Background & objectives: The National Tuberculosis (TB) Control Programme has transitioned from thrice-weekly to daily drug treatment regimens in India. This preliminary study was conceived to compare the pharmacokinetics of rifampicin (RMP), isoniazid (INH) and pyrazinamide (PZA) in TB patients being treated with daily and thrice weekly anti-TB treatment (ATT). Methods: This prospective observational study was undertaken in 49 newly diagnosed adult TB patients receiving either daily ATT (n=22) or thrice-weekly ATT (n=27). Plasma RMP, INH and PZA were estimated by high-performance liquid chromatography. Results: The peak concentration (C max ) of RMP was significantly higher (RMP: 8.5 µg/ml vs . 5.5 µg/ml; P =0.003) and C max of INH was significantly lower (INH: 4.8 µg/ml vs . 10.9 µg/ml; P <0.001) in case of daily dosing compared to thrice-weekly ATT. C max of drugs and doses was significantly correlated. A higher proportion of patients had subtherapeutic RMP C max (8.0 µg/ml) during thrice-weekly compared to daily ATT (78% vs . 36%; P =0.004). Multiple linear regression analysis showed that C max of RMP was significantly influenced by the dosing rhythm, pulmonary TB and C max of INH and PZA by the mg/kg doses. Interpretation & conclusions: RMP concentrations were higher and INH concentrations were lower during daily ATT, suggesting that INH doses may need to be increased in case of a daily regimen. Larger studies are, however, required using higher INH doses when monitoring for adverse drug reactions and treatment outcomes.

Background Thoracic air leak syndrome (TALS) is a rare complication associated with chronic lung graft-versus-host disease (GVHD) and bronchiolitis obliterans syndrome (BOS). In the present case, TALS was the sole pulmonary manifestation of GVHD. Case presentation A 30-year-old woman presented with dyspnea on exertion and swelling of the neck and face after allogeneic stem cell transplantation for acute myeloid leukemia. She was found to have subcutaneous emphysema, and chest imaging suggested pneumomediastinum, with normal lung parenchyma. Her clinical and radiological findings indicated TALS. There were no other features suggestive of lung GVHD. Her condition improved with conservative management and increased immunosuppression. However, she subsequently had two relapses, developed severe infection and pneumothorax, and died. Conclusions The present case report illustrates a unique presentation of TALS, a rare complication of GVHD, in a post-stem cell transplant patient. It highlights the challenges in the diagnosis and management of this condition.

Background and Objective: India, a highly heterogeneous country, has no common reference standards for predicting spirometry values, with very few recent studies from south India. This study aimed to create reference equations for rural south Indian adults, based on a population-based survey in Vellore, south India and compare it with other equations from India. Methods: The data from 583 non-smoking, asymptomatic participants (30 years and older) from a spirometry-based survey for airflow obstruction (rural Vellore, 2018), were used to develop equations for FEV1, FEV1/FVC, and FVC. The dataset was divided for development (70%) and validation (30%), by gender. Differences between observed and predicted values were assessed using the new equations and comparisons made with other equations from India. Results: Predictions with Vellore rural equations were closest to the previous south Indian equations from urban Bangalore. However, the Bangalore equations led to overestimation of FVC values in males, and of both FEV1 and FVC values in females. Using the rural Vellore equations also led to a higher percent of males being classified as having airflow obstruction, compared to the Bangalore equations which underestimated airflow obstruction in this rural population. Comparison with previously derived Indian equations from other parts of the country showed pronounced variations. Conclusions: Our study reiterates the need for representative rural and urban studies of adults from various parts of India, to obtain region specific reference equations, given the wide variations in spirometry values in “normal” individuals, due to social heterogeneities of the Indian population and resulting complexities in defining normal.

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Background. Idiopathic pulmonary fibrosis (IPF) is a specific type of chronic fibrosing interstitial lung disease (ILD) that is progressive in course. Although evidence-based guidelines for IPF are available, these are difficult to interpret for the average physician and may not be suitable for use in resource-constrained settings. There was an unmet need to formulate guidelines that are pragmatic, easy to understand and suited for application in resource-limited settings.Methods. This statement was made by a group of expert pulmonologists. Twenty-five questions regarding diagnosis and management of IPF were framed. A literature search was conducted using the PubMed and EmBase databases. The expert group discussed available evidence relevant to each question and recommendations were arrived at by consensus. Results.A thorough clinical and laboratory evaluation should be performed in patients suspected to have ILDs and potential underlying causes should be ruled out. A high resolution computed tomography (HRCT) of the chest is essential to identify the pattern of ILD. The need for a lung biopsy should be decided based on the appearance on the HRCT. Once a diagnosis of IPF is made, anti-fibrotic drugs (pirfenidone or nintedanib) should be offered after discussing the expected benefits and potential adverse effects with the patient. Recommendations have been made on other issues in the management of IPF, such as management of cough and dyspnoea, role of supplemental oxygen, mechanical ventilation and lung transplantation. Conclusion.This consensus statement provides practical and easy-to-use recommendations for the diagnosis and management of IPF in resource-limited settings.