Diagnoses and management of adult cough: An Indian Environmental Medical Association (EMA) position paper.

BACKGROUND: Cough is a common yet distressing symptom that results in significant health care costs from outpatient visits and related consultations. OBJECTIVE: The understanding of the pathobiology of cough in recent times has undergone an evolution with Cough hypersensitivity syndrome (CHS) being suggested in most cases of dry cough. However, in the case of productive cough, ancillary mechanisms including impaired Mucociliary clearance, in addition to hypermucosecretory bronchospastic conditions of Smoker's cough, asthma-COPD overlap, bronchiectasis, and allergic bronchopulmonary aspergillosis, need to be critically addressed while optimizing patient care with symptomatic therapy in outpatient settings of India. METHODS: In this review, evidence-based graded recommendations on use of antitussives - & protussives as a Position Paper were developed based on the Level and Quality of Scientific evidence as per Agency for Health Care and Quality (AHRQ) criteria listing and Expert opinions offered by a multidisciplinary EMA panel in India. RESULTS: Management of acute or chronic cough involves addressing common issues of environmental exposures and patient concerns before instituting supportive therapy with antitussives or bronchodilatory cough formulations containing mucoactives, anti-inflammatory, or short-acting beta-2 agonist agents. CONCLUSION: The analyses provides a real world approach to the management of acute or chronic cough in various clinical conditions with pro- or antitussive agents while avoiding their misuse in empirical settings.

Pulmonary involvement in idiopathic hypereosinophilic syndrome.

A case of idiopathic hypereosinophilic syndrome (HES) is presented. The patient had been symptomatic and had documented peripheral blood eosinophilia for 9 years. The patients having only pulmonary involvement, seem to have a good prognosis and hence must be considered as a separate subgroup of HES.

Jaundice due to anti-tuberculous drugs--a dose related phenomenon.

Data of 429 cases proved to have tuberculosis and on anti-tuberculous short course chemotherapy was analysed to find the incidence of jaundice due to anti-tuberculous drugs. The group included 257 males and 172 females (M : F ratio of 3 : 2), aged 7 to 75 years. 336 patients received short course chemotherapy for a duration of 6 months, while 93 patients were cases of relapse and hence received treatment for 9 months duration. Of these, 7 patients developed drug induced jaundice; 2 each in the age group of 21 to 35 years, and 36 to 50 years while 3 patients were in the age group of 51-65 years. All of these patients developed jaundice within 2 months of treatment and 6 of these 7 patients were receiving drugs in doses which were not adjusted as per the weight of the patient. None of these 6 patients redeveloped jaundice when the drugs were started in doses adjusted accurately as per the weight of the patients, in accordance with IUAT recommendations. One patient (0.21%), who was staredon weight adjusted dosage of anti-TB drugs developed jaundice which was probably due to isoniazed hypersensitivity.

Assessment of exercise tolerance in chronic bronchitis and interstitial lung disease.

Cardiopulmonary exercise testing has a definitive place in objective evaluation of the subjective sensation of breathlessness. In the present study 21 patients with COPD, 10 with ILD and 17 normals were subjected to stage 1 exercise testing and correlations were sought between Vo2 and work, FVC, FeV1, Ve, respiratory rate and tidal volume and between VCO2 and work. In COPD and ILD the Vo2 correlated with work, Fev1, Fvc and Ve whereas in normals it correlated with the VE but not with the FeV1 and FVC. In COPD VO2 correlated with TV though this was not the case in ILD. Thus stage 1 exercise testing can be a useful additional method to assess the disability in COPD and ILD although differentiation between these two respiratory diseases on basis of exercise testing alone may not be possible.

Effect of ipratropium bromide in bronchial asthma.

The effect of inhalation of ipratropium bromide was evaluated in 20 patients with bronchial asthma. It was observed that there was no significant improvement in the forced vital capacity and the forced expired volume in one second, while there was significant improvement in the peak expiratory flow rate (PEFR) measured at 9 pm, after inhalation of 2 puffs of ipratropium bromide aerosol (0.02mg/puff) three to four times a day for 2 weeks. Since PEFR is a measure of large airway function and cholinergic mechanisms are primarily involved for airflow obstruction at large airways, improvement in PEFR by ipratropium bromide highlights its role as a useful bronchodilator in patients in whom vagal reflexes are responsible for the provocation of bronchoconstriction.

Progressive supranuclear palsy: relationship between extrapyramidal disturbances, dementia, and brain neurotransmitter markers.

Biochemical markers for the major neurotransmitter systems were measured in the brains of 5 patients who had died with neuropathologically confirmed progressive supranuclear palsy. A marked nigrostriatal dopamine deficiency, observed in 4 of the 5 patients, was sufficient to explain the parkinsonian features (especially bradykinesia) observed in patients with progressive supranuclear palsy. Dopamine concentrations, however, were normal in the nucleus accumbens, hypothalamus, and temporal cortex. Brain noradrenalin, serotonin, gamma-aminobutyric acid, and aspartic acid levels were generally normal. Normal brain choline acetyltransferase activity (the marker enzyme for cholinergic neurons) in the 2 patients with severe dementia suggests that, at least in some patients, the cognitive impairment in this disorder is likely to be related to noncholinergic neurotransmitter system changes. The glutamic acid concentration was elevated in many brain areas in 3 of the 5 patients studied.

Brain neurotransmitter abnormalities in neuronal intranuclear inclusion body disorder.

Biochemical markers for the major neurotransmitter systems were measured in the brain of a patient who died with neuronal intranuclear inclusion disease. A severe nigrostriatal dopamine deficiency constitutes the basis for the parkinsonian features in the patient. A marked loss of brain norepinephrine and serotonin was found in the basal ganglia and hypothalamus. Brain amino acid (gamma-aminobutyric acid and glutamate) and cholinergic (choline acetyltransferase activity) systems were either normal or less severely affected.