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Papers by tarang kulkarni

Introduction: Fraction of exhaled nitric oxide (FeNO) is a quantitative, non-invasive, simple but... more Introduction: Fraction of exhaled nitric oxide (FeNO) is a quantitative, non-invasive, simple but expensive method of assessing airways inflammation.ΔFEF 25-75 is the difference in FEF25-75 value measured before and after inhalation of a short acting beta agonist. Aims and objectives: To determine if ΔFEF 25-75 can be used as a surrogate marker of FeNO to assess mild intermittent asthma in patients with clinical asthma phenotype but with normal spirometry. Methods: A cross sectional study performed on 100 consecutive patients with normal spirometry (according to the GINA guidelines) but with a clinical phenotype of asthma in the outpatient department of a tertiary care hospital. A clinical phenotype of Asthma was defined as patients raising clinical suspicion of asthma and with history of intermittentrespiratory symptoms ie. wheeze, shortness of breath, chest tightness and cough. FeNO was performed on these patients using an electrochemical nitric oxide analyser (NIOX MINO;Aerocrine;Sweden) and the data was recorded and submitted for multivariate analysis. Results: Of the 100 patients 68% were males and 32%were female.The mean age of the patients was 34.97 years. 38% were smokers. The mean FeNO level was 35.99.A linear correlation was observed between FeNO and ΔFEF 25-75 (p-value- 0.0078) implying that ΔFEF 25-75 can be used as a surrogate marker for FeNO. Conclusion: This study suggests that a simple spirometry providing a ΔFEF 25-75 value can be used with a certain degree of confidence instead of an expensive and less available FeNO to evaluate mild intermittent asthma. This makes the diagnosis and management of mild intermittent asthma cost effective.

Archives of pulmonology and respiratory care, Apr 20, 2021

There is limited data for overlap between Obstructive Sleep Apnea (OSA) and obstructive airway di... more There is limited data for overlap between Obstructive Sleep Apnea (OSA) and obstructive airway disease (OAD) in Indian population. In obese patients, the reduction of VC can potentially increase the FEV1/FVC ratio leading to underestimation of airflow obstruction. Methods: Patients with moderate and severe OSA (AHI>15) using CPAP for at least 6 months were included in the study. Patients with post-bronchodilator FEV1/VC ratio 30kg/m2 and/or CAT score >10 were treated for 6 weeks with either ICS AND LABA (for asthma) or LABA/LAMA (for COPD) depending on smoking history. These patients were subjected to spirometry, COPD Assessment Test (CAT), Pittsburgh Sleep Quality Index (PSQI), and 6MWD at baseline and post-treatment. Comparative data was submitted for analysis. Results: 80 patients (57 males) with OSA were screened. 27% of these patients (n=22) had co-existing airflow limitation. In this group, 12 had a FEV1/VC ratio 10 and/or BMI >30kg/m2. 7 patients were treated as Asthma and 15 were treated as COPD. High Baseline scores suggested a symptomatic population. After 6 weeks of treatment, there was a statistically significant improvement in CAT (p-0.0008), PSQI (p-0.014), ESS (p-0.0003) and 6MWD(p-5.21E-09) but not in FEV1. Conclusion: In our population, 15% patients had overlap (FEV1/FVC 70) with another 12% with FEV1/VC ratio 30kg/m2 and CAT score >10. All patients experienced clinical improvement with appropriate treatment. This open-label study demonstrates that treating underlying Airflow Obstruction improves OSA control.

Introduction: COPD‘Care bundles’ have been proposed as an effective approach to improve the quali... more Introduction: COPD‘Care bundles’ have been proposed as an effective approach to improve the quality of patient care. The components of the bundle were chosen after an elaborate literature search of non-invasive interventions which reduced COPD exacerbation rates. Aims & Objectives: To demonstrate that exacerbation rates in COPD patients administered the COPD care bundle is lower than the exacerbations rates in COPD patients given standard care. Methods: It is a Prospective randomized control trial for a duration of 1 year. 40 patients with Moderate/severe COPD with history of atleast 1 exacerbation in the past year were randomized 1:1 to receive the COPD bundle or regular care. The components of the bundle included pulmonary rehab regimen, daily oral statin ( Simvastatin 20 mg), daily Oral Low Dose Bisoprolol 2.5 mg, Vaccination- (Pneumococcal and Influenza Vaccine), Limited Sleep Study, once weekly Vitamin D3(60,000IU). All the cases and controls were assessed monthly using the same tools. The primary outcome was the rate of all COPD exacerbations. Results: After 1 year the outcomes were analysed for statistical significance. Exacerbations in study group (30%) was lower than the control group (45.00%)(P- 0.02572; OR 1.87808). Hospitalizations in the study group (15%) was lower than the control group (20%) but not statistically significant. Statistically Significant improvements in Fev1, Fvc, 6MWD and Mean CAT scores were seen in the study group. Conclusions: Our study shows there is indeed a benefit of administering the bundle in COPD patients in terms of lung function, symptom improvement, exercise tolerance and excerbations. Hence the concept of a care bundle should be explored.

Background and Aim of Study: Aspergillus spp are ubiquitous fungi causing pulmonary diseases depe... more Background and Aim of Study: Aspergillus spp are ubiquitous fungi causing pulmonary diseases depending on the immune status. We looked at patients with refractory wheeze, who grew Aspergillus spp in their Bronchoalveolar Lavage (BAL) and responded to antifungal therapy. We aimed to establish an association between Aspergillus and refractory wheeze, while highlighting the relevance of BAL and initiating Voriconazole therapy. Methods: The period of study was 1 year. All the patients with refractory bronchospasm not responding to asthma therapy had HRCT done,followed by bronchoscopy where indicated. Patients who grew Aspergillus spp were treated with voriconazole. Post-discharge spirometry and clinical evaluation were performed during follow up. Results: 27 of the BAL samples for fungal culture showed growth of Aspergillus sp ( 92.5% grew Aspergillus fumigatus). Average time to positivity was 3.9 days. 23 of the patients were inpatients (5 in ICU9s) and 4 outpatients. Male:Females 15 : 12. Mean age of the patients was 62 ± 7 years. 48% had diabetes mellitus, 33.3% had underlying heart disease, 22% had a history of pulmonary tuberculosis. 74% had HRCT changes of new infection. 81% patients responded well to the treatment, as assessed by post discharge spirometry, clinical evaluation and quality of life. The overall mortality was 19%. Conclusions: A high index of suspicion is needed for Aspergillus infections in patients with refractory bronchospasm. Bronchoscopy with BAL should be performed where indicated with prompt Voriconazole therapy. A bigger prospective study would be needed to clarify whether this is a clinical variant of pulmonary aspergillosis, which has not been described previously.

Sleep and control of breathing, 2019

Respiratory infections, 2018

Introduction: The incidence of Aspergillus lung infections is increasing in patients with structu... more Introduction: The incidence of Aspergillus lung infections is increasing in patients with structural lung disease & immune-suppressive conditions for the last few decades. Favourable environmental factors such as temperature and humidity exhibit an influence on the atmospheric concentration of aerosolized fungal spores. Material & Method: Patients with a diagnosis of lower respiratory tract infection growing Aspergillus in their respiratory samples were recruited from the inpatient and the outpatient department of a tertiary care hospital in the study over a period of two years. Results were retrospectively analyzed to find out if any correlation existed between the monsoon season & surge of Aspergillus lung infections. Results: Of the 31 patients recruited in the study, 16 patients had structural lung disease with a majority suffering from bullous lung disease. A higher incidence was observed in patients with multiple comorbidities. Most patients got admitted (n=22) and the predominant symptom was severe refractory cough (n=16). 20% patients had a co-existing bacterial infection. 10 out of 17 patients in 2016 and similarly 10 out of 14 patients in 2017 had positive aspergillus growths during the months of June to August implying that almost 74% patients recruited in the study had aspergillus growths in the monsoon season. Conclusion: Our study suggests that there is a definite surge of Aspergillus lung infections especially in patients with pre-existing lung diseases and multiple comorbidities during the monsoon season. Our study aims at increasing awareness in physicians about pulmonary Aspergillus infections especially in the monsoon season, although a larger study is however warranted to validate the findings.

Monitoring Airway Disease, 2018

The legality principle is an important principle in the enforcement of penal law in addition to t... more The legality principle is an important principle in the enforcement of penal law in addition to the culpability principle. These two principles are a requirement that must be fulfilled by the person to be penalized. However, law enforcement officers in the Criminal Justice System often only pay attention to the formulation of the legality principle in Article 1 (1) of the Criminal Code (KUHP) than the other principle that is culpability principle. So that court decisions often do not reflect a sense of justice. This is due to the interpretation of the legality principle contained in Article 1 paragraph (1) of the Criminal Code (KUHP) as "lex scripta", "lex stricta" and "lex certa" and also the unformulated culpability principle in the Criminal Code (KUHP). Therefore, it is necessary to reconstruct the meaning of the legality principle so that it is not only understood formally, but materially by regarding the living law referred to Pancasila as a ground norm and constitution of the UUD 1945, the legality principle is not interpreted as a certainty of law but interpreted as the principle of legal certainty. The law is not only interpreted as a written law, but also an unwritten law, so it is expected to bring about a court decision in accordance with the sense of justice. In law enforcement "in abstracto" implemented through formulation policy by penal reform in the formulation of a New Criminal Code (New KUHP), the principle of legality has been interpreted in material term that states that the source of law used by the Criminal Code is written law (Article 1) and unwritten law/ the living law (Article 2), also the culpability principle has been formulated explicitly (Article 38). Based "in abstracto" law enforcement is expected to be implemented "in inconcreto" law enforcement so as to realize court decision in accordance with the sense of community justice.

European Respiratory Journal, 2015

Background and Aim of Study: Aspergillus spp are ubiquitous fungi causing pulmonary diseases depe... more Background and Aim of Study: Aspergillus spp are ubiquitous fungi causing pulmonary diseases depending on the immune status. We looked at patients with refractory wheeze, who grew Aspergillus spp in their Bronchoalveolar Lavage (BAL) and responded to antifungal therapy. We aimed to establish an association between Aspergillus and refractory wheeze, while highlighting the relevance of BAL and initiating Voriconazole therapy. Methods: The period of study was 1 year. All the patients with refractory bronchospasm not responding to asthma therapy had HRCT done,followed by bronchoscopy where indicated. Patients who grew Aspergillus spp were treated with voriconazole. Post-discharge spirometry and clinical evaluation were performed during follow up. Results: 27 of the BAL samples for fungal culture showed growth of Aspergillus sp ( 92.5% grew Aspergillus fumigatus). Average time to positivity was 3.9 days. 23 of the patients were inpatients (5 in ICU9s) and 4 outpatients. Male:Females 15 : 12. Mean age of the patients was 62 ± 7 years. 48% had diabetes mellitus, 33.3% had underlying heart disease, 22% had a history of pulmonary tuberculosis. 74% had HRCT changes of new infection. 81% patients responded well to the treatment, as assessed by post discharge spirometry, clinical evaluation and quality of life. The overall mortality was 19%. Conclusions: A high index of suspicion is needed for Aspergillus infections in patients with refractory bronchospasm. Bronchoscopy with BAL should be performed where indicated with prompt Voriconazole therapy. A bigger prospective study would be needed to clarify whether this is a clinical variant of pulmonary aspergillosis, which has not been described previously.

Archives of Pulmonology and Respiratory Care, 2021

European Respiratory Journal, 2016

Introduction: Fraction of exhaled nitric oxide (FeNO) is a quantitative, non-invasive, simple but... more Introduction: Fraction of exhaled nitric oxide (FeNO) is a quantitative, non-invasive, simple but expensive method of assessing airways inflammation.ΔFEF 25-75 is the difference in FEF25-75 value measured before and after inhalation of a short acting beta agonist. Aims and objectives: To determine if ΔFEF 25-75 can be used as a surrogate marker of FeNO to assess mild intermittent asthma in patients with clinical asthma phenotype but with normal spirometry. Methods: A cross sectional study performed on 100 consecutive patients with normal spirometry (according to the GINA guidelines) but with a clinical phenotype of asthma in the outpatient department of a tertiary care hospital. A clinical phenotype of Asthma was defined as patients raising clinical suspicion of asthma and with history of intermittentrespiratory symptoms ie. wheeze, shortness of breath, chest tightness and cough. FeNO was performed on these patients using an electrochemical nitric oxide analyser (NIOX MINO;Aerocrine;Sweden) and the data was recorded and submitted for multivariate analysis. Results: Of the 100 patients 68% were males and 32%were female.The mean age of the patients was 34.97 years. 38% were smokers. The mean FeNO level was 35.99.A linear correlation was observed between FeNO and ΔFEF 25-75 (p-value- 0.0078) implying that ΔFEF 25-75 can be used as a surrogate marker for FeNO. Conclusion: This study suggests that a simple spirometry providing a ΔFEF 25-75 value can be used with a certain degree of confidence instead of an expensive and less available FeNO to evaluate mild intermittent asthma. This makes the diagnosis and management of mild intermittent asthma cost effective.

Introduction: COPD‘Care bundles’ have been proposed as an effective approach to improve the quali... more Introduction: COPD‘Care bundles’ have been proposed as an effective approach to improve the quality of patient care. The components of the bundle were chosen after an elaborate literature search of non-invasive interventions which reduced COPD exacerbation rates. Aims & Objectives: To demonstrate that exacerbation rates in COPD patients administered the COPD care bundle is lower than the exacerbations rates in COPD patients given standard care. Methods: It is a Prospective randomized control trial for a duration of 1 year. 40 patients with Moderate/severe COPD with history of atleast 1 exacerbation in the past year were randomized 1:1 to receive the COPD bundle or regular care. The components of the bundle included pulmonary rehab regimen, daily oral statin ( Simvastatin 20 mg), daily Oral Low Dose Bisoprolol 2.5 mg, Vaccination- (Pneumococcal and Influenza Vaccine), Limited Sleep Study, once weekly Vitamin D3(60,000IU). All the cases and controls were assessed monthly using the same tools. The primary outcome was the rate of all COPD exacerbations. Results: After 1 year the outcomes were analysed for statistical significance. Exacerbations in study group (30%) was lower than the control group (45.00%)(P- 0.02572; OR 1.87808). Hospitalizations in the study group (15%) was lower than the control group (20%) but not statistically significant. Statistically Significant improvements in Fev1, Fvc, 6MWD and Mean CAT scores were seen in the study group. Conclusions: Our study shows there is indeed a benefit of administering the bundle in COPD patients in terms of lung function, symptom improvement, exercise tolerance and excerbations. Hence the concept of a care bundle should be explored.

European Respiratory Journal, 2020

European Respiratory Journal, 2020

Sleep and control of breathing

There is limited data for overlap between Obstructive Sleep Apnea (OSA) and obstructive airway di... more There is limited data for overlap between Obstructive Sleep Apnea (OSA) and obstructive airway disease (OAD) in Indian population. In obese patients, the reduction of VC can potentially increase the FEV1/FVC ratio leading to underestimation of airflow obstruction. Methods: Patients with moderate and severe OSA (AHI>15) using CPAP for at least 6 months were included in the study. Patients with post-bronchodilator FEV1/VC ratio 30kg/m2 and/or CAT score >10 were treated for 6 weeks with either ICS AND LABA (for asthma) or LABA/LAMA (for COPD) depending on smoking history. These patients were subjected to spirometry, COPD Assessment Test (CAT), Pittsburgh Sleep Quality Index (PSQI), and 6MWD at baseline and post-treatment. Comparative data was submitted for analysis. Results: 80 patients (57 males) with OSA were screened. 27% of these patients (n=22) had co-existing airflow limitation. In this group, 12 had a FEV1/VC ratio 10 and/or BMI >30kg/m2. 7 patients were treated as Asth...

Introduction: Fraction of exhaled nitric oxide (FeNO) is a quantitative, non-invasive, simple but... more Introduction: Fraction of exhaled nitric oxide (FeNO) is a quantitative, non-invasive, simple but expensive method of assessing airways inflammation.ΔFEF 25-75 is the difference in FEF25-75 value measured before and after inhalation of a short acting beta agonist. Aims and objectives: To determine if ΔFEF 25-75 can be used as a surrogate marker of FeNO to assess mild intermittent asthma in patients with clinical asthma phenotype but with normal spirometry. Methods: A cross sectional study performed on 100 consecutive patients with normal spirometry (according to the GINA guidelines) but with a clinical phenotype of asthma in the outpatient department of a tertiary care hospital. A clinical phenotype of Asthma was defined as patients raising clinical suspicion of asthma and with history of intermittentrespiratory symptoms ie. wheeze, shortness of breath, chest tightness and cough. FeNO was performed on these patients using an electrochemical nitric oxide analyser (NIOX MINO;Aerocrine;Sweden) and the data was recorded and submitted for multivariate analysis. Results: Of the 100 patients 68% were males and 32%were female.The mean age of the patients was 34.97 years. 38% were smokers. The mean FeNO level was 35.99.A linear correlation was observed between FeNO and ΔFEF 25-75 (p-value- 0.0078) implying that ΔFEF 25-75 can be used as a surrogate marker for FeNO. Conclusion: This study suggests that a simple spirometry providing a ΔFEF 25-75 value can be used with a certain degree of confidence instead of an expensive and less available FeNO to evaluate mild intermittent asthma. This makes the diagnosis and management of mild intermittent asthma cost effective.

Archives of pulmonology and respiratory care, Apr 20, 2021

There is limited data for overlap between Obstructive Sleep Apnea (OSA) and obstructive airway di... more There is limited data for overlap between Obstructive Sleep Apnea (OSA) and obstructive airway disease (OAD) in Indian population. In obese patients, the reduction of VC can potentially increase the FEV1/FVC ratio leading to underestimation of airflow obstruction. Methods: Patients with moderate and severe OSA (AHI>15) using CPAP for at least 6 months were included in the study. Patients with post-bronchodilator FEV1/VC ratio 30kg/m2 and/or CAT score >10 were treated for 6 weeks with either ICS AND LABA (for asthma) or LABA/LAMA (for COPD) depending on smoking history. These patients were subjected to spirometry, COPD Assessment Test (CAT), Pittsburgh Sleep Quality Index (PSQI), and 6MWD at baseline and post-treatment. Comparative data was submitted for analysis. Results: 80 patients (57 males) with OSA were screened. 27% of these patients (n=22) had co-existing airflow limitation. In this group, 12 had a FEV1/VC ratio 10 and/or BMI >30kg/m2. 7 patients were treated as Asthma and 15 were treated as COPD. High Baseline scores suggested a symptomatic population. After 6 weeks of treatment, there was a statistically significant improvement in CAT (p-0.0008), PSQI (p-0.014), ESS (p-0.0003) and 6MWD(p-5.21E-09) but not in FEV1. Conclusion: In our population, 15% patients had overlap (FEV1/FVC 70) with another 12% with FEV1/VC ratio 30kg/m2 and CAT score >10. All patients experienced clinical improvement with appropriate treatment. This open-label study demonstrates that treating underlying Airflow Obstruction improves OSA control.

Introduction: COPD‘Care bundles’ have been proposed as an effective approach to improve the quali... more Introduction: COPD‘Care bundles’ have been proposed as an effective approach to improve the quality of patient care. The components of the bundle were chosen after an elaborate literature search of non-invasive interventions which reduced COPD exacerbation rates. Aims & Objectives: To demonstrate that exacerbation rates in COPD patients administered the COPD care bundle is lower than the exacerbations rates in COPD patients given standard care. Methods: It is a Prospective randomized control trial for a duration of 1 year. 40 patients with Moderate/severe COPD with history of atleast 1 exacerbation in the past year were randomized 1:1 to receive the COPD bundle or regular care. The components of the bundle included pulmonary rehab regimen, daily oral statin ( Simvastatin 20 mg), daily Oral Low Dose Bisoprolol 2.5 mg, Vaccination- (Pneumococcal and Influenza Vaccine), Limited Sleep Study, once weekly Vitamin D3(60,000IU). All the cases and controls were assessed monthly using the same tools. The primary outcome was the rate of all COPD exacerbations. Results: After 1 year the outcomes were analysed for statistical significance. Exacerbations in study group (30%) was lower than the control group (45.00%)(P- 0.02572; OR 1.87808). Hospitalizations in the study group (15%) was lower than the control group (20%) but not statistically significant. Statistically Significant improvements in Fev1, Fvc, 6MWD and Mean CAT scores were seen in the study group. Conclusions: Our study shows there is indeed a benefit of administering the bundle in COPD patients in terms of lung function, symptom improvement, exercise tolerance and excerbations. Hence the concept of a care bundle should be explored.

Background and Aim of Study: Aspergillus spp are ubiquitous fungi causing pulmonary diseases depe... more Background and Aim of Study: Aspergillus spp are ubiquitous fungi causing pulmonary diseases depending on the immune status. We looked at patients with refractory wheeze, who grew Aspergillus spp in their Bronchoalveolar Lavage (BAL) and responded to antifungal therapy. We aimed to establish an association between Aspergillus and refractory wheeze, while highlighting the relevance of BAL and initiating Voriconazole therapy. Methods: The period of study was 1 year. All the patients with refractory bronchospasm not responding to asthma therapy had HRCT done,followed by bronchoscopy where indicated. Patients who grew Aspergillus spp were treated with voriconazole. Post-discharge spirometry and clinical evaluation were performed during follow up. Results: 27 of the BAL samples for fungal culture showed growth of Aspergillus sp ( 92.5% grew Aspergillus fumigatus). Average time to positivity was 3.9 days. 23 of the patients were inpatients (5 in ICU9s) and 4 outpatients. Male:Females 15 : 12. Mean age of the patients was 62 ± 7 years. 48% had diabetes mellitus, 33.3% had underlying heart disease, 22% had a history of pulmonary tuberculosis. 74% had HRCT changes of new infection. 81% patients responded well to the treatment, as assessed by post discharge spirometry, clinical evaluation and quality of life. The overall mortality was 19%. Conclusions: A high index of suspicion is needed for Aspergillus infections in patients with refractory bronchospasm. Bronchoscopy with BAL should be performed where indicated with prompt Voriconazole therapy. A bigger prospective study would be needed to clarify whether this is a clinical variant of pulmonary aspergillosis, which has not been described previously.

Sleep and control of breathing, 2019

Respiratory infections, 2018

Introduction: The incidence of Aspergillus lung infections is increasing in patients with structu... more Introduction: The incidence of Aspergillus lung infections is increasing in patients with structural lung disease & immune-suppressive conditions for the last few decades. Favourable environmental factors such as temperature and humidity exhibit an influence on the atmospheric concentration of aerosolized fungal spores. Material & Method: Patients with a diagnosis of lower respiratory tract infection growing Aspergillus in their respiratory samples were recruited from the inpatient and the outpatient department of a tertiary care hospital in the study over a period of two years. Results were retrospectively analyzed to find out if any correlation existed between the monsoon season & surge of Aspergillus lung infections. Results: Of the 31 patients recruited in the study, 16 patients had structural lung disease with a majority suffering from bullous lung disease. A higher incidence was observed in patients with multiple comorbidities. Most patients got admitted (n=22) and the predominant symptom was severe refractory cough (n=16). 20% patients had a co-existing bacterial infection. 10 out of 17 patients in 2016 and similarly 10 out of 14 patients in 2017 had positive aspergillus growths during the months of June to August implying that almost 74% patients recruited in the study had aspergillus growths in the monsoon season. Conclusion: Our study suggests that there is a definite surge of Aspergillus lung infections especially in patients with pre-existing lung diseases and multiple comorbidities during the monsoon season. Our study aims at increasing awareness in physicians about pulmonary Aspergillus infections especially in the monsoon season, although a larger study is however warranted to validate the findings.

Monitoring Airway Disease, 2018

The legality principle is an important principle in the enforcement of penal law in addition to t... more The legality principle is an important principle in the enforcement of penal law in addition to the culpability principle. These two principles are a requirement that must be fulfilled by the person to be penalized. However, law enforcement officers in the Criminal Justice System often only pay attention to the formulation of the legality principle in Article 1 (1) of the Criminal Code (KUHP) than the other principle that is culpability principle. So that court decisions often do not reflect a sense of justice. This is due to the interpretation of the legality principle contained in Article 1 paragraph (1) of the Criminal Code (KUHP) as "lex scripta", "lex stricta" and "lex certa" and also the unformulated culpability principle in the Criminal Code (KUHP). Therefore, it is necessary to reconstruct the meaning of the legality principle so that it is not only understood formally, but materially by regarding the living law referred to Pancasila as a ground norm and constitution of the UUD 1945, the legality principle is not interpreted as a certainty of law but interpreted as the principle of legal certainty. The law is not only interpreted as a written law, but also an unwritten law, so it is expected to bring about a court decision in accordance with the sense of justice. In law enforcement "in abstracto" implemented through formulation policy by penal reform in the formulation of a New Criminal Code (New KUHP), the principle of legality has been interpreted in material term that states that the source of law used by the Criminal Code is written law (Article 1) and unwritten law/ the living law (Article 2), also the culpability principle has been formulated explicitly (Article 38). Based "in abstracto" law enforcement is expected to be implemented "in inconcreto" law enforcement so as to realize court decision in accordance with the sense of community justice.

European Respiratory Journal, 2015

Background and Aim of Study: Aspergillus spp are ubiquitous fungi causing pulmonary diseases depe... more Background and Aim of Study: Aspergillus spp are ubiquitous fungi causing pulmonary diseases depending on the immune status. We looked at patients with refractory wheeze, who grew Aspergillus spp in their Bronchoalveolar Lavage (BAL) and responded to antifungal therapy. We aimed to establish an association between Aspergillus and refractory wheeze, while highlighting the relevance of BAL and initiating Voriconazole therapy. Methods: The period of study was 1 year. All the patients with refractory bronchospasm not responding to asthma therapy had HRCT done,followed by bronchoscopy where indicated. Patients who grew Aspergillus spp were treated with voriconazole. Post-discharge spirometry and clinical evaluation were performed during follow up. Results: 27 of the BAL samples for fungal culture showed growth of Aspergillus sp ( 92.5% grew Aspergillus fumigatus). Average time to positivity was 3.9 days. 23 of the patients were inpatients (5 in ICU9s) and 4 outpatients. Male:Females 15 : 12. Mean age of the patients was 62 ± 7 years. 48% had diabetes mellitus, 33.3% had underlying heart disease, 22% had a history of pulmonary tuberculosis. 74% had HRCT changes of new infection. 81% patients responded well to the treatment, as assessed by post discharge spirometry, clinical evaluation and quality of life. The overall mortality was 19%. Conclusions: A high index of suspicion is needed for Aspergillus infections in patients with refractory bronchospasm. Bronchoscopy with BAL should be performed where indicated with prompt Voriconazole therapy. A bigger prospective study would be needed to clarify whether this is a clinical variant of pulmonary aspergillosis, which has not been described previously.

Archives of Pulmonology and Respiratory Care, 2021

European Respiratory Journal, 2016

Introduction: Fraction of exhaled nitric oxide (FeNO) is a quantitative, non-invasive, simple but... more Introduction: Fraction of exhaled nitric oxide (FeNO) is a quantitative, non-invasive, simple but expensive method of assessing airways inflammation.ΔFEF 25-75 is the difference in FEF25-75 value measured before and after inhalation of a short acting beta agonist. Aims and objectives: To determine if ΔFEF 25-75 can be used as a surrogate marker of FeNO to assess mild intermittent asthma in patients with clinical asthma phenotype but with normal spirometry. Methods: A cross sectional study performed on 100 consecutive patients with normal spirometry (according to the GINA guidelines) but with a clinical phenotype of asthma in the outpatient department of a tertiary care hospital. A clinical phenotype of Asthma was defined as patients raising clinical suspicion of asthma and with history of intermittentrespiratory symptoms ie. wheeze, shortness of breath, chest tightness and cough. FeNO was performed on these patients using an electrochemical nitric oxide analyser (NIOX MINO;Aerocrine;Sweden) and the data was recorded and submitted for multivariate analysis. Results: Of the 100 patients 68% were males and 32%were female.The mean age of the patients was 34.97 years. 38% were smokers. The mean FeNO level was 35.99.A linear correlation was observed between FeNO and ΔFEF 25-75 (p-value- 0.0078) implying that ΔFEF 25-75 can be used as a surrogate marker for FeNO. Conclusion: This study suggests that a simple spirometry providing a ΔFEF 25-75 value can be used with a certain degree of confidence instead of an expensive and less available FeNO to evaluate mild intermittent asthma. This makes the diagnosis and management of mild intermittent asthma cost effective.

Introduction: COPD‘Care bundles’ have been proposed as an effective approach to improve the quali... more Introduction: COPD‘Care bundles’ have been proposed as an effective approach to improve the quality of patient care. The components of the bundle were chosen after an elaborate literature search of non-invasive interventions which reduced COPD exacerbation rates. Aims & Objectives: To demonstrate that exacerbation rates in COPD patients administered the COPD care bundle is lower than the exacerbations rates in COPD patients given standard care. Methods: It is a Prospective randomized control trial for a duration of 1 year. 40 patients with Moderate/severe COPD with history of atleast 1 exacerbation in the past year were randomized 1:1 to receive the COPD bundle or regular care. The components of the bundle included pulmonary rehab regimen, daily oral statin ( Simvastatin 20 mg), daily Oral Low Dose Bisoprolol 2.5 mg, Vaccination- (Pneumococcal and Influenza Vaccine), Limited Sleep Study, once weekly Vitamin D3(60,000IU). All the cases and controls were assessed monthly using the same tools. The primary outcome was the rate of all COPD exacerbations. Results: After 1 year the outcomes were analysed for statistical significance. Exacerbations in study group (30%) was lower than the control group (45.00%)(P- 0.02572; OR 1.87808). Hospitalizations in the study group (15%) was lower than the control group (20%) but not statistically significant. Statistically Significant improvements in Fev1, Fvc, 6MWD and Mean CAT scores were seen in the study group. Conclusions: Our study shows there is indeed a benefit of administering the bundle in COPD patients in terms of lung function, symptom improvement, exercise tolerance and excerbations. Hence the concept of a care bundle should be explored.

European Respiratory Journal, 2020

European Respiratory Journal, 2020

Sleep and control of breathing

There is limited data for overlap between Obstructive Sleep Apnea (OSA) and obstructive airway di... more There is limited data for overlap between Obstructive Sleep Apnea (OSA) and obstructive airway disease (OAD) in Indian population. In obese patients, the reduction of VC can potentially increase the FEV1/FVC ratio leading to underestimation of airflow obstruction. Methods: Patients with moderate and severe OSA (AHI>15) using CPAP for at least 6 months were included in the study. Patients with post-bronchodilator FEV1/VC ratio 30kg/m2 and/or CAT score >10 were treated for 6 weeks with either ICS AND LABA (for asthma) or LABA/LAMA (for COPD) depending on smoking history. These patients were subjected to spirometry, COPD Assessment Test (CAT), Pittsburgh Sleep Quality Index (PSQI), and 6MWD at baseline and post-treatment. Comparative data was submitted for analysis. Results: 80 patients (57 males) with OSA were screened. 27% of these patients (n=22) had co-existing airflow limitation. In this group, 12 had a FEV1/VC ratio 10 and/or BMI >30kg/m2. 7 patients were treated as Asth...