Amit Banga

All Publications

• Alterations in Pulmonary Physiology with Lung Transplantation. Comprehensive Physiology Mohanka, M., Banga, A. 2023; 13 (1): 4269-4293

  Abstract

  Lung transplant is a treatment option for patients with end-stage lung diseases; however, survival outcomes continue to be inferior when compared to other solid organs. We review the several anatomic and physiologic changes that result from lung transplantation surgery, and their role in the pathophysiology of common complications encountered by lung recipients. The loss of bronchial circulation into the allograft after transplant surgery results in ischemia-related changes in the bronchial artery territory of the allograft. We discuss the role of bronchopulmonary anastomosis in blood circulation in the allograft posttransplant. We review commonly encountered complications related to loss of bronchial circulation such as allograft airway ischemia, necrosis, anastomotic dehiscence, mucociliary dysfunction, and bronchial stenosis. Loss of dual circulation to the lung also increases the risk of pulmonary infarction with acute pulmonary embolism. The loss of lymphatic drainage during transplant surgery also impairs the management of allograft interstitial fluid, resulting in pulmonary edema and early pleural effusion. We discuss the role of lymphatic drainage in primary graft dysfunction. Besides, we review the association of late posttransplant pleural effusion with complications such as acute rejection. We then review the impact of loss of afferent and efferent innervation from the allograft on control of breathing, as well as lung protective reflexes. We conclude with discussion about pulmonary function testing, allograft monitoring with spirometry, and classification of chronic lung allograft dysfunction phenotypes based on total lung capacity measurements. We also review factors limiting physical exercise capacity after lung transplantation, especially impairment of muscle metabolism. © 2023 American Physiological Society. Compr Physiol 13:4269-4293, 2023.

  View details for DOI 10.1002/cphy.c220008

  View details for PubMedID 36715279

• Significance of Best Spirometry in the First Year After Bilateral Lung Transplantation: Association With 3-Year Outcomes. Transplantation Mohanka, M. R., Kanade, R., Garcia, H., Mahan, L., Bollineni, S., Mullins, J., Joerns, J., Kaza, V., Torres, F., Zhang, S., Banga, A. 2020; 104 (8): 1712-1719

  Abstract

  Spirometry is the cornerstone of monitoring allograft function after lung transplantation (LT). We sought to determine the association of variables on best spirometry during the first year after bilateral LT with 3-year posttransplant survival.We reviewed charts of patients who survived at least 3 months after bilateral LT (n = 157; age ± SD: 54 ± 13 y, male:female = 91:66). Best spirometry was calculated as the average of 2 highest measurements at least 3 weeks apart during the first year. Airway obstruction was defined as forced expiratory volume in 1-second (FEV1)/forced vital capacity (FVC) ratio <0.7. Survival was compared based on the ventilatory defect and among groups based on the best FEV1 and FVC measurements (>80%, 60%-80%, and <60% predicted). Primary outcome was 3-year survival.Overall, 3-year survival was 67% (n = 106). Obstructive defect was uncommon (7%) and did not have an association with 3-year survival (72% versus 67%, P = 0.7). Although one-half patients achieved an FVC>80% predicted (49%), 1 in 5 (19%) remained below 60% predicted. Irrespective of the type of ventilatory defect, survival worsened as the best FVC (% predicted) got lower (>80: 80.8%; 60-80: 63.3%; <60: 40%; P < 0.001). On multivariate logistic regression analysis, after adjusting for age, gender, transplant indication, and annual bronchoscopy findings, best FVC (% predicted) during the first year after LT was independently associated with 3-year survival.A significant proportion of bilateral LT patients do not achieve FVC>80% predicted. Although the type of ventilatory defect on best spirometry does not predict survival, failure to achieve FVC>80% predicted during the first year was independently associated with 3-year mortality.

  View details for DOI 10.1097/TP.0000000000003046

  View details for PubMedID 32732851

  View details for PubMedCentralID PMC7373484

• Incidence and variables associated with 30-day mortality after lung transplantation. Clinical transplantation Banga, A., Mohanka, M., Mullins, J., Bollineni, S., Kaza, V., Huffman, L., Peltz, M., Bajona, P., Wait, M., Torres, F. 2019; 33 (2): e13468

  Abstract

  With the introduction of the lung allocation score (LAS), sicker patients are prioritized for lung transplantation (LT). There is a lack of data regarding variables independently associated with 30-day mortality after LT.We queried the UNOS database for adult patients undergoing LT between 1989 and 2014. Patients with dual organ or previous transplantation and those with missing survival data were excluded. Mortality during the first 30 days after LT was the primary outcome variable.The yearly trends indicate a statistically significant reduction in the 30-day mortality during the study period (P < 0.001, overall mortality: 5.5%) which has continued in the post-LAS era (P = 0. 014, overall mortality: 3.6%). Among patients with 30-day mortality, "primary non-function" (n = 118, 72.8%) was reported as the most common etiology. Transplant indication of vascular diseases, history of non-transplant cardiac or lung surgery, mean pulmonary pressures >35 mm Hg, disabled functional status, ECMO support, high LAS, ischemic time >6 hours, and blunt injury as the mechanism of donor death are independently associated with 30-day mortality.The incidence of early mortality after LT continues to decline in the post-LAS era. Apart from the mechanism of donor death and ischemic time, early mortality appears to be primarily driven by the recipient characteristics.

  View details for DOI 10.1111/ctr.13468

  View details for PubMedID 30578735

• Characteristics and outcomes among patients with need for early dialysis after lung transplantation surgery. Clinical transplantation Banga, A., Mohanka, M., Mullins, J., Bollineni, S., Kaza, V., Tanriover, B., Torres, F. 2017; 31 (11)

  Abstract

  With the introduction of lung allocation score (LAS), increasingly sicker patients are undergoing lung transplantation (LT). This study was conducted to determine the time trends in need for dialysis after LT, identify variables independently associated with need for dialysis, and evaluate its association with 1- and 5-year mortality.We queried the United Network of Organ Sharing database for adult patients undergoing LT between 1994 and 2014. We excluded patients with simultaneous dual organ transplantation and where data regarding the need for dialysis were not available.Time trends in the yearly incidence of the need for dialysis showed a gradual increase (P = .012). In the post-LAS era, ethnicity, underlying diagnosis, estimated GFR <90 mL/min/1.73 m2 and mean pulmonary pressures>35 mm Hg, ventilator or extracorporeal membrane oxygenation support at LT, and >20% increase in serum creatinine between listing and match were independently associated with the need for dialysis. Patients with need for dialysis had significantly increased hazard of 1-year (n = 13 849; adjusted hazard ratio, 95% CI:7.23, 6.2-8.4, P < .001) and 5-year mortality (n = 7287; adjusted hazard ratio, 95% CI:3.96, 3.43-4.56, P < .001).There is a gradual increase in the incidence of the need for early dialysis after LT, and these patients have significantly worse early and late survival. Several pre-transplant recipient characteristics are independently associated with the need for dialysis.

  View details for DOI 10.1111/ctr.13106

  View details for PubMedID 28871631

• Interaction of pre-transplant recipient characteristics and renal function in lung transplant survival. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation Banga, A., Mohanka, M., Mullins, J., Bollineni, S., Kaza, V., Torres, F., Tanriover, B. 2017

  Abstract

  There has been little investigation into the potential interaction of recipient characteristics with the association of pre-transplant renal functions and survival after lung transplantation. In this study we tested the hypothesis that association of pre-transplant renal function and post-transplant mortality varies among recipient subgroups.We queried the United Network for Organ Sharing (UNOS) database for adult patients (≥18 years of age) undergoing lung transplantation between May 2005 and March 2015. The study population (n = 15,540) was split into 3 groups (90 to 150, 60 to 89.9 and 30 to 59.9 ml/min/1.73 m2) based on the estimated glomerular filtration rate (Chronic Kidney Disease Epidemiology Collaboration equation) at the time of listing. We utilized multivariable inverse probability weighted Cox proportional hazard models to compare the association of glomerular filtration rate (GFR) groups with mortality among recipient subgroups.Overall, there was an independent and graded inverse association between the estimated GFR (eGFR) and mortality, with the hazard of mortality significantly rising with listing eGFR <60 ml/min/1.73 m2. The association between low eGFR and mortality was more consistent and stronger for older (>45 years), non-African-American and non-diabetic patients as well as those with low lung allocation score (LAS <40). Among the diagnosis groups, patients with vascular diseases had the strongest association between low eGFR and poor survival. Sensitivity analyses conducted using an alternate equation to estimate the GFR (Modification of Diet in Renal Disease) supported these associations.Prognostic significance of pre-transplant renal functions varies significantly among recipient subgroups. It may be appropriate to develop a customized approach toward assessing and interpreting renal function to determine transplant candidacy.

  View details for DOI 10.1016/j.healun.2017.08.006

  View details for PubMedID 28947250

• Association of pretransplant kidney function with outcomes after lung transplantation. Clinical transplantation Banga, A., Mohanka, M., Mullins, J., Bollineni, S., Kaza, V., Torres, F., Tanriover, B. 2017; 31 (5)

  Abstract

  There is a lack of data regarding the independent association of pretransplant kidney function with early and late outcomes among lung transplant (LT) recipients.We queried the United Network for Organ Sharing database for adult patients (≥18 years of age) undergoing LT between 1987 and 2013. Glomerular filtration rate (GFR) was estimated using the modification of diet in renal disease (MDRD) and the Chronic kidney disease epidemiology collaboration (CKD-EPI) equations. The study population was split into four groups (>90, 60-90, 45-59.9, and <45 mL/min/1.73 m2 ) based on the estimated GFR at the time of listing.Overall, there was a good correlation between the GFR estimated from the two equations (n=17884, Pearson r=.816, P<.001). There was a consistent and independent association of worse early and late outcomes with declining GFR throughout the spectrum including those above 60 mL/min/1.73 m2 (P<.001 for overall comparisons). Although GFR<45 mL/min/1.73 m2 was associated with worse early and late survival, patients with GFR 45-59.9 mL/min/1.73 m2 do not appear to have survival advantage beyond 3 years post-transplant.There is a good correlation between GFR estimated using MDRD and CKD-EPI equations among patients being considered for LT. Early and late outcomes after LT worsen in a linear fashion with progressively lower pretransplant GFR.

  View details for DOI 10.1111/ctr.12932

  View details for PubMedID 28196295

• Hospital length of stay after lung transplantation: Independent predictors and association with early and late survival. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation Banga, A., Mohanka, M., Mullins, J., Bollineni, S., Kaza, V., Ring, S., Bajona, P., Peltz, M., Wait, M., Torres, F. 2017; 36 (3): 289-296

  Abstract

  Duration of index hospitalization after lung transplantation (LTx) is an important variable that has not received much attention. We sought to determine independent predictors of prolonged hospital length of stay (LOS) and its association with early and late outcomes.The United Network of Organ Sharing database was queried for adult patients undergoing LTx between 2006 and 2014 (N = 14,320). Patients with dual organ or previous transplantation and patients who died during the first 25 days after LTx were excluded (n = 12,647, mean age 55.2 years ± 13.1). Primary outcome was prolonged LOS (>25 days) (3,251/12,647; 25.7%). Donor, recipient, and procedure-related variables were analyzed as potential predictors of prolonged LOS. Association of prolonged LOS with 1-year and 5-year survival was evaluated using Cox proportional hazards analysis.Independent predictors of prolonged LOS included serum albumin, lung allocation score, functional status, and need of extracorporeal membrane oxygenation or ventilator support at the time of transplant; donor age >40 years; gender mismatch (female donor to male recipient); donor body mass index; African American ethnicity; ischemic time >6 hours; and double LTx. Prolonged LOS was independently associated with increased mortality at 1 year (hazard ratio, 3.96; 95% confidence interval, 3.48-4.50; p < 0.001) and 5 years (hazard ratio, 2.00; 95% confidence interval, 1.79-2.25; p < 0.001).A significant proportion of patients have a prolonged LOS after LTx, and several recipient, donor, and procedure-related variables are independent predictors of this outcome. Patients with prolonged LOS after LTx have significantly increased risk of death at 1 year and 5 years.

  View details for DOI 10.1016/j.healun.2016.07.020

  View details for PubMedID 27642060

• Mast cell phenotypes in the allograft after lung transplantation. Clinical transplantation Banga, A., Han, Y., Wang, X., Hsieh, F. H. 2016; 30 (7): 845-51

  Abstract

  The burden of mast cell (MC) infiltration and their phenotypes, MC-tryptase (MCT ) and MC-tryptase/chymase (MCTC ), after lung transplantation (LT) has not been evaluated in human studies.We reviewed 20 transbronchial lung biopsy (TBLB) specimen from patients with early normal allograft (<6 months post-LT, n=5), late normal allograft (>6 months, n=5), A2 or worse acute cellular rejection (ACR, n=5), and chronic lung allograft dysfunction (CLAD, n=5). Slides were immunostained for tryptase and chymase. Total MC, MCT , MCTC and MCTC to-MCT ratio were compared between the four groups using a generalized linear mixed model.Irrespective of clinicopathologic diagnosis, MC burden tends to increase with time (r(2) =.56, P=.009). MCTC phenotype was significantly increased in the CLAD group (8.2±4.9 cells per HPF) in comparison with the other three groups (early normal: 1.6±1.7, P=.0026; late normal: 2.5±2.3, P=.048; ACR: 2.7±3.5, P=.021). Further, the ratio of MCTC to MCT was significantly increased in CLAD group as compared to the other three groups (P<.001 for all comparisons).The burden of MC may increase in the allograft as function of time. Patients with CLAD have an increased relative and absolute burden of MCTC phenotype MC. Future studies are needed to confirm these findings and evaluate the potential pathologic role of MCTC in allograft dysfunction.

  View details for DOI 10.1111/ctr.12758

  View details for PubMedID 27146340

  View details for PubMedCentralID PMC5735837

• Disease Recurrence and Acute Cellular Rejection Episodes During the First Year After Lung Transplantation Among Patients With Sarcoidosis. Transplantation Banga, A., Sahoo, D., Lane, C. R., Farver, C. F., Budev, M. M. 2015; 99 (9): 1940-5

  Abstract

  Sarcoidosis is reported to recur after lung transplantation (LT). We sought to determine the frequency of recurrent disease after LT and predictors of recurrence. We also evaluated the incidence and severity of acute cellular rejection (ACR) episodes among these patients.The database of LT patients at Cleveland Clinic was interrogated for sarcoidosis patients who underwent LT between May 1993 and 2011. Charts were reviewed for demographics, type of transplant, posttransplant biopsy findings, and outcomes.Data were available for 30 patients (mean age, 50 ± 9.3 years; range, 30-65 years; M-to-F ratio, 17:13; single-to-double-to-heart lung ratio, 5:24:1). Recurrence of sarcoidosis was noted among 7 patients (pathological recurrence in all and radiological findings suggesting recurrence in 1 patient) with no impact on overall outcomes. Presence of granulomas on explanted lungs was the only predictor of recurrence (85.7% vs 30.4%, odds ratio, 13.7; 1.4-136.2; P = 0.02).Overall burden of ACR episodes on all bronchoscopies was significantly lower in patients with disease recurrence (7.6 % vs 21.3% of biopsies, P = 0.038). Among patients with recurrent disease, ACR did not develop once disease recurrence had been seen on transbronchial biopsy.A significant proportion of sarcoidosis patients have disease recurrence after LT and presence of active granulomas on explant is associated with subsequent recurrence. There may be an association of recurrence with lower frequency of ACR episodes. There does not appear to be any impact of sarcoidosis recurrence on 1-, 3-, or 5-year survivals.

  View details for DOI 10.1097/TP.0000000000000673

  View details for PubMedID 25757213

• Characteristics and outcomes of patients with lung transplantation requiring admission to the medical ICU. Chest Banga, A., Sahoo, D., Lane, C. R., Mehta, A. C., Akindipe, O., Budev, M. M., Wang, X. F., Sasidhar, M. 2014; 146 (3): 590-599

  Abstract

  There are few data on characteristics and outcomes among patients with lung transplantation (LT) requiring admission to the medical ICU (MICU) beyond the perioperative period.We interrogated the registry database of all admissions to the MICU at Cleveland Clinic (a 53-bed closed unit) to identify patients with history of LT done > 30 days ago (n = 101; mean age, 55.4 ± 12.6 years; 53 men, 48 women). We collected data regarding demographics, history of bronchiolitis obliterans syndrome, preadmission FEV1, clinical and laboratory variables at admission, MICU course, length of stay, hospital survival, and 6-month survival.The most common indication for MICU admission was acute respiratory failure (n = 51, 50.5%). Infections were most frequently responsible for respiratory failure, whereas acute rejection (cellular or humoral) was less likely (16%). Nearly one-fourth of the patients required hemodialysis (24.1%), and more than one-half required invasive mechanical ventilation (53.5%). Despite excellent hospital survival (88 of 101), 6-month survival was modest (56.4%). APACHE (Acute Physiology and Chronic Health Evaluation) III score at admission and single LT were independent predictors of hospital survival but did not predict outcome at 6 months. Functional status at discharge was the only independent predictor of 6-month survival (adjusted OR, 5.1; 95% CI, 1.1-22.7; P = .035).Acute rejection is an infrequent cause of decompensation among patients with LT requiring MICU admission. For patients admitted to the MICU, 6-month survival is modest. Functional status at the time of discharge is an independent predictor of survival at 6 months.

  View details for DOI 10.1378/chest.14-0191

  View details for PubMedID 24832379

• The natural history of lung function after lung transplantation for α(1)-antitrypsin deficiency. American journal of respiratory and critical care medicine Banga, A., Gildea, T., Rajeswaran, J., Rokadia, H., Blackstone, E. H., Stoller, J. K. 2014; 190 (3): 274-81

  Abstract

  Lung transplantation (LT) is an established treatment for end-stage lung diseases, including chronic obstructive pulmonary disease (COPD) associated with α1-antitrypsin deficiency (AATD).We sought to compare the post-transplantation course of patients with AATD and AAT-replete COPD.Between June 1991 and January 2008, a total of 231 patients with AAT-replete COPD and 45 with AATD underwent LT at Cleveland Clinic. Data reviewed included baseline recipient, donor, and surgical data; all spirometry evaluations; acute cellular rejection (ACR) events; and survival data. Endpoints included temporal change in FEV1, severity of ACR, and survival. A longitudinal temporal decomposition model was used for analysis.Comparison of overall rates of FEV1 decline in AATD and AAT-replete patients with COPD showed no significant differences (P > 0.09). However, although the single LT patients had similar trends in FEV1 in both groups, patients with AATD with double LT declined faster (P < 0.002) than the AAT-replete patients. No differences in the frequency or severity of ACR episodes were observed (P = 0.32). Furthermore, there was no difference in early or late mortality between patients with AATD and patients with AAT-replete COPD (P > 0.09).Although overall the post-LT FEV1 slope, severity of ACR, and survival among patients with AATD is similar to that of AAT-replete patients with COPD, patients with AATD with double LT have a faster rate of FEV1 decline. These findings support the eligibility of patients with AATD for LT, and suggest the need for additional studies to better understand the difference between single and double LT in AATD.

  View details for DOI 10.1164/rccm.201401-0031OC

  View details for PubMedID 25003824

• Delayed-Onset Psychosis Secondary to Tacrolimus Neurotoxicity After Lung Transplant: A Case Report and Systematic Review. Journal of the Academy of Consultation-Liaison Psychiatry Gunther, M., Jiang, S., Banga, A., Sher, Y. 2023

  Abstract

  Tacrolimus is the most common immunosuppressant used after transplant, yet it can result in moderate-to-severe neurotoxicity in up to 32% of patients. Signs of neurotoxicity can vary from mild (tremor or headache) to severe (posterior reversible encephalopathy syndrome or psychosis. Prompt recognition and management is needed to lead to symptom resolution.The objective of this study is to describe the clinical presentation of tacrolimus-induced psychosis, a type of tacrolimus-inducted neurotoxicity, and distinguish it from other central nervous system disturbances, including delirium.We present a case of delayed onset tacrolimus-induced psychosis with focus on unique clinical features and management strategies. We conducted a systematic review of cases of tacrolimus-induced psychosis using the PubMed database and included 15 manuscripts in our review.Tacrolimus-induced psychosis is a unique presentation of tacrolimus-related neurotoxicity and can present without the cardinal symptoms of delirium. The data on isolated psychotic symptoms are limited with current literature focusing on more common presentations of tacrolimus-induced neurotoxicity, such as delirium and tremor. Development of psychosis can occur later in the treatment course and at normal tacrolimus serum levels. It can improve with antipsychotic therapies, but primary management should include cross-titration to an alternate immunosuppressant regimen.

  View details for DOI 10.1016/j.jaclp.2023.09.002

  View details for PubMedID 37778461

• A Case Report of Breakthrough Infections With 2 SARS-CoV-2 Variants in a Lung Transplant Patient. Transplantation proceedings Mahan, L. D., Mohanka, M. R., Joerns, J., Lawrence, A., Bollineni, S., Kaza, V., Timofte, I., La Hoz, R. M., Sorelle, J., Terada, L. S., Kershaw, C. D., Torres, F., Banga, A. 2022

  Abstract

  A lung transplant (LT) patient developed 2 distinct episodes of COVID-19, confirmed by whole-genome sequencing, which was caused by the Delta, and then followed 6 weeks later, by the Omicron variant. The clinical course with Omicron was more severe, leading us to speculate that Omicron may not be any milder among LT patients. We discuss the potential mechanisms behind the Omicron not being any milder among LT patients and emphasize the need for outcomes data among these patients. Until such data become available, it may be prudent to maintain clinical equipoise as regards the relative virulence of the newer variants among LT patients.

  View details for DOI 10.1016/j.transproceed.2022.07.003

  View details for PubMedID 36116948

• Non-pulmonary complications after lung transplantation: part II. Indian journal of thoracic and cardiovascular surgery Kanade, R., Kler, A., Banga, A. 2022; 38 (Suppl 2): 290-299

  Abstract

  Lung transplantation (LT) is a viable therapeutic option in the treatment of advanced lung disease. With improvements in post-transplant survival, complications involving different organ systems after LT are increasingly seen. While non-infectious, extrapulmonary complications after LT are not frequently responsible for early post-transplant mortality, they significantly impact the quality of life and long-term survival. These complications are, therefore, becoming increasingly relevant as patients with LT are living longer. These complications encompass almost all organ systems and are driven by a combination of the pre-existing comorbidities, events, and complications around the operative procedure and recovery, and perhaps most importantly, medication side effects of the post-LT regimen. In the first of the two-part review, we covered the general approach to management of extrapulmonary complications and covered specific complications pertaining to cardiovascular, renal, neuropsychiatric, and ophthalmologic organ systems. In the current article, we discuss most relevant complications pertaining to the hematologic, endocrine, and gastrointestinal organ systems. In addition, we discuss two of the most common and consequential complications under the miscellaneous category, namely malignancy and venous thrombo-embolism after LT. These two complications have gained increasing significance in the lung allocation score era where progressively sicker and older patients are being transplanted.

  View details for DOI 10.1007/s12055-021-01231-z

  View details for PubMedID 35756956

  View details for PubMedCentralID PMC9226255

• Non-pulmonary complications after lung transplantation: Part I. Indian journal of thoracic and cardiovascular surgery Kanade, R., Kler, A., Banga, A. 2022; 38 (Suppl 2): 280-289

  Abstract

  Lung transplantation (LT) is a viable therapeutic option in the treatment of advanced lung disease. With improvements in post-transplant survival, complications involving different organ systems after LT are increasingly seen. While non-infectious, extrapulmonary complications after LT are not frequently responsible for early post-transplant mortality, they significantly impact the quality of life and long-term survival. These complications are, therefore, becoming increasingly relevant as patients with LT are living longer. These complications encompass almost all organ systems and are driven by a combination of the preexisting comorbidities, events, and complications around the operative procedure and recovery, and perhaps most importantly, medication side effects of the post-LT regimen. We will discuss the wide array of non-infectious extrapulmonary complications after LT in a two-part series of review articles. While we intend to discuss the relevant literature around these complications, there is little in terms of consensus documents to guide the management approach of these complications. We will, therefore, share our experience and learnings that have shaped the management protocols we have in place in an effort to prevent and treat such complications. The goal of the first part of this two-part review is to provide an overview of the most pertinent non-infectious extrapulmonary complications pertaining to cardiovascular, renal, neuropsychiatric and ophthalmologic organ systems.

  View details for DOI 10.1007/s12055-021-01223-z

  View details for PubMedID 35756951

  View details for PubMedCentralID PMC9226221

• Characteristics and outcomes among patients with community-acquired respiratory virus infections during the first year after lung transplantation. Clinical transplantation Mahan, L. D., Kanade, R., Mohanka, M. R., Bollineni, S., Joerns, J., Kaza, V., Torres, F., La Hoz, R. M., Banga, A. 2021; 35 (1): e14140

  Abstract

  The current study describes the spectrum of community-acquired respiratory infections (CARV) during the first year after lung transplantation (LT). Additionally, we elucidate variables associated with CARV, management strategies utilized, and impact on early and late outcomes.This was a retrospective study among patients transplanted between 2012 and 2015 (n = 255, mean age 55.6 ± 13.5 years, M: F 152:103). The diagnosis of CARV was based on the multiplex PCR on nasopharyngeal swab samples. Baseline characteristics, post-transplant variables, and outcomes were compared among patients with and without CARV.Eighty CARV infections developed among a quarter of the study group (n = 62, 24.3%). Rhinovirus/enterovirus was the most commonly isolated CARV (n = 24) followed by coronavirus (n = 17) and RSV (n = 9). A significant proportion of episodes (43.8%) required hospitalization. The use of nasal corticosteroids and left single LT was independently associated with an increased risk of CARV. CARV infections did not impact the lung functions during the first year or the CLAD-free survival at 3 years.There is a significant burden of CARV infections during the first year after LT. The use of nasal corticosteroids may increase the risk of CARV infection. CARV infections did not impact outcomes.

  View details for DOI 10.1111/ctr.14140

  View details for PubMedID 33146445

• Characteristics and Outcomes of Lung Transplant Candidates With Preexisting Renal Dysfunction. Transplantation proceedings Woll, F., Mohanka, M., Bollineni, S., Joerns, J., Kaza, V., Torres, F., Tanriover, B., Banga, A. 2020; 52 (1): 302-308

  Abstract

  The proportion of lung transplant candidates with comorbid renal dysfunction (RD) may rise as sicker patients are being considered for lung transplant (LT). There is lack of data regarding the characteristics and outcome of patients with RD and the role of simultaneous lung-kidney transplant (SLuKi) among these patients.The United Network of Organ Sharing database was queried for adult patients (18 years or older) undergoing LT between 1995 and 2014. Pretransplant RD was defined as estimated glomerular filtration rate (eGFR), using the Chronic Kidney Disease Epidemiology Collaboration equation of <60 mL/min/1.73 m2 at the time of transplant listing. The recipient, donor, and procedure-related variables and survival were compared among patients with RD undergoing LT alone (split on the basis of eGFR impairment: 30-60 mL/min/1.73 m2 and ≤ 30 mL/min/1.73 m2) vs those with SLuKi.The frequency of pretransplant RD was 5.42% (n = 1337). Patients with RD have significantly higher 1-year mortality (23.2% vs 15%; P < .001) and 3-year mortality (38.3% vs 28%; P < .001) than patients with eGFR > 60mL/min/1.73 m2. The proportion of patients with RD undergoing SLuKi was 2.84% (38 of 1337). Both the number and proportion of patients undergoing SLuKi progressively increased during the study period, especially in the lung allocation score era (30 of 38 SLuKi patients in the post lung allocation score era (linear R2 = 0.641, P < .001). The patients who underwent SLuKi were significantly younger, had lower body mass index, serum albumin, and listing eGFR (P < .001 for all comparisons). Patients with SLuKi were more likely to have cystic fibrosis or vascular diseases as the underlying diagnosis (29.7% vs 13.8%, P = .004). Despite higher need of early dialysis support after transplant, there was no difference in the 30-day, 1-year, or 3-year survival between the 2 groups.A significant proportion of LT candidates have a pre-existing RD, and this comorbidity is associated with significantly worse 1- and 3-year survival. Despite being the sicker group at baseline, patients with RD who undergo SLuKi have 1-year outcomes similar to patients with LT alone.

  View details for DOI 10.1016/j.transproceed.2019.10.032

  View details for PubMedID 31926746

• Ventilation perfusion pulmonary scintigraphy in the evaluation of pre-and post-lung transplant patients. Transplantation reviews (Orlando, Fla.) Pinho, D. F., Banga, A., Torres, F., Mathews, D. 2019; 33 (2): 107-114

  Abstract

  Lung transplantation is an established treatment for patients with a variety of advanced lung diseases. Imaging studies play a valuable role not only in evaluation of patients prior to lung transplantation, but also in the follow up of patients after transplantation for detection of complications. After lung transplantation, complications can occur as a result of surgical procedure, pulmonary embolism and ultimately chronic lung allograft dysfunction. Lung scintigraphy, which includes physiologic assessment of lung ventilation and perfusion by imaging, has become an important procedure in the evaluation of these patients, assuming a complementary role to high resolution anatomic imaging (computed tomography [CT]), as well as spirometry. The purpose of this atlas article is to demonstrate the uses of ventilation perfusion scintigraphy in the pre-transplantation setting for surgical planning and in the evaluation of complications post-lung transplantation based upon experience at our institution.

  View details for DOI 10.1016/j.trre.2018.10.003

  View details for PubMedID 30415913

• Predictors of outcome among patients on extracorporeal membrane oxygenation as a bridge to lung transplantation. Clinical transplantation Banga, A., Batchelor, E., Mohanka, M., Bollineni, S., Kaza, V., Mullins, J., Tran, M., Bajona, P., Peltz, M., Wait, M., Torres, F. 2017; 31 (7)

  Abstract

  There is a lack of data regarding clinical variables associated with successful bridge to lung transplantation (LT) using extracorporeal membrane oxygenation (ECMO) support.We reviewed the institutional database for patients supported with veno-venous (VV) or veno-arterial ECMO as a bridge to LT (n=25; mean age: 50.6±14.2 years). We recorded clinical and laboratory variables, findings on echocardiogram and development of organ dysfunction along with hospital and one-year survival. Variables were compared between patients successfully bridged to LT versus those who were not.The most common diagnostic group was interstitial lung disease (18/25, 72%). VV-ECMO was used in the majority (84%). Fifteen patients (60%) were successfully bridged to LT, and the majority were alive at 1 year (14/15, 93.3%). The presence of right ventricular systolic dysfunction on pre-ECMO echocardiogram was associated with increased risk of unsuccessful bridging (OR, 95% CI: 2.67, 1.01-6.99, P=.041). While on ECMO, trough albumin levels <2.5 gm%, peak blood urea nitrogen levels >35 mg/dL and positive fluid balance were also associated with failure to bridge to LT.Among patients awaiting LT, the presence of RV systolic dysfunction before ECMO initiation along with worsening renal functions, low albumin levels, and volume overload is associated with poor outcomes.

  View details for DOI 10.1111/ctr.12990

  View details for PubMedID 28445586

• Incidence and variables associated with inadequate antibody titers after pre-exposure rabies vaccination among veterinary medical students. Vaccine Banga, N., Guss, P., Banga, A., Rosenman, K. D. 2014; 32 (8): 979-83

  Abstract

  This study sought to determine the proportion of subjects with inadequate antibody titers at two years after pre-exposure rabies vaccination and identify variables associated with inadequate antibody titers.A retrospective chart review of vaccination records of veterinary students in Michigan, 2004-2009, was conducted. Antibody titers <0.5 IU/ml as estimated by rapid fluorescent focus inhibition test were classified as inadequate. Variables were compared between the two groups to identify factors associated with inadequate titers at two years.A total of 603 subjects (mean age 24.1 ± 4.2 years, male:female 106:497) were included. Nearly one third (177/603, 29.4%) had inadequate titers at two years. Male gender (adjusted odds ratio (AOR) 1.87, 1.07-3.27; p=0.029), vaccine manufacturer (AOR 1.49, 1.16-1.92; p=0.002), BMI >25 (AOR 1.61, 1.02-2.54; p=0.043), and duration between first and third doses of vaccine >21 days (AOR 2.49, 1.26-4.97; p=0.009) were independently associated with inadequate titers.Twenty-nine percent of subjects had inadequate antibody titers against rabies at 2 years. Gender, vaccine type/manufacturer, BMI of 25 or greater, and more than 21 days between the first and third doses of vaccine were independently associated with inadequate antibody titers at two years. Our data would support modifying the recommendations, so the third dose is recommended at 21 days rather than 21-28 days.

  View details for DOI 10.1016/j.vaccine.2013.12.019

  View details for PubMedID 24394442

• Non-invasive ventilation for acute exacerbation of COPD with very high PaCO(2): A randomized controlled trial. Lung India : official organ of Indian Chest Society Khilnani, G. C., Saikia, N., Banga, A., Sharma, S. K. 2010; 27 (3): 125-30

  Abstract

  To assess the role of non-invasive positive pressure ventilation (NIPPV) for management of Indian patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).Forty patients (mean age 57.6 ± 10.8 years; M:F 31:9) with AECOPD with pH <7.35, admitted to the intensive care unit were included. Patients were randomized to receive NIPPV (N, n = 20) with conventional therapy or conventional therapy (C, n = 20) alone at admission. NIPPV was given through the nasal mask. Incidence of need of endotracheal intubation (ETI) was the primary efficacy variable. Hospital mortality, duration of hospital stay and change in clinical and blood gas parameters were the secondary outcome variables.Mean pH at baseline for N and C groups were similar (7.23 ± 0.07) whereas PaCO(2) was 85.4 ± 14.8 and 81.1 ± 11.6 mm of Hg, respectively. At one hour, patients in N group had greater improvement in pH (P = 0.017) as well as PaCO(2) (P = 0.04) which corroborated with clinical improvement. Whereas need of ETI was reduced in patients who received NIPPV (3/20 vs 12/20, P = 0.003), in-hospital mortality was similar (3/20 and 2/20, P = NS). The mean duration of hospital stay was significantly shorter in N group (9.4 ± 4.3 days) as compared to C group (17.8 ± 2.6 days); P = 0.001.In patients with AECOPD, NIPPV leads to rapid improvement in blood gas parameters and reduces the need for ETI.

  View details for DOI 10.4103/0970-2113.68308

  View details for PubMedID 20931029

  View details for PubMedCentralID PMC2946712

• A prospective study of risk factor profile & incidence of deep venous thrombosis among medically-ill hospitalized patients at a tertiary care hospital in northern India. The Indian journal of medical research Sharma, S. K., Gupta, V., Kadhiravan, T., Banga, A., Seith, A., Kumar, A., Saxena, R., Thabah, M. M., Gulati, V., Bhatia, I., Kavimandan, A. A. 2009; 130 (6): 726-30

  Abstract

  Hospitalization for medical-illness is associated with an increased risk of deep venous thrombosis (DVT). However, there are no published data from India addressing at this issue. We sought to study the risk factor profile and the incidence of DVT among hospitalized medically-ill patients, a tertiary care hospital in northern India.All adults admitted to the medical wards and intensive care unit with level 1 or 2 mobility over a period of two years (July 2006 to July 2008) at the All India Institute of Medical Sciences hospital, New Delhi, were prospectively studied. Patients having DVT at admission or an anticipated hospital stay less than 48 h were excluded. The presence of clinical risk factors for DVT was recorded and laboratory evaluation was done for hypercoagulable state. A routine surveillance venous compression Doppler ultrasonography was performed 12 +/- 8 days after hospital admission.Of the 163 patients, 77 (47%) had more than one risk factor for DVT. Five (3%) patients developed DVT; none of them had symptomatic DVT. None of these patients received anticoagulation prior to the development of DVT. The mean age of those who developed DVT was 40 +/- 13 (25-50) yr; two of five were male. The incidence rate of DVT was 2.7 per 1000 person-days of hospital stay [95% confidence interval (CI): 0.87 to 6.27]. None of the factors was found to be significantly associated with the risk of DVT.In our setting, although many hospitalized medically-ill patients had risk factors for DVT, the absolute risk of DVT was low compared to the western population but clearly elevated compared to non hospitalized patients. Large studies from India are required to confirm our findings.

  View details for PubMedID 20090134

• Post-hypercapnic alkalosis is associated with ventilator dependence and increased ICU stay. COPD Banga, A., Khilnani, G. C. 2009; 6 (6): 437-40

  Abstract

  Posthypercapnic alkalosis (PHA) is frequently overlooked as a complication of mechanical ventilation in patients with exacerbation of chronic obstructive pulmonary disease (COPD). The current study was conducted to determine the incidence, risk factors for development and effect on outcome of PHA. Eighty-four patients (62 +/- 11 years, range 42-78 years, M:F 58: 26) with exacerbation of COPD with underlying chronic hypercapnic respiratory failure requiring mechanical ventilation were included in a retrospective fashion. PHA was defined as static or rising serum bicarbonate levels, 72 hours or more after return of PaCO2 to baseline, with concurrent pH > 7.44. Development of PHA was noted in 17 patients (20.2%). Corticosteroid use >or=10 days during the hospital stay was an independent risk factor for development of PHA (Adjusted OR, 95% CI: 9.4, 1.6-55.3; P = 0.013). Development of PHA was associated with an increased incidence of ventilator dependence (64.7% vs. 37.3%, OR, 95% CI: 3.1, 1.1-9.4, P = 0.04) and duration of ICU stay (14.7 +/- 6.7 vs. 9.5 +/- 5.9, P = 0.01) but no increase in hospital mortality (43.3% vs. 41.2%, P = NS). It is concluded that PHA is a common complication in patients with exacerbation of COPD requiring mechanical ventilation and is associated with increased incidence of ventilator dependence and ICU stay.

  View details for DOI 10.3109/15412550903341448

  View details for PubMedID 19938966

• A clinical prediction rule to identify patients with tuberculosis at high risk for HIV co-infection. The Indian journal of medical research Sharma, S. K., Kadhiravan, T., Banga, A. 2009; 130 (1): 51-7

  Abstract

  Many patients presenting with tuberculosis (TB) have underlying human immunodeficiency virus (HIV) co-infection. Routine HIV testing, however, is not a component of the national TB control programme in India. We sought to derive and validate a clinical prediction rule, based on clinical and laboratory parameters, to identify patients at high risk for HIV co-infection among those treated for active TB.Case records of adult patients with active TB treated between 1997 and 2003 at the All India Institute of Medical Sciences hospital, New Delhi were retrospectively reviewed. The data set was randomly split into a training set and a testing set. First a clinical prediction rule was derived by multivariable logistic regression on the training set and was subsequently validated on the testing set.The study group comprised 1074 patients [training set 711 (66%), HIV co-infected 66 (9%); testing set 363 (34%), HIV co-infected 30 (8%)]. In the training set, male gender [odds ratio (95% CI) 5.31(1.52- 18.61)], axillary lymphadenopathy [9.71 (3.24-29.10)], anaemia [7.56 (2.48-23.05)], hypoalbuminaemia [3.67(1.31-10.26)], and reduced triceps skinfold thickness [2.91(0.95-8.89)] were independently associated with HIV co-infection. In the testing set, presence of any two of these five features was 94 per cent (95% CI 84-100%) sensitive and 54 per cent (49-60%) specific for predicting HIV co-infection; negative predictive value was 99 per cent (98-100%). Area under the receiver-operating characteristic curve was 0.93 (0.86-1.0) in the testing set.A simple clinical prediction rule based on clinical and laboratory parameters could be used to identify a subgroup of patients, among those treated for active TB in a hospital setting, for targeted HIV testing.

  View details for PubMedID 19700801

• Use of non-invasive ventilation in a pregnant woman with acute respiratory distress syndrome due to pneumonia. The Indian journal of chest diseases & allied sciences Banga, A., Khilnani, G. C. 2009; 51 (2): 115-7

  Abstract

  Utility of non-invasive ventilation (NIV) in patients with acute respiratory distress syndrome (ARDS) is not proven. We report a case of a 28-year-old primigravida female with ARDS due to community-acquired severe pneumonia in whom non-invasive ventilation was instituted in an attempt to improve oxygenation and avoid intubation. This lead to an improvement in arterial oxygenation and reduction in respiratory rate of the patient and gradual disappearance of fetal distress.

  View details for PubMedID 19445449

• Lemierre's syndrome due to community-acquired meticillin-resistant Staphylococcus aureus infection and presenting with orbital cellulitis: a case report. Journal of medical case reports Kadhiravan, T., Piramanayagam, P., Banga, A., Gupta, R., Sharma, S. K. 2008; 2: 374

  Abstract

  Lemierre's syndrome is septic thrombophlebitis of the internal jugular vein leading to metastatic septic complications following an oropharyngeal infection. It is usually caused by the anaerobe, Fusobacterium necrophorum. Of late, meticillin-resistant Staphylococcus aureus is increasingly being recognised as a cause of community-acquired skin and soft tissue infections. We report a rare case of Lemierre's syndrome caused by community-acquired meticillin-resistant Staphylococcus aureus infection.A previously healthy 16-year-old girl presented with fever of 13 days duration, painful swelling around the right eye and diplopia followed by the appearance of pulmonary infiltrates. Imaging studies confirmed the clinical suspicion of bilateral jugular venous thrombosis with septic pulmonary embolism. Meticillin-resistant Staphylococcus aureus was isolated on blood cultures. The hospital course was complicated by massive haemoptysis and pulmonary aspiration necessitating mechanical ventilation. The patient subsequently made a complete recovery.Lemierre's syndrome, although rare, is a potentially lethal but treatable complication of head and neck sepsis. Early clinical recognition of Lemierre's syndrome and appropriate antibiotic treatment can be life-saving. One should consider the possibility of community-acquired meticillin-resistant Staphylococcus aureus infection in patients with suspected Lemierre's syndrome.

  View details for DOI 10.1186/1752-1947-2-374

  View details for PubMedID 19063718

  View details for PubMedCentralID PMC2628934

• Noninvasive ventilation in patients with chronic obstructive airway disease. International journal of chronic obstructive pulmonary disease Khilnani, G. C., Banga, A. 2008; 3 (3): 351-7

  Abstract

  Recent years have seen the emergence of noninvasive ventilation (NIV) as an important tool for management of patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). Several well conducted studies in the recent years have established its role in the initial, as well as later management of these patients. However, some grey areas remain. Moreover, data is emerging on the role of long term nocturnal NIV use in patients with very severe stable COPD. This review summarizes the evidence supporting the use of NIV in various stages of COPD, discuss the merits as well as demerits of this novel ventilatory strategy and highlight the grey areas in the current body of knowledge.

  View details for DOI 10.2147/copd.s946

  View details for PubMedID 18990962

  View details for PubMedCentralID PMC2629986

• Prevalence and risk factors for wheezing in children from rural areas of north India. Allergy and asthma proceedings Sharma, S. K., Banga, A. 2007; 28 (6): 647-53

  Abstract

  Phase I of the International Study of Asthma and Allergies in Childhood (ISAAC) showed marked variability in the global pattern of allergic disorders. Risk factors for asthma in children from rural areas of developing countries have not been studied. The purpose of this study was to document the prevalence of asthma-associated symptoms in children residing in rural areas and to determine risk factors for its development. We studied 8470 school children, aged 6-7 years and 13-14 years, from 10 villages on the outskirts of Delhi, India, over a 6-month period. The study was performed using the Hindi translated version of Phase III of the ISAAC questionnaires. All of the questionnaires were self-reported by children and/or parents. Frequent passage of trucks through the street near home (odds ratio [OR]: 95% CI, 1.7 [1.2-2.4]), maternal smoking (OR: 95% CI, 1.5, [1.1-2.1]), paternal smoking (OR: 95% CI, 1.3 [1.0-1.8]), total number of cigarettes smoked by both parents of more than seven per day (OR: 95% CI, 1.9 [1.3-2.7]), paracetamol intake of more than once a month (OR: 95% CI, 1.9 [1.4-2.6]), and current exposure to cats (OR: 95% CI, 1.5 [1.1-1.9]) were independently associated with occurrence of recent wheezing (in the last 12 months), whereas fruit intake of more than twice a week had a protective effect (OR: 95% CI, 0.7 [0.5-0.9]). There is a significant burden of asthma-associated symptoms in children of rural areas of north India. Occurrence of wheezing among children from rural areas of Delhi is determined by a complex interplay of environmental agents that induce allergic sensitization and are proinflammatory and environmental agents that supplement the antioxidant stores.

  View details for DOI 10.2500/aap.2007.28.3059

  View details for PubMedID 18201428

• Obesity, and not obstructive sleep apnea, is responsible for metabolic abnormalities in a cohort with sleep-disordered breathing. Sleep medicine Sharma, S. K., Kumpawat, S., Goel, A., Banga, A., Ramakrishnan, L., Chaturvedi, P. 2007; 8 (1): 12-7

  Abstract

  To assess the profile of metabolic abnormalities in subjects with obstructive sleep apnea (OSA).In a case-control study conducted in two years, from April 2003 to March 2005, data obtained from polysomnography study, lipid profile, fasting blood sugar, serum insulin, insulin resistance, leptin and adiponectin levels, were compared between the various groups. Included in the study were OSA subjects from a sleep laboratory and matched controls from the community. Those with recent myocardial infarction, upper airway surgery, class III/IV heart failure, pregnancy, acromegaly, chronic renal failure, or who were on treatment for hyperthyroidism, on systemic steroid treatment, or on hormonal replacement therapy, were excluded from the study.Forty apneic obese subjects (AHI=32.19, range 13-52.75) were compared with 40 non-apneic obese controls (AHI=1.3, range 0-2.45) and 40 normal weight control subjects (AHI=0.7, range 0-1). No significant difference was noted in levels of fasting blood sugar, insulin resistance (obese apneics 61.9, obese controls 47.8, non-obese controls 19.1), leptin (obese apneics 10.65 microg/L, obese controls 8.52 microg/L, non-obese controls 2.83 microg/L) or adiponectin (obese apneics 4959.3 ng/ml, obese controls 5706 ng/ml, non-obese controls 7412 ng/ml) in the OSA group compared to obese controls.OSA has no independent association with lipid abnormalities, insulin resistance, serum leptin and adiponectin levels. In multivariate analysis, obesity was the major determinant of metabolic abnormalities in this cohort.

  View details for DOI 10.1016/j.sleep.2006.06.014

  View details for PubMedID 17157064

• Prediction of obstructive sleep apnea in patients presenting to a tertiary care center. Sleep & breathing = Schlaf & Atmung Sharma, S. K., Malik, V., Vasudev, C., Banga, A., Mohan, A., Handa, K. K., Mukhopadhyay, S. 2006; 10 (3): 147-54

  Abstract

  The objective of this prospective observational clinical study is to derive and validate a diagnostic model for prediction of obstructive sleep apnea (OSA) in subjects presenting with non-sleep-related complaints in a tertiary care center in north India. We included 102 subjects (group I, range 31-70 years) presenting to the hospital with non-sleep-related complaints. None of the subjects had any significant comorbid illness such as respiratory or congestive cardiac failure. All subjects underwent detailed evaluation including polysomnography (PSG). Various parameters were compared between the cases (apnea-hypopnea index, AHI > or =15/h) and controls (AHI <15/h). Using multivariate logistic regression analysis, a diagnostic model for prediction of OSA was derived. Subsequently, using similar selection criteria, 104 subjects (group II, range 32-68 years) were included for validation of the newly derived diagnostic model. Body mass index [BMI; OR (95% CI), 1.14(1.1-1.2)], male gender 5.0(1.4-27.1), relative-reported snoring index (SI) 2.8(1.7-5.0), and choking index (ChI) 8.1(1.4-46.5) were significant, independent predictors of OSA. Diagnostic model was computed as score = [1.61 x (gender)] + [1.01 x (S1)] + [2.09 x (ChI)] + [0.1 x (BMI)] where, gender: 0 = female, 1 = male and SI, ChI, BMI are actual values. The diagnostic model had an area under the receiver operator characteristics curve of 89.6%. A cutoff of 4.3 for the score was associated with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 91.3, 68.5, 70.5, and 92.3%, respectively. Misclassification rate with the application of the diagnostic model on group II subjects was 13.5% (14/104). Sensitivity, specificity, PPV, and NPV of the model for predicting OSA in this group were 82, 90.7, 89.1, and 84.5%, respectively. BMI, male gender, SI, and ChI are independent predictors of OSA. Diagnostic model derived from these parameters is useful for predicting presence of OSA and screening subjects for PSG.

  View details for DOI 10.1007/s11325-006-0062-1

  View details for PubMedID 16699807

• Prevalence and risk factors of obstructive sleep apnea syndrome in a population of Delhi, India. Chest Sharma, S. K., Kumpawat, S., Banga, A., Goel, A. 2006; 130 (1): 149-56

  Abstract

  Obstructive sleep apnea (OSA) has been recognized in the Western world as a public health burden, but there has been no community-based study performed to assess the prevalence of the condition in India. The study was performed to assess the prevalence and risk factors of OSA in a semi-urban Indian population.A two-stage, cross-sectional, community-based prevalence study.A semi-urban community in Delhi.Two years (2003 to 2005).All citizens residing in the community who were 30 to 60 years of age. Exclusion criteria included those patients with recent myocardial infarction, upper airway surgery, class III/IV congestive heart failure, pregnancy, hypothyroidism on treatment, acromegaly, chronic renal failure, systemic steroid treatment, and hormone replacement therapy.An OSA assessment was performed in 2,400 subjects who were screened in stage 1 of the study by means of a sleep questionnaire. Subjects were then divided into habitual and nonhabitual snorers. Eighty-three randomly selected habitual snorers and 80 nonhabitual snorers were invited to participate in stage 2 of the study, which consisted of in-hospital polysomnography studies.A total of 2,150 subjects returned questionnaires (response rate, 90%). Of 550 habitual snorers and 1,596 nonhabitual snorers, 77 habitual snorers and 73 nonhabitual snorers underwent polysomnography. A total of 36 habitual snorers (46.75%) and 2 nonhabitual snorers (2.73%) were found to have OSA, giving prevalence rates of 13.74% and 3.57%, respectively, for OSA and OSA syndrome (OSAS) on extrapolation. Multivariate analysis revealed that male gender, age, obesity (defined by a high body mass index), and waist/hip ratio as significant risk factors for OSAS.This study demonstrated that the risk factors and prevalence for OSA in India are similar to those in the West, which is contrary to the findings of some previous reports, which had a strong inclusion bias.

  View details for DOI 10.1378/chest.130.1.149

  View details for PubMedID 16840395

• Pleural fluid interferon-gamma and adenosine deaminase levels in tuberculosis pleural effusion: a cost-effectiveness analysis. Journal of clinical laboratory analysis Sharma, S. K., Banga, A. 2005; 19 (2): 40-6

  Abstract

  Pleural fluid levels of interferon-gamma (IFN-gamma) and adenosine deaminase (ADA) have been found to be high in patients with tuberculosis (TB). The present study was carried out to compare the diagnostic utility of these two markers and to carry out a cost-effectiveness analysis of performing IFN-gamma estimation in comparison to ADA. A total of 52 patients with pleural effusion, 35 of which were found to have TB etiology, were prospectively included for estimation of ADA and IFN-gamma levels. The difference in the cost of performing the two diagnostic tests was compared with the cost of the treatment for a patient with TB. Pleural fluid IFN-gamma (median [range]: 2,100 [70-14,000] vs. 3 [0-160]; P<0.001) as well as ADA levels (mean [SD]: 93.1 [62.3] vs 15.4 [8.7]; P<0.001) were significantly higher in patients with TB effusion. Even though IFN-gamma estimation was more sensitive (97.1 vs. 91.4%), the extra cost of IFN-gamma estimation for detecting one patient with TB was found to be equivalent to the cost of a complete course of antituberculosis treatment for six patients. In developing countries, where TB is rampant and cost is a major concern, pleural fluid IFN-gamma estimation does not seem to be a cost-effective investigation method for differentiating TB from non-TB pleural effusion.

  View details for DOI 10.1002/jcla.20054

  View details for PubMedID 15756707

  View details for PubMedCentralID PMC6808038

• Predictors of mortality of patients with acute respiratory failure secondary to chronic obstructive pulmonary disease admitted to an intensive care unit: a one year study. BMC pulmonary medicine Khilnani, G. C., Banga, A., Sharma, S. K. 2004; 4: 12

  Abstract

  Patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) commonly require hospitalization and admission to intensive care unit (ICU). It is useful to identify patients at the time of admission who are likely to have poor outcome. This study was carried out to define the predictors of mortality in patients with acute exacerbation of COPD and to device a scoring system using the baseline physiological variables for prognosticating these patients.Eighty-two patients with acute respiratory failure secondary to COPD admitted to medical ICU over a one-year period were included. Clinical and demographic profile at the time of admission to ICU including APACHE II score and Glasgow coma scale were recorded at the time of admission to ICU. In addition, acid base disorders, renal functions, liver functions and serum albumin, were recorded at the time of presentation. Primary outcome measure was hospital mortality.Invasive ventilation was required in 69 patients (84.1%). Fifty-two patients survived to hospital discharge (63.4%). APACHE II score at the time of admission to ICU {odds ratio (95 % CI): 1.32 (1.138-1.532); p < 0.001} and serum albumin (done within 24 hours of admission) {odds ratio (95 % CI): 0.114 (0.03-0.432); p = 0.001}. An equation, constructed using the adjusted odds ratio for the two parameters, had an area under the ROC curve of 91.3%. For the choice of cut-off, sensitivity, specificity, positive and negative predictive value for predicting outcome was 90%, 86.5%, 79.4% and 93.7%.APACHE II score at admission and SA levels with in 24 hrs after admission are independent predictors of mortality for patients with COPD admitted to ICU. The equation derived from these two parameters is useful for predicting outcome of these patients.

  View details for DOI 10.1186/1471-2466-4-12

  View details for PubMedID 15566574

  View details for PubMedCentralID PMC539254

• Spectrum of clinical disease in a series of 135 hospitalised HIV-infected patients from north India. BMC infectious diseases Sharma, S. K., Kadhiravan, T., Banga, A., Goyal, T., Bhatia, I., Saha, P. K. 2004; 4: 52

  Abstract

  Literature on the spectrum of opportunistic disease in human immunodeficiency virus (HIV)-infected patients from developing countries is sparse. The objective of this study was to document the spectrum and determine the frequency of various opportunistic infections (OIs) and non-infectious opportunistic diseases, in hospitalised HIV-infected patients from north India.One hundred and thirty five consecutive, HIV-infected patients (age 34 +/- 10 years, females 17%) admitted to a tertiary care hospital in north India, for the evaluation and management of an OI or HIV-related disorder between January 2000 and July 2003, were studied.Fever (71%) and weight loss (65%) were the commonest presenting symptoms. Heterosexual transmission was the commonest mode of HIV-acquisition. Tuberculosis (TB) was the commonest OI (71%) followed by candidiasis (39.3%), Pneumocystis jiroveci pneumonia (PCP) (7.4%), cryptococcal meningitis and cerebral toxoplasmosis (3.7% each). Most of the cases of TB were disseminated (64%). Apart from other well-recognised OIs, two patients had visceral leishmaniasis. Two cases of HIV-associated lymphoma were encountered. CD4+ cell counts were done in 109 patients. Majority of the patients (82.6%) had CD4+ counts <200 cells/microL. Fifty patients (46%) had CD4+ counts <50 cells/microL. Only 50 patients (37%) received antiretroviral therapy. Twenty one patients (16%) died during hospital stay. All but one deaths were due to TB (16 patients; 76%) and PCP (4 patients; 19%).A wide spectrum of disease, including both OIs and non-infectious opportunistic diseases, is seen in hospitalised HIV-infected patients from north India. Tuberculosis remains the most common OI and is the commonest cause of death in these patients.

  View details for DOI 10.1186/1471-2334-4-52

  View details for PubMedID 15555069

  View details for PubMedCentralID PMC535567

• Diagnostic utility of pleural fluid IFN-gamma in tuberculosis pleural effusion. Journal of interferon & cytokine research : the official journal of the International Society for Interferon and Cytokine Research Sharma, S. K., Banga, A. 2004; 24 (4): 213-7

  Abstract

  Pleural fluid interferon-gamma (IFN-gamma) levels are increased in patients with tuberculosis (TB) pleural effusion. Recent studies from the west have found that estimation of pleural fluid IFN-gamma levels is an excellent diagnostic strategy for these patients. The diagnostic utility of pleural effusion IFN-gamma level estimation has not been evaluated in patients from developing countries, however. This work was carried out to study the diagnostic utility of IFN-gamma level estimation in patients with TB pleural effusion and to define the best cutoff of IFN-gamma for diagnosis TB pleural effusion. We studied 101 patients with pleural effusion. Of these, 64 were found to have a TB etiology, established by means of various conventional modalities. Measurement of pleural fluid IFN-gamma levels was done by ELISA technique. The median value of pleural fluid IFN-gamma levels in patients with TB (1480 pg/ml, range 3-14,000 pg/ml) was significantly higher (p < 0.001) compared with the non-TB group (3 pg/ml, range 0-900 pg/ml). The receiver operator characteristic (ROC) curve for IFN-gamma showed an area under the curve (AUC) value of 0.954, and the best cutoff was computed to be 138 pg/ml. Using this cutoff for IFN-gamma levels in pleural fluid for the diagnosis of TB, sensitivity, specificity, negative predictive value, and positive predictive value were found to be 90.2%, 97.3%, 85.7%, and 98.3%, respectively. Estimation of IFN-gamma levels in pleural fluid is a useful diagnostic modality for TB pleural effusion. A cutoff of 138 pg/ml provides the best sensitivity and specificity for diagnosis of TB.

  View details for DOI 10.1089/107999004323034088

  View details for PubMedID 15144567