Prescription pattern of inhalational medications for chronic obstructive pulmonary disease in India: insights from cross-sectional survey of pulmonologists across India

Background: Treatment of COPD depends on disease severity, phenotype and exacerbation risk. Inhaled medications are the treatment of choice in COPD. We undertook this survey to find the most commonly prescribed inhalational medication in COPD as per the severity of the disease. Methods: It was a cross-sectional questionnaire-based survey of pulmonologists in real-world clinical practice settings conducted across India. Results: The participants included 806 pulmonologists across India. Seventy-five per cent of pulmonologists ranked symptom relief, reduction in the frequency of exacerbations and improvement in lung function as the most important treatment targets. In COPD patients falling under GOLD group A, the treatment choice by pulmonologists in descending rank order was fomroterol/glycopyrronium (32%), ipratropium (38%), and tiotropium (30%) and for gold group B, this was fomroterol/glycopyrronium (34%), followed by indacaterol/glycopyrronium (26%) and tiotropium/formoterol (40%). In the GOLD group E, triple therapy (formoterol/glycopyrronium/budesonide) was preferred by 41% of pulmonologists. In the frequent exacerbator, predominant emphysema, chronic bronchitis and concomitant asthma phenotype, 44%, 38%, 46% and 32% of pulmonologists ranked formoterol/ glycopyrronium/budesonide as their preferred 1st therapy, respectively. Among COPD patients with cardiovascular disease (CVD) comorbidity, 31% of pulmonologists selected formoterol/glycopyrronium/budesonide as 1st-preference drug therapy. Similar results were obtained for COPD patients with metabolic syndrome comorbidity. Conclusions: For the management of COPD patients, pulmonologists predominantly preferred a triple drug combination of formoterol/glycopyrronium/budesonide in GOLD group E and also in patients with cardiovascular and metabolic comorbidities. Fomroterol/glycopyrronium was the most preferred combination for GOLD group A and GOLD group B.

Study of clinical profile of acute respiratory distress syndrome in pneumonia and outcome in intensive care unit

Background: ARDS is a progressive inflammatory lung injury in patients with hypoxemic respiratory failure. Aspiration pneumonia and pneumonia are the most common cause of ARDS in direct lung injury whereas sepsis is the most common cause of ARDS in Indirect lung injury. Methods: This was observational study conducted in Intensive care unit, Department of Medicine, CPR Hospital, Kolhapur, Maharashtra for 6 months from 1 June to 30 November 2023 in 41 patients. Results: Most common cause of ARDS secondary to pneumonia, in this study population is bacterial pneumonia, followed by viral and parasitic infections. Average day of hospital stay for bacterial pneumonia is 13 days and 11 and 10 days for viral and parasitic infections respectively. For bacterial pneumonia mortality was 36%, for viral pneumonia was 37% and parasitic pneumonia was 33.33%. Out of 41 patients,16 patients were in mild ARDS with the SOFA score range of 2 to 5 and 12 patients were in moderate ARDS with SOFA score range of 6 to 9 and 12 patients were in severe ARDS with SOFA score range of 12 to 14. Conclusions: With our study we would like to conclude that sofa score is a good predictor of mortality in c/o ARDS patients in ICU setting. Patients who had sofa score of equal or more than 9 and who were in the category of moderate to severe ARDS, had poorer outcomes and high mortality rate.

Study of the bronchoscopic evaluation of patients undergoing bronchoscopy in respiratory medicine department

Background: Bronchoalveolar lavage or BAL is a minimally invasive procedure that involves instillation of sterile normal saline into a subsegment of the lung, followed by suction and collection of the instillation for analysis. This procedure is typically facilitated by the introduction of a flexible bronchoscope into a sub-segment of the lung. The purpose of this study was to investigate the pathological variations in the tracheobronchial tree in various respiratory diseases. Methods: The study evaluated the bronchoscopic profile of 150 patients who underwent flexible bronchoscopy in the respiratory medicine department of MGM Medical College in Aurangabad, India from October 2020 to September 2022. Results: The majority of the patients were males (65%) and above the age of 50. The most common reason for bronchoscopy was radiological opacity (80% of cases), followed by diffuse pulmonary infiltration (10%). The study found that bronchoscopy was useful in obtaining samples for diagnosis of various respiratory diseases, including malignancies, tuberculosis, bacterial pneumonia, and hematological malignancies. The study also noted the therapeutic utility of bronchoscopy in managing inoperable stenosis of the central airways. Conclusions: The authors concluded that bronchoscopy is an important diagnostic and therapeutic tool for the management of pulmonary diseases.

Study of the clinical profile and treatment outcome of pulmonary and extrapulmonary tuberculosis patients coming to respiratory medicine OPD

Background: The major risk factors for development of tuberculosis are extremes of age, malnutrition, overcrowding and immune deficient states like AIDS, diabetes mellitus, measles, whooping cough and leukaemia. Chronic malaria and worm infestation are less important risk factors. Tobacco smoking, high alcohol consumption, corticosteroid therapy and immunosuppressive drug therapy reduce body defences there by increasing the susceptibility to tuberculous infection. This study was undertaken to analyse the various clinical presentations in patients with pulmonary tuberculosis and extra pulmonary tuberculosis. Methods: This was a retrospective study of patients from October 2020 to September 2022 (2 years). Data collected from 300 patients who were diagnosed with pulmonary and extrapulmonary tuberculosis visited. The subjects were divided into subjects who had pulmonary TB (PTB), and who had extrapulmonary TB (EPTB). Results: The most common systemic disorders accompanying EPTB were DM (n=11; 8.8%) and chronic renal failure (n=8; 6.4%); while DM (n=16; 9.1%) and chronic obstructive pulmonary disease (n=13; 7.4%) were those detected frequently in PTB group. Conclusions: Present study showed higher percentage of males and greater predominance of pulmonary TB. It is also observed high percentage extrapulmonary TB. High percentage of positive treatment outcomes with fewer relapses and failures was observed in this study. A high positive treatment outcome noted may be attributed to the availability of specialist doctors and diagnostic facilities in the tertiary care centre.

Prevalence of obstructive airway disease in pulmonary function tests of patients visiting respiratory medicine out patient department

Background: The recognition of obstructive airway disease as a public health problem, however, has failed to keep pace with its increasing impact on health-care resources. This study is conducted to evaluate the prevalence of obstructive airway disease in pulmonary function tests (PFT) of patients visiting respiratory medicine out patient department (OPD). Methods: This is a retrospective study of patients from October 2020 to September 2022 (2 years), on 80 subjects reporting to respiratory medicine OPD, MGM medical college, Aurangabad. Data collected from 80 subjects who were diagnosed with obstructive airway disease in PFT. Results: The study population had a COPD prevalence of 16 (19.7%). GOLD criterion revealed that 54.2% (9/16) of COPD patients had mild COPD. This research showed no evidence of very severe COPD. In terms of gender distribution, 8 (16.6%) of 46 males and 7 (19.5%) of 34 women had COPD. However, there was no statistically significant (p=0.167) difference in COPD prevalence between sexes. Furthermore, univariable analysis revealed no significant differences in marital status (p=0.836), co-morbidities (p=0.541), family size (p=0.535), educational status (p=0.827), employment status (p=0.643), and medical visits (p=0.366) between persons with and without COPD. Conclusions: According to the findings of this research, the variables that increase a person's likelihood of developing COPD are as follows: advancing age, prolonged exposure to smoke from biomass burning, tobacco use, and inadequate ventilation in the kitchen.

Thyroid profile in perimenopausal women: A study to rule out hypothyroidism in the subclinical stage and its relationship to cholesterol levels

Background: One of the most frequent problems affecting perimenopausal women is thyroid dysfunction, symptoms of which might be so subtle that they go unrecognized for a long time. In older women, subclinical hypothyroidism (SCH) is frequent. A significant percentage of individuals are at risk of developing primary hypothyroidism as a result of their SCH. Aim and Objectives: The goal of this study is to know the incidence of thyroid dysfunction and its clinical manifestations, to determine thyroid profile the incidence of SCH, and its relation with the cholesterol levels in perimenopausal women in patients who visit gynecology outpatient department. Materials and Methods: The present study is a descriptive cross-sectional research undertaken in the department of the research comprised 100 women between the ages of 40 and 55 Patients were assessed using a complete history, clinical examination, and laboratory tests such as ELISA was used to test thyroid function in the serum of all patients diagnosed with SCH and also assessed serum cholesterol in patients with SCH. Results: There were 100 patients in the present study and all were women were between the ages of 40 and 55. Menorrhagia was the most common menstrual disorder seen in the study group, with 56% of patients experiencing it. 32% of patients developed oligomenorrhea, which is one of the most common perimenopausal symptoms. Menstrual irregularities (88%) and weight increase were common symptoms in thyroid insufficiency individuals. (65%), irritation and mood changes (74%) Anxiety and sadness (61%) are the most common symptoms, followed by loss of employment. Sexual libido (5%) Subjects with normal free t3 and t4 but increased serum thyroid-stimulating hormone were classified as SCH. 20 of the patients had SCH, 4 had overt hypothyroidism, and the other 76 were euthyroid. Seventy-five percent of the patients with SCH had hypercholesterolemia when they were diagnosed. Conclusion: We propose that perimenopausal women with or without symptoms be routinely screened based on the findings of this study. Early diagnosis and treatment of these issues will aid in lowering morbidity and preventing subsequent consequences.

Positron emission tomography thyroid incidentaloma: Is it different in Indian subcontinent.

BACKGROUND: Positron emission tomography (PET) forms an integral part in work‑up and follow‑up of various malignancies. With the increased use of PET in oncology, finding of an incidental focal thyroid uptake (incidentaloma) is not unusual and presents a diagnostic challenge. AIM: The aim of the following study is to evaluate the frequency and radio‑pathologic correlation of focal 18‑fluoro deoxyglucose uptake (FDG) on PET within the thyroid from a large series. MATERIALS AND METHODS: Retrospective review of 37,000 consecutive patients who underwent FDG‑PET at tertiary cancer center in India. Radiological, pathological, PET scan and follow‑up details were evaluated. Statistical analyzes were carried out using Mann Whitney test and Pearson correlation. RESULTS: Abnormal thyroid uptake was seen in 78 (0.2%) patients. Nearly 61 (0.16%) scans had focal and 17 (0.04%) had diffuse FDG uptake. A total of 57 patients with focal uptake were available for further evaluation. No further evaluation was done in 24 (42.1%) patients who had advanced index malignancy. Of the remaining 33 patients 26 were benign and seven were a cause for concern (four primary thyroid cancers, one follicular neoplasm with hurthle cell change and two metastatic cancers). There was no significant correlation in Standardized uptake value (SUV) max of benign and malignant lesion (P = 0.5 on Mann Whitney) or size (r = 0.087 Pearson correlation co‑efficient P = 0.667). CONCLUSION: Incidence of PET incidentaloma is low in this large cohort of Indian patients. Nearly 27% of focal incidentaloma were malignant. There was no correlation between the SUVmax, size and malignancy.

Standard operating procedure for audio visual recording of informed consent: An initiative to facilitate regulatory compliance.

The office of the Drugs Controller General (India) vide order dated 19th November 2013 has made audio visual (AV) recording of the informed consent mandatory for the conduct of all clinical trials in India. We therefore developed a standard operating procedure (SOP) to ensure that this is performed in compliance with the regulatory requirements, internationally accepted ethical standards and that the recording is stored as well as archived in an appropriate manner. The SOP was developed keeping in mind all relevant orders, regulations, laws and guidelines and have been made available online. Since, we are faced with unique legal and regulatory requirements that are unprecedented globally, this SOP will allow the AV recording of the informed consent to be performed, archived and retrieved to demonstrate ethical, legal and regulatory compliance. We also compared this to the draft guidelines for AV recording dated 9th January 2014 developed by Central Drugs Standard Control Organization. Our future efforts will include regular testing, feedback and update of the SOP.

Is there a role of induction chemotherapy followed by resection in T4b oral cavity cancers.

Objective: The objective of the following study is to investigate the efficacy and impact of induction chemotherapy in T4b oral cavity cancers. Materials and Methods: It's a retrospective analysis of prospectively collected data of T4b oral cavity cancer patients who were offered induction chemotherapy and then assessed for resectability at the end of 2 cycles of chemotherapy. Post-induction these patients either underwent surgical or non-surgical local intervention depending upon their response. These patients were then followed-up until either recurrence progression or death whichever was later. Statistical analysis was performed by SPSS version 16. Descriptive analysis was performed. Factors affecting achievement of resectability were sought by univariate and multivariate analysis. The impact of surgery on overall survival (OS) was studied using Kaplan Meier survival analysis with the use of log rank test. Results: A total of 110 patients received chemotherapy. Median age been 41.5 years (range 25-66 years). 21 (20%) of our patient received 3 drug regimen while the rest of our patients received 2 drug regimen. Partial response was achieved in 28 patients, stable disease in 49 patients and progression was noted in 23 patients. Resectability was achieved in 34 (30.9%) of 110 patients. The estimated median OS in patients who underwent surgery was 18.0 months (95% confidence interval [CI]: 13.6-22.46 months) and for those treated with non-surgical treatment was 6.5 months (95% CI: 5.6-7.4 months) (P = 0.0001). Conclusion: Use of induction chemotherapy is safe and can achieve resectability in 30.9% of our T4b patients. In those patients undergoing resection have much better OS then those who underwent non-surgical local treatment.

Utility of PET in unknown primary with cervical metastasis: A retrospective study.

Background: FDG-PET is recommended as an investigation in unknown primary tumors, but its definitive role and cost effectiveness are yet to be established. Aims: dditional value of FDG-PET over conventional imaging in unknown primary tumors with cervical metastasis. Setting and Design: Retrospective study in a tertiary level oncology centre. Materials and Methods: A total of 112 patients were divided into three groups; 53 with conventional modalities (either computed tomography or magnetic resonance imaging) (group I), 59 with FDG-PET (group II), and group III (subgroup of group II) with both (40 patients). Statistical Analysis: Sensitivity and specificity of both conventional modality and PET were calculated. Association between neck nodes and distant metastasis was analysed using multivariate logistic regression analysis. Results: Sensitivity and specificity for conventional modalities was 92.3% and 50% and sensitivity and specificity of FDG-PET was 92.8% and 71.4%, respectively. FDG-PET detected metastasis in 52.54% of patients. Multivariate logistic regression analysis showed statistically significant association between distant metastasis and multiplicity of nodes (N2b, N2c) (P = 0.007). Among all patients with low neck nodes in group II, FDG-PET detected primaries in 12 patients, 9 of which were infraclavicular (75%). FDG-PET added information to conventional imaging in 32.5% of patients and influenced an overall change in management in 38.9% of patients. Conclusions: FDG-PET is a valuable tool influencing change of management in unknown primary with cervical metastasis. It is recommended especially in the presence of low or multiple neck nodes in view of high incidence of infraclavicular primary and distant metastasis, respectively.

Bacteriological and mycological study of corneal ulcers in and around Aurangabad.

In the present study an attempt was made to find out bacteria and fungi causing corneal ulcers. Sixty cases of corneal ulcer were studied. Corneal scrapings from patient of corneal ulcer were collected and processed for isolation of bacterial and fungal agents. The commonest age group affected was 21-30 yrs. Incidence of corneal ulcer was more in males 39 (65%) as compared to females 21 (35%). Trauma was the commonest predisposing factor. Out of sixty cases of corneal ulcer positive cultures were obtained in 23 (38.33%). Bacteria were isolated in 10 (16.66%) fungi in 12 (20%) and mixed culture in 1 (1.66%) of the patients. Among the bacterial isolates commonest was Staphylococcus aureus 6 (10%). Among fungal isolates Fusarium species was the commonest isolate 4 (6.66).

A comparative clinico-pathological study of single dose ROM in paucibacillary leprosy patients with 1-3 skin lesions.

A controlled clinical and histopathological study was carried out to compare the efficacy of a combination of rifampicin 600 mg plus ofloxacin 400 mg plus minocycline 100 mg (ROM) administered as a single dose with that of standard WHO/MDT-PB six months' regimen with regard to resolution of lesion clinically and histopathologically. Skin biopsy was performed at the intake and at 6 months. The study subjects were 32 previously untreated, smear-negative patients, without nerve trunk involvement and having 1-3 skin lesions. The results were analyzed for mean clinical score for marked, moderate and no improvement and mean histopathological score was graded as active, resolving and complete resolution, according to granuloma fraction at the end of 6 months. Marked clinical improvement was seen in 25% and 12%, moderate improvement in 50% and 56% patients treated with ROM and standard regimens respectively. Histopathologically, activity was seen in 62.5% and 43.7% and resolution of granuloma in 25% and 31.2% in the ROM and standard regimens respectively. Both the regimens were equally efficacious in the reduction of clinical score and granuloma fraction. No adverse drug reactions or reversal reactions were seen during the study period in both the groups.

Epidemiology of cholera--a five year study.

A total of 286 strains of Vibro Cholerae were isolated and tested over a period of five years. The strains were identified by standard methods and confirmed by slide agglutination tests with polyvalent, Ogawa and Inaba antisera. The non-agglutinating strains were tested with O-139 antisera. The maximum number of cases were found in the age group of 0-10 years. The number of females affected was more than the males. V. cholerae O-139 was isolated in the year 1998 and then again in 2000. V. cholerae serotype Inaba was found only in the year 1999. All of the other isolates belonged to the serotype Ogawa. The periodic shift between O1 and O-139 serogoups is reminiscent of the shifts from the Ogawa to the Inaba serotypes periodically witnessed among V. cholerae, possibly mediated by the immune pressure in the population.

Surgical anatomy of retrohepatic inferior vena cava and hepatic veins: a quantitative assessment.

BACKGROUND: Accurate knowledge of the surgical anatomy of the retrohepatic inferior vena cava (IVC) and hepatic veins is necessary for hepatic surgery. METHODS: Lengths of different segments of retrohepatic IVC and their diameters, and prevalence of various types of ramification and lengths of different hepatic veins, were noted in 100 disease-free human livers during autopsy. RESULTS: The mean lengths of the IVC from entry into atrium to diaphragmatic hiatus, from the hiatus to the upper margin of right hepatic vein, between the upper margins of the right hepatic vein and the right suprarenal vein, from right suprarenal vein to the lowermost dorsal hepatic vein, and from the lower-most dorsal hepatic vein to the right renal vein were 29.1 mm, 8.6 mm, 40.6 mm, 28.6 mm and 33.7 mm, respectively. The mean diameter of IVC at the diaphragmatic level was 30.1 mm. The commonest ramification pattern of the hepatic veins was type I (82%) for the right hepatic vein, type II (63%) for the middle and left hepatic veins, and type II (55%) for the caudate veins. In 96% of cases the middle and left hepatic veins formed a common trunk. In a majority of cases, the diameters of the right and left hepatic veins were between 7 mm and 12 mm. No gender differences were found. CONCLUSION: This study provides an anatomical perspective for various hepatic surgical techniques.

Prevalence of resistant Staphylococcus aureus at Aurangabad.

Seven hundred and eighty three isolates of Staphylococcus aureus isolated from pus (586), blood (78), sputum (25), urine (23), cerebrospinal fluid (23) and various other body fluids (48) were subjected to in-vitro antimicrobial susceptibility testing by modified Kirby-Bauer method. Almost all the isolates were resistant to penicillin (99.62 per cent) and ampicillin (99.62 per cent). Resistance to erythromycin, tetracycline and cotrimoxazole was observed in 88.5, 87.62, and 80.85 per cent isolates respectively. Resistance to gentamicin was 68.32 per cent. Resistance to most of the commonly used antimicrobial agents indicates a need to replace these drugs with other agents and maintenance of surveillance to detect changing patterns of resistance.

Changing aetiology of urinary tract infections and emergence of drug resistance as a major problem.

A study was undertaken to ascertain the spectrum of causative agents responsible for UTI and to detect the magnitude of anti microbial resistance in aetiological agents. Klebsiella species caused urinary tract infection in maximum number of cases (124, 37.35%) followed by Escherichia coli (114, 34.4%), Pseudomonas aeruginosa 32 (9.64%) and Staphylococcus aureus 23 (6.93%). Other organisms caused urinary tract infection in 39 (11.75%) cases. Resistance to gentamicin was observed in 83% S. aureus, 84.7% Klebsiella species, 78.1% Escherichia coli, 71.9% Pseudomonas aeruginosa and 94.8% of remaining isolates. A large number of isolates (> 90%) were resistant to ampicillin, Cotrimoxazole erythromycin, and chloramphenicol. All the isolates of S.aureus were resistant to penicillin. This observations indicate extremely high degree of resistance in urinary pathogen and warrant change in antibiotic usage as well as formulation of policy for rational use of antibiotics.