Association of Physicians of India: National Expert Opinion and Clinical Practice Recommendations for Primary Care Cough Management in India.

INTRODUCTION: Pathological cough in primary care is a significant concern. With a prevalence ranging from 5 to 10% in India, cough is the second most common symptom seen by general practitioners (GPs). The existing algorithms and tools that are available are generally meant for cough categorization in specialized fields; their limited adoption by GPs results in insufficient screening and categorization of cough, which results in the use of irrational fixed drug combination formulations. OBJECTIVES: Formulation of recommendations for GPs to enable them to appropriately screen and categorize cough for efficient management and avoid irrational treatments. METHODS: An expert panel (seven experts specializing in pulmonology and internal medicine) held a virtual discussion to assess the necessity for cough categorization and develop user-friendly tools, along with a simplified format for history taking in cough evaluation and management. Panel discussions were based on a questionnaire that contained items related to the categorization of cough, assessment tools, and approaches to treating cough. RESULTS: After deliberations, simplified clinical practice recommendations and assessment tools were developed by the experts to facilitate the categorization of cough into wet or dry categories, thereby helping in the symptom-based management of cough. CONCLUSION: By adhering to these principles and using assessment tools, primary care practitioners can optimize cough management, avoid irrational drug combinations, minimize potential risks, and improve patient well-being.

Expert Opinion on the Management of Acute and Chronic Cough: An Indian Perspective in Primary Care Setting.

Cough is the body's reflex when the throat or airway is irritated by a foreign body, such as irritants, microbes, and fluids. Cough caused due to a disorder or infection can last for a few days to a couple of weeks and is usually self-limiting and self-resolving. However, in certain cases, cough can persist for months, disrupting everyday activities, affecting the patient's mental health, and causing pain and fatigue. There are a number of different therapeutic strategies to manage acute and chronic cough, depending on the cause. Dry cough can be treated using opioids, nonopioids, antitussives, and antihistamines. Expectorants and mucolytics are widely used in the management of productive cough. The underlying cause of cough should be appropriately managed with specific therapy. The choice of treatment regimen is dependent on the patient's medical history, symptoms, and preexisting conditions. Based on the literature review and clinical practice, a comprehensive approach to the management of cough as a symptom has been proposed.

Scoring System for the Use of Nebulizers in the Primary Care Settings: An Expert Consensus Statement.

BACKGROUND: The use of nebulizers is an important and useful method for delivering drugs to the lungs in patients with various airway and lung parenchymal disorders. They are primarily used in patients with acute symptoms and in a selected group of patients for maintenance treatment. Its use has increased, especially during the coronavirus disease 2019 (COVID-19) pandemic. To ensure the appropriate use of nebulizers by primary care physicians and to guide them, we aimed to develop a simple nebulizer use score. METHODS: An expert working group (EWG) of pulmonologists were formed who using a semi- Delphi method, developed a list of variables and a cut-off score to decide when to use nebulizers. We started with a total of 55 variables that were developed through an exhaustive review of the literature. These were further reduced to smaller numbers that had the maximum score as well as concordance with the EWG. The scores ranged from 1 to 10 (completely disagree to completely agree), and only those above 7.5 were selected. RESULTS: A total of 8 variables with the highest scores were selected (Table 1), which had a total maximum score of 40. A score of <15 was suggested to indicate no use of nebulizer and >20 to suggest definite use of nebulizer. A score between 15 and 20 was suggested for physician judgment. A separate table of 12 conditions was made where the use of nebulizers was mandatory. CONCLUSION: This first-of-its-kind nebulizer score can be used by primary care physicians to decide which patients should be put on nebulizer treatment.

Household air pollution in India and respiratory diseases: current status and future directions.

PURPOSE OF REVIEW: Combustion of solid cooking fuels employed by more than 3 billion people globally, contributes to approximately one third of ambient air pollution. In the recent past, the issue has drawn global attention because of its threat to the health of rural communities, particularly women and children. This review is focused on the evidence from India on effects of household air pollution (HAP) on respiratory health and interventions to replace the solid fuels. RECENT FINDINGS: HAP exposure is a major risk factor for increased respiratory symptoms, respiratory infections, and chronic obstructive pulmonary disease. In most studies, the odds ratio for the risk of development of respiratory disorders is more than one in HAP exposed individuals. HAP is also associated with increased risk of tuberculosis, asthma, mortality from cardio-respiratory illnesses, and nonrespiratory problems such as adverse pregnancy outcomes, prematurity, and low birth weight. SUMMARY: Household air pollution is a common but preventable risk factor for respiratory diseases. Replacement of solid cooking fuels with clean fuels such as LPG gas as exemplified by the 'Ujjwala' program of India is likely to be most effective intervention to reduce the HAP related disease burden.

Protective association of TIM1-1454G>a polymorphism with asthma in a North Indian population.

PURPOSE: TIM1 is a key regulator of Th2-dominated immune responses, including allergy, asthma, autoimmunity, and response to the pathogens. They are mainly expressed by hepatocytes and lymphoid cells. Analysis of the sequence of TIM1 was found to have range of SNPs which increases the transcriptional activity of the TIM1 gene. METHODS: A case-control study was conducted with a total of 964 subjects, including 483 healthy controls and 481 asthma patients in the present study. DNA samples were extracted from blood, and genotyping was done using polymerase chain reaction-restriction fragment length polymorphism method. RESULTS: Statistical analysis revealed that both heterozygous (GA) as well as the mutant (AA) genotype of -1454G>A (rs41297579) polymorphism shows resistance toward asthma with OR = 0.74, 95 % CI (0.55-0.98), p = 0.029 and OR = 0.43, 95 % CI (0.28-0.65), p = 0.000, respectively. The mutant (A) allele was also found to be highly protective toward asthma with OR = 0.68, 95 % CI (0.56-0.82) p = 0.000. However, no statistical difference was found between the TIM1-416G>C (rs9313422) polymorphism and asthma patients (p > 0.05). CONCLUSIONS: This is the first study conducted in India conferring -1454G>A polymorphism provides resistance toward asthma while lack of association was found between -416G>C polymorphism and asthma in the studied North Indian population.

Guidelines for Diagnosis and Management of Bronchial Asthma: Joint Recommendations of National College of Chest Physicians (India) and Indian Chest Society.

Bronchial asthma is an important public health problem in India with significant morbidity. Several international guidelines for diagnosis and management of asthma are available, however there is a need for country-specific guidelines due to vast differences in availability and affordability of health-care facilities across the globe. The Indian Chest Society (ICS) and the National College of Chest Physicians (NCCP) of India have collaborated to develop evidence-based guidelines with an aim to assist physicians at all levels of health-care in diagnosis and management of asthma in a scientific manner. Besides a systematic review of the literature, Indian studies were specifically analysed to arrive at simple and practical recommendations. The evidence is presented under these five headings: (1) definitions, epidemiology and impact, (2) diagnosis, (3) pharmacologic management of stable disease, (4) management of acute exacerbations, and (5) non-pharmacologic management and special situations. The modified grade system was used for classifying the quality of evidence as 1, 2, 3, or usual practice point (UPP). The strength of recommendation was graded as A or B depending upon the level of evidence.

High risk association of IL-4 VNTR polymorphism with asthma in a North Indian population.

BACKGROUND: A case-control study was conducted to evaluate the role of IL-4 VNTR polymorphism in asthma that has been associated with various inflammatory diseases worldwide. This is the first case-control study conducted in India, investigating the role of IL-4 VNTR polymorphism in asthma pathogenesis. METHODS: A case-control study was performed with a total of 824 adult subjects, inducting 410 asthma patients and 414 healthy controls from North India. The genotypes were identified by polymerase chain reaction. RESULTS: Statistical analysis for the IL-4 VNTR polymorphism revealed that the Rp1 allele was significantly associated with asthma with OR=1.47, 95% CI (1.11-1.94) and p=0.005. The Rp1/Rp1 homozygous mutant genotype posed a high risk towards asthma with OR=2.39, 95% CI (0.96-6.14) and p=0.040. The Rp2/Rp1 heterozygous genotype also posed a risk towards asthma with OR=1.39, 95% CI (1.00-1.94) and p=0.040. Most of the phenotypic traits were significantly associated with the disease. CONCLUSIONS: IL-4 VNTR polymorphism is a high risk factor for asthma in the studied North Indian population.

The effect of biomass fuel exposure on the prevalence of asthma in adults in India - review of current evidence.

INTRODUCTION: The combustion of biomass fuels is a major source of respiratory disease among individuals in the developing world. Over two million people world-wide rely on biomass fuels to supply their household energy needs with an estimated 1.6 million deaths annually being attributable to biomass smoke exposure. As a developing country, India relies heavily on the use of solid fuels as a source of energy. These materials supply 75% of the country's domestic energy need and are attributed as the cause of over 600 000 deaths annually. Diseases such as chronic bronchitis and acute lower respiratory tract infections are strongly correlated to biomass smoke exposure. While not as strongly correlated, accumulating evidence suggests that asthma prevalence may be related to solid fuel smoke. METHODS: This review examines the current literature linking biomass smoke exposure to the reporting of asthma symptoms. A PubMed search was performed using key terms biomass, asthma, India and respiratory disease. Preference was given to recent articles that surveyed the adult population within India. RESULTS: The reviewed articles showed an increased odds ratio for reporting a diagnosis of asthma or symptoms consistent with asthma following biomass smoke exposure. While the literature supports a strong association between household air pollution and the development of chronic bronchitis and acute lower respiratory tract infections in India, this review establishes a more firm relationship between reported asthma symptoms and biomass smoke exposure. CONCLUSION: The exposure to biomass fuel smoke results in respiratory diseases in developing countries. Among these diseases, asthma appears to be a preventable pulmonary pathology that is associated with household air pollution. Measures to reduce exposure may decrease the burden of disease which could help advance social and economic progress in these nations. Further research and out-reach efforts are needed to reduce the total burden of lung diseases, including asthma, across the developing world. This reduction could save millions of dollars annually and lower morbidity and mortality in the affected populations.

Association of 24 bp duplication of human CHIT1 gene with asthma in a heterozygous population of north India: a case-control study.

PURPOSE: CHIT1 is expressed by pulmonary macrophages, which is typically the site of entry for many environmental fungi that may increase the risk of pulmonary fungal infection and lead to hypersensitivity. The conserved expression of this gene in humans suggests its physiological importance in the mammalian lung. METHODS: The present study was conducted with a total of 964 subjects, including 483 healthy controls and 481 asthma patients. DNA samples were extracted from blood, and the genotyping was done using polymerase chain reaction method. RESULTS: Statistical analysis revealed that the 24 bp duplication in CHIT1 gene polymorphism shows highly significant association in heterozygous (wild/dup) genotype with OR 1.74, 95 % CI (1.29-2.36), and p = 0.000. However, the homozygous mutant genotype (dup/dup) was found to be non-significant with OR 1.06, 95% CI (0.69-1.63), and p = 0.786. The combination of both wild/dup and dup/dup was also found to be highly significant with OR 1.57, 95% CI (1.18-2.11), and p = 0.002. CONCLUSIONS: This is the first study conducted in India which reports a significant association between 24 bp duplication in CHIT1 gene polymorphism and asthma in the studied North Indian population.

Expert panel opinion on adult pneumococcal vaccination in the post-COVID era (NAP- EXPO Recommendations-2024).

INTRODUCTION: Pneumococcal diseases pose a significant public health concern in India, with substantial morbidity and mortality, with the elderly and those with coexisting medical conditions being most at risk. Pneumococcus was also seen to be one of the main reasons for co-infection, pneumonia and complications in COVID. Current guidelines recommend vaccination for specific adult populations, but there is a lack of uniformity and guidance on risk stratification, prioritisation and optimal timing. METHODS: Nation Against Pneumococcal Infections - Expert Panel Opinion (NAP-EXPO) is a panel convened to review and update recommendations for adult pneumococcal vaccination in India. The panel of 23 experts from various medical specialties engaged in discussions and evidence-based reviews, discussed appropriate age for vaccination, risk stratification for COPD and asthma patients, vaccination strategies for post-COVID patients, smokers and diabetics, as well as methods to improve vaccine awareness and uptake. OUTCOME: The NAP-EXPO recommends the following for adults: All healthy individuals 60 years of age and above should receive the pneumococcal vaccine; all COPD patients, regardless of severity, high-risk asthma patients, post-COVID cases with lung fibrosis or significant lung damage, should be vaccinated with the pneumococcal vaccine; all current smokers and passive smokers should be educated and offered the pneumococcal vaccine, regardless of their age or health condition; all diabetic individuals should receive the pneumococcal vaccine, irrespective of their diabetes control. Strategies to improve vaccine awareness and uptake should involve general practitioners (GPs), primary health physicians (PHPs) and physicians treating patients at high risk of pneumococcal disease. Advocacy campaigns should involve media, including social media platforms. CONCLUSION: These recommendations aim to enhance pneumococcal vaccination coverage among high-risk populations in India in order to ensure a reduction in the burden of pneumococcal diseases, in the post-COVID era. There is a need to create more evidence and data to support the recommendations that the vaccine will be useful to a wider range of populations, as suggested in our consensus.

Pleural effusion guidelines from ICS and NCCP Section 1: Basic principles, laboratory tests and pleural procedures.

Pleural effusion is a common problem in our country, and most of these patients need invasive tests as they can't be evaluated by blood tests alone. The simplest of them is diagnostic pleural aspiration, and diagnostic techniques such as medical thoracoscopy are being performed more frequently than ever before. However, most physicians in India treat pleural effusion empirically, leading to delays in diagnosis, misdiagnosis and complications from wrong treatments. This situation must change, and the adoption of evidence-based protocols is urgently needed. Furthermore, the spectrum of pleural disease in India is different from that in the West, and yet Western guidelines and algorithms are used by Indian physicians. Therefore, India-specific consensus guidelines are needed. To fulfil this need, the Indian Chest Society and the National College of Chest Physicians; the premier societies for pulmonary physicians came together to create this National guideline. This document aims to provide evidence based recommendations on basic principles, initial assessment, diagnostic modalities and management of pleural effusions.

High risk association of IL-1 receptor antagonist (IL-1RN) VNTR polymorphism with asthma in a North Indian population: a pilot study.

BACKGROUND: A pilot case-control study was conducted to evaluate the role of IL-1 receptor antagonist (IL-1RN) VNTR penta-allelic polymorphism in asthma that has been associated with various inflammatory diseases worldwide. This is the first case-control study conducted in India, investigating the role of IL-1RN VNTR polymorphism in asthma pathogenesis. METHODS: A case-control study was performed with a total of 824 adult subjects, inducting 410 asthma patients and 414 healthy controls from North India. The genotypes were identified by polymerase chain reaction. RESULTS: Statistical analysis for the IL-1RN VNTR polymorphism revealed that the IL-1RN(*)2 allele was significantly associated with asthma with OR=1.45, 95% CI (1.15-1.85) and p=0.001. The IL-1RN(*)2/2 genotype posed a risk towards asthma with OR=1.66, 95% CI (0.97-2.86) and p=0.048. Most of the phenotypic traits were significantly associated with the disease. CONCLUSIONS: IL-1RN(*)2 allele is a high risk factor for asthma in the studied North Indian population.

Protective role of IL-18 -137G/C polymorphism in a North Indian population with asthma: a pilot study.

BACKGROUND: IL-18, a pleiotropic, pro-inflammatory cytokine that plays a major role in innate as well as acquired immunity, has been implicated in asthma etiology and this is the first study investigating the role of IL-18 -137G/C (rs 187238) promoter polymorphism in asthma pathogenesis in a North Indian population. METHODS: A pilot study was conducted with a total of 824 subjects, out of which 410 were asthma patients including 323 patients suffering from allergic rhinitis and 414 healthy controls from regions of North India. Tetra-Primer Amplification Refractory Mutation System Polymerase Chain Reaction (Tetra-Primer ARMS PCR) was used for genotyping the IL-18 -137G/C polymorphism. RESULTS: While the homozygous wild (GG) genotype was equally prevalent in asthma patients as well as control subjects (70.0%), the homozygous mutant (CC) genotype was more prevalent among the controls (8.0%) than in asthma patients (3.4%), which yielded a significant protection or decreased risk towards asthma. Statistical analysis revealed Odds Ratio (OR)=0.43 (95% CI=0.21-0.85), Chi2 (χ2)=6.93 and p-value=0.008 (p<0.005). Moreover, a few asthma phenotypic traits also revealed significant protective associations with the polymorphism. CONCLUSIONS: The IL-18 -137G/C polymorphism confers a significant protection from asthma in the studied North Indian population. This is the first study to report the protective association of the polymorphism with the disease.

Silicosis in India: past and present.

PURPOSE OF REVIEW: This particular review focusses on the burden of the problem of silicosis and its clinical manifestations reported from India. RECENT FINDINGS: In recent estimates from India, there are over 3 million workers exposed to silica dust, whilst 8.5 million more work in construction and building activities, similarly exposed to quartz. Several recent reports on lung function assessment show both restrictive and obstructive patterns. Tuberculosis is a common complication reported in Indian studies. Occasionally, silico-mycosis, lung cancer and connective tissue disorders in association with silicosis are also reported. The National Human Rights Commission (NHRC) in response to the direction from the Supreme Court of India has made several recommendations on preventive, remedial and rehabilitative measures. The NHRC has been asked to work with various stakeholders such as individual organizations, state and central governments and other agencies to implement the measures. SUMMARY: Silicosis is a common occupational disorder seen all over India, particularly in the Central and Western States. It is an important cause of respiratory morbidity. The problem has been highlighted on the national level as a major human-rights concern in India.

Economic analysis of costs associated with a Respiratory Intensive Care Unit in a tertiary care teaching hospital in Northern India.

BACKGROUND: There is a paucity of cost analytical studies from resource constrained developing countries defining intensive care costs and their containment. OBJECTIVE: Economic analysis of costs in a Respiratory Intensive Care Unit (RICU) of a tertiary care teaching hospital in northern India. MATERIALS AND METHODS: A prospective study was conducted in 74 patients admitted in the RICU. Costs were segregated into fixed and variable costs. Total and categorized costs averaged per day and costs incurred on the first day of the RICU stay were calculated. Correlation of the costs was performed with the length of stay, length of mechanical ventilation, survival, and therapeutic intervention scoring system-28 (TISS-28). RESULTS: The total cost per day was Indian rupees (INR) 10,364 (US $ 222). 46.4% of the total cost was borne by hospital and rest by patients. The mean cost represented 36.8% of the total cost and 69.8% of the variable cost. Expenditure on personnel salary constituted 37% of the total costs and 86% of the fixed cost. Length of stay in RICU was significantly higher in nonsurvivors (14.73 ± 13.6 days) vs. survivors (8.3 ± 7.8 days) (P < 0.05). The TISS-28 score points in survivors was 30.6 vs. nonsurvivors 69.2 per nurse (P < 0.05) correlating strongly with the total cost (r = 0.91). CONCLUSION: Although considerably less expensive than in economically developed countries, intensive care in India remains expensive relative to the cost of living. The cost block methodology provides a framework for cost estimation, aids resource allocation and allows international comparisons of economic models.

Less Social Deprivation Is Associated With Better Health-Related Quality of Life in Asthma and Is Mediated by Less Anxiety and Better Sleep Quality.

BACKGROUND: Previous studies on health-related quality of life (HRQoL) in asthma have mainly focused on clinical and environmental determinants. Little is known about the role of social determinants on HRQoL in asthma. OBJECTIVES: We aimed to investigate the association between social deprivation and HRQoL in asthma. METHODS: A total of 691 adult asthmatics from Canada, India, New Zealand, and the United Kingdom were administered a digital questionnaire containing demographic information and questions about social and psychological attributes, sleep disturbances, and alcohol abuse. HRQoL was measured using the Short Form of the Chronic Respiratory Questionnaire (SF-CRQ). We analyzed the direct and indirect relationships between social deprivation and HRQoL using structural equation models with social deprivation as a latent variable. We tested for mediation via anxiety, depression, sleep disturbances, and alcohol abuse. RESULTS: We found that less social deprivation (latent variable) was directly associated with better SF-CRQ domain scores such as dyspnea (regression coefficient ß: 0.33; 95% confidence interval [CI]: 0.07 to 0.58), fatigue (ß: 0.39; 95% CI: 0.14 to 0.64), and emotional function (ß: 0.37; 95% CI: 0.11 to 0.62), but with the worse mastery score (ß: -0.29; 95% CI: -0.55 to -0.03); however, those associations varied across participating countries. We also observed that among all individual social deprivation indicators, education, companionship, emotional support, instrumental support, and social isolation were directly associated with HRQoL, and the relationship between social deprivation and HRQoL was mediated through anxiety and sleep disturbances. CONCLUSIONS: Our results demonstrated that less social deprivation was directly, and indirectly through less anxiety and better sleep quality, associated with better HRQoL in asthma.

COVID-19 infodemic and health-related quality of life in patients with chronic respiratory diseases: A multicentre, observational study.

Background: The explosion of information, misinformation and disinformation (the "infodemic") related to the coronavirus disease 2019 (COVID-19) pandemic on digital and social media is reported to affect mental health and quality of life. However, reports assessing the COVID-19 infodemic on health-related quality of life (HRQL) in patients with chronic diseases are scarce. In this study, we investigated the associations between the infodemic and HRQL in uninfected individuals with pre-existing chronic respiratory diseases (CRDs) such as asthma, chronic obstructive pulmonary disease (COPD) and other CRDs. Methods: We conducted a multi-national, cross-sectional, observational study in Canada, India, New Zealand and the United Kingdom where we distributed a set of digitised questionnaires among 1018 participants with chronic respiratory diseases who were not infected with the SARS-CoV-2 virus at least three months prior to the study. We collected information about the infodemic such as news watching or social media use more than usual during the pandemic. HRQL was assessed using the short form of the chronic respiratory questionnaire (SF-CRQ). Demographic information, comorbidities, compliance, mental health, behavioural function, and social support were also recorded. We analysed the direct and indirect relationships between infodemic and HRQL using structural equation models (SEM). Results: Of all participants, 54% were females and had a mean (standard deviation (SD)) age of 53 (17) years. We found that higher infodemic was associated with worse emotional function (regression coefficient ß = -0.08; 95% confidence interval (CI) = -0.14 to -0.01), which means a one SD change of the higher infodemic latent variable was associated with a 0.08 SD change of emotional function level. The association between higher infodemic and worse emotional function was mediated by worse mental health and behavioural functions but is marginally ameliorated by improved social support. In stratification analysis, we found significant disease and country-wise variations in the associations between infodemic and SF-CRQ domain scores. Conclusions: These results provide new evidence that the COVID-19 infodemic significantly influences the HRQL in patients with CRDs through a complex interplay between mental health, behavioural function, and social support. This new dimension of research also opens avenues for further research on infodemic-related health effects in other chronic diseases.

Developing Standard Treatment Workflows-way to universal healthcare in India.

Primary healthcare caters to nearly 70% of the population in India and provides treatment for approximately 80-90% of common conditions. To achieve universal health coverage (UHC), the Indian healthcare system is gearing up by initiating several schemes such as National Health Protection Scheme, Ayushman Bharat, Nutrition Supplementation Schemes, and Inderdhanush Schemes. The healthcare delivery system is facing challenges such as irrational use of medicines, over- and under-diagnosis, high out-of-pocket expenditure, lack of targeted attention to preventive and promotive health services, and poor referral mechanisms. Healthcare providers are unable to keep pace with the volume of growing new scientific evidence and rising healthcare costs as the literature is not published at the same pace. In addition, there is a lack of common standard treatment guidelines, workflows, and reference manuals from the Government of India. Indian Council of Medical Research in collaboration with the National Health Authority, Govt. of India, and the WHO India country office has developed Standard Treatment Workflows (STWs) with the objective to be utilized at various levels of healthcare starting from primary to tertiary level care. A systematic approach was adopted to formulate the STWs. An advisory committee was constituted for planning and oversight of the process. Specialty experts' group for each specialty comprised of clinicians working at government and private medical colleges and hospitals. The expert groups prioritized the topics through extensive literature searches and meeting with different stakeholders. Then, the contents of each STW were finalized in the form of single-pager infographics. These STWs were further reviewed by an editorial committee before publication. Presently, 125 STWs pertaining to 23 specialties have been developed. It needs to be ensured that STWs are implemented effectively at all levels and ensure quality healthcare at an affordable cost as part of UHC.