Catheter ablation for atrial fibrillation: indications and future perspective.

Recent advances in techniques, technologies and proven superiority over anti-arrhythmic drugs have made catheter ablation the cornerstone of management for atrial fibrillation (AF), which has shown a steady increase in prevalence in the ageing population worldwide. The aim of therapeutic interventions is to achieve stable sinus rhythm that would improve the quality of life and reduce the risk of AF-associated complications. Pulmonary veins (PVs) were first described as the source of initiation of ectopic triggers driving AF, which led to the establishment of PV isolation (PVI) as the most widely practiced procedure to treat AF. Antral PVI is still recognized as the stand-alone ablation strategy for newly diagnosed paroxysmal AF (PAF). However, in non-PAF patients, PVI seems to be inadequate and several adjunctive strategies, including ablation of left atrial posterior wall and non-PV triggers, AF mapping and ablation of rotors and drivers, ethanol infusion of vein of Marshall and renal denervation, etc. have been reported with mixed results. Recent trials have also documented the benefits of early rhythm control in preventing cardiovascular events in addition to slowing the progression of PAF to more persistent forms. Similarly, very late relapse of the arrhythmia after successful PVI has drawn attention to the critical role of non-PV triggers and highlighted their relevance as potential ablation targets during repeat procedures. Ablation technology is also under constant evolution with the introduction of non-thermal energy sources and new tools to create durable lesions. This review summarizes the indications, advancements, and future perspective of AF ablation.

Cardiovascular Risk Predictors High Sensitivity C-Reactive Protein and Plasminogen Activator Inhibitor-1 in Women with Lean Phenotype of Polycystic Ovarian Syndrome: A Prospective Case-Control Study.

Objective Accumulating evidence suggests increased cardiovascular risk in women with polycystic ovarian syndrome (PCOS) due to a cluster of factors, such as obesity, lipid abnormalities, impaired glucose tolerance (IGT), and hypertension. Markers such as high-sensitivity C-reactive protein (hs-CRP) and plasminogen activator inhibitor-1 (PAI-1) can provide an adjunctive method for the assessment of cardiovascular risk and can indicate future coronary heart diseases in women with lean PCOS. Materials and Methods In this prospective case-control study, women clinically diagnosed with PCOS ( n = 25) with normal body mass index (BMI) and age and BMI-matched healthy controls ( n = 75) were enrolled. The quantitative data were expressed as mean ± standard deviation (SD). Unpaired Student's t -test was used to compare the values (PCOS vs. controls) and Pearson's correlation coefficient was used to elucidate the relationship between the variables. Results The mean level of fasting blood sugar, serum total cholesterol, low-density lipoprotein (LDL), thyroid-stimulating hormone (TSH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), hs-CRP, and PAI-1 were significantly increased in PCOS patients ( p < 0.000) compared with the control patients. Of the reported cases, 54.16% had hs-CRP levels greater than 3 mg/L. When the cases were further divided into normal ( n = 20) and IGT ( n = 5), hs-CRP values were significantly higher in IGT group as compared with normal glucose tolerance (NGT) group. On bivariate correlation analysis, hs-CRP had significant correlations with PAI-1 ( r = 0.41, p < 0.000), waist-to-hip ratio (WHR; r = 0.23, p = 0.02), fasting blood sugar (FBS; r = 0.26, p = 0.009), LDL ( r = 0.20, p = 0.03), TSH ( r = 0.42, p < 0.000), and LH-to-FSH ratio ( r = 0.24, p = 0.01). Conclusion Women with lean phenotype of PCOS suffer from many metabolic abnormalities such as abdominal obesity, dyslipidemia, hyperandrogenemia, and insulin resistance. The findings of the study suggest that environment of ongoing low-grade inflammation due to infiltration further exacerbates the metabolic derangements and cardiovascular risk. The investigations as hs-CRP and PAI-1 will help in early identification, diagnosis, and management of cardiovascular diseases associated with lean type of PCOS. These markers can prove to be beneficial in monitoring any unfavorable changes in cardiometabolic profile of such patients.

Comparative evaluation of INF-γ as an immunological healing marker based on anti-tubercular treatment among diabetic and non-diabetic pulmonary tuberculosis patients.

OBJECTIVES: Tuberculosis is an infectious airborne disease caused by Mycobacterium tuberculosis. Pulmonary tuberculosis is the ninth most frequent complication of diabetes mellitus. The co-existence of TB and DM in patient causes severe TB symptoms, modify radiological findings, slower response to treatment outcomes and prognosis. IFN-γ is the key cytokine which play role in the protective immune response against mycobacterium infection. The main function of IFN-γ is macrophage activation which is able to exert its microbicidal functions. Estimation and comparison of pre and post treatment serum IFN-γ among pulmonary tuberculosis among diabetic and non-diabetic patients. METHODS: The study was conducted in the Departments of Biochemistry and Pulmonary Medicine, FMHS, SGT University, Budhera, Gurugram and District TB Centre, Gurugram, Haryana, India. In this study, 100 newly diagnosed PTB patients without diabetes mellitus and 100 newly diagnosed PTB patients with diabetes mellitus (PTB-DM) above 15 years of age were included after obtaining written consent. 5 mL venous blood was collected from patients of pre and post anti-tubercular treatment. The level of IFN-γ was measured by ELISA method. RESULTS: The circulating level of IFN-γ in PTB patients was significantly decreased in post-treatment (25.53 ± 6.12 pg/mL) compared to pre-treatment (58.76 ± 16.02 pg/mL) with t-value 32.03 and p-value <0.001. The circulating level of IFN-γ in PTB-DM patients was significantly decreased in post treatment (29.11 ± 7.41 pg/mL) compared to pre-treatment (44.14 ± 10.85 pg/mL) with t-value 31.35 and p-value <0.001. In the present study, level of IFN-γ in pre-treatment PTB patients (58.76 ± 16.02 pg/mL) was significantly raised compared to PTB-DM patients (44.14 ± 10.85 pg/mL) with t-value 7.55 and p-value <0.001. However, level of IFN-γ in post-treatment PTB patients (25.53 ± 6.12 pg/mL) was significantly low compared to PTB-DM patients (29.11 ± 7.41 pg/mL) with t-value 3.71 and p-value <0.001. CONCLUSIONS: The decreased level of IFN-γ in post-treatment compared to pre-treatment in both PTB and PTB-DM patients had shown efficacy of anti-tubercular treatment. However, the post treatment level of IFN-γ was high in PTB-DM patients compared to PTB patients which verified that effect of ATT was low in PTB-DM.

An online survey of clinical practice for allergic rhinitis among the Asia-Pacific representatives.

BACKGROUND: Physicians' knowledge and practice which are consistent with evidence-based guidelines can improve allergic rhinitis (AR) patients' care. Compared with western countries, the available literature about Asian doctors' perceptions and clinical practices regarding Allergic Rhinitis and its Impacts on Asthma (ARIA) guidelines is limited. OBJECTIVE: To collect detailed information about the practical management patterns specific for AR patients and investigate compliance with ARIA in the clinical practice of Asian physicians and elucidate the possible inadequacy in the existing ARIA guidelines. METHODS: An e-mail with a structured questionnaire was sent to members of the Asia-Pacific Association of Allergy, Asthma and Clinical Immunology. The questionnaire consisted of doctors' characteristics, environment of medical practice, routine clinical practice following ARIA guidelines and patients' adherence to the prescription. RESULTS: Physicians from 14 countries and regions sent valid questionnaires back, 94.12% of whom were senior doctors with more than 10 years of experience. 88.24% of doctors diagnosed AR depending on the history combined with allergy tests. 82.35% of participants employed the classification criteria by ARIA. 94.12%, 88.24% and 41.8% of respondents recommended intranasal corticosteroids, oral antihistamines and leukotriene receptor antagonists as first-line medications. 5.88% treated perennial AR by intranasal corticosteroids alone. 11.76% of clinicians recommended no allergen immunotherapy (AIT) or biologics and 58.82% of interviewees reported AR patients occasionally or sometimes agreed with the recommendation of AIT. CONCLUSIONS: There was high compliance with ARIA guidelines in Asian senior physicians' actual notion and practice in the management of AR. New-generation ARIA guidelines are imperative for unmet needs.

A study on lipoprotein-a and PAI-1 in women with polycystic ovary syndrome.

OBJECTIVES: PCOS is the most common endocrinological disorder amongst women of reproductive age. The consequences of PCOS extend beyond the reproductive axis and may lead to the development of metabolic syndrome leading to a high risk for hypertension and cardiovascular disease. Therefore, a more comprehensive evaluation of biochemical markers that reflect the cardiovascular risk is required for further understanding of pathophysiologic mechanisms, diagnosis and management. METHODS: In this case-control study, women diagnosed with PCOS (n=100) in the age group (18-35 years) years were taken as cases and age matched healthy controls (n=100) were enrolled. Estimations of fasting plasma Glucose, serum total cholesterol (TC), triglycerides (TG) and High-density lipoprotein (HDL) concentrations were assayed while Low-density lipoprotein (LDL) was calculated by using Fredrickson Friedwald's formula. Serum Lipoprotein-a (Lp-a) was estimated using ELISA (Enzyme Linked Immunosorbent Assay). The quantitative data were expressed as Mean ± Standard Deviation (SD). Unpaired Student's t-test was used to compare the values (PCOS vs Controls) and Pearson's correlation coefficient was used to elucidate the relationship between the variables. RESULTS: FBS and all lipid parameters were significantly increased in PCOS patients compared to control subjects. On the other hand, HDL-C was significantly decreased as compared to the control subjects. The hormones TSH, LH, FSH, PRL and LH/FSH ratio were significantly increased in PCOS patients compared to control subjects. Lipoprotein-a and PAI-1 was significantly increased in PCOS patients compared to the control subjects. Upon bivariate correlation analysis, Lp(a) had significant correlations with PAI-1 (r=0.35, p=0.000), WHR (r=0.25, p=0.000), LDL (r=0.52, p=0.000) and TSH (r=0.24, p=0.000). While the correlations with FBS (r=-0.008, p=0.91) and LH/FSH ratio (r=-0.004, p=0.95) were statistically insignificant. CONCLUSIONS: The evaluation of serum biomarkers such as Lp-a, PAI-1 and lipid profile routinely in PCOS patients may have diagnostic role in the early detection of metabolic abnormalities and endocrine derangements and timely management of comorbid Diabetes and Cardiovascular disease in PCOS females.

Unilateral 'Crazy-Paving' pattern: An exceptional presentation of squamous cell carcinoma of the lung.

The 'crazy-paving' pattern on high resolution computed tomography (HRCT) is a distinct imaging appearance that is still considered to be a radiological hallmark of pulmonary alveolar proteinosis. However, since its first description about three decades ago, more than 40 different clinical entities presenting as 'crazy-paving' patterns have been documented. This rather remarkable but uncommon imaging appearance is now considered to be a non-specific manifestation. A 62-year-old male referred for evaluation of productive cough, breathlessness and fever presented with 'crazy-paving' pattern on HRCT. Endobronchial biopsy done on presentation was consistent with the diagnosis of squamous cell carcinoma. This report highlights this atypical presentation of squamous cell carcinoma of the lung and adds to the increasing list of clinical entities presenting as a 'crazy-paving' pattern. To our knowledge, squamous cell carcinoma presenting as a 'crazy-paving' pattern on HRCT is yet to be documented.

The 'double transition': a novel electrocardiogram sign to discriminate posteroseptal accessory pathways ablated from the right endocardium from those requiring a left-sided or epicardial coronary venous approach.

AIMS: The precise localization of manifest posteroseptal accessory pathways (APs) often poses diagnostic challenges considering that a small area may encompass AP that may be ablated from the right or left endocardium, or epicardially within the coronary sinus (CS). We sought to explore whether the QRS transition pattern in the precordial lead may help to discriminate the necessary ablation approach. METHODS AND RESULTS: Consecutive patients who underwent a successful ablation of a single manifest AP over a 5-year period were included. Standard 12-lead electrocardiograms were reviewed. A total of 273 patients were identified. Mean age was 31 ± 15 years and 62% were male. Of the 110 identified posteroseptal AP, 64 were ablated from the right endocardium, 33 from the left endocardium, and 13 inside the CS. While a normal precordial QRS transition was most often observed, a subset of 33 patients presented an atypical 'double transition' pattern which specifically identified right endocardial AP. The combination of a q wave in V1 with a proportion of the positive QRS component in V1 < V2 > V3, predicted a right endocardial AP with a 100% specificity. In case of a positive QRS sum in V2, this 'double transition' pattern predicted a posteroseptal right endocardial AP with 99.5% specificity and 44% sensitivity. The positive predictive value was 97%. The only false positive was a midseptal AP. In the case of a negative or isoelectric QRS sum in V2, APs were located more laterally on the tricuspid annulus. CONCLUSION: The combination of a q wave in V1 with a double QRS transition pattern in the precordial leads is highly specific of a right endocardial AP and rules out the need for CS or left-sided mapping.

Multidrug-resistant and extended-spectrum beta-lactamase-producing uropathogens in children in Bhaktapur, Nepal.

BACKGROUND: The emergence of multidrug-resistant (MDR) and extended-spectrum beta-lactamase (ESBL)-producing uropathogens has complicated the treatment of urinary tract infections (UTI). Paediatric UTI is a common illness, which if not treated properly, may lead to acute and long-term complications, such as renal abscess, septicaemia, and renal scarring. This study aimed to determine the prevalence of MDR and ESBL-producing uropathogens among children. METHODS: During the study period (April 2017-April 2018), midstream urine samples were collected following aseptic procedures from children < 16 years in Siddhi Memorial Hospital. Standard culture and biochemical tests were performed to identify uropathogens and antimicrobial susceptibility test was done by modified Kirby-Bauer disc diffusion method following Clinical and Laboratory Standard Institute (CLSI) guidelines. ESBL-producing uropathogens were screened by ceftazidime (30 µg) and cefotaxime (30 µg) discs, and confirmed by the combination disc tests: ceftazidime + clavulanic acid (30/10 µg) or cefotaxime + clavulanic acid (30/10 µg) as recommended by CLSI. RESULTS: We processed 5545 non-repeated urine samples from the children with symptoms of UTI. A significant growth of uropathogens was observed in 203 samples (3.7%). The median age of the children was 24 months (interquartile range (IQR), 12-53 months). Escherichia coli (n = 158, 77.8%) and Klebsiella pneumoniae (n = 30, 14.8%) were common among the uropathogens. Among them, 80.3% were resistant to amoxycillin and 51.2% were resistant to cotrimoxazole. Most of them were susceptible to amikacin, nitrofurantoin, and ofloxacin. MDR was detected in 34.5% (n = 70/203) and ESBL producers in 24.6% (n = 50/203) of them. The proportion of MDR isolates was higher in children < 5 years (n = 59/153, 38.6%) than children ≥ 5 years (n = 11/50, 22%) (P = 0.03). CONCLUSIONS: Nitrofurantoin, ofloxacin, and amikacin can be used for the empirical treatment for UTI in children in Bhaktapur, Nepal. MDR and ESBL-producing uropathogens are prevalent; this warrants a continuous surveillance of antimicrobial resistance.

Low-Dose Ibutilide Combined with Catheter Ablation of Persistent Atrial Fibrillation: Procedural Impact and Clinical Outcome.

BACKGROUND: In patients with persistent atrial fibrillation (AF), the procedural and clinical outcomes of ablation combined with infusion of antiarrhythmic drug are unknown. OBJECTIVES: To determine the impact of low-dose ibutilide after circumferential pulmonary vein isolation (CPVI) and/or left atrial (LA) substrate modification on acute procedural and clinical outcome of persistent AF. METHODS: In a prospective cohort of 135 consecutive patients with persistent AF, intravenous 0.25 mg ibutilide was administered 3 days before the procedure and intraprocedurally, if required, after CPVI and/or additional LA substrate modification of sites with continuous, rapid or fractionated, and low-voltage (0.05-0.3 mv) atrial activity. RESULTS: Persistent AF was terminated by CPVI alone (n=15) or CPVI + ibutilide (n=32) in 47 (34.8%) patients (CPVI responders). Additional LA substrate modification without (n=33) or with subsequent administration of 0.25 mg ibutilide (n=19) terminated AF in another 52 (38.5%) patients (substrate modification responders). Sinus rhythm was restored by electrical cardioversion in the remaining 36 (26.7%) patients (nonresponders). The mean LA substrate ablation time was 14 ± 6 minutes. At follow-up of 24 ± 10 months, the rates of freedom from atrial tachyarrhythmias among the responders in CPVI and substrate modification groups were mutually comparable (66.0% and 69.2%) and higher than among the nonresponders (36.1%; P < 0.01). Among the responders, there was no difference in clinical outcome between patients whose persistent AF was terminated without or with low-dose ibutilide. CONCLUSION: Administration of low-dose ibutilide during ablation of persistent AF may allow select patients wherein substrate ablation is not or minimally required to optimize procedural and clinical outcomes.

Bronchial anthracofibrosis: The spectrum of radiological appearances.

Bronchial anthracofibrosis (BAF), caused by long-standing exposure to biomass fuel smoke, has emerged as a distinct pulmonary disease. It is usually seen in elderly females who have worked long hours in poorly ventilated kitchen full of smoke due to incomplete combustion of biomass fuel. The diagnosis is confirmed on bronchoscopic visualization of bluish-black anthracotic pigmentation along with narrowing/distortion of the affected bronchus. BAF has been associated with clinical conditions such as pulmonary tuberculosis, chronic obstructive pulmonary disease, pneumonia, and malignancy. Tuberculosis, once thought to be the causative agent for BAF, is now considered to be an association. BAF has a diverse radiological presentation and the presence of associated clinical conditions often confound the radiological picture. The imaging features of BAF include primary imaging characteristics, which pertains to the disease entity directly, and secondary features based on the presence of associated conditions. High-resolution computed tomography findings of multifocal bronchial narrowing and peribronchial cuffing are considered to be specific diagnostic features of BAF. In addition, the diagnostic probability is increased in the presence of mediastinal adenopathy and collapse/atelectasis with middle lobe syndrome being the most common presentation. This pictorial essay highlights the range of imaging appearances in patients with BAF.

Predictive efficacy of procalcitonin, platelets, and white blood cells for sepsis in pediatric patients undergoing cardiac surgeries who are admitted to intensive care units: Single-center experience.

BACKGROUND: Sepsis is one of the major contributor of morbidity and mortality in pediatric cardiac surgeries. AIM: The aim of this study was to compare the predictive efficacy of total leukocyte counts (TC), platelet count (PC), and procalcitonin (PCT) for sepsis in patients undergoing cardiac surgeries who are admitted to the Intensive Care Unit. MATERIALS AND METHODS: This prospective, single-center study included 300 neonates, infants, and pediatric patients who had undergone various open heart surgeries at our center from September 2014 to November 2015. RESULTS: Overall, the incidence of sepsis was 14% in pediatric patients undergoing cardiac surgeries. TC of postoperative 48 h were significantly lower (11889.19 ± 5092.86 vs. 14583.22 ± 6562.96; P = 0.004) in septic patients. The low levels of platelets on postoperative 24 h and 72 h were observed in patients with sepsis as compared to patients without sepsis, whereas the levels of PCT at various time intervals (preoperative, postoperative - 24 h, 48 h, and 72 h) had shown no association with sepsis in the study population. Low PC (24 h) was the strongest predictor of sepsis showing an odds ratio of 1.9 (95% confidence interval [CI]: 1.42-3.51; P = 0.001) and area under curve of 0.688 with 95% CI of 0.54-0.83 (P = 0.018). CONCLUSION: We may conclude that in Indian pediatric population platelet levels are highly associated with sepsis as compared to any other hematological parameter. The immediate postoperative level of platelet is the strongest predictor of sepsis and could be effectively used in the clinical settings.

Useful Electrocardiographic Features to Help Identify the Mechanism of Atrial Tachycardia Occurring After Persistent Atrial Fibrillation Ablation.

OBJECTIVES: The purpose of this study was to describe and identify useful electrocardiographic characteristics to help identify the mechanism of atrial tachycardia (AT) occurring after persistent atrial fibrillation (PsAF) ablation. BACKGROUND: Electrocardiographic analysis to help identify the mechanism of AT after PsAF ablation is much limited by the fact that remodeling and ablation alter the normal activation pattern. METHODS: All consecutive patients who underwent mapping and ablation of AT after PsAF ablation were included. Surface P waves were analyzed during higher (>2:1) grades of atrioventricular block. RESULTS: One hundred ninety-six ATs with visible P waves were identified in 127 patients (macro-re-entry in 57%, centrifugal AT in 43%). One-third displayed low-voltage P waves (≤0.1 mV). An isoelectric line >80 ms was more common in centrifugal compared with macro-re-entrant AT (47% vs. 24%; p < 0.001), but its positive predictive value was limited (60%). A minority of peritricuspid ATs displayed the classic saw-tooth pattern (27% [n = 22]). However, the "precordial transition" (a gradual transition from an upright component in lead V1 to a negative component with progression across the precordium) remained often observed and specifically identified peritricuspid AT (specificity, 98%; sensitivity, 59%). Only 2 unique features could help identify perimitral AT (n = 60). First, the presence of a negative or negative-positive P-wave in any of leads V2 to V6 identified perimitral AT with 97% specificity and 30% sensitivity. Second, a "notched" negative component at the beginning of a positive P-wave in the inferior leads specifically identified clockwise perimitral AT (specificity, 98%; sensitivity, 25%). CONCLUSIONS: Only few unique electrocardiographic characteristics help identify the mechanism of AT after PsAF ablation. Knowledge of these characteristics may aid in planning and performing ablation.

Atrial tachycardias: Cause or effect with ablation of persistent atrial fibrillation?

INTRODUCTION: It is largely believed that atrial tachycardias (ATs) encountered during ablation of persistent atrial fibrillation (PsAF) are a byproduct of ablative lesions. We aimed to explore the alternative hypothesis that they may be a priori drivers of AF remaining masked until other AF sources are reduced or eliminated. METHODS AND RESULTS: Radiofrequency ablation of fibrillatory drivers mapped by electrocardiographic imaging (ECGI; ECVUE™, Cardioinsight Technologies, Cleveland, OH, USA) terminated PsAF in 198 (73%) out of 270 patients (61 ± 10 years, 9 ± 9 m). Two hundred and six ATs in 158 patients were subsequently mapped. Their anatomic relationship to the fibrillatory drivers prospectively identified by ECGI was then established. There were 26 (13%), 52 (25%), and 128 (62%) focal, localized, and macrore-entrant ATs, respectively. In focal/localized re-entrant ATs, 64 (82%) were terminated within an AF-driver region, in which 26 (81%) among 32 focal/localized ATs analyzed with 3-D-mapping system merged to driver map occurred from AF-driver regions in 1.0 ± 1.0 cm distance from the driver core. Importantly, there was no attempt at ablation of the associated AF-driver region in 25 of 64 (39%) of focal/localized re-entrant ATs. The sites of ATs origin generally had low-voltage, fractionated, and long-duration electrograms in AF. All but two focal/localized re-entrant ATs were successfully ablated. CONCLUSION: The majority of post-AF-ablation focal and localized re-entrant ATs originate from the region of prospectively established AF-driver regions. A third of these are localized to regions not subsequently submitted to ablation. These data suggest that many ATs exist, although not necessarily manifest independently, prior to ablation. They may have a role in the maintenance of PsAF in these individuals.

Frequency and effect of type 1 hypersensitivity in patients from India with chronic obstructive pulmonary disease and associated upper airways symptoms.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is now recognized as a systemic disorder with many comorbidities. Atopy in patients with COPD and upper airways symptoms has not been characterized. OBJECTIVE: We investigated the occurrence and impact of aeroallergen sensitisation in patients with COPD and upper airways symptoms. METHODS: All 41 subjects with COPD diagnosed as per Global Initiative for Chronic Obstructive Lung Disease guidelines, underwent spirometry with reversibility, computed tomography of the paranasal sinuses (CT-PNS), skin prick test (SPT) against common aeroallergens and responded to St. George's Respiratory Questionnaire (SGRQ) and Sino Nasal Outcome Test - 22 (SNOT-22) questionnaires. Upper airways symptoms were assessed as per the Allergic Rhinitis and its Impact on Asthma guidelines. RESULTS: As documented earlier, 27 of the 41 patients (65.9%) with COPD had upper airways symptoms. Of these 27 patients, 11 had SPT positivity against at least one aeroallergen (group 1). One patient had monosensitisation to pollens of grass Imperata while polysensitisation was seen in 10/11 patients commonly to weeds, trees, and insects. Fungal sensitisation to Aspergillus fumigatus was seen in 3 of 11 patients (27.2%). In group 1, all 11 patients (100%) had radiological sinusitis as compared to 8 of 16 (50%) in group 2. The mean CT-PNS scores were significantly higher in group 1 as compared to group 2. Similarly, the SNOT-22 scores were significantly higher in group 1 as compared to group 2. However, there was no difference in SGRQ scores between the 2 groups. In group 1, there was a significant correlation between CT-PNS and SNOT-22 scores. CONCLUSION: Patients with COPD, associated upper airways symptoms and a positive SPT had a significantly higher frequency of radiological sinusitis on CT-PNS. They even had worse quality of life as compared to those with a negative SPT. The study suggested that atopic patients with COPD and upper airways involvement were more symptomatic. It is therefore possible that upper airways symptoms, if left untreated, would result in less than desirable control of the disease.

A review of 42 asthmatic children with allergic bronchopulmonary aspergillosis.

BACKGROUND: Allergic bronchopulmonary aspergillosis (ABPA) in children with asthma, not associated with cystic fibrosis, is yet to receive the recognition it deserves. OBJECTIVE: To highlight the presentation of ABPA in children with asthma. METHODS: This retrospective review documents the occurrence of pediatric ABPA over a period of 31 years in one unit. Children with asthma, eosinophilia and infiltrates on chest radiograph were screened for ABPA. In these patients, demonstration of immediate hypersensitivity response against Aspergillus species along with serological profile and pulmonary function testing were done. Bronchography/computed tomography (CT) of the chest demonstrated central bronchiectasis (CB). CT of the paranasal sinuses was done in patients with upper airways symptoms. In those suspected with allergic Aspergillus sinusitis (AAS) consent was sought from the parents for the invasive procedure needed for the diagnosis of AAS. RESULTS: Of the 349 patients with ABPA diagnosed, 42 (12.03%) were in the pediatric age group. The mean age on presentation was 12.9 ± 4 years with a male preponderance. All patients had asthma and positive intradermal/skin prick test against Aspergillus species. Ring shadows, the most common radiological presentation, were seen in 28 of 42 patients. Bronchography/CT of the chest demonstrated CB, a feature pathognomic of ABPA, in 32 of 42 patients. High attenuation mucus plugs was observed in 7 of 36 patients while ABPA-seropositive was diagnosed in 10 of 42 patients. On imaging, sinusitis was seen in 20 of 30 patients with upper airways symptoms of whom eight had suspected AAS. Three parents consented for surgery, which confirmed the diagnosis. CONCLUSION: This study highlights the need to evaluate asthmatic children for ABPA as also to exclude AAS.

Occurrence of bronchial anthracofibrosis in respiratory symptomatics with exposure to biomass fuel smoke.

INTRODUCTION: Bronchial anthracofibrosis (BAF), confirmed bronchoscopically, is characterised by bluish-black mucosal pigmentation and distortion/narrowing of the bronchus. We investigated the occurrence of BAF in respiratory symptomatics with biomass fuel smoke exposure and evaluated its clinico-radiological attributes and impact on functional status. MATERIAL AND METHODS: Of the eighty subjects evaluated, 60 consented for fiberoptic bronchoscopy (FOB). All 60 subjects also underwent chest radiography, high resolution computed tomography (HRCT) of the thorax, complete pulmonary function testing including diffusion capacity and six-minute-walk test. Information regarding cardinal respiratory symptoms and duration of biomass fuel smoke exposure was documented. FOB evaluation revealed that 24 patients had BAF (Group 1), 17 had bronchial anthracosis (Group 2) and 19 had normal appearance (Group 3). RESULTS: Group 1 patients had significantly higher biomass fuel smoke exposure (p < 0.0001), lower mean post bronchodilator FEV1/FVC values (P = 0.02) and lower walk distance (p = 0.003) with greater desaturation. On HRCT, segmental collapse and consolidation were significantly higher in Group 1 while fibrotic lesions were the predominantly seen in Groups 2 and 3. A significant inverse correlation in Group 1 was seen between exposure index, six-minute-walk distance and spirometric parameters. In Group 1, the right middle lobe (RML) bronchus was most commonly involved (15/24 [62.5%]). In Group 2, RML and left upper lobe bronchi were affected in 8/17 (47.1%) patients each. CONCLUSIONS: All patients in our study were females. Those with BAF had poorer lung functions and functional status as compared to those with anthracosis only. On imaging, multifocal bronchial narrowing was specific to BAF.    .

Middle lobe syndrome: an intriguing presentation of tracheobronchial amyloidosis.

Pulmonary involvement in amyloidosis is a distinct rarity. This clinical entity usually presents as tracheobronchial amyloidosis (TBA). A 32-year-old, never-smoker man presented with episodic dyspnoea and wheezing along with cough and mucoid sputum. The chest radiograph was suggestive of a middle lobe syndrome (MLS). High-resolution CT (HRCT) of the chest confirmed the presence of MLS. In addition, HRCT showed circumferential thickening of the trachea and the main bronchi, with thickening of the posterior membranous wall of trachea. Fibrebronchoscopy, done to evaluate MLS, visualised multiple small polypoidal lesions in the lower part of trachea and carina. Endobronchial biopsies showed homogeneous, acellular amorphous deposit in the subepithelial region, which was congophilic in nature. A diagnosis of TBA presenting as MLS was made. To the best of our knowledge, this is the first detailed report of MLS as a presentation of TBA in the English literature.