Efficacy and safety of ipratropium bromide/salbutamol sulphate administered in a hydrofluoroalkane metered-dose inhaler for the treatment of COPD.

BACKGROUND: The use of chlorofluorocarbons (CFCs) has contributed to the depletion of the stratospheric ozone layer resulting in serious health concerns. Ipratropium bromide/salbutamol sulphate CFC-pressurized metered-dose inhalers (IB/SAL-CFC pMDI) have been in widespread use for many years without any apparent ill consequences. This combination has now been reformulated using the hydrofluoroalkane (HFA) propellant. This study sought to establish the clinical noninferiority of a new HFA-containing IB/SAL pMDI to the conventional IB/SAL-CFC pMDI in subjects with mild/moderate COPD. METHODS: This was a randomized, double-blind, parallel-group, multicenter study in two consecutive periods: a 14-day run-in period followed by a 85-day treatment period. Eligible mild-to-moderate stable COPD subjects aged 40-75 years were enrolled into the study and entered the run-in period during which subjects withdrew all the bronchodilators, except for salbutamol as rescue medication. Subjects were randomized to 85 days treatment with either IB/SAL-HFA or IB/SAL-CFC, 20 µg qid. RESULTS: Of the 290 randomized patients, 249 completed the study. The primary efficacy variable was the change in forced expiratory volume in one second from predose to 60 minutes after dosing on day 85. At the end of the treatment period, the adjusted mean change in forced expiratory volume in one second at 60 minutes was 123 mL in the IB/SAL-HFA pMDI group and 115 mL in the IB/SAL-CFC pMDI group. Because the lower limit of the 95% confidence interval for the between-group difference (-62 mL) was well within the noninferiority margin (-100 mL), the HFA formulation was deemed clinically noninferior to the CFC formulation. This finding was supported by secondary efficacy assessments. Both formulations of IB/SAL were well tolerated during the prolonged multiple dosing. CONCLUSION: It is concluded that IB/SAL-HFA pMDI provides effective bronchodilation of similar degree to that achieved with IB/SAL-CFC pMDI. Therefore, IB/SAL-HFA pMDI is a valuable alternative to IB/SAL-CFC pMDI.

Factors Related to Non-Referral of Patients with Presumptive Pulmonary TB to Designated Microscopy Centers (DMCs) by Registered Private Practitioners in Urban Areas of Punjab, India.

BACKGROUND: Early diagnosis and proper treatment under RNTCP guidelines, forms the mainstay of management of a TB patient. A large proportion of patients with presumptive tuberculosis (TB) visit a Private Practitioner (PP) in the first place. Studies have shown that PPs rely more on X-rays and other diagnostic tools rather than referring the patient to the nearest Designated Microscopy Centre (DMC) for sputum microscopy. AIM: The present study was planned to look in to factors responsible for non-referral of patients with presumptive pulmonary TB to the DMCs for diagnosis by PPs. MATERIALS AND METHODS: Present study was a case-control study conducted over a period of one year among registered PPs in urban areas of Punjab. The study was carried out in five major cities which have approximately half of the urban population of Punjab. Forty three Private Practitioners per city for referral group and 43 matched PPs for non-referral group were selected. RESULTS: Knowledge regarding RNTCP was low in both the referral (38.1%) as well as non-referral (25.6%) group of PPs. Allopathic doctors had significantly higher knowledge regarding TB as compared to ayurvedic and homeopathy doctors, and Registered Medical Practitioners (RMP). Both the knowledge of PPs regarding nearest DMC as well as perception about accessibility of the nearest DMC for the patients were found to be significantly higher in the referral group. Only 15.3% of practitioners in the non-referral group said that they had been contacted by RNTCP staff. CONCLUSION: The main factors responsible for non-referral of pulmonary TB suspects to DMCs for diagnosis in the present study included low knowledge regarding RNTCP, lack of awareness regarding place and accessibility of nearest DMC, and inadequate sensitization of PPs by the RNTCP staff.

Pulmonary function parameters in workers of woolen industry.

There is an increase in proportion of workers suffering from occupational diseases. In occupational respiratory diseases, pulmonary function tests are the most important and widely used diagnostic tool. Limited studies have been conducted to evaluate the effect of wool dust on pulmonary function parameters. Hence, the present study was undertaken to evaluate the pulmonary function parameters in workers of woolen industry. This study was done on 150 subjects of either gender who were divided into two groups of 75 each. Group I comprised of healthy subjects who served as controls and group II included workers of woolen industry. The values of lung function parameters i.e. volumes and flow rates in these workers were found to be lower than the healthy controls. The significant reduction in percentage predicted values of FEV1 (82 vs 59), FVC (79 vs 63) and MVV (77 vs 64) in workers as compared to healthy controls indicates obstructive pattern of respiratory abnormality. In male workers, percentage predicted FEV1% was significantly lower. The values of all other parameters were lower in female workers. There was a significant decrease in FEV and FVC with increase in age in group I and this negative correlation was statistically significant. The decrease in respiratory volumes and flow rates was more with increase in duration of exposure to wool dust. It can be concluded that wool dust present in environment of woolen industry affected the pulmonary function parameters of the workers leading to obstructive pattern of respiratory changes.

Hand hygiene compliance in the intensive care units of a tertiary care hospital.

CONTEXT: Hand hygiene (HH) is the most important measure to prevent hospital-acquired infections but the compliance is still low. AIMS: To assess the compliance, identify factors influencing compliance and to study the knowledge, attitude and perceptions associated with HH among health care workers (HCW). SETTINGS AND DESIGN: Cross-sectional study conducted in 42 bedded Medical (Pulmonary, Medicine and Stroke) intensive care units (ICU) of a tertiary care hospital. MATERIALS AND METHODS: HCWs (doctors and nurses) were observed during routine patient care by observers posted in each ICU and their HH compliance was noted. Thereafter, questionnaire regarding knowledge, perception and attitudes toward HH was filled by each HCW. STATISTICAL ANALYSIS: Percentages and χ(2) test. RESULTS: The overall compliance was 43.2% (394/911 opportunities). It was 68.9% (31/45) in the intensivists, 56.3% (18/32) in attending physicians, 40.0% (28/70) in the postgraduate residents and 41.3% (301/728) in the nurses. Compliance was inversely related to activity index. Compliance for high, medium and low risk of cross-transmission was 38.8% (67/170), 43.8% (175/401) and 44.7% (152/340), respectively. CONCLUSIONS: Compliance of the study group is affected by the activity index (number of opportunities they come across per hour) and professional status. The HCWs listed less knowledge, lack of motivation, increased workload as some of the factors influencing HH.

Bilateral chylothorax, chylopericardium and chylous ascitis.

Non-Hodgkin's lymphoma (NHL) can commonly present as chylothorax and rarely as chylopericardium. Here we are presenting a case of a 21-years-old female with bilateral chylothorax, chylopericardium and chylous ascites all together finally diagnosed to have NHL as the etiology. To the best of our knowledge, it has been reported very infrequently.

Diffuse alveolar hemorrhage in Wegener's granulomatosis.

Diffuse alveolar hemorrhage is a life-threatening though rare manifestation of Wegener's granulomatosis (WG). An active diagnostic workup, intensive observation, and aggressive immunosuppressive treatment are cornerstones of the management. The treatment modalities available for such complications are pulse cyclophosphamide therapy with steroids. We report here a case of WG with diffuse alveolar hemorrhage as the first manifestation of the disease in life that responded to steroids and cyclophosphamide.

Pulmonary embolism in cases of pulmonary tuberculosis: a unique entity.

Pulmonary tuberculosis is very prevalent in developing countries but its thrombogenic potential is a new entity. There are reports stating the relation of Deep Vein Thrombosis (DVT) with severe forms of tuberculosis but no literature is available for correlation of pulmonary tuberculosis and pulmonary embolism. We are presenting series of five patients with different forms of tuberculosis presenting with pulmonary embolism having no risk factor for hypercoagulability. Also, serum protein C, protein S, antithrombin and factor V levels were normal in all. We are highlighting an unreported phenomenon so that high suspicion, adequate prophylaxis and prompt management of pulmonary embolism can play a vital role in the survival of this subset of patients.

Erythema nodosum: Atypical presentation of common disease.

Tuberculosis is a very common disease often presenting in an uncommon form. High level of suspicion is required to diagnose it, thereby preventing its morbidity and mortality. We present a case of young female with multiple tuberculo-protein hypersensitivity reactions without any evidence of active tuberculosis in the body.

Changes in pulmonary function in patients with chronic renal failure after successful renal transplantation.

OBJECTIVE: Pulmonary function abnormalities have been described in patients with chronic renal failure. There are very few longitudinal studies showing the effect of renal transplantation on pulmonary function. We aimed to study the effects of renal failure on pulmonary functions and to observe the changes following successful renal transplantation. MATERIAL AND METHODS: Patients with end-stage renal failure (n=25) of various etiologies who presented to the renal transplant unit of a teaching hospital were included in this prospective, longitudinal study. Patients with a prior history of pulmonary disease and chronic smokers were excluded. Pulmonary function tests were performed and blood gases evaluated before and 6 months after successful renal transplantation. RESULTS: Most patients showed pulmonary function abnormalities which improved significantly after transplantation. The mean vital capacity increased from 2.89 (95% CI 2.63-3.15) l pre-transplantation to 3.32 (95% CI 3.09-3.54) l post-transplantation (p<0.001), indicating that subjects had a restrictive pulmonary function defect which improved after transplantation. The large airways were normal, as evidenced by normal forced expiratory volume in the first second:forced vital capacity ratios. There was significant small airways dysfunction, as shown by low maximal mid-expiratory flow rates, which tended to improve after renal transplantation (p=0.013). There was also a highly significant (p<0.001) improvement in maximal voluntary ventilation (MVV) after transplantation. The MVV test is a composite test which measures all aspects of pulmonary function, including respiratory muscle strength. However, not all patients achieved normal pulmonary function due to uremia-induced irreversible pre-transplantation changes. CONCLUSION: Pulmonary function abnormalities are common in patients with chronic renal failure but can be significantly ameliorated following successful renal transplantation.