Predictors of mortality in acute exacerbations of chronic obstructive pulmonary disease using the dyspnea, eosinopenia, consolidation, acidemia and atrial fibrillation score.

BACKGROUND: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are common and often fatal; however, accurate prognosis of patients hospitalized with an exacerbation is difficult. The Dyspnea, Eosinopenia, Consolidation, Acidemia, and Atrial Fibrillation (DECAF) score uses indices routinely available at the time of hospital admission and can accurately predict the inhospital mortality and outcomes in patients hospitalized with AECOPD. METHODOLOGY: A cross-sectional study was conducted in Jawaharlal Nehru Medical College, Belagavi, from January 2016 to June 2018. Consecutive patients hospitalized with an exacerbation of chronic obstructive pulmonary disease were included. DECAF indices and inhospital death rates were recorded. The prognostic value of DECAF was assessed by comparing the total score with the inhospital mortality. Statistical analysis was done using SPSS version 20. RESULTS: Two hundred and twenty-eight patients were recruited. The mean (standard deviation) age was 61.09 ± 10.6 years; 73.68% were male and 48 patients (21.05%) died in hospital. One hundred and twelve patients were identified as low risk (DECAF: 0-1) with 6 (5.4%) patients dying in the hospital and 56 patients were identified as high risk (DECAF: 3-6) with an inhospital mortality of 60.1%. Length of stay for scores of 0-1, 2, and ≥3 was 6.42, 7.47, and 9.64 days, respectively, with P < 0.05. The receiver operating characteristic curve analysis showed P < 0.001, thereby proving that the DECAF is a significant predictor of mortality in AECOPD. CONCLUSION: This study proved that with an increase in the DECAF score, the mortality among patients in AECOPD increased. The DECAF score helps clinicians predict prognosis accurately by identifying low-risk patients potentially suitable for home-based care or early hospital discharge and high-risk patients requiring escalated palliation with high-level care to improve their outcome.

Effects of oral montelukast on airway function in acute asthma: A randomized trial.

BACKGROUND: The role of leukotriene receptor antagonist is well known in the management of chronic asthma, but their efficacy in acute exacerbation of asthma is unknown. The present study was done to evaluate the clinical efficacy of oral montelukast as an add on therapy to the usual standard therapy of acute attack of bronchial asthma. MATERIALS AND METHODS: A randomized single-blinded controlled study was conducted in a tertiary care teaching hospital. A total of 162 patients with age >18 years of acute exacerbations due to bronchial asthma were included in the study. The patients were randomized into two study and control groups. The study group patients received oral montelukast (10 mg) once daily for 2 weeks, while the control group received a placebo. All the patients received standard therapy according to GINA guidelines. Improvements in lung function tests, clinical symptoms, and relapse rates were monitored at baseline, 1 week, 2 weeks, and 4 weeks. Side effects profile was also monitored. RESULTS: A total of 160 patients were finally assessed. Seventy-eight patients belonged to study group and 82 in the control group. Baseline characteristics were similar and well matched in both groups. Mean age was 39.9 ± 15.8 years in the study group and 42.8 ± 12.8 in the control group and majority were female patients in both groups. At the end of 4 weeks, it was observed that the study group patients who received montelukast had better forced expiratory volume in 1 s (FEV1) improvement by 21% (0.21 L) as compared to the control group (P < 0.0033). It was also observed that there was a better improvement in peak expiratory flow rate (PEFR) at 2 weeks (0.4 L/s, 12%) and at 4 weeks (0.9 L/s, 23%) as compared to the control group (P < 0.0376 and P < 0.0003 respectively). There was no difference in forced vital capacity (FVC), FEV1/FVC ratio and relapse rates between the two groups. No serious adverse effects were observed during the study. CONCLUSIONS: In acute asthma exacerbations, the present study showed that additional administration of oral montelukast resulted in significantly higher FEV1at 4 weeks and PEFR at 2 weeks and 4 weeks as compared to the standard treatment alone. These findings should be confirmed by conducting a larger population-based clinical study.

Outcomes associated with acute exacerbations of chronic obstructive pulmonary disorder requiring hospitalization.

BACKGROUND: Acute exacerbations of chronic obstructive pulmonary disorder (AECOPD) are known to be associated with increased morbidity and mortality and have a significant socioeconomic impact. The factors that determine frequent hospital readmissions for AECOPD are poorly understood. The present study was done to ascertain failures rates following AECOPD and to evaluate factors associated with frequent readmissions. MATERIALS AND METHODS: We conducted a prospective study among 186 patients with COPD with one or more admissions for acute exacerbations in a tertiary care hospital. Frequency of previous re-admissions for AECOPD in the past year, and clinical characteristics, including spirometry were ascertained in the stable state both before discharge and at 6-month post-discharge. Failure rates following treatment were ascertained during the follow-up period. All the patients were followed up for a period of 2 years after discharge to evaluate re-admissions for the AECOPD. RESULTS: Of 186 COPD patients admitted for AECOPD, 54% had one or more readmission, and another 45% had two or more readmissions over a period of 2 years. There was a high prevalence of current or ex-heavy smokers, associated co-morbidity, underweight patients, low vaccination prevalence and use of domiciliary oxygen therapy among COPD patients. A total of 12% mortality was observed in the present study. Immediate failure rates after first exacerbation was observed to be 34.8%. Multivariate analysis showed that duration >20 years (OR = 0.37; 95% CI: 0.10-0.86), use of Tiotropium (OR = 2.29; 95% CI: 1.12-4.69) and use of co-amoxiclav during first admission (OR = 2.41; 95% CI: 1.21-4.79) were significantly associated with higher immediate failure rates. The multivariate analysis for repeated admissions revealed that disease duration >10 years (OR = 0.50; 95% CI: 0.27-0.93), low usage of inhaled ICS + LABA (OR = 2.21; 95% CI: 1.08-4.54), and MRC dyspnea grade >3 (OR = 2.51; 95% CI: 1.08-5.82) were independently associated with frequent re-admissions for AECOPD. CONCLUSIONS: The outcomes of patients admitted for an acute exacerbation of COPD were poor. The major factors influencing frequency of repeated COPD exacerbations were disease duration, low usage of inhaled ICS + LABA, and MRC dyspnea grade >3.

Drug-induced hepatitis and the risk factors for liver injury in pulmonary tuberculosis patients.

INTRODUCTION: Short-course chemotherapy containing rifampicin and isoniazid in combination has proved to be highly effective in the treatment of tuberculosis, but one of its adverse effects is hepatotoxicity. Various risk factors have been found to be associated with drug-induced liver injury (DILI) in general population. The study aimed to determine the prevalence of drug-induced hepatitis and the risk factors associated with the DILI among the patients of pulmonary tuberculosis in Indian patients. SETTING AND DESIGN: Prospective nested case control study. MATERIALS AND METHODS: Out of the cohort of 3900 tuberculosis patients who were initiated on anti-tubercular therapy, 150 patients who developed drug-induced liver injury due to short-course chemotherapy under RNTCP were included in the analysis. Thirty cases were being followed up in our hospital and other 120 were referred to us for the management of drug-induced hepatitis from the primary health centers. The diagnostic criteria's for DILI were made according to the American Thoracic Society criteria. Analyses of various risk factors were done for the development of DILI. RESULTS: The prevalence of DILI in the present study was 3.8%. It was observed that DILI patients were older and their serum albumin levels were lower, and they had multiple co-morbid conditions. Regular alcohol intake, more extensive disease associated with radiological and female gender were observed to be independent risk factors for the development of DILI. CONCLUSIONS: Of the various risk factors analyzed, advanced age, hypoalbuminemia, regular alcohol intake and advanced nature of the disease were independent risk factors for the development of DILI. The risk of development of hepatitis is increased in the presence of one or more of these risk factors.

Premitive neuro-ectodermal tumour of the lung.

Primitive neuro-ectodermal tumour of the lung is an extremely rare occurrence and we hereby report a case of a neuro-ectodermal tumour of the lung which was proved by immuno-histochemical examination of the resected specimen, and he had a very aggressive pattern of behavior.

Risk factors and drug-resistance patterns among pulmonary tuberculosis patients in northern Karnataka region, India.

BACKGROUND: India is one of the high tuberculosis (TB)-burden countries in the world. Resistance to anti-tuberculosis (anti-TB) drugs has already become an important and alarming threat in most of the regions worldwide. India ranks second in the world in harbouring multi-drug resistant cases (MDRTB). Prevalence of MDR-TB mirrors the functional state and efficacy of TB control programmes and realistic attitude of the community towards implementation of such programmes. The most important risk factor in the development of MDRTB is improper implementation in the guidelines in the management of TB, and high rate of defaults on the part of the patients. The study was carried out to evaluate the drug resistance pattern to first line anti-TB drugs in Northern Karnataka region, India. MATERIALS AND METHODS: A prospective study was conducted at J. N. Medical College and its associated Hospitals, Belgaum. Between January 2011 and December 2012, 150 sputum samples of suspected pulmonary TB patients based on the history were examined for the AFB culture by Lowenstein-Jensen (LJ) culture technique. A total of two early morning samples were collected for the smear [Ziehl-Neelsen (ZN) staining] and culture methods. It was observed that ZN staining for AFB was positive in 113 patients (75%), while AFB culture by LJ medium yielded growth in 66 cases (44%). Thus, a total of 66 AFB culture-positive samples by LJ medium were subjected for AFB drug-sensitivity testing (DST). DST was done for Isoniazid (INH), Rifampicin (RIF), Pyrazinamide (PZA), Ethambutol (EMB) and Streptomycin (SM) after isolation by using the resistance proportion method. RESULTS: A total of 66 AFB culture-positive specimens, 20 (30.3%) cases were sensitive to all the five drugs while 46 (69.7%) cases showed resistance to one or more drugs. Among these, the resistance to rifampicin was highest (80.4%), while resistance to isoniazid, pyrazinamide, ethambutol and streptomycin were observed to be 60%, 58.7%, 52.1% and 63%, respectively. It was also observed that, resistance to all five drugs was highest (39.18%). MDR isolates were obtained in 52.2% of the cases. Illiteracy, low socio-economic status, previous history of TB and alcoholism were found to have statistically significant association for the development of MDR. CONCLUSIONS: The prevalence of drug resistance in the present study was observed to be 69.7%. More than half of the cases were multi-drug resistant. The most common resistant pattern observed in this study was resistance to all the first-line drugs. Therefore, during initiation of new case proper explaining and completion of the treatment is very important to avoid the development of future drug resistance in the society.

Prevalence and correlates of osteoporosis in chronic obstructive pulmonary disease patients in India.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a syndrome of progressive airflow limitation caused by the abnormal inflammatory reaction of the airway and lung parenchyma. Osteoporosis is one of the major extrapulmonary manifestations of COPD. The, prevalence of osteoporosis in COPD patients in Indian population is unknown. OBJECTIVES: To study the prevalence of osteoporosis in COPD and to define various risk factors associated with reduced bone mineral density (BMD) in COPD. MATERIALS AND METHODS: The study was done in the department of Pulmonary Medicine of a tertiary care hospital. All the diagnosed cases of COPD according to the Global Initiative for Obstructive Lung Disease (GOLD) guidelines were included in this study. The present study was a prospective study in for a period of 1 year. A brief history of the patients was taken, especially regarding duration of illness, number of exacerbations in the past 3 years, smoking in pack years, and history of steroid use (both systemic and inhaled steroids) after which cumulative dose of steroids was calculated. Spirometry was done in all these patients to stage the severity of COPD according to GOLD criteria. DEXA scan of the lumbar spine was done using bone densitometer to determine osteoporosis. A world Health Organization (WHO) criterion for definition of osteoporosis was applied and patients with T-score of > -2.5 standard deviation (SD) were diagnosed to have osteoporosis, -1 SD to -2.5 SD were diagnosed to have osteopenia and < -1 SD as normal. Statistical analysis for association of COPD with osteoporosis was done using chi-square test. Risk factors for osteoporosis were identified by univariate and multivariate logistic regression analysis. RESULTS: A total of 102 COPD patients were included in the study. Among these, 68 patients (66.6%) had osteoporosis and 20 patients (19.6%) had osteopenia. Majority (64.7%) of the patients who had osteoporosis had stage III and stage IV COPD disease. It was observed that as the severity grade of COPD increased, the risk of osteoporosis also increased. The bone mineral density (BMD) showed a significant difference among different stages of COPD. As the severity of the stage of COPD increased, BMD decreased. It was also observed that patients with lower body mass index (BMI) had higher prevalence of osteoporosis (37.3%) as compared to overweight patients. On univariate analysis, it was observed that risk factors for osteoporosis were female sex, higher number of exacerbations, BMI, and severity of COPD. After using multivariate logistic regression analysis, stage IV COPD (odds ratio (OR): 34.48, 95% confidence interval (CI): 1.59-1,000, P < 0.02), number of acute exacerbations >3 (OR: 30.3, 95% CI: 4.74-200, P < 0.01), and steroid cumulative dose >1,000 mg (OR: 7.35, 95% CI: 0.92-58.5, P < 0.04) were observed to be significant risk factors for osteoporosis in COPD patients. CONCLUSIONS: In the present study, the prevalence of osteoporosis was 66.6% and another 19.6% had osteopenia. As the severity of COPD increased, the risk of osteoporosis increased. GOLD stage III and stage IV patient had significantly lower BMD as compared to stage I and stage II of COPD disease. Stage IV COPD disease, use of oral or parenteral glucocorticoids, and repeated number of exacerbations were found to be independent risk factors for osteoporosis in COPD patients. Thus, high clinical suspicion and early diagnosis and treatment is required in the evaluation of osteoporosis in COPD patients so that the quality of life can be improved in these patients.

Role of health education and self-action plan in improving the drug compliance in bronchial asthma.

BACKGROUND: Considering the prevalence and associated burden of disease due to bronchial asthma, it is mandatory to obtain an optimal control of the disease and to improve outcomes for these patients. But it has been observed that there is very poor adherence to the inhalational therapy which leads to the suboptimal control of the disease. OBJECTIVES OF THE STUDY: To study the adherence for aerosol therapy in bronchial asthma patients and to assess the impact of health education and self-action plan in improving the compliance to the therapy. METHODOLOGY: A prospective study was done in a total of 500 bronchial asthma patients over a period of 2 years. Once included in the study, the patients were followed-up for a total of 12 weeks for calculation of nonadherence to the aerosol therapy. In nonadherent patients, we employed various health education strategies to improve the compliance in these cases. RESULTS: A total of 500 patients of bronchial asthma who were started on aerosol therapy over duration of 2 years were included in the study. At the end of 12 weeks, it was observed that, only 193 patients (38.6%) had regular compliance and 307 patients (61.4%) were noncompliant to aerosol therapy as prescribed for bronchial asthma. Factors that were associated with poor compliance were: Lower educational level status, poor socioeconomic status, cumbersome regimens, dislike of medication, and distant pharmacies. Nondrug factors that reduced the compliance were: Fears about side effects, anger about condition or its treatment, forgetfulness or complacency, and patient's ill attitudes toward health. After employing the various strategies for improving the compliance in these patients, the compliance increased in 176 patients (57.3%) among the earlier defaulted patients, while the remaining 131 patients (42.7%) were found to be noncompliant even after various educational techniques. CONCLUSION: Noncompliance in asthma management is a fact of life and no single compliance improving strategy probably will be as effective as a good physician-patient relationship. Optimal self-management allowing for optimization of asthma control by adjustment of medications may be conducted by either self-adjustment with the aid of a written action plan or by regular medical review. Individualized written action plans based on peak expiratory flow are equivalent to action plans based on symptoms.

Primary neuroendocrine carcinoma of the thymus.

Primary neuroendocrine tumors of the thymus, previously known as carcinoid tumors of the thymus, are unusual and rare tumors, and prognosis for these patients has been difficult to predict. We hereby report a case of primary neuroendocrine tumor of the thymus that had an aggressive and fatal course in spite of surgical resection and adjuvant chemotherapy. These tumors must be regarded as a malignant neoplasm that is prone to metastasize to distant sites, even after total excision.

Bone mineral density among elderly patients with chronic obstructive pulmonary disease patients in India.

BACKGROUND: Osteoporosis is one of the major extra-pulmonary manifestations of chronic obstructive pulmonary disease (COPD), which limits the physical activity. The present study was undertaken to study the bone mineral density (BMD) and osteoporosis in the elderly COPD patients. MATERIALS AND METHODS: This was a cross-sectional study carried out among elderly COPD patients. After a detailed clinical history spirometry was done to stage the severity of COPD. DEXA scan of the lumbar spine was performed using bone densitometer to determine osteoporosis. Statistical analysis was based on Chi-square test. Risk factors were identified by univariate and multivariate logistic regression analysis. RESULTS: A total of 70 elderly COPD patients were included. Fourty-six patients (65.7%) had osteoporosis and 13 (18.6%) had osteopenia. Majority of the osteoporosis patients had stage III or stage IV COPD disease (77.2%). As the severity grade of COPD increased, the risk of osteoporosis also increased. Also, with the increasing severity of COPD, BMD decreased. Patients with lower body mass index (BMI) had higher prevalence of osteoporosis (45.7%). Using multivariate regression analysis, stage IV COPD, number of acute exacerbations >3 and steroid cumulative dose >1000 mg were independent risk factors for osteoporosis in elderly COPD patients. CONCLUSIONS: The prevalence of osteoporosis was 65.7%, and 18.6% had osteopenia. Stage III and IV patients had significantly lower BMI in elderly COPD patients. High clinical suspicion and early diagnosis and treatment are required in the evaluation of osteoporosis in elderly COPD patients.

Critical illness myopathy and polyneuropathy - A challenge for physiotherapists in the intensive care units.

The development of critical patient related generalized neuromuscular weakness, referred to as critical illness polyneuropathy (CIP) and critical illness myopathy (CIM), is a major complication in patients admitted to intensive care units (ICU). Both CIP and CIM cause muscle weakness and paresis in critically ill patients during their ICU stay. Early mobilization or kinesiotherapy have shown muscle weakness reversion in critically ill patients providing faster return to function, reducing weaning time, and length of hospitalization. Exercises in the form of passive, active, and resisted forms have proved to improve strength and psychological well being. Clinical trials using neuromuscular electrical stimulation to increase muscle mass, muscle strength and improve blood circulation to the surrounding tissue have proved beneficial. The role of electrical stimulation is unproven as yet. Recent evidence indicates no difference between treated and untreated muscles. Future research is recommended to conduct clinical trials using neuromuscular electrical stimulation, exercises, and early mobilization as a treatment protocol in larger populations of patients in ICU.

Effect of multimodality chest physiotherapy on the rate of recovery and prevention of complications in patients with mechanical ventilation: a prospective study in medical and surgical intensive care units.

BACKGROUND: Mechanically ventilated patients have an increased risk of complications leading to ventilation weaning more difficult resulting in excessive morbidity and mortality. Chest physiotherapy plays an important role in management of ventilated patients. However, these techniques have been studied on patients as a single entity or with combination of two techniques. The present study was designed to evaluate the effect of multimodality chest physiotherapy on the rate of recovery and prevention of complications in adult ventilated patients. MATERIALS AND METHODS: Out of 173 patients who were randomly allocated to two groups, 86 patients received MH and suctioning in control group and 87 patients were treated with multimodality chest physiotherapy in the study group twice daily till they were extubated. All patients were followed up for the global outcomes and complications during mechanical ventilation. RESULTS: There were significant improvements in terms of rate of recovery in study group compared to the control group (P = 0.000). Complication rates were higher with 61.6% in the control group as compared to 26.4% in the study group. Duration of hospitalization was longer in the study group (16 ± 9.40 days) as compared to the control group (12.8 ± 6.12 days). Successful weaning from mechanical ventilation was noted in 58 patients in the study group and 24 patients in the control group which was statistically significant. CONCLUSIONS: Multi-modality chest physiotherapy protocol has shown to prevent ventilator-associated pneumonia and enhance the clinical outcome in ventilated patients and may be recommended as a treatment option in ICU. It has also shown to enhance the weaning process and proved to be safe.

Pulmonary manifestations of gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) may cause, trigger or exacerbate many pulmonary diseases. The physiological link between GERD and pulmonary disease has been extensively studied in chronic cough and asthma. A primary care physician often encounters patients with extra esophageal manifestations of GERD in the absence of heartburn. Patients may present with symptoms involving the pulmonary system; noncardiac chest pain; and ear, nose and throat disorders. Local irritation in the esophagus can cause symptoms that vary from indigestion, like chest discomfort and abdominal pain, to coughing and wheezing. If the gastric acid reaches the back of the throat, it may cause a bitter taste in the mouth and/or aspiration of the gastric acid into the lungs. The acid can cause throat irritation, postnasal drip and hoarseness, as well as recurrent cough, chest congestion and lung inflammation leading to asthma and/or bronchitis/ pneumonia. This clinical review examines the potential pathophysiological mechanisms of pulmonary manifestations of GERD. It also reviews relevant clinical information concerning GERD-related chronic cough and asthma. Finally, a potential management strategy for GERD in pulmonary patients is discussed.

Primary endobronchial Hodgkin's disease.

We report a case of primary pulmonary Hodgkin's disease presenting as an endobronchial mass. Tissue diagnosis was made by microscopic examination following open thoracotomy and excision biopsy of the mass. The patient responded well to the chemotherapy regimen.