The key to successful elimination of tuberculosis (TB) is treatment of cases with optimum chemotherapy. Poor chemotherapy over time has led to drug-resistant disease. Drug resistance of Mycobacterium tuberculosis develops by the selective growth of resistant mutants. The incidence of drug-resistant cases depends on the number of bacilli and the drug-resistant mutants in the lesion. The latter is low for individual drugs and even lower for two and three drugs. Therefore, use of combination chemotherapy with three or more drugs results in cure. However, irregular treatment, inadequate drugs, inadequate drug doses or addition of a single drug to a failing regimen allows selective growth of resistant mutants and acquired drug-resistant TB. Contacts of these resistant cases develop primary drug resistant TB. Thus, drug resistance in tuberculosis is a "man-made problem". Anti-TB chemotherapy must be given optimally by (i) ensuring adequate absorption of drugs, (ii) timely diagnosis and management of drug toxicities and (iii) treatment adherence. New classes of anti-TB drugs are needed; but are unlikely to become available soon. It is vital that the 21 ^st century physicians understand the basic principles of TB chemotherapy to ensure efficient use of available drugs to postpone or even reverse epidemics drug-resistant TB.

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Background: Idiopatiic pulmonary fibrosis (IPF) is a disease of dysregulated fibrogenesis with abnormal matrix metalloproteinase (MMPs) activity, angiogenesis, and profibrotic milieu wherein MMPs inhibition appears to be target-based therapy. We evaluated the role of doxycycline as a nonspecific inhibitor of MMPs in IPF patients. Materials and Methods: Patients of IPF diagnosed on the basis of ATS-ERS consensus criteria were put on oral doxycycline in an open prospective trial. They were followed up for long term with spirometry, 6 min walk test (6MWT), St. Georges respiratory questionnaire (SGRQ), forced vital capacity (FVC), and repeat bronchoscopy while on doxycycline monotherapy for over 24 weeks. Both the initial and follow-up broncho alveolar lavage fluids (BALF) from IPF patients (n = 6) and control subjects (n = 6) were looked for MMP-9, -3, tissue inhibitor of metalloproteinase (TIMP)-1 and vascular endothelial growth factor (VEGF) expression. Additionally, doxycycline's action on MMP activities in vitro was tested in BALF of IPF patients. Results: Doxycycline intervention showed significant improvement in IPF patients in terms of change in 6MWT, SGRQ, FVC, and quality of life. The level of MMP-9, -3, TIMP-1 and VEGF in the BALF were found significantly higher in the IPF patients compared to the controls while doxycycline therapy reduced those parameters nearer to control value. Doxycycline also showed a significant dose-dependent reduction in the in vitro MMPs activities in BALF. Conclusion: Doxycycline shows significant prospect in the treatment of IPF through its anti MMPs activities. This is the first report on a case series of long-term doxycycline monotherapy in IPF patients.

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Background: The present evaluation study has been conducted with the following objectives: (i) To assess the treatment outcomes of revised national tuberculosis control program (RNTCP) in five microscopic centers of Kangra district under five tuberculosis units and (ii) To identify gaps and underlying contributing factors. Based upon the findings of (i) and (ii) we suggest appropriate measures to narrow down the existing gaps. Materials and Methods: We identified and interviewed health personnel involved, reviewed the documents and records pertaining to evaluation plan/guidelines, training records and reports generated by five tuberculosis units. We assessed the inputs, processes and outputs of the program across five tuberculosis units. We calculated the proportion of staff of various categories trained and internal quality control (case detection); availability of drugs, directly observed treatment short course (DOTS) providers, and supervision (case management) and information, education and communication (IEC), and funds distribution. (logic model). Result: Around 60%-88% of staffs of various categories trained with overall 25% gap of supervisory visits. In tuberculosis unit (TU) Nurpur, the discordant slides while cross-checking were 8% and 25%. The total proportions of sputum positivity are 5.1%; the highest in Kangra, i.e., 2.3% (national norms of 10-15%.). There was no full cross-checking of the positive slides despite internal quality in place. Increased numbers of the extra pulmonary tuberculosis cases (EPTB) are present in all TUs, as high as 61% in TU Dharamshala (Normal range 15%-20%). A gap of 20% DOT center exists-the least in (58%) in TU Nurpur. The awareness level in the TU Dehra is minimum (51%); more so in females and rural set up. Conclusion: RNTCP has successfully achieved all its targets in all the five TUs of Kangra District as per national norms despite several gaps. We recommend (i) filling of vacancies of medics and paramedics with reorientation trainings/refresher courses; (ii) conduction of supportive supervision by the seniors; (iii) investigation of cause of increased number of the extra pulmonary cases, and (iv) need of aggressive IEC activities.

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Background: Cigarette smoking is well correlated with lung diseases such as chronic obstructive pulmonary disease. It is common among men than women in India. In addition, sedentary lifestyle is associated with less efficient pulmonary function. Effectiveness of upper body resistance training (UBRT) in improving pulmonary function is unclear. Keeping all these factors in view, this study aims to examine the effect of UBRT on pulmonary function in male sedentary smokers. Materials and Methods: This study recruited 36 sedentary male smokers, of which 30 were randomized into two groups after fulfilling eligibility criteria-an exercising experimental group (EG) (N=15) or non-exercising control group (CG) (N=15). The EG group were assigned to exercise for 4 weeks, 3 times weekly on non-consecutive days using UBRT program and breathing exercise. In the CG, only breathing exercise was given for 10 min. Both groups were equivalent in baseline characteristics. Results: The improvement in forced expiratory volume in one second (FEV ₁ ) and FEV ₁ /forced vital capacity (FVC) values were seen significant in EG after 4 weeks of UBRT: from 3.62±0.56 to 3.96±0.51 (P=0.000) and 0.88±0.11 to 0.96±0.13 (P<0.001), respectively. But FVC did not show significant change in the EG (P=0.430). There were no significant changes in FEV ₁ , FVC, and FEV ₁ /FVC values in CG after 4 weeks of intervention. On inter-group comparison, significant difference was found between CG and EG for FEV ₁ and FEV ₁ /FVC values. Conclusion: Four weeks of UBRT program brought about significant changes in the pulmonary function in male sedentary smokers.

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Pulmonary Langerhans cell histiocytosis is a rare interstitial lung disease characteristically affecting middle-aged smokers. It has unpredictable clinical course and may be associated with malignant neoplasms. Opportunistic lung infections are frequently considered when patients with Human immunodeficiency virus (HIV) infection present with respiratory symptoms and an abnormal chest X-ray. Though fiberoptic bronchoscopy with bronchoalveolar lavage is diagnostic for infectious etiologies, surgical lung biopsies are preferred to diagnose noninfectious lung diseases and to help guide appropriate therapy. In the present study, we report a case of progressive bilateral lung infiltrates in a smoker with HIV infection which presented a diagnostic dilemma in view of coexistent HIV infection. Analysis of clinical symptomatology aided by surgical lung biopsy helped in diagnosis.

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Blunt diaphragmatic rupture is an uncommon injury and even less common is the bilateral form. This entity poses diagnostic and therapeutic challenges to the treating team. Despite the advances in diagnostic modalities, it remains a difficult diagnosis leading to missed or late presentations with increased risk of morbidity and mortality. We report a case of a 12-year-old girl who sustained a blunt abdominal trauma and found to have left hemidiaphragmatic rupture for which she underwent laparotomy and repair. Postoperatively, persistent elevation of the right hemidaiphragm was noticed, and right-side rupture was suspected and confirmed by collar sign on repeated computed tomography scan. The second repair was done successfully through a right posteriolateral thoracotomy. She improved dramatically and was discharged in an optimal state to be followed in the surgical outpatient department.

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Background: There are various anatomic variations in tracheobronchial system (tracheal bronchus, ectopic bronchus, and accessory bronchus). We aimed to investigate the bronchoscopic findings of the patients with tracheobronchial variations (TBVs) during bronchoscopy and to describe their clinical characteristics. Materials and Methods: A total of 3322 records of bronchoscopic examinations in university hospital and 1560 in chest disease hospital total 4882 were retrospectively analyzed and 198 (134 male, 64 female) patients were diagnosed as TBV. Results: Mean age of patients was 48.5 ΁ 17.8 (range, 15-78) years. Most of the tracheobronchial variations (n = 68, 33.1%) were localized at the right upper lobe bronchus. The most common type of TBVs at this region was right upper lobe with two segments. Symptoms were found in 21 (10.2%) patients with TBVs (7 accessory cardiac bronchus, 5 tracheal bronchus, 5 accessory segmental bronchus in left main bronchus and 4 accessory segmental bronchus in right main bronchus). Their symptoms cough, hemoptysis and recurrent pneumonia with unknown etiologies were thought as related to TBVs. No other potential causes leading these symptoms were found in these patients. Conclusion: According to our best of knowledge our study population is one of the largest series of bronchoscopy for investigate of TBVs. Although TBVs were usually reported as asymptomatic, nearly 10% of our patients with TBVs had symptoms such as recurrent pneumonia, cough and hemoptysis. TBVs should be taken into consideration in symptomatic patients before fiber-optic bronchoscopic examination.

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Background: Reduction of bone mineral density (BMD) is a known and established phenomenon in chronic obstructive pulmonary disease (COPD). However, there have been no data regarding osteoporosis/osteopenia in COPD patients in India. Aim: To look for the degree and frequency of osteoporosis/osteopenia in our OPD patients being diagnosed as COPD. Materials and Methods: Thirty-seven randomly selected patients with COPD were assessed for BMD with commercially available ultrasound bone densitometer (HOLOGIC SAHARA) in a pulmonary OPD. Some cofactors for reduced BMD were also noted. Results: Out of the 37 COPD (all belonging to the GOLD III/IV category) patients studied, the BMD was found to be normal in 10 (27%) patients, while 27 (73%) patients were found to have osteopenia/osteoporosis [19 (51.35%) and 8 (21.62%) patients having osteopenia and osteoporosis, respectively]. Conclusion: Frequency of osteoporosis and osteopenia was found to be very high (73%) in our population of advanced COPD. The data suggest a need for further in-depth study regarding the issue.

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Background: Diabetes mellitus (DM) has been reported to modify the presenting features of pulmonary tuberculosis (PTB), but data regarding the effect of diabetes on the presentation of PTB are highly variable. Objective: To determine whether DM alters the demographic, clinical, and radiological manifestations of tuberculosis and whether the effect of diabetes varies with the age group of PTB patients. Materials and Methods : This prospective observational study was conducted on new smear-positive PTB patients with DM (PTB-DM group) and non-diabetic PTB patients (PTB group). Patients of both groups were again divided into six age groups (15-29, 30-39, 40-49, 50-59, 60-69, and >70 rears) to analyze and compare the impact of age on clinicoradiological presentations of PTB. Results: Patients in the PTB-DM group were significantly older (53.34 ± 14.06 year) in comparison to their nondiabetic counterparts (PTB group) (44.35 ± 18.14 year) (P < 0.001). The former group also had a lower male:female ratio, although the difference was not statistically significant (1.16:1 vs. 2.05:1, P = 0.101). Tuberculin positivity was significantly higher in the PTB group, compared with patients in the PTB-DM group (P < 0.004). The proportion of patients with lower lung field involvement (P = 0.003) and cavitations (P = 0.005) was also higher in the former group compared with the latter. Conclusion: Diabetic patients with tuberculosis were relatively older, had lower tuberculin positivity, and higher proportion of lower lung field involvement and cavitation in comparison to nondiabetic patients.

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Pulmonary sequestration cyst is a rare entity in pediatric patients. Most of the time, it is diagnosed as an incidental finding. It is associated with other congenital anomalies, especially congenital diaphragmatic hernia. We report a patient of cerebral palsy presented with vomiting and recurrent chest infections. He was diagnosed to have hiatal hernia on computed tomography scan of chest. At operation, a pulmonary sequestration cyst along with hiatal hernia, malrotation, and meckel's diverticulum was encountered. The sequestration cyst was managed through transhiatal approach.

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Transfusion-related acute lung injury (TRALI) is a rare but serious complication of blood transfusion. We present a suspected case of TRALI in a 39-year-old female patient who underwent total abdominal hysterectomy under uneventful general anesthesia. The patient developed acute desaturation due to noncardiogenic pulmonary edema while receiving compatible blood transfusion on the second postoperative day. As her symptoms were refractory to supportive treatment, she was mechanically ventilated for 3 days and successfully extubated on the fourth day. By exclusion, a clinical diagnosis of TRALI was made. The treatment for TRALI requires discontinuing transfusion and giving respiratory and cardiovascular support. Most cases show clinical improvement in first few hours and resolve completely within 96 h.

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Desmoplastic mesothelioma (DMM) is a rare and highly lethal subtype of diffuse malignant mesothelioma and is often difficult to distinguish from reactive pleural fibrosis. The term "desmoplastic" refers to the growth of fibrous or connective tissue. We report the clinical, radiological, and pathological features of a primary DMM of the pericardium and a short review of the literature. A 72-year-old man was admitted presenting shortness of breath, cough, and asthenia. Computed tomography scan showed thickenings and effusions both in the pleura and in the pericardium. Histopathological diagnosis was performed by surgical pericardial biopsy and confirmed by autopsy. The patient had a history of asbestos exposure. Primary mesothelioma of the pericardium is a rare tumor occurring in the fourth to seventh decades with nonspecific symptoms and a rapid clinical course. The diagnosis is difficult and often needing a surgical pericardial biopsy. The prognosis is poor although newer antiblastic drugs seem to prolong survival times.

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Rickettsial diseases are common in Srilanka. The spotted fever group of rickettsiae presents in many ways, including very severe disease causing significant morbidity and mortality. A regional variation of the R ickettsia conorii subspecies and differences in clinical presentations are reported. This case describes disseminated Rickettsia conorii infection in a pregnant woman presenting with endocarditis.

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