and full flap loss was seen in only 1(10%) patient. Re-exploration surgery was done in 5(50%) patients during the same hospital stay. The length of hospital stay varied greatly from 4 to 105 days depending on associated diagnoses and whether the free flap surgery was performed during an elective admission. One patient did not survive to discharge, and the cause of death was attributed to septic complications. Functional outcomes on follow-up could not be determined. CONCLUSIONS: Free flap reconstruction surgery is an effective solution for management of lower limb trauma and has a high flap survival rate. Further studies are needed to ascertain the functional outcomes of limb salvage after free flap surgery.