Beyond COVID-19: Evidence-Based Consensus Statement on the Role of Physiotherapy in Pulmonary Rehabilitation in the Indian Context.

Post COVID-19 sequelae includes breathlessness, weakness, fatigue, decreased exercise tolerance and impaired quality of life. Physiotherapy based rehabilitation program is an essential component for post COVID-19 patients in facilitating maximum functional recovery. Expert consensus statements are available from the developed countries. There is a need for a guidelines to manage post COVID-19 sequelae in Indian context. The objective of this consensus statement is to provide evidence informed guidelines for post COVID-19 physiotherapy management as a component of pulmonary rehabilitation. This consensus statement was developed by expert panel across India. Published literatures were appraised and used to prepare the recommendations. This is the first of its kind of work providing preliminary guidelines for post COVID-19 physiotherapy.

Effect of Pulmonary Rehabilitation (PR) Program in Patients with Interstitial Lung Disease (ILD)-Indian scenario.

INTRODUCTION: Interstitial Lung diseases (ILD) are group of disorders wherein due to varied etiologies, interstitium goes into progressive inflammation or fibrosis. Although, the awareness has improved but the therapy is still facing challenges. Pulmonary Rehabilitation (PR) is a worthy modality, which not only supports but also imparts evident benefits in these patients. MATERIAL AND METHODS: The study is a retrospective observational study conducted over a period of 2 years at Pulmonary Rehabilitation center, a private clinic setup on patients with different restrictive lung diseases like interstitial lung diseases, neuromuscular disorders and post-surgical patients. A total of 100 patients were enrolled, out of which 21 patients were lost to follow up. The study population included 34% males and 66 % females with a mean age of 56.3 ± 14.2 years. 24 patients required oxygen support (where SpO2< 90% at baseline). Outcome measures were assessed in these patients at the time of enrollment into the program (0 week) and at the end of the program (8 weeks). Effect of PR programme was then analyzed with appropriate statistical methods. RESULTS: Overall, statistically significant benefits were noted in 6 Minute walk distance (6MWD), muscle strength, dyspnea and Quality of life with 8 weeks. The mean 6 MWTD was 297.9 meters pre PR, which improved to 359.7 meters at the completion of 8 weeks post PR. Mean difference was 61.8 meters, which was found to be statistically significant (p value<0.001) Improvement in muscle strength of different upper and lower limb muscle groups were noted. Also, significant improvement in comprehensive score of Chronic Respiratory Diseases Questionnaire (CRDQ) scores was documented. Statistically significant improvement was found in the dyspnea, fatigue and emotional components. However, mastery components did not show statistically significant change. CONCLUSION: PR has proven to be a very useful modality in the management of restrictive lung diseases, especially with the known limitations of pharmacological options to treat this disabling chronic lung diseases, even with those with evident type I respiratory failure at the beginning.

Syringo-pleural shunt: a rare cause of recurrent pleural effusion.

case of a patient with reported spinal tuberculosis (TB) that developed syringomyelia, a rare sequelae of the disease is presented in this report. He underwent syringo-pleural shunting for syringomyelia. After 15 years, the patient presented with recurrent pleural effusion. Diagnostic thoracentesis revealed fluid of transudative nature. Pleural fluid was positive for beta-2 transferrin. Pleural biopsy was negative for any malignancy or TB. Computed tomography scan focusing on the shunt showed that it was undisplaced. Video-assisted thoracoscopic exploration showed the distal tip of the shunt adherent to the lung parenchyma. The effusion resolved after the dislodgement of distal tip from lung parenchyma.

An unusual case of invasive Aspergillus ulcerative tracheobronchitis without involvement of lung parenchyma in a post-renal transplant patient.

We present the case of a 54-year-old male, who presented with respiratory complaints four months after he underwent renal transplantation. Bronchoscopy showed ulcerated mucosa of the left main bronchus and computed tomography (CT) of the thorax showed foci of air within the bronchial wall. A biopsy from the lesion showed septate fungal hyphae, dichotomously branching at acute angles. A locally invasive Aspergillus ulcerative tracheobronchitis with no parenchymal involvement is an important cause of tracheobronchitis in post-renal transplant patients. An early diagnosis and institution of appropriate treatment can improve the outcome. A combination treatment of caspofungin and voriconazole can be considered if patient is not responding to voriconazole alone.

Granulocyte macrophage colony stimulating factor therapy for pulmonary alveolar proteinosis.

We report a case of 58 year old female diagnosed with Pulmonary Alveolar Proteinosis (PAP) with recurrence of PAP after 5 repeated whole lung lavage, responding to subcutaneous injections of Granulocyte Macrophage Colony Stimulating Factor therapy (GM-CSF). Thus indicating that GM-CSF therapy is a promising alternative in those requiring repeated whole lung lavage

Role of impulse oscillometry in diagnosis and follow-up in bronchial asthma.

Background: Asthma is defined as a chronic inflammatory disorder of the airways, characterized by bronchial hyper-responsiveness and variable airflow obstruction, that is often reversible either spontaneously or with treatment. Impulse oscillometry is a newer diagnostic modality for asthma. It is based on the measurement of sound waves reflected by airway resistance. Objectives: The aim of this article is to study the role of impulse oscillometry in diagnosis and follow-up of bronchial asthma. Methods: Fifty-five clinically diagnosed bronchial asthma patients were evaluated with spirometry and impulse oscillometry before and after 3 months of inhaled treatment. The sensitivity to diagnose and follow-up was compared using proper statistical tests. Results: Impulse oscillometry was superior to spirometry in diagnosing bronchial asthma and also in accessing the treatment response after 3 months. Conclusion: Impulse oscillometry is superior in predicting bronchial asthma and its parameters are also more sensitive in accessing treatment response. It can replace spirometry as it is easy to perform and effort independent.

Genetic insight into Birt-Hogg-Dubé syndrome in Indian patients reveals novel mutations at FLCN.

BACKGROUND: Birt-Hogg-Dubé syndrome (BHDS) is a rare monogenic condition mostly associated with germline mutations at FLCN. It is characterized by either one or more manifestations of primary spontaneous pneumothorax (PSP), skin fibrofolliculomas and renal carcinoma (chromophobe). Here, we comprehensively studied the mutational background of 31 clinically diagnosed BHDS patients and their 74 asymptomatic related members from 15 Indian families. RESULTS: Targeted amplicon next-generation sequencing (NGS) and Sanger sequencing of FLCN in patients and asymptomatic members revealed a total of 76 variants. Among these variants, six different types of pathogenic FLCN mutations were detected in 26 patients and some asymptomatic family members. Two of the variants were novel mutations: an 11-nucleotide deletion (c.1150_1160delGTCCAGTCAGC) and a splice acceptor mutation (c.1301-1G > A). Two variants were Clinvar reported pathogenic mutations: a stop-gain (c.634C > T) and a 4-nucleotide duplication (c.1329_1332dupAGCC). Two known variants were: hotspot deletion (c.1285delC) and a splice donor mutation (c.1300 + 1G > A). FLCN mutations could not be detected in patients and asymptomatic members from 5 families. All these mutations greatly affected the protein stability and FLCN-FNIP2 interaction as observed by molecular docking method. Family-based association study inferred pathogenic FLCN mutations are significantly associated with BHDS. CONCLUSION: Six pathogenic FLCN mutations were detected in patients from 10 families out of 15 families in the cohort. Therefore, genetic screening is necessary to validate the clinical diagnosis. The pathogenic mutations at FLCN affects the protein-protein interaction, which plays key roles in various metabolic pathways. Since, pathogenic mutations could not be detected in exonic regions of FLCN in 5 families, whole genome sequencing is necessary to detect all mutations at FLCN and/or any undescribed gene/s that may also be implicated in BHDS.

An Unusual Case of Atrial Wall Cardiac Sarcoidosis Detected on Fluorine-18 Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography Scan.

Isolated cardiac sarcoidosis (ICS) accounts for 5%-10% of patients with sarcoidosis. It can involve atrioventricular node causing heart block, as well as the basal septum, papillary muscles, focal regions in the free wall, and the myocardium being more commonly involved. The diagnosis is achieved on magnetic resonance imaging (MRI) and endomyocardial biopsy. Recently, Fluorine-18 fluorodeoxyglucose positron emission tomography and computed tomography (F-18 FDG PET) has been incorporated in the diagnosis as well as management algorithm. We describe an interesting case of ICS detected on F-18 FDG PET and MRI and discuss its role in the management of this rare presentation.

Resistance patterns among multidrug-resistant tuberculosis patients in greater metropolitan Mumbai: trends over time.

BACKGROUND: While the high burden of multidrug-resistant tuberculosis (MDR-TB) itself is a matter of great concern, the emergence and rise of advanced forms of drug-resistance such as extensively drug-resistant TB (XDR-TB) and extremely drug-resistant TB (XXDR-TB) is more troubling. The aim of this study was to investigate the trends over time of patterns of drug resistance in a sample of MDR-TB patients in greater metropolitan Mumbai, India. METHODS: This was a retrospective, observational study of drug susceptibility testing (DST) results among MDR-TB patients from eight health care facilities in greater Mumbai between 2005 and 2013. We classified resistance patterns into four categories: MDR-TB, pre-XDR-TB, XDR-TB and XXDR-TB. RESULTS: A total of 340 MDR-TB patients were included in the study. Pre-XDR-TB was the most common form of drug-resistant TB observed overall in this Mumbai population at 56.8% compared to 29.4% for MDR-TB. The proportion of patients with MDR-TB was 39.4% in the period 2005-2007 and 27.8% in 2011-2013, while the proportion of those with XDR-TB and XXDR-TB was changed from 6.1% and 0% respectively to 10.6% and 5.6% during the same time period. During the same periods, the proportions of patients with ofloxacin, moxifloxacin and ethionamide resistance significantly increased from 57.6% to 75.3%, from 60.0% to 69.5% and from 24.2% to 52.5% respectively (p<0.05). DISCUSSION: The observed trends in TB drug-resistance patterns in Mumbai highlight the need for individualized drug regimens, designed on the basis of DST results involving first- and second-line anti-TB drugs and treatment history of the patient. A drug-resistant TB case-finding strategy based on molecular techniques that identify only rifampicin resistance will lead to initiation of suboptimal treatment regimens for a significant number of patients, which may in turn contribute to amplification of resistance and transmission of strains with increasingly advanced resistance within the community.