Author Response: Unanswered Questions and Contradictory Statements in the Antibiotics Prescription Guidelines.

How to cite this article: Khilnani GC, Tiwari P, Mittal S. Author Response: Unanswered Questions and Contradictory Statements in the Antibiotics Prescription Guidelines. Indian J Crit Care Med 2024;28(7):717-718.

ISCCM Position Statement on the Approach to and Management of Critically Ill Patients with Tuberculosis.

Tuberculosis (TB) is an important cause of morbidity and mortality globally. About 3-4% of hospitalized TB patients require admission to the intensive care unit (ICU); the mortality in these patients is around 50-60%. There is limited literature on the evaluation and management of patients with TB who required ICU admission. The Indian Society of Critical Care Medicine (ISCCM) constituted a working group to develop a position paper that provides recommendations on the various aspects of TB in the ICU setting based on available evidence. Seven domains were identified including the categorization of TB in the critically ill, diagnostic workup, drug therapy, TB in the immunocompromised host, organ support, infection control, and post-TB sequelae. Forty-one questions pertaining to these domains were identified and evidence-based position statements were generated, where available, keeping in focus the critical care aspects. Where evidence was not available, the recommendations were based on consensus. This position paper guides the approach to and management of critically ill patients with TB. How to cite this article: Chacko B, Chaudhry D, Peter JV, Khilnani G, Saxena P, Sehgal IS, et al. isccm Position Statement on the Approach to and Management of Critically Ill Patients with Tuberculosis. Indian J Crit Care Med 2024;28(S2):S67-S91.

Guidelines for Antibiotics Prescription in Critically Ill Patients.

How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.

Guidelines for the Use of Procalcitonin for Rational Use of Antibiotics.

How to cite this article: Khilnani GC, Tiwari P, Zirpe KG, Chaudhary D, Govil D, Dixit S, et al. Guidelines for the Use of Procalcitonin for Rational Use of Antibiotics. Indian J Crit Care Med 2022;26(S2):S77-S94.

Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method.

BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice. METHODS: Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ2) test (p < 0·05 was considered as unstable). RESULTS: Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16-24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment. CONCLUSION: Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited. TRIAL REGISTRATION: The study was registered with Clinical trials.gov Identifier: NCT04534569.

Challenges in Preparing and Managing the Critical Care Services for a Large Urban Area During COVID-19 Outbreak: Perspective From Delhi.

The coronavirus disease-2019 (COVID-19) pandemic has put healthcare services all over the world into a challenging situation. The contagious nature of the disease and the respiratory failure necessitating ventilatory care of these patients have put extra burden on intensive care unit (ICU) services. India has been no exception; by March 2020, the number of COVID-19 patients started increasing in India. This article describes the measures taken and challenges faced in creating ample ICU bed capacity to cater to the anticipated load of patients in the state of Delhi, India, as a result of the COVID-19 pandemic. The main challenges faced, among others, were estimating the number of ICU beds to be created; deciding on dedicated hospitals to treat COVID-19 patients; procuring ventilators, personal protective equipment, and other related material; mobilizing human resources and providing their training; and providing isolated in-house accommodations to the staff on duty. The authors acknowledge and agree that the methodology proposed in this article is but one way of approaching this difficult scenario and that there could be other, perhaps better, methods of dealing with such a problem.

Indian Antimicrobial Prescription Guidelines in Critically Ill Immunocompromised Patients.

How to cite this article: Kulkarni AP, Sengar M, Chinnaswamy G, Hegde A, Rodrigues C, Soman R, Khilnani GC, Ramasubban S, Desai M, Pandit R, Khasne R, Shetty A, Gilada T, Bhosale S, Kothekar A, Dixit S, Zirpe K, Mehta Y, Pulinilkunnathil JG, Bhagat V, Khan MS, Narkhede AM, Baliga N, Ammapalli S, Bamne S, Turkar S, Bhat KV, Choudhary J, Kumar R, Divatia JV. Indian Journal of Critical Care Medicine 2019;23(Suppl 1): S64-S96.

Air pollution in India and related adverse respiratory health effects: past, present, and future directions.

PURPOSE OF REVIEW: The review describes current status of air pollution in India, summarizes recent research on adverse health effects of ambient and household air pollution, and outlines the ongoing efforts and future actions required to improve air quality and reduce morbidity and mortality because of air pollution in India. RECENT FINDINGS: Global burden of disease data analysis reveals more than one million premature deaths attributable to ambient air pollution in 2015 in India. More than one million additional deaths can be attributed to household air pollution. Particulate matter with diameter 2.5 µm or less has been causatively linked with most premature deaths. Acute respiratory tract infections, asthma, chronic obstructive pulmonary disease, exacerbations of preexisting obstructive airway disease and lung cancer are proven adverse respiratory effects of air pollution. Targeting air quality standards laid by WHO can significantly reduce morbidity and mortality because of air pollution in India. SUMMARY: India is currently exposed to high levels of ambient and household air pollutants. Respiratory adverse effects of air pollution are significant contributors to morbidity and premature mortality in India. Substantial efforts are being made at legislative, administrative, and community levels to improve air quality. However, much more needs to be done to change the 'status quo' and attain the target air quality standards. VIDEO ABSTRACT: http://links.lww.com/COPM/A24.

Noninvasive Ventilation for Acute Respiratory Failure due to Noncystic Fibrosis Bronchiectasis.

PURPOSE OF THE STUDY: Data regarding the use of noninvasive ventilation (NIV) for treatment of acute respiratory failure (ARF) among patients with noncystic fibrosis (CF) bronchiectasis are limited. We intend to describe our experience with NIV use in this setting. METHODOLOGY: This was a retrospective study which included 99 patients with bronchiectasis and ARF who required either NIV or invasive mechanical ventilation (IMV). RESULTS: NIV was started as the primary modality of ventilatory support in 81 (66.3%) patients. Fifty-three (65.4%) patients were managed successfully with NIV. Twenty-eight (34.56%) patients failed NIV and required endotracheal intubation. Reasons for NIV failure were worsening or nonimprovement of ventilatory or oxygenation parameters (n = 15), hypotension (n = 6), worsening of sensorium (n = 3), and intolerance (n = 4). None of the patients failed NIV due to excessive respiratory secretions. The rate of correction of arterial blood gases was comparable between NIV and IMV groups. The total duration of stay (median [interquartile range] days) in hospital was comparable between patients treated with NIV and IMV (8 [7-10] vs. 11 [5-11]; P = 0.99), respectively. The mortality rate between NIV and IMV groups were statistically comparable (8.64% vs. 16.6%; P = 0.08). High APACHE score at admission was associated with NIV failure (odd's ratio [95% confidence interval]: 1.21 (1.07-1.38)]. CONCLUSIONS: NIV is feasible for management of ARF with non-CF bronchiectasis. High APACHE may predict NIV failure among these patients.

Intra- and Inter-observer Reliability of Quadriceps Muscle Thickness Measured with Bedside Ultrasonography by Critical Care Physicians.

BACKGROUND: Muscle wasting is common among critically ill patients with sepsis and has a significant effect on clinical outcome. However, appropriate tool for measurement of muscle loss is debatable. Ultrasonography (USG) has been used for objective assessment of quadriceps muscle thickness among these patients; however, there is limited data on its reliability. AIMS AND OBJECTIVE: This study was aimed to assess the reliability of quadriceps muscle thickness as measured by critical care physicians. METHODOLOGY: This cross-sectional study included twenty patients with sepsis. Quadriceps muscle thickness was measured on right mid-thigh at a predefined point by two critical care fellows using bedside USG. Intra- and inter-observer reliability of the measurements was assessed by intra-class correlation coefficient (ICC). RESULTS: Hundred and twenty quadriceps muscle thickness measurements, three by each of the two critical care fellows, were done in twenty patients with sepsis. First, second, and third measurements (mean ± standard deviation) taken by the first observer (RK) were 35.030 ± 3.546 mm, 35.055 ± 3.307 mm, and 35.245 ± 3.027 mm, respectively. The three values recorded by the second observer (AD) were 35.585 ± 3.746 mm, 35.1 ± 3.006 mm, and 34.89 ± 2.556 mm, respectively. ICC for observer 1 and 2 was 0.925 (95% confidence interval [CI]: 0.851-0.967) and 0.835 (95% CI: 0.689-0.925), respectively. The mean difference of measurement between two observers was 0.082 mm (95% CI: -1.194-1.031). The mean ICC (95% CI) for inter-observer reliability was 0.992 (0.979-0.997); P < 0.001. CONCLUSIONS: This study shows that ultrasound is a reliable tool for the measurement of quadriceps muscle thickness by critical care physicians with excellent inter- and intra-class reliability.

"I Would Rather Die Drinking than take the Medicine": Role of Alcohol Use Disorder in Loss-to-follow-up of Tuberculosis Treatment in a Rural Area of Ballabgarh, Haryana.

Introduction: Alcohol use disorder (AUD) is a significant risk factor for tuberculosis (TB) treatment loss-to-follow-up (LTFU). This field-based study was undertaken to understand the role of AUD and TB treatment LTFU and the reasons behind this association in a rural area of Ballabgarh, Haryana. Material and Methods: TB patients who had completed their treatment and who had been LTFU were included in the study, along with the National TB Elimination Program (NTEP) staff, healthcare providers, family, and community members from Ballabgarh block of the north Indian state of Haryana. In-depth interviews (IDIs) and focused group discussions (FGDs) were conducted to gauge the perceptions of stakeholders regarding reasons for LTFU, especially in the context of alcohol use. Inductive analysis of the transcripts was done in keeping with the grounded theory, and themes with their sub-themes were identified. A conceptual framework of TB-AUD was constructed, and potential areas for intervention were determined. Results: Fifty-eight IDIs and four FGDs were conducted in mid-2018. Almost all key informants and many patient participants believed that alcohol use makes TB patients highly susceptible to treatment LTFU. Key themes identified were shared personality traits and attitudes, combined side effects of anti-tubercular drugs and alcohol use, lack of family support, and an adverse financial situation. Conclusion: These findings call for a change in NTEP's approach to AUD-TB. Interventions may include collecting alcohol use information at patient enrolment and closure, integrating brief interventions for alcohol cessation in NTEP, and linking patients to deaddiction centers with the provision of appropriate dietary and financial support.

"Better to Die Than Take These Medicines": A Community-Based Qualitative Study on the Determinants of Treatment Loss-to-Follow-Up in Tuberculosis Patients in District Faridabad, Haryana, India.

Introduction India is the biggest contributor to the global incidence of tuberculosis (TB). A major reason behind the persistently high incidence of TB in India is treatment loss-to-follow-up (LTFU). The consequences of LTFU include continuous transmission to uninfected individuals, drug resistance, and a higher rate of death in incompletely treated patients. It is a significant hurdle to making India 'TB-Free' by 2025. Hence, we conducted a community-based qualitative study to understand the determinants of treatment of LTFU in TB patients in the Faridabad district of Haryana, India.  Methodology We enrolled TB patients who had completed treatment as well as those who had been LTFU. We also enrolled National Tuberculosis Elimination Programme (NTEP) functionaries, healthcare providers, family members, and community members. In-depth interviews (IDIs) and focus group discussions (FGDs) were conducted to understand stakeholders' perceptions of reasons for LTFU. The grounded theory approach was used with inductive analysis. Data were triangulated from stakeholders' interviews. Themes and sub-themes were identified. A Health Belief Model for TB treatment completion was developed. Results Fifty-eight IDIs and four FGDs were conducted between May-June 2018. The major themes influencing the treatment of LTFU which emerged from the analyses were - the role of external motivators, regular use of alcohol, lack of/or inappropriate knowledge related to treatment, lack of family support, and side effects of anti-tubercular drugs, and a poor experience with the health system. Stigma was not found to be a major determinant - in the few cases that it affected treatment, it spurred treatment completion rather than LTFU. "I completed the course with great difficulty. Then they started it again! […] I said-Sorry, sir, I can't go through this again. It's better to die once than to die a thousand deaths." - Fifty-one-year-old male patient who was lost-to-follow-up on re-treatment. Discussion This study was a comprehensive multi-stakeholder qualitative undertaking to identify the determinants of LTFU. Our qualitative approach explained the associations between LTFU and certain factors (e.g.: alcohol use, side effects, etc.) found in previous quantitative studies. The strength of this study was that we ensured participation by patients as well as all district-level stakeholders from the national health programme, which no previous qualitative study on the treatment LTFU in India had achieved. The entire qualitative analysis was done manually and in Hindi (the language in which interviews were conducted). Hence, no data were lost in translation. The limitation was that its findings were specific to the study area and study population, as is the case with all qualitative studies. Conclusion All healthcare providers should be sensitised to the determinants of treatment LTFU, so that they can pay special attention to at-risk patients and take appropriate steps to prevent LTFU. For instance, patients with a pattern of regular alcohol use should be counselled and may be referred to deaddiction centres, with the continuum of care maintained. The journey from tuberculosis diagnosis to treatment completion is often extremely traumatic for the patient. The onus to successfully complete treatment lies not with the patient alone, but with the health system as well.

Co-existing obstructive sleep apnea among patients with chronic obstructive pulmonary disease.

BACKGROUND AND OBJECTIVES: Chronic obstructive pulmonary disease (COPD) is a common airway disease that is frequently associated with comorbidities. In this study, we assessed the co-existence of obstructive sleep apnea (OSA) among patients with stable COPD. METHODOLOGY: This cross-sectional study included patients with stable COPD who were screened with Epworth's Sleepiness Scale (ESS). Those with ESS score of >10 were subjected to in-lab polysomnography (PSG). PSG was manually analyzed and reported. Patients with apnea-hypopnea index of >5/h were diagnosed as OSA. RESULTS: This study included 301 patients (78.1% male, 76.4% smokers, age 59.6 ± 10 years) with stable COPD. ESS score of >10 was observed in 47 (15.6%) patients. Among patients with ESS score of >10, OSA was observed in 34 (72.3%) patients. The overall prevalence of OSA among patients with COPD was 10.9%. Patients with co-existing OSA were older and had thicker neck and higher body mass index (BMI) as compared to COPD alone. In addition, patients with associated OSA had worse health-related quality of life (QOL) as shown by higher St. George's Respiratory Questionnaire score (42.42 ± 7.22 vs. 25.22 ± 8.66;P < 0.001). CONCLUSIONS: Co-existing OSA is common among patients with COPD and has a significant adverse effect on the QOL. Among COPD patients, older age, thick neck, and high BMI may predict co-existing OSA and require PSG for the confirmation.

A comparison of three strategies for withdrawal of noninvasive ventilation in chronic obstructive pulmonary disease with acute respiratory failure: Randomized trial.

BACKGROUND: The optimal strategy for the withdrawal of noninvasive ventilation (NIV) remains unknown. This study was planned to compare three different strategies for the withdrawal of NIV among patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with hypercapnic respiratory failure (HcRF). MATERIALS AND METHODS: Patients with AECOPD with HcRF who improved on NIV were randomized into three groups - immediate withdrawal (Group A), stepwise reduction of pressure support (Group B), and stepwise reduction of duration (Group C) of NIV. The probability of successful withdrawal was compared among the groups. RESULTS: This study included 90 patients (males - 86.6%) with a mean (±standard deviation [SD]) age of 59.9 ± 8.3 years. The mean (±SD) pH and PaCO2 at admission were 7.23 ± 0.04 and 84.4 ± 12.0 mm Hg, respectively. The duration of NIV received before randomization was 31.6 ± 9.2 h with maximum inspiratory positive airway pressure and expiratory positive airway pressure of 17.6 ± 2.7 cm H2O and 7.4 ± 1.4 cm H2O, respectively. NIV was successfully withdrawn in 23/30 (76.6%) in Group A, 27/30 (90%) in Group B, and 26/30 (86.6%) in Group C (P = 0.31). The total duration of NIV use and length of hospital stay was lower in Group A and B as compared to Group C (P = 0.001). CONCLUSIONS: Immediate withdrawal of the NIV after recovery of respiratory failure among patients with exacerbation of COPD is feasible. Immediate withdrawal did not increase the risk of weaning failure from the NIV.

A Prospective Outcome Assessment After Bronchoscopic Interventions for Malignant Central Airway Obstruction.

BACKGROUND: A systematic assessment of comprehensive clinical outcomes after various therapeutic procedures for malignant central airway obstruction (CAO) is lacking. METHODS: Patients with symptomatic malignant CAO undergoing various therapeutic bronchoscopy procedures were assessed for symptomatic and functional improvement using the Speiser Score, spirometry, 6-minute walk distance (6MWD), and St. George Respiratory Questionnaire (SGRQ) up to 3 months after the procedures. RESULTS: A total of 83 intervention procedures were performed in 65 patients, comprising 43 (66.2%) male individuals [overall mean age, 52.4; SD, 15.4 y]. The majority of these (92.3%) was done using rigid bronchoscope under general anesthesia. Airway stenting was the most common intervention performed (56.6%), followed by mechanical debulking (26.5%), cryodebulking (6%), electrosurgical removal (4.8%), balloon dilatation (3.6%), and laser ablation (2.4%).A total of 15 complications (18.1%) were noted. Of these, 8 (53.3%) were early complications and 7 (46.7%) were late complications. Early complications included airway bleeding, hypoxia, vocal cord injury, laryngeal injury, and pneumothorax. Late complications included significant granulation tissue formation in metallic stents and lung collapse because of mucus plug.The survival rates at 4, 8, and 12 weeks were 83%, 70.7%, and 66.1%, respectively. Significant improvement was observed in dyspnea, cough, Speiser Score, 6MWD, forced expiratory volume in 1 s, forced vital capacity, and SGRQ scores at 48 hours, 4 weeks, and at 12 weeks after the procedures and no procedure-related mortality occurred. CONCLUSION: Various therapeutic bronchoscopic interventions, including combined modalities, provide rapid and sustained improvements in symptoms, respiratory status, exercise capacity, and quality of life in malignant CAO and have a good safety profile.

Rigid Mini-Thoracoscopy Versus Semirigid Thoracoscopy in Undiagnosed Exudative Pleural Effusion: The MINT Randomized Controlled Trial.

BACKGROUND: There is debate regarding the ideal instrument for medical thoracoscopy. The authors compared rigid mini-thoracoscopy with semirigid thoracoscopy for thoracoscopic pleural biopsy. METHODS: Consecutive subjects with undiagnosed exudative pleural effusion were randomized (1:1 ratio) to mini-thoracoscopy or semirigid thoracoscopy groups. The primary objective was a comparison of the diagnostic yield of pleural biopsy. Key secondary outcomes were the comparison of sedative/analgesic dose, operator-rated and patient-rated pain on visual analog scale (VAS), operator-rated overall procedural satisfaction (VAS), pleural biopsy size, and complications between the groups. RESULTS: Of the 88 screened subjects, 73 were randomized: 36 to mini-thoracoscopy and 37 to semirigid thoracoscopy. Diagnostic yield of pleural biopsy in the mini-thoracoscopy (69.4%) and semirigid thoracoscopy groups (81.1%) was similar on intention-to-treat analysis (P=0.25). Although the operator-rated overall procedure satisfaction scores were similar between groups (P=0.87), operator-rated pain [VAS (mean±SD), 43.5±16.7 vs. 31.7±15.8; P<0.001] and patient-rated pain (VAS, 41.9±17.3 vs. 32.1±16.5; P=0.02) scores were greater in the mini-thoracoscopy group. Mean dose of fentanyl and midazolam received was similar between the 2 groups (P=0.28 and 0.68, respectively). Biopsy size was larger in the mini-thoracoscopy group (16.1±4.5 vs. 8.3±2.9 mm; P<0.001). Three minor complications occurred in the mini-thoracoscopy group and 6 in the semirigid thoracoscopy group (P=0.11). There were no serious adverse events or procedure-related mortality. CONCLUSION: Diagnostic yield of rigid mini-thoracoscopy is not superior to semirigid thoracoscopy. Use of semirigid thoracoscope may provide greater patient comfort.

Impact and prognosis of the expression of IFN-α among tuberculosis patients.

Mycobacterium tuberculosis (M.tb) infection stimulates the release of cytokines, including interferons (IFNs). IFNs are initiators, regulators, and effectors of innate and adaptive immunity. Accordingly, the expression levels of Type I (α, ß) and II (γ) IFNs, among untreated tuberculosis (TB) patients and household contacts (HHC) clinically free of TB was assessed. A total of 264 individuals (TB patients-123; HHC-86; laboratory volunteers-55; Treated TB patients-36) were enrolled for this study. IFN-α mRNA expression levels predominated compared to IFN-γ and IFN-ß among untreated TB patients. IFN-α transcripts were ~3.5 folds higher in TB patients compared to HHC, (p<0.0001). High expression of IFN-α was seen among 46% (56/ 123) of the TB patients and 26%, (22/86) of HHCs. The expression levels of IFN-α correlated with that of IFN transcriptional release factor 7 (IRF) (p<0.0001). In contrast, an inverse relationship exists between PGE2 and IFN-α expression levels; high IFN-α expressers were associated with low levels of PGE2 and vice-versa (Spearman's rho = -0.563; p<0.0001). In-vitro, IFN-α failed to restrict the replication of intracellular M.tb. The anti-mycobacterial activity of IFN-γ was compromised in the presence of IFN-α, but not by IFN-ß. The expression of IFN-α and ß diminished or is absent, among successfully treated TB patients. These observations suggest the utility of assessment of Type I IFNs expression levels as a prognostic marker to monitor tuberculosis patient response to chemotherapy because changes in Type I IFNs expression are expected to precede the clearance and /reduction in bacterial load.

An Aptamer Linked Immobilized Sorbent Assay (ALISA) to Detect Circulatory IFN-α, an Inflammatory Protein among Tuberculosis Patients.

Dysregulation of IFN-α is the basis for pathogenesis of autoimmune as well as infectious diseases. Identifying inflammatory signatures in peripheral blood of patients is an approach for monitoring active infection. Hence, estimation of type I IFNs as an inflammatory biomarker to scrutinize disease status after treatment is useful. Accordingly, an Aptamer Linked Immobilized Sorbent Assay (ALISA) for the detection of IFN-α in serum samples was developed. Sixteen aptamers were screened for their ability to bind IFN-α. Aptamer IFNα-3 exhibited specificity for IFN-α with no cross-reactivity with interferons ß and γ and human serum albumin. The disassociation constant (Kd) was determined to be 3.96 ± 0.36 nM, and the limit of detection was ∼2 ng. The characterized IFNα-3 aptamer was used in ALISA to screen tuberculosis (TB) patients' sera. An elevated IFN-α level in sera derived from untreated TB patients (median = 0.31), compared to nontuberculous household contacts (median = 0.13) and healthy volunteers (median = 0.12), and further a decline in IFN-α level among treated patients (median = 0.13) were seen. The ALISA assay facilitates direct estimation of inflammatory protein(s) in circulation unlike mRNA estimation by real time PCR. Designing of aptamers similar to the IFNα-3 aptamer provides a novel approach to assess other inflammatory protein(s) in patients before, during, and after completion of treatment and would denote clinical improvement in successfully treated patients.

Management of interstitial lung diseases: A consensus statement of the Indian Chest Society (ICS) and National College of Chest Physicians (NCCP).

BACKGROUND: Interstitial lung disease (ILD) is a complex and heterogeneous group of acute and chronic lung diseases of several known and unknown causes. While clinical practice guidelines (CPG) for idiopathic pulmonary fibrosis (IPF) have been recently updated, CPG for ILD other than IPF are needed. METHODS: A working group of multidisciplinary clinicians familiar with clinical management of ILD (pulmonologists, radiologist, pathologist, and rheumatologist) and three epidemiologists selected by the leaderships of Indian Chest Society and National College of Chest Physicians, India, posed questions to address the clinically relevant situation. A systematic search was performed on PubMed, Embase, and Cochrane databases. A modified GRADE approach was used to grade the evidence. The working group discussed the evidence and reached a consensus of opinions for each question following face-to-face discussions. RESULTS: Statements have been made for each specific question and the grade of evidence has been provided after performing a systematic review of literature. For most of the questions addressed, the available evidence was insufficient and of low to very low quality. The consensus of the opinions of the working group has been presented as statements for the questions and not as an evidence-based CPG for the management of ILD. CONCLUSION: This document provides the guidelines made by consensus of opinions among experts following discussion of systematic review of evidence pertaining to the specific questions for management of ILD other than IPF. It is hoped that this document will help the clinician understand the accumulated evidence and help better management of idiopathic and nonidiopathic interstitial pneumonias.