Eosinophilic Airway Inflammation in Patients with Stable Biomass Smoke- versus Tobacco Smoke-Associated Chronic Obstructive Pulmonary Disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is an inflammatory disease with predominant involvement of neutrophils, macrophages and CD8+ lymphocytes. Eosinophilic airway inflammations are reported in stable state and during acute exacerbations of tobacco smoke-associated COPD (TS-COPD). Women exposed to biomass fuel smoke are known to have eosinophils in sputum. However, little is known about the sputum cellular inflammatory profile in biomass fuel smoke-associated COPD (BMS-COPD). We therefore aimed to compare the sputum cellular inflammatory profile in tobacco smoke- and biomass smoke-associated COPD. METHODS: The study was conducted in a tertiary care hospital in Goa, India. A total of 113 patients with stable COPD reporting to the outpatient pulmonary clinic were recruited. All participants were ≥ 40 years of age. Sputum induction studies were performed by the method of Pizzichini et al. after baseline subject characterization. Significant eosinophilia was defined as induced sputum eosinophils ≥ 3%. RESULTS: There were 85 TS-COPD and 28 BMS-COPD patients. The mean age [standard deviation (SD)] was 64.7 (7.8) and 63.0 years (8.3), p = 0.32 in TS and BMS-COPD, respectively. Eighteen subjects (21.1%) were female smokers. The smoking pack-year median [interquartile range (IQR)] was 36 (20, 58) and hour-years of biomass smoke exposure mean (SD) was 192.4 (61). The TS-COPD and BMS-COPD cases showed a post-bronchodilator forced expiratory volume in one second (FEV1%) mean (SD) of 57.9 (17.1), and 62.6 (19.4), p= 0.22, respectively. Both groups had similar symptoms and severity of disease. Induced sputum total cell count per gram of sputum × 106 mean (SD) was 3.05 (1.53) for TS-COPD, and 2.55(1.37) for BMS-COPD p=0.12. The neutrophils % mean (SD) was 86.4 (16.5) and 87.9 (10.2), p = 0.64; eosinophils % median (IQR) was 2.5 (1, 10) and 8 (2, 12.8), p = 0.07; lymphocytes % median (IQR) was 0 (0, 0.75) and 0 (0, 1) p = 0.13; macrophages % median (IQR) was 2.5 (0.75, 5.7) and 1 (0, 4.7) p = 0.13; and significant eosinophilia (eosinophils ≥3%) was 42 (49.4%) and 20 (71%), p=0.04, for TS-COPD and BMS-COPD, respectively. CONCLUSIONS: For similar severity of disease and clinical symptoms, significant eosinophilic inflammation was observed in stable BMS-COPD, while both groups had similar neutrophilic inflammation. PARTICIPANT CONSENT: Obtained. ETHICS APPROVAL: The study was approved by the Institutional Ethics Committee of the Goa Medical College, Goa, India. COMPETING INTERESTS: The authors declare no competing financial interests.

Developing knowledge and clinical competency in a respiratory system-based practice of final-year medical students through a novel structured bedside teaching module.

BACKGROUND: Respiratory diseases are a major cause of mortality and morbidity worldwide. A sound knowledge of management of respiratory diseases is thus very vital. The clinical exposure of undergraduate medical students is limited to 2 weeks in pulmonary medicine. We hypothesized that the short duration of posting can be best utilized by developing need-based modules for bedside teaching. AIMS: This study aimed to determine gain in knowledge and skills of final-year medical students in diagnosis and management of common pulmonary diseases and assess students' perception of the module. METHODS: A one-group pretest-posttest quasi-experimental study design enrolled a convenience sample of 48 final-year medical students. Twenty-four students were posted at a given time for the bedside clinical posting in pulmonary medicine between August 2013 and November 2013. These students were divided randomly into two groups of 12 students each. All students consented to be part of the study. Two trained faculty taught in rotation. The bedside teaching module was prepared by Delphi technique and curriculum was based on Kern's six-step approach. History taking, physical examination, tuberculosis, chronic obstructive pulmonary disease, asthma, lung cancer, chest X-rays, and spirometry were taught. Students were administered pre- and post-test questionnaires to assess knowledge, while Objective Structured Clinical Examination assessed skills. Students' feedback questionnaire evaluated the teaching module. A two-tailed paired sample t-test assessed mean gain in knowledge and skills. Effect size was calculated by Cohen's d, while Cronbach's alpha estimated the reliability testing of perception questionnaire. Statistical analysis was performed using statistical software package IBM SPSS version 23. RESULTS: Mean pre- and posttest knowledge scores were 12.46 (8.09) and 43.17 (10.7), respectively, P = 0.001. Mean pre- and posttest skills scores were 7.00 (4.76) and 24.79 (3.31), respectively, P = 0.001, and Cohen's d showed large effect size. Most students stated that the module enhanced their clinical skills, helped to understand difficult material, and promoted inquiry and thinking. Cronbach's alpha for perception questionnaire was 0.854. CONCLUSIONS: Structured bedside teaching module in pulmonary medicine improved the knowledge and skills of undergraduate medical students. The contents and various teaching methodologies were evaluated positively.

Small airway imaging phenotypes in biomass- and tobacco smoke-exposed patients with COPD.

Biomass and functional small airway disease http://ow.ly/gXu730abpKu.

The success and safety profile of sputum induction in patients with chronic obstructive pulmonary disease: An Indian experience.

BACKGROUND: Neutrophilic inflammation is common in chronic obstructive pulmonary disease while Asthma COPD overlap syndrome has eosinophilic predominance. Identifying the type of inflammation will aid in better management of COPD, but published studies show that induced sputum examination is more frequently used in asthma than COPD, with safety being the limiting factor. We aimed to determine the success and safety of sputum induction (SI) in COPD patients. METHODS: 116 stable COPD patients underwent SI. Success was defined as adequate sputum sample resulting in a cytospin sufficient to assess differential count while safety by the fall in FEV1. RESULTS: The mean (SD) FEV1% predicted post bronchodilator was 58.8 (17.8) and 59 (51.8%) patients had moderate COPD. Success was 98.28%. The procedure was safe with overall fall in FEV1 of 11.1% (5.1, 15.2). ≥20% fall was noted in 13 (11.4%) patients, 10-20% in 24 (21.0%) patients, and less than 10% in 29 (25.4%) patients while 48 (42.1%) had no fall. There was an inverse correlation between reversibility in FEV1 and percentage fall in FEV1; r=-0.437 and p=0.001. Stepwise multivariate linear regression showed reversibility as an independent predictor of fall in FEV1; R2=0.137. CONCLUSIONS: Sputum induction is successful and safe in COPD. Even a fall in FEV1>20% is reversible.

Quantitative computed tomography imaging in chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease having small airway inflammation, emphysema, and pulmonary hypertension. It is now clear that spirometry alone cannot differentiate each component. Quantitative computed tomography (QCT) is increasingly used to quantify the amount of emphysema and small airway involvement in COPD. Inspiratory CT guides in assessing emphysema while expiratory CT identifies areas of air trapping which is a surrogate of small airway inflammation. By constructing a three-dimensional model of airways, we can also measure the airway wall thickness of segmental and subsegmental airways. The aim of this review is to present the current knowledge and methodologies in QCT of the lung that aid in identifying discrete COPD phenotypes.

Reference Equation for Six Minute Walk Test in Healthy Western India Population.

INTRODUCTION: The Six Minute Walk Test (6MWT) is used to assess disease progression and survival in chronic cardiopulmonary disorders. However, variability is noted in the six minute walk test distance (6MWD) in different populations. AIM: We aimed to develop a reference equation for 6MWD in healthy Western India population and compare the results with previously published Indian and Caucasian reference equations. MATERIALS AND METHODS: Total 174 healthy subjects between 25 to 75 years performed the 6MWT. Variables assessed were age, height, weight, body mass index and sex. Predicted equations were derived using multiple linear regression and compared with the equations for North Indian male, South Indian and Caucasian population using Bland - Altman method. RESULTS: The 6MWD mean (SD) was 512.38 (67.84) m for men and 457.27 (56.75) m for women with p=0.001. The 6MWD correlated with age (r=-0.44), height (r=0.43), weight (r=0.21) in univariate analysis. Stepwise multiple regression analysis showed age and sex to be independent predictors of 6MWD, R(2) =0.307. The reference equation for healthy Western India population is 553.289 + (-2.11 x age) + (45.323 x sex; men=1 and women =0). Bland Altman analysis showed that the mean bias was 50.87m (95% limits of agreement 134.77 to - 33.0) for North Indian male equation, 50.75m (95% limits of agreement 105.72 to - 4.22) for South Indian equation and 122.72m (95%limits of agreement 254.11 to - 8.67) for Enright and Sherrill's equation. CONCLUSIONS: The North Indian male, South Indian and Caucasian equations significantly over-estimated the predicted walk distance for our healthy population. Hence, there is a need to develop subgroup population specific reference equations.

Hypersensitivity Pneumonitis in a Housewife Exposed to Aspergillus flavus in Poor Living Conditions: A Case Report.

Hypersensitivity Pneumonitis (HP) or Extrinsic Allergic Alveolitis (EAA) is a disease resulting from immunologically induced inflammation in response to inhalation of a wide variety of airborne allergens. The condition develops mainly in non atopic individuals sensitized to organic dust due to repeated exposures. It is a relatively rare disease constituting upto 2% of interstitial lung diseases. Knowledge of classical High Resolution Computed Tomography (HRCT) of lung findings aid in early diagnosis. We report a case of subacute hypersensitivity pneumonitis in a housewife who despite being symptomatic remained undiagnosed for two years. She showed a good response to therapy, but soon relapsed. Visit to her home revealed that she lived in a damp house full of moldy walls.

Role of Semi-quantitative Serum Procalcitonin in Assessing Prognosis of Community Acquired Bacterial Pneumonia Compared to PORT PSI, CURB-65 and CRB-65.

INTRODUCTION: Community Acquired Pneumonia (CAP) is one of the commonest causes of patient's visit to the Emergency Room (ER). Hospitalisation of patient depends on severity of pneumonia. Various pneumonia severity assessment scores are available to predict mortality in community acquired pneumonia but these scores are not commonly used. Procalcitonin is a biomarker which is raised in bacterial infection and is easy and quick to measure. The aim of our study was to assess the ability of baseline serum procalcitonin level to predict mortality of community acquired bacterial pneumonia compared to PSI, CURB-65 and CRB-65 and its add-on value to the simple CRB-65 score. MATERIALS AND METHODS: Fifty five patients admitted with Com-munity Acquired Bacterial Pneumonia were enrolled after taking informed consent and satisfying all inclusion and exclusion criteria. PSI, CURB -65, CRB-65 and PCT scores were determined on admission. PCT was measured by semi- quantitative assay; PCT Q. Primary outcome was 30 day mortality. Sensitivity, specificity, positive and negative predictive value of PCT for assessing mortality was calculated and compared to validated pneumonia severity scores; PSI, CURB-65 and CRB-65. We also assessed the ability of the combination of PCT to each of the scores to predict 30 day pneumonia specific mortality. RESULTS: In receiver operating characteristic analysis for mortality prediction, area under curve (95% CI) for PCT, PSI, CURB-65 and CRB-65 was 0.92 (0.85, 1.0), 0.88 (0.78, 0.98), 0.88 (0.76, 0.99), 0.9 (0.78, 1.0) respectively. Combination of PCT to each of the scores improved the prognostic ability to predict 30 day pneumonia specific mortality. CONCLUSION: Semi-quantitative PCT level at admission is an excellent test to predict the outcome of pneumonia. It predicts patients at low risk of mortality from community acquired bacterial pneumonia.

Rare interstitial lung disease: Pulmonary Langerhans Cell Histiocytosis in a young non smoking Indian female.

Adult Pulmonary Langerhans Cell Histiocytosis (PLCH) is a rare interstitial lung disease which occurs almost exclusively in smokers. A marked male predominance was initially reported, but recent studies show both men and women are equally affected due to the increasing smoking habits in women. The natural history is variable with 25% of patients having asymptomatic disease while 10-20% progress rapidly to respiratory insufficiency and death. The diagnosis is not easily recognized by clinicians or pathologists. Awareness of the clinical presentation and classical HRCT findings helps in early diagnosis and management of this disease. We report a rare case of severe PLCH in a young non smoking female with a short history who progressed rapidly to respiratory failure and died.