Comparison between Diagnostic Yield of Pleural Fluid ELISPOT and Thoracoscopic Guided Pleural Biopsy in Undiagnosed Pleural Effusion

Context: Despite recent advances in the available diagnostic modalities, diagnosis of pleural tuberculosis remains a challenge because of the low yield of conventional methods. Pleural biopsy is the gold standard for confirmation of diagnosis, which is invasive and cumbersome. The concentration of mycobacterial peptide-specific activated lymphocytes at the site of infection can be utilized as the basis for using IGRA (interferon-gamma release assays) based evaluation of undiagnosed exudative pleural effusions.  Aim: To evaluate the performance of IGRA (Enzyme-linked Immunospot (ELISPOT) in pleural fluid for the diagnosis of pleural tuberculosis in histopathologically confirmed cases. Settings and Design: A prospective observational study compared the utility of ELISPOT with thoracoscopy guided pleural biopsies for the diagnosis of tubercular pleural effusions. Methods and Material: Forty-two consecutive cases of undiagnosed pleural effusions were enrolled and subjected to thoracoscopy guided pleural biopsy. Thirteen patients were confirmed to have tuberculosis, 27 had malignancy, and 2 had normal pleura. A total of 1x103 pleural fluid mononuclear cells (PFMCs) were cultured in the presence of early secretory antigenic target-6 (ESAT-6) and culture filtrate protein-10 (CFP-10) for 24 hours. The individual spots were then counted using an automated analyzer ELISPOT reader system.  Results: The number of spots developed in the pleural fluid was significantly higher in tubercular pleural effusions as compared to non-tubercular effusions (CFP-10:154.76±14.61 vs 49.24±8.9; ESAT-6: 150.3±17.27 v/s 45.34±8.23, p<0.001). At a cut-off value of more than 67 spots taken as positive for tuberculosis, the sensitivity of the test was 100% (95% CI 75.29% to 100.00%), specificity was 96.5% (95 % CI 82.24% to 99.91%), positive predictive value was 92.86% (95 % CI 65.45% to 98.89%) and negative predictive value was 100%.  Conclusions: ELISPOT can be a useful non-invasive test for the evaluation of undiagnosed pleural effusions and making a diagnosis of pleural tuberculosis with confidence.

Impact of awareness about hypertension on compliance to antihypertensive medication

Background: Hypertension, a common cardiovascular disorder accounts for 20-50% of all deaths. This risk can be greatly ameliorated by creating awareness about disease and its effective treatment alongside regular medical check-ups. Therapeutic failures result from patient non-compliance, manifested as intentional or unintentional errors in dosage or schedule, overuse or underuse of prescribed drugs and early termination of therapy. Adherence is helpful for management of hypertension and cost minimization. Non-adherence to the drug treatment is an important factor for uncontrolled hypertension and its complications.Methods: Patients were interviewed individually after taking informed consent, using pretested, predesigned, self- administered and closed ended questionnaire both before and 4 weeks after creating awareness about hypertension and its complications. Compliance measured by self-reporting in which knowledge of the patient about number of antihypertensive drugs being used, formulations of drugs, frequency of administration, duration of taking the drugs and knowledge of complications due to uncontrolled and untreated hypertension were assigned 1 score each. Patient having score of at least 4 out of total 5 was considered compliant.Results: No significant association of compliance with demographic and other variables like age, sex, marital status, economic status, education, urbanization, duration of treatment and drug procurement were noted. A significant increase in compliance in patients on antihypertensive medication was found 4 weeks after creating awareness about hypertension and its complication. A significant increase in compliance scores was also seen in non-compliant patients showing their shifting from non-compliance to compliance group. Overall compliance increased from 59.38% to 84.38%. A percentage decrease from 58.82% to 25% in patients having uncontrolled hypertension was also observed after the awareness about hypertension.Conclusions: Demographic variables, duration of hypertension and drug procurement have no significant effect on compliance to antihypertensive medication. There is persistence and improvement in compliance to antihypertensive medications after an education of the patients about hypertension and its complications.

Exhaled breath condensate analysis in chronic obstructive pulmonary disease.

The increasing focus on airway inflammation in the pathogenesis of chronic obstructive pulmonary disease (COPD) has led to development and evolution of tools to measure it. Direct assessment of airway inflammation requires invasive procedures, and hence, has obvious limitations. Non-invasive methods to sample airway secretions and fluids offer exciting prospects. Analysis of exhaled breath condensate (EBC) is rapidly emerging as a novel non-invasive approach for sampling airway epithelial lining fluid and offers a convenient tool to provide biomarkers of inflammation. It has definite advantages that make it an attractive and a feasible option. It is a source of mediators and molecules that are the causes or consequences of the inflammatory process. Measurement of such markers is increasingly being explored for studying airway inflammation qualitatively and quantitatively in research studies and for potential clinical applications. These biomarkers also have the potential to develop into powerful research tools in COPD for identifying various pathways of pathogenesis of COPD that may ultimately provide specific targets for therapeutic intervention. The EBC analysis is still an evolving noninvasive method for monitoring of inflammation and oxidative stress in the airways. The limited number of studies available on EBC analysis in COPD have provided useful information although definite clinical uses are yet to be defined. Evolving technologies of genomics, proteomics, and metabonomics may provide deeper and newer insights into the molecular mechanisms underlying the pathogenesis of COPD.

Coexistent chronic obstructive pulmonary disease-heart failure: Mechanisms, diagnostic and therapeutic dilemmas.

Mortality in chronic obstructive pulmonary disease (COPD) is more often due to cardiac rather than respiratory causes. The coexistence of heart failure (HF) and COPD is frequent but remains under-diagnosed. Both conditions share several similarities including the age of the population affected, a common risk factor in smoking and symptoms of exertional dyspnoea. There is also a strong possibility of COPD promoting atherosclerotic vascular disease through systemic inflammation. Both the conditions are punctuated by episodes of acute exacerbations of symptoms from time to time where differentiation between these two can be especially challenging. Although coexistence of the two is common, more often, only one of the two is diagnosed resulting in under-treatment and unsatisfactory response. Awareness of co-occurrence is essential among both pulmonologists and cardiologists and a high index of suspicion should be maintained. The coexistence of the COPD and HF also poses several challenges in management. Active search for the second disease using clinical examination supplemented with specialised investigations including plasma natriuretic peptides, lung function testing and echocardiography should be carried out followed by appropriate management. Issues such as adverse effects of drugs on cardiac or pulmonary function need to be sorted out by studies in coexistent COPD-HF patients. Caution is advised with use of β2-agonists in COPD when HF is also present, more so in acute exacerbations. On current evidence, the beneficial effects of selective β1-blockers should not be denied in stable patients who have coexistent COPD-HF. The prognosis of coexistent COPD and HF is poorer than that in either disease alone. A favourable response in the patient with coexistent COPD and HF depends on proper evaluation of the severity of each of the two and appropriate management with judicious use of medication.