NCCP-ICS joint consensus-based clinical practice guidelines on medical thoracoscopy.

ABSTRACT: Medical Thoracoscopy (MT) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. The aim of the study was to provide evidence-based information regarding all aspects of MT, both as a diagnostic tool and therapeutic aid for pulmonologists across India. The consensus-based guidelines were formulated based on a multistep process using a set of 31 questions. A systematic search of published randomized controlled clinical trials, open labelled studies, case reports and guidelines from electronic databases, like PubMed, EmBase and Cochrane, was performed. The modified grade system was used (1, 2, 3 or usual practice point) to classify the quality of available evidence. Then, a multitude of factors were taken into account, such as volume of evidence, applicability and practicality for implementation to the target population and then strength of recommendation was finalized. MT helps to improve diagnosis and patient management, with reduced risk of post procedure complications. Trainees should perform at least 20 medical thoracoscopy procedures. The diagnostic yield of both rigid and semirigid techniques is comparable. Sterile-graded talc is the ideal agent for chemical pleurodesis. The consensus statement will help pulmonologists to adopt best evidence-based practices during MT for diagnostic and therapeutic purposes.

Catastrophic costs for tuberculosis patients in India: Impact of methodological choices.

As financial risk protection is one of the goals towards universal health coverage, detailed information on costs, catastrophic costs and other economic consequences related to any disease are required for designing social protection measures. End Tuberculosis (TB) Strategy set a milestone of achieving zero catastrophic cost by 2020. However, a recent literature review noted that 7%-32% TB affected households in India faced catastrophic cost. Studies included in the review were small scale cross-sectional. We followed a cohort of 1482 notified drug-susceptible TB patients from four states in India: Assam, Maharashtra, Tamil Nadu, and West Bengal to provide a comprehensive picture of economic burden associated with TB treatment. Treatment cost was calculated using World Health Organization guidelines on TB patient cost survey and both human capital and output approaches of indirect cost (time, productivity, and income loss related to an episode) calculation were used to provide the range of households currently facing catastrophic cost. Depending on choice of indirect cost calculation method, 30%-61% study participants faced catastrophic cost. For over half of them, costs became catastrophic even before starting TB treatment as there was average 7-9 weeks delay from symptom onset to treatment initiation which was double the generally accepted delay of 4 weeks. During that period, they made average 8-11 visits to different providers and spent money on consultations, drugs, tests, and travel. Following the largest cohort of drug-susceptible TB patients till date, the study concluded that a significant proportion of study participants faced catastrophic cost and the proportion was much higher when income loss was considered as indirect cost calculation method. Therefore, ensuring uninterrupted livelihood during TB treatment is an absolute necessity. Another reason of high cost was the delay in diagnosis and costs incurred during pre-diagnosis period. This delay and consequently, economic burden, can be reduced by both supply side (intense private sector engagement, rapid diagnosis) and demand side (community engagement) initiatives. Reimbursement of expenses incurred before treatment initiation could be used as short-term measure for mitigating financial hardship.

Journey of the tuberculosis patients in India from onset of symptom till one-year post-treatment.

Historically, economic studies on tuberculosis estimated out-of-pocket expenses related to tuberculosis treatment and catastrophic cost, however, no study has yet been conducted to understand the post-treatment economic conditions of the tuberculosis patients in India. In this paper, we add to this body of knowledge by examining the experiences of the tuberculosis patients from the onset of symptoms till one-year post-treatment. 829 adult drug-susceptible tuberculosis patients from general population and from two high risk groups: urban slum dwellers and tea garden families were interviewed during February 2019 to February 2021 at their intensive and continuation phases of treatment and about one-year post-treatment using adapted World Health Organization tuberculosis patient cost survey instrument. Interviews covered socio-economic conditions, employment status, income, out-of-pocket expenses and time spent for outpatient visits, hospitalization, drug-pick up, medical follow-ups, additional food, coping strategies, treatment outcome, identification of post-treatment symptoms and treatment for post-treatment sequalae/recurrent cases. All costs were calculated in 2020 Indian rupee (INR) and converted into US dollar (US$) (1 US$ = INR 74.132). Total cost of tuberculosis treatment since the onset of symptom till one-year post-treatment ranged from US$359 (Standard Deviation (SD) 744) to US$413 (SD 500) of which 32%-44% of costs incurred in pre-treatment phase and 7% in post-treatment phase. 29%-43% study participants reported having outstanding loan with average amount ranged from US $103 to US$261 during the post-treatment period. 20%-28% participants borrowed during post-treatment period and 7%-16% sold/mortgaged personal belongings. Therefore, economic impact of tuberculosis persists way beyond treatment completion. Major reasons of continued hardship were costs associated with initial tuberculosis treatment, unemployment, and reduced income. Therefore, policy priorities to reduce treatment cost and to protect patients from the economic consequences of the disease by ensuring job security, additional food support, better management of direct benefit transfer and improving coverage through medical insurances need consideration.

Superior mesenteric artery syndrome and disseminated tuberculosis: "Double troubleË®.

Superior Mesenteric Artery (SMA) Syndrome is a rare condition characterized by compression of the third part of the duodenum between the aorta and superior mesenteric artery due to decreased angle between these two vessels due to loss of intervening pad of fat. Tuberculosis is one of the causes, and its association with it is rare. However, SMA syndrome with significant gastrointestinal symptoms in TB poses a greater challenge in management, particularly in dissemination. Strong clinical suspicion, timely diagnosis and appropriate antituberculosis therapy are the keys to successful management.

Can Fine Needle Aspiration Cytology be Used as a "Proxy Gold Standard" to Diagnose Tuberculous Mastitis?

OBJECTIVE: To assess the performance of fine needle aspiration cytology (FNAC) in the diagnosis of tuberculosis mastitis. MATERIALS AND METHODS: Diagnostic test performance evaluation using two methods-as compared to an alloyed gold standard as well as in the absence of a gold standard. Alloyed gold standard combined the results of acid fast bacilli in cytology smears, histopathological confirmation, and response to treatment. Bayesian estimation of test parameters was done in the absence of the gold standard. RESULTS: FNAC was carried out in 6,496 consecutive cases of breast lump and 104 cases of granulomatous mastitis were detected. Both methods of test parameter estimation identified a high specificity of FNAC for the diagnosis of tuberculosis mastitis (98.9% and 98.4%, respectively). Estimation of sensitivity was falsely high (100%) using the alloyed gold standard because of a workup bias and falsely low (8.41%) using the Bayesian estimation because of low prevalence. Likelihood ratios by both methods suggested that FNAC has good discriminatory capability. CONCLUSION: In situations where prevalence of tuberculosis is high and where facilities for histopathological evaluation do not exist, FNAC can offer an optional alternative to base the therapeutic decision for starting antitubercular treatment.

Multidrug-resistant TB among previously treated TB cases: A retrospective study in Nagpur, India.

BACKGROUND: Multidrug-resistant TB (MDR-TB) is a major public health concern and threat for tuberculosis control efforts worldwide. Globally, 3.6% of new TB cases and 20.2% of previously treated cases, are estimated to have MDR-TB. The prevalence of MDR-TB in India has been estimated to be 1-3% in new TB cases and around 12-14% in previously treated TB cases. There is limited information of the trends of MDRTB among various types of previously treated cases, i.e. relapse, treatment after failure, treatment after default and other cases. This study was conducted to know the trends of MDR-TB among various types of previously treated cases treated as per Revised National TB Control Program (RNTCP) guidelines. METHODS: This was a retrospective record review of MDRTB cases diagnosed during 2007-2011 who were previously treated for anti-TB treatment under RNTCP. RESULTS: A total of 249 retreatment tuberculosis patients diagnosed as having MDRTB were included. Majority 84 (34%) of cases were from 25 to 34 years age group, which is productive age group. Among the MDRTB cases, 177 (71%) were male and 72 (29%) were female. The proportion of MDR-TB among different subcategories of retreatment TB cases were relapse 117 (47%), treatment failure 96 (39%), treatment after default 22 (9%) and others 14 (6%). CONCLUSION: Study findings highlight high proportion of MDRTB among the relapse and treatment failure cases. Further research is needed to understand high occurrence rates of MDRTB among relapse and failure cases treated under RNTCP and need for early detection of MDR-TB among these high-risk groups.

Utility of fiberoptic bronchoscopy in diagnosis of various lung conditions: Our experience at rural medical college.

AIM: To evaluate the utility of fiberoptic bronchoscopy in order to find out the etiology in various lung conditions. MATERIALS AND METHODS: Fiberoptic bronchoscopy was performed in 120 adult patients who had persistent opacities on chest radiography in the form of collapse, consolidation, hilar mass and cavity with proper antibiotic course of 1 to 3 months. Bronchoscopic aspirates, brushing and biopsy (as and when required) were taken. Patient with known lung cancer, sputum positive pulmonary TB, recent myocardial infarction, allergic diseases and blood dyscrasias were excluded. RESULTS: Fiberoptic bronchoscopy was diagnostic in 90 (75%) patients. Bacterial pneumonias were found in 32 (26.66%), malignancy in 28(23.33%), pulmonary TB in 20 (16.66%), fungal pneumonia in 6(5%) and foreign bodies in 4(3.33%) patients. In 30(25%) patients no specific diagnosis was made. CONCLUSION: We conclude that fiberoptic bronchoscopy was found to be extremely useful in finding specific etiology of various lung diseases.