Inhaler Competence in Nepalese Patients with Asthma and Chronic Obstructive Pulmunory Disease: A Systematic Review.

BACKGROUND: Incorrect use of inhalers in patients with asthma and chronic obstructive pulmonary disease is prevalent internationally. This review aims to determine the prevalence and associated factors of incorrect inhaler use and effectiveness of intervention to improve the correct use among Nepalese patients with asthma and chronic obstructive pulmonary disease. METHODS: The protocol was registered in PROSPERO. Systematic literature search was performed in PubMed, Embase, CINAHL,and Google Scholar using predefined search terms. Studies in patients with asthma or chronic obstructive pulmonary disease, reporting at least one overall or critical error, using dry powder inhalers and pressurized metered dose inhalers were included. The quality of included studies was assessed using the National Heart, Lung, and Blood Quality Assessment Tools. A descriptive narrative synthesis was undertaken. RESULTS: Twelve studies were eligible for analysis. At least one overall and critical step of the inhaler technique was performed incorrectly by the large number of patients, ranging from 64-100% and 9-100%, respectively. The incorrect use was associated with factors related to patients, inhalers, and health care professionals. The interventions included a combination of verbal instruction, physical demonstration, and/or face-to-face training on correct inhaler use. Following the intervention, an improvement of 23-37% in the overall inhaler technique and 7-42% in the critical steps was achieved. CONCLUSIONS: Existing literature suggests that Nepalese patients with asthma and chronic obstructive pulmonary disease have high overall and critical error rates in the use of dry powder inhalers and pressurized metered dose inhalers. A well-designed educational intervention is necessary to improve the correct use of inhalers in this population.

A multicenter survey study of antifibrotic use for symptomatic patients with post-COVID-19 interstitial lung abnormalities.

Background: Little data exist on antifibrotic drugs for treating symptomatic patients with persistent interstitial lung abnormalities in the postacute phase of coronavirus disease 2019 (COVID-19). Herein, we describe the physician practices of prescribing pirfenidone and nintedanib for these patients and the physician-assessed response. Materials and Methods: This was a multicenter, retrospective survey study of subjects administered pirfenidone or nintedanib for post-COVID-19 interstitial lung abnormalities. Data on the demographic details, comorbidities, abnormalities on the computed tomography (CT) of the chest, treatment, antifibrotic drug use, and physician-assessed response were collected on a standard case record pro forma. We explored physician practices of prescribing antifibrotics (primary objective) and the physician-assessed response (secondary objective). Results: We included 142 subjects (mean age, 55.9 years; 16.2% women) at eight centers. The most common abnormalities on CT chest included ground glass opacities (75.7%), consolidation (49.5%), reticulation (43.9%), and parenchymal bands (16.8%). Of the 5701 patients discharged after hospitalization at six centers, 115 (2.0%) received antifibrotics. The drugs were prescribed an average of 26 days after symptom onset. One hundred and sixteen subjects were administered pirfenidone; 11 (9.5%) received the full dose (2400 mg/day). Thirty subjects were prescribed nintedanib; 23 (76.7%) received the full dose (300 mg/day). Of 76 subjects with available information, 27 (35.6%) and 26 (34.2%) had significant or partial radiologic improvement, respectively, according to the physician's assessment. Conclusions: Antifibrotic agents were administered to a minority of patients discharged after recovery from acute COVID-19 pneumonia. Larger, randomized studies on the efficacy and safety of these agents are required.

Convex probe endobronchial ultrasound guided transbronchial/transoesophageal fine needle aspiration (C-EBUS-TBNA/EUS-B FNA) of pleural lesions: A single center experience and review of literature.

The evaluation of pleural diseases has been well established. If pleurocentensis is non-diagnostic, the second investigation depending upon availability could be either closed pleural biopsy or image guided pleural biopsy or thoracoscopic pleural biopsy (medical or surgical). Pleural disease presenting as thickness/mass/nodule in the mediastinum is difficult to access through ultrasound or computed tomography and will need thoracoscopy. Thoracoscopy is an invasive procedure which can be difficult to perform in localized mediastinal pleural disease without effusion or poor health condition not suitable for general anesthesia. An alternative method that can be utilized is sampling of pleural lesion through convex probe endobronchial ultrasound (CEBUS) either through the central large airways or from esophagus if the lesions are in proximity. We present our center's experience in diagnosing pleural lesion using C-EBUS in 4 patients along with review of the literature.

Multivitamin pill aspiration leading to hemorrhagic bronchial necrosis.

This article highlights the serious but reversible effects of multivitamin pill aspiration into the lungs. If diagnosed early and treated promptly the harmful effects of the pill constituents on the lungs and airways can be attenuated. An early bronchoscopy and a high index of suspicion is required in order not to miss these events. We have described a case of multivitamin pill aspiration in a young healthy male and the good response to early intervention.

Pyrexia, Lung nodules, Granulomas: Pulmonary Lymphomatoid Granulomatosis.

The differential diagnosis of pyrexia, lung nodules and granulomas includes tuberculosis, vasculitis and rarely a malignancy. In countries where tuberculosis or histoplasmosis is endemic, these are the first consideration and often ruled out by microbiological investigations. Vasculitis like granulomatosis with polyangitis (Wegener's granulomatosis), Churg strauss syndrome and sarcoidosis, which are the second consideration, are ruled out by serological investigations. Confirmation of malignancy merits histopathology. This case highlights how a rare diagnosis of pulmonary lymphomatoid granulomatosis was reached after an open lung biopsy. The following case also describes the natural history of this rare disease as it showed transient spontaneous remission but ultimately required therapy.

Diagnostic performance of various tests and criteria employed in allergic bronchopulmonary aspergillosis: a latent class analysis.

AIM: The efficiency of various investigations and diagnostic criteria used in diagnosis of allergic bronchopulmonary aspergillosis (ABPA) remain unknown, primarily because of the lack of a gold standard. Latent class analysis (LCA) can provide estimates of sensitivity and specificity in absence of gold standard. Herein, we report the performance of various investigations and criteria employed in diagnosis of ABPA. METHODS: Consecutive subjects with asthma underwent all the following investigations Aspergillus skin test, IgE levels (total and A.fumigatus specific), Aspergillus precipitins, eosinophil count, chest radiograph, and high-resolution computed tomography (HRCT) of the chest. We used LCA to estimate the performance of various diagnostic tests and criteria in identification of ABPA. RESULTS: There were 372 asthmatics with a mean age of 35.9 years. The prevalence of Aspergillus sensitization was 53.2%. The sensitivity and specificity of various tests were Aspergillus skin test positivity (94.7%, 79.7%); IgE levels>1000 IU/mL (97.1%, 37.7%); A.fumigatus specific IgE levels>0.35 kUA/L (100%, 69.3%); Aspergillus precipitins (42.7%, 97.1%); eosinophil count>1000 cells/µL (29.5%, 93.1%); chest radiographic opacities (36.1%, 92.5%); bronchiectasis (91.9%, 80.9%); and, high-attenuation mucus (39.7%, 100%). The most accurate criteria was the Patterson criteria using six components followed by the Agarwal criteria. However, there was substantial decline in accuracy of the Patterson criteria if components of the criteria were either increased or decreased from six. CONCLUSIONS: A.fumigatus specific IgE levels and high-attenuation mucus were found to be the most sensitive and specific test respectively in diagnosis of ABPA. The Patterson criteria remain the best diagnostic criteria however they have good veridicality only if six criteria are used.

Immune restoration syndrome with disseminated Penicillium marneffei and cytomegalovirus co-infections in an AIDS patient.

BACKGROUND: Penicillium marneffei is a dimorphic fungus, endemic in South-east Asia. The fungus causes severe disease in immunocompromised patients such as AIDS. However, no case of immune restoration disease of Penicillium marneffei is reported in literature from a non-endemic area. CASE PRESENTATION: We report the first case of Penicillium marneffei and Cytomegalovirus infection manifesting as a result of immune restoration one month after initiating HAART. This severely immunocompromised patient had presented with multiple lymphadenopathy, massive hepatosplenomegaly, visual impairment and mild icterus, but no skin lesions. Penicillium marneffei was isolated from lymph node fine-needle aspirates and blood cultures. CONCLUSION: In order to diagnose such rare cases, the clinicians, histopathologists and microbiologists alike need to maintain a strong index of suspicion for making initial diagnosis as well as for suspecting immune reconstitution syndrome (IRS) with Penicillium marneffei.