Etiology and Clinical Profile of Patients with a Tree-in-bud Appearance on High-resolution Computed Tomogram of the Thorax.

We read with great interest the article "the deadly duo of hypertension and diabetes in India: further affirmation from a new epidemiological study" by Metri et al.1 They rightly pointed out that the prevalence of hypertension in Indian patients with type 2 diabetes patients is high and therefore early screening and management of hypertension should be included in the treatment of patients with type 2 diabetes. We wish to share our study findings on the prevalence of hypertension in newly onset diabetes mellitus (DM). We find that the prevalence of hypertension in all males and females with DM was 44.59, 44.34, and 45.16%, respectively.2.

Vitamin D in Prevention and Treatment of COVID-19: Current Perspective and Future Prospects.

Vitamin D deficiency (VDD) partly explains geographical differences in COVID-19 susceptibility, severity, and mortality. VDD among African-Americans, diabetics, hypertensive, and aged populations possibly explain the higher death rate, aggravated by cocooning. Vitamin D is pleiotropic, mediating bone metabolism, calcium homeostasis, and immune functions, whereas VDD is associated with inflammatory reactions and immune dysfunction, predisposing individuals to severe infections. Vitamin D modulates innate and adaptive immunity via the expression of genes that code antimicrobial peptides (AMPs). And the expression of cluster of differentiation (CD)14, the co-receptor for epidermal toll-like receptor (TLR)4. AMPs stimulate TLR2 in macrophages, increasing the conversion of vitamin D into its active form by cytochrome P450 27B1. Antiviral properties of vitamin D-induced AMPs can shift the polarization of the adaptive immune response from helper T cells (Th)1 to the more regulatory Th2 responses that suppress immune over-reactivity by preventing cytokine storm, which is already demonstrated during the Spanish flu episode. Vitamin D induces antiviral effects by both direct and indirect mechanisms via AMPs, immunomodulation, the interplay between major cellular and viral elements, induction of autophagy and apoptosis, variation of genetic and epigenetic factors. The crosstalk between vitamin D and intracellular signaling pathways may operate as a primary regulatory action on viral gene transcription. VDD may increase the likelihood of infection with enveloped viruses, including retrovirus, hepatitis, and dengue. Global data correlates severe VDD with COVID-19 associated coagulopathy, disrupted immune response and mortality, reduced platelet count, and prolonged prothrombin time, suggesting benefits from supplementation.Key teaching pointsVitamin D induces antiviral effects by direct and indirect mechanisms via AMPs, immunomodulation, induction of autophagy, etc.Epidemiology of VDD partly explains geographical differences in COVID-19 susceptibility, severity, and mortality.Global data correlates severe VDD with COVID-19 associated coagulopathy, disrupted immune response and mortality, reduced platelet count, and prolonged prothrombin time, together suggesting benefits from supplementation.Many clinical trials are underway globally to delineate the role of vitamin D in both prevention and treatment of COVID-19.

Impact of tuberculosis disease on human gut microbiota: a systematic review.

INTRODUCTION: This systematic review evaluates the gut microbiota (GM) status in tuberculosis (TB) patients compared to healthy volunteers due to the disease or its treatment. AREAS COVERED: We conducted a systematic review of all articles published in PubMed, Web of Science, and Embase that assessed the impact of TB disease and anti-tubercular therapy (ATT) on GM from inception till January 2022 (Protocol registration number in PROSPERO: CRD42021261884). Regarding the microbial diversity indices and taxonomy, we found a significant difference in GM status between the TB and healthy control (HC) groups. We found an overabundance of Phylum Proteobacteria and depletion of some short-chain fatty acid-producing bacteria genera like Bifidobacteria, Roseburia, and Ruminococcus in the TB group. We found that ATT exacerbates the degree of dysbiosis caused by Mycobacteria tuberculosis disease. EXPERT OPINION: The modulation of GM in TB patients in clinical practice may serve as a promising target to reverse the dysbiosis caused. Moreover, this can optimistically change the TB treatment outcome. We expect that appropriate probiotic supplementation with antimycobacterial treatment during tuberculosis disease will help stabilize the GM throughout the treatment phase and protect the GM from dysbiosis.

Psychological stress and health-related quality of life among tuberculosis patients: a prospective cohort study.

Economic, social and psychological distress is common in individuals affected by tuberculosis (TB). However, the magnitude of distress, psychological interventions and their effect on the treatment outcomes are often under-evaluated. We examined the level of psychological stress and health-related quality of life (HRQoL) of such patients and the effect of antituberculosis therapy on them. Our prospective cohort study included newly diagnosed adult pulmonary and extrapulmonary TB patients. Assessment of psychological stress was done using the seven-item Generalised Anxiety Disorder questionnaire for anxiety and the nine-item Patient Health Questionnaire for depression. HRQoL was assessed by using the WHOQOL-BREF questionnaire. Of the 86 patients studied, 21 (24.4%) had anxiety symptoms at the baseline, which reduced to 5.8% and 1.2% at 2 months and treatment completion, respectively (p<0.001). Among the subjects, 18 (20.9%) patients had depression, which reduced to 7% and 2.3% at 2 months and treatment completion, respectively (p<0.001). All the mean domain scores of HRQoL were poor at the baseline, which showed improvement at treatment completion (p<0.001). Anxiety and depression were common among TB patients, and there was significant progressive reduction during and after treatment. TB had remarkable negative impacts on HRQoL, with the physical domain being the most affected, and all the domain scores showed significant improvement at treatment completion. Routine screening for depression and anxiety and timely referral to a psychiatrist are required in TB patients to improve the outcome of the disease and quality of life.

Probiotics in Prevention and Treatment of COVID-19: Current Perspective and Future Prospects.

Saving lives and flattening the curve are the foremost priorities during the ongoing pandemic spread of SARS-CoV-2. Developing cutting-edge technology and collating available evidence would support frontline health teams. Nutritional adequacy improves general health and immunity to prevent and assuage infections. This review aims to outline the potential role of probiotics in fighting the COVID-19 by covering recent evidence on the association between microbiota, probiotics, and COVID-19, the role of probiotics as an immune-modulator and antiviral agent. The high basic reproduction number (R0) of SARS-CoV-2, absence of conclusive remedies, and the pleiotropic effect of probiotics in fighting influenza and other coronaviruses together favour probiotics supplements. However, further support from preclinical and clinical studies and reviews outlining the role of probiotics in COVID-19 are critical. Results are awaited from many ongoing clinical trials investigating the benefits of probiotics in COVID-19.

Comparison of fractional exhaled nitric oxide, spirometry, and Asthma Control Test, in predicting asthma exacerbations: A prospective cohort study.

CONTEXT: Fractional exhaled nitric oxide (FeNO) is a noninvasive test for airway inflammation in asthma. The usefulness of FeNO in predicting exacerbations is uncertain. AIMS: The study aims to assess and compare the ability of FeNO, spirometry, and asthma control test (ACT) in predicting future exacerbations of asthma and their correlation with each other. SETTINGS AND DESIGN: This prospective, cohort study was conducted at the Department of Respiratory Medicine, Kasturba Medical College, Manipal. MATERIALS AND METHODS: Adult asthma patients of age 18-65 years were included. Patients with a smoking history of >10 pack-years and those in whom spirometry was contraindicated were excluded. Patients who consented underwent FeNO and spirometry. The control of asthma was assessed using the ACT questionnaire. We captured the number of exacerbations in the follow-up period of 4 months. STATISTICAL ANALYSIS USED: Mann-Whitney test was used to compare the utility of FeNO, spirometry, ACT in predicting exacerbations and Spearman's correlation coefficient was used to ascertain the correlation among them. RESULTS: Of 154 study patients, 28% had exacerbations. We found that there was no significant difference in FeNO in patients with and without exacerbations. The median (interquartile range [IQR]) FEV1% in the patients with and without exacerbations were 68 (55-79) and 75 (65-88), respectively (P = 0.013). The median (IQR) ACT score in patients with exacerbations was 12 (10-16) which was significantly lower than in those without exacerbation in whom it was 16 (14-18) (P = 0.003). There was a negative correlation of ACT with FeNO (Correlation coefficient: -0.167, P = 0.038). The median (IQR) FeNO level (ppb) was lower in patients who were on inhaled corticosteroid (ICS) than in the other group values being 22 (14-38) and 30 (17-58), respectively (P = 0.05). CONCLUSIONS: In our study, FEV1% and ACT score could predict exacerbations of asthma whereas FeNO could not. FeNO level correlated inversely with ACT score. FeNO level decreased with inhaled corticosteroid usage.

Impact of a Clinical Pharmacist Intervention on Medicine Costs in Patients with Chronic Obstructive Pulmonary Disease in India.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality, especially in low- and middle-income countries (LMICs) such as India. Medicine costs are a key issue in LMICs, with typically high patient co-payments. In addition, pharmacists are underutilised in LMICs, including India. However, pharmacist-led educational interventions may improve the care of patients with COPD, as well as reduce medicine costs. Consequently, the objective of this study was to assess the effectiveness of a pharmacist-led intervention in reducing medicine costs. METHODOLOGY: We assessed the impact of a pharmacist intervention on direct medicine costs in COPD patients (medicine costs and pharmacist time) in a randomised controlled study involving an intervention and control group, conducted at a tertiary care teaching hospital in India. RESULTS: The 6-monthly cost of medicines at baseline increased with disease severity, from a maximum of US$29.46 for those with mild COPD to US$63.28 for those with very severe COPD. Substantial savings in medical costs were achieved with the pharmacist-led programme, to a maximum of US$20.49 over 6 months for very severe patients. This equates to a reduction of 30.6% in medicine costs (p < 0.001), reduced to 26.1% when pharmacists' time (US$3.00/patient) was included. CONCLUSION: There could be a key role for pharmacists as educators for COPD patients in LMICs, to improve care and reduce costs, including patient co-payments.

Comparison of reaction time and functional balance in chronic obstructive pulmonary disease and healthy participants.

BACKGROUND: Reaction time is one of the components of functional balance and could contribute to balance impairment. Information regarding this relationship is scant among Chronic Obstructive Pulmonary Disease (COPD) participants. OBJECTIVES: To compare stepping reaction time between participants with COPD and age; gender-matched healthy individuals to find out whether reaction time in COPD population is affected. METHODS: This cross-sectional study included 41 COPD participants and 41 age and gender-matched healthy individuals. All the participants underwent measurements of stepping reaction time (SRT) and timed up and go test (TUG). RESULTS: SRT was significantly higher in COPD participants compared to healthy individuals [median of difference- 350 milliseconds (110, 830), p < 0.001]. TUG was significantly higher in COPD participants compared to healthy individuals [median of difference = 2.82 seconds (0.34 and 4.5), p < 0.001]. CONCLUSIONS: Participants with COPD exhibit marked increase in SRT and demonstrate a deficiency in functional balance compared to the healthy participants.

Serum magnesium levels and its correlation with level of control in patients with asthma: A hospital-based, cross-sectional, prospective study.

CONTEXT: Magnesium (Mg) is an intracellular cation which takes part in various functions including smooth muscle contractility. Studies have shown that serum Mg level has no significant effect on asthma severity. There are only sparse data on the effect of serum Mg level on asthma control. AIMS: The aim of this study was to evaluate the effect of serum Mg level on asthma control. SETTINGS AND DESIGN: This hospital-based cross-sectional study was conducted at the Department of Respiratory Medicine, Kasturba Medical College, Manipal. SUBJECTS AND METHODS: Our participants were adult asthma patients over 18 years of age. Asthma control was assessed using a questionnaire. Serum Mg level was estimated. The study was approved by the Institutional Ethics Committee, and informed consent was obtained from the participants. STATISTICAL ANALYSIS USED: Welch's ANOVA test was used to analyze the correlation between serum Mg level and level of control of asthma. RESULTS: We screened 256 patients who met the inclusion criteria. After 96 patients were removed based on exclusion criteria, 160 patients were grouped into three based on the level of symptom control. Forty-eight patients belonged to the "well controlled" group, 59 in "partly controlled" group, and the remaining 53 in "uncontrolled" group. The mean serum Mg level (mg/dl) was 2.08 ± 0.37, 2.07 ± 0.28, and 1.83 ± 0.34 in well, partly, and uncontrolled groups, respectively. As the level of control of asthma decreased from well controlled to uncontrolled, the level of mean serum Mg also decreased. CONCLUSIONS: Serum Mg levels have a positive correlation with the level of symptom control in asthma. In uncontrolled asthma, serum Mg is significantly low. Hence, it might be useful as a biomarker in assessing control or severity of asthma.

The effect of 6 months or longer duration of chronic obstructive respiratory disease medication on the oral health parameters of adults.

The objectives of this study were to study the effect of COPD medication of 6 months or more duration on oral health parameters of adult patients. A cross-sectional study was conducted to assess and compare the decayed, missing, and filled teeth (DMFT), oral hygiene index-simplified (OHI-S), periodontal disease index (PDI) scores, and presence of candida (colony-forming units [CFU]) among adult patients aged 20-45 years who had a history of 6 months or longer duration usage of chronic respiratory disease medications, with controls. A total of 170 participants each were taken in both the groups. Oral health parameters like DMFT scores (p ≤ 0.002), OHI-S (p ≤ 0.001), calculus scores (p ≤ 0.001), plaque scores (p ≤ 0.001), and CFU/ml of candida species (p ≤ 0.001) were higher among cases than controls. DMFT scores and candida presence were significantly higher among those whose treatment duration was greater than 5 years as compared to those with lesser duration. Gingival-periodontal component scores of PDI were lower among cases than controls (p ≤ 0.001). Our findings suggest the need for regular oral health maintenance for those under COPD treatment and for greater research into the possible protective role of inhaled corticosteroids in limiting periodontal disease among patients.

Structured pharmacist-led intervention programme to improve medication adherence in COPD patients: A randomized controlled study.

BACKGROUND: COPD is characterised by a progressive airflow limitation in the lungs. However, adherence to therapy improves management of symptoms and delays disease progression. Therefore, patients' knowledge and awareness about the disease are important. Hence, pharmacist-led educational interventions could achieve this and improve medication adherence. OBJECTIVE: This study evaluated the effectiveness of a clinical pharmacist-led intervention on medication adherence in COPD patients in a teaching hospital. METHODS: In an open-labelled randomized controlled study at Kasturba Medical College Hospital, Manipal, India, patients were randomly assigned to two groups (Intervention group [IG] and Control group [CG]), and were matched for socio-demographics and clinical characteristics. Medication adherence was assessed by the Morisky, Green and Levine Medication Adherence Questionnaire (MAQ). In IG, pharmacist intervention placed emphasis on (1) compliance, (2) smoking cessation, (3) exercise, (4) inhaler use and (5) need for timely follow up. The MAQ assessment was repeated at 6, 12, 18 and 24 months. Data were analysed statistically by SPSS version 20.0. RESULTS: Out of 328 patients screened during March 2012 to June 2013, 260 were recruited. Of these, 206 completed the follow-up (98 in CG and 104 in IG). Medication adherence improved significantly after pharmacist intervention in IG at all follow-up time points (P < 0.001). It increased from 49% at the baseline to 80% after 24 months (P < 0.001). Carelessness about taking medicines was one of the main reasons for non-adherence in COPD patients, but was effectively reduced by the intervention. CONCLUSIONS: This is the first randomized controlled trial in India that demonstrates the pivotal role of pharmacist-led educational intervention in improving medication adherence in COPD. Involving non-physician health professionals could be the best strategy, for resource-poor nations like India, because the current physician-centric healthcare has no emphasis on patient education and counselling.

Protective effect of metformin against tuberculosis infections in diabetic patients: an observational study of south Indian tertiary healthcare facility.

BACKGROUND: World Health Organization estimated that people with diabetes (DM) are at 2-3 times higher risk for tuberculosis (TB). Studies have shown that DM not only increases the risk of active TB, but also puts co-affected persons at increased risk of poor outcomes. OBJECTIVES: To determine the protective effect of metformin against TB in DM patients and also, to investigate the relationship between poor glycemic control and TB. METHODS: A case-control study was conducted over 8 months, where cases and controls were selected based on the inclusion and exclusion criteria of the study. The diabetics diagnosed with TB were selected as study group (SG=152) and without TB were as control group (CG=299). Exposure status of metformin in both groups were analyzed. RESULTS: The mean (SD) age of both CG and SG were 55.54±11.82 and 52.80±11.75, respectively. Majority of the subjects in the study were males. The mean hospital stay of SG and CG were 7 days and 6 days, respectively. Poor glycemic control (HbA1c>8) observed in SG (51.7%) vs CG (31.4%). HbA1c value <7 is associated protective factor for TB occurrence [OR=0.52 (95% CI 0.29-0.93)]. The protective effect of metformin against TB was 3.9-fold in diabetics (OR=0.256, 0.16-0.40). CONCLUSION: Poor glycemic control among diabetics is a risk factor for TB occurrence. The result shows metformin use is a protective agent against TB infection in diabetics. Hence, incorporation of metformin into standard clinical care would offer a therapeutic option for the prevention of TB.

Influence of pseudomonas aeruginosa on exacerbation in patients with bronchiectasis.

BACKGROUND: A majority of the studies done on the western population have shown that Pseudomonas aeruginosa causes many severe infections in patients with bronchiectasis as compared to other pathogens. There is scarcity of similar data from the Asian population. MATERIALS AND METHODS: A prospective study was undertaken to identify the various pathogens isolated from the respiratory samples of 117 patients with bronchiectasis from south India and to compare the clinicomicrobiological profile of infections caused by P. aeruginosa and other respiratory pathogens. RESULTS: The respiratory pathogens were isolated from 63 (53.8%) patients. P. aeruginosa was the most common isolate (46.0%) followed by Klebsiella pneumoniae (14.3%) and other pathogenic bacteria. Patients included in the P. aeruginosa group had a higher number of exacerbations (p: 0.008), greater number of hospital admissions (p: 0.007), a prolonged hospital stay (p: 0.03), and poor lung function, compared to the patients infected with the non-Pseudomonas group. CONCLUSION: It is necessary to investigate the etiology of respiratory tract infections among bronchiectasis patients followed by the prompt management of cases diagnosed with P. aeruginosa infections, so as to lower the morbidity and have a better prognosis.

Ortner's syndrome.

A 42-year-old man with a significant smoking history presented with chronic expectorative cough and exertional shortness of breath with recent-onset hoarseness. Chest examination was essentially normal and cardiovascular examination was suggestive of aortic regurgitation. Ears, nose and throat evaluation showed left vocal cord palsy and CT scan revealed an aortic arch aneurysm. Ortner's syndrome refers to hoarseness due to recurrent laryngeal nerve palsy secondary to a cardiovascular abnormality. Aortic aneurysms usually present with chest pain, back pain or epigastric pain, depending on the site of the aneurysm. An aortic arch aneurysm presenting as hoarseness is extremely rare.

Tuberculous lymphadenitis and borderline leprosy in a patient with isolated unconjugated hyperbilirubinaemia.

A 35-year-old man was diagnosed with tuberculous lymphadenitis and multibacillary borderline tuberculoid leprosy. On investigation, isolated unconjugated hyperbilirubinaemia was detected and evaluation led us to conclude that the probable cause was Gilbert's syndrome. He was successfully managed by administration of chemotherapy for the treatment of both the mycobacterial infections, with no adverse effects on liver function tests.

Chryseobacterium indologenes pneumonia in a patient with non-Hodgkin's lymphoma.

A 42-year-old man diagnosed with gastric non-Hodgkin's lymphoma 2 years earlier, for which he had undergone treatment, presented with expectorative cough, exertional shortness of breath and left-sided chest pain of 3 months duration. Respiratory system examination was suggestive of left-sided pneumonia with pleural effusion. Routine haemogram showed leukocytosis with high erythrocyte sedimentation rate. Chest radiograph showed blunting of left-sided cardiophrenic angle. Sputum culture grew Chryseobacterium indologenes. Diagnostic thoracocentesis was suggestive of lymphomatous metastasis. Pleural fluid culture was sterile. Contrast-enhanced CT (CECT) of the thorax showed left lower lobe consolidation with bilateral pleural effusion. The patient was treated with antibiotics, following which his cough improved and total leukocyte count normalised. Sputum culture repeated after the antibiotic course showed no growth of C. indologenes. However, the pleural effusion soon aggravated along with features suggestive of multiple metastasis. The patient finally succumbed to his underlying advanced malignancy.

Image guided biopsy of the pleura: a useful diagnostic tool even when fluid is minimal.

A man in his late thirties presented with left-sided chest pain, recurrent fever and cough. Radiographical study revealed left pleural effusion which on ultrasonic imaging was minimal and non-tappable. Image guided trucut pleural biopsy yielded pleural specimens which helped in confirming the diagnosis of tuberculosis.