Cardiopulmonary exercise testing in evaluation of patients of chronic obstructive pulmonary disease.

Background. Objective assessment of severity in patients with chronic obstructive pulmonary disease (COPD) is mainly limited to pulmonary function testing performed at rest. But, accurate assessment of exercise capacity in patients with COPD may be possible with cardiopulmonary exercise testing (CPET). Methods. Forty-three patients with stable COPD were included and were divided into three groups based upon the spirometry data as per the Global Initiative for Obstructive Lung Disease (GOLD) guidelines as follows: Group A: mild COPD, Group B: moderately severe COPD and Group C: severe COPD. Symptom-limited CPET was performed using treadmill on incremental continuous ramp protocol in all of them. Results. Five patients (11.6%) had mild COPD; 16 (37.2%) had moderately severe COPD and the remaining 22 (51.6%) patients had severe COPD. Anaerobic threshold was attained in all the 43 patients. The dominant symptom at peak exercise were dyspnoea (n=19) and both dyspnoea and leg fatigue (n=7). The other causes of exercise limitation included dyspnoea with significant oxygen desaturation (n=6); and dyspnoea with severe oxygen desaturation (n=2). Six patients complained only of leg fatigue at peak exercise. A significant correlation between forced expiratory volume in the first second (FEV1) percent predicted and the predicted maximum oxygen uptake (VO2 max % predicted) was observed in all the three groups (r=0.39, p=0.011) but with marked variability of peak VO2 for a given degree of airflow obstruction. Twenty-three (53.5%) patients with low anaerobic threshold (<30%) were identified as potential group likely to benefit from exercise training for pulmonary rehabilitation. Conclusions. Cardiopulmonary exercise testing is useful to determine the causes of exercise limitation and to assess the maximal exercise capacity of patients with COPD.

Spirometry and diffusion studies in patients with type-2 diabetes mellitus and their association with microvascular complications.

Background. Diabetes is a systemic disease with-well known complications involving eyes, kidneys and nerves. The presence of an extensive pulmonary microvascular circulation and abundant connective tissue raises the possibility that lung may also be a target organ in diabetes. Methods. A total of 45 subjects were included in the study. All patients were evaluated for diabetic microangiopathies: nephropathy (by 24-hour protein excretion), retinopathy (by direct ophthalmoscopy) and neuropathy (by clinical examination). The patients were divided into following three groups: Group A: patients with type-2 diabetes mellitus (DM) with evidence of microangiopathy (n=15); Group B: patients with type-2 DM without any evidence of microangiopathy (n=15); Group C: non-diabetic subjects (n=15) as controls. Glycosylated haemoglobin (HbA1C) was measured as an indicator of glycemic control. Spirometry and single-breath diffusion capacity for carbon-monoxide (DLCO) were performed on all patients using Elite Series Body Plethysmograph machine. Results. A significant reduction of diffusion capacity corrected for alveolar volume (%DL/VA) was observed in group A (p<0.001), as compared to the other groups. There were no differences among the three groups for other pulmonary functions. There was a significant correlation between DL/VA percent predicted and albuminuria (r= -0.975, p<0.001), and DL/VA percent predicted and the retinopathy (r = -0.550, p< 0.05). Conclusion. This study shows a mild reduction in diffusing capacity in patients with type-2 DM with microangiopathy.

Utility of intrapleural streptokinase in management of chronic empyemas.

BACKGROUND: The nonsurgical medical approach with use of fibrinolytic agent is an alternative modality in management of chronic empyemas. With the introduction of purer forms of streptokinase, there has been renewed interest generated in the use of intrapleural thrombolytics with documented successful drainage of difficult to drain chronic empyemas. To evaluate the utility of streptokinase in the management of chronic difficult to drain empyemas in a single blind randomized case control study. MATERIAL AND METHODS: Twenty four cases of chronic/multiloculated empyema were included which had cases preferred having loculations or multiloculations and failure of drainage via thoracostomies for less than 100 ml during last 24 hours. Cases were randomized into two groups as 12 cases of streptokinases group and 12 cases of placebo group. Streptokinase given as 2.5 lac units in 100 ml of normal saline instilled intrapleurally for 6 consecutive days. In control group, 100 ml of normal saline without streptokinase was instilled intrapleurally through intercostal drain for 6 days. They were assessed by amount of drainage through intercostal drain for six days after instillation of streptokinase/placebo, duration of intercostal drainage in situ, and radiological improvement by standard x-ray chest. RESULTS: The study revealed increased drainage through intercostal drain in streptokinase group compared to control group. The mean duration of intercostal drainage in situ was shorter in streptokinase group compared to control group. Radiologically, streptokinase group revealed score 3 improvement in eight out of twelve cases and score 2 improvement in rest of the four cases. In control group, score 1 improvement was seen in two out of twelve cases and no improvement was seen in rest of the 10 cases. The observation difference is found to be highly significant statistically (p <0.001). No major adverse effects were noted in the streptokinase group. CONCLUSION: The study concludes the safety, efficacy, reduced hospital stay and decreased morbidity in patients treated with intrapleural streptokinase as compared to control group.

Study of superior vena cava syndrome--aetiopathology, diagnosis and management.

Thirty two patients of superior vena cava syndrome (SVCS) were studied. Clinical features noted were diffuse neck swelling, breathlessness, chest pain, engorged neck veins, facial swelling and dilated engorged veins over chest wall. Radiography revealed a superior mediastinal mass in 31.2% of patients and right upper lobe mass in 50% patients. FNAC of lung showed aetiology in 34.5% patients and lymph node biopsy in 31.2% patients. Aetiology of SVCS was benign in 12.5% patients and malignant in 87.5% patients. Squamous cell carcinoma was the commonest cause of SVSC. Radiotherapy proved to be the most beneficial form of treatment. The mean survival period in patients due to malignant etiology was 6 months.

Cryptococcosis: involvement of more than one system.

We report a 37-year-old female patient with pulmonary cryptococcosis who presented with a one week old history of cough and fever. Within a week of admission, she developed cryptococcal meningitis and 5 months later cryptococcomas of the brain were detected. She was successfully treated with 2 courses of amphotericin-B at an interval of 5 months. 5-flucytosine was also administered initially along with amphotericin-B. The pulmonary lesions resolved completely whereas the cryptococcomas reduced in number.