Saurabh Mittal

Background and objectives: There is limited data on prescription behaviour and compliance with interstitial lung disease (ILD) guidelines among pulmonologists. This study aimed to evaluate ILDs treatment prescription behaviour in India. Methods: Prescriptions of treatment-naive ILD patients from 13 tertiary care hospitals were reviewed and classified as guideline compliant (GCP) or non-compliant (GNCP) for pharmacological and non-pharmacological components. Change in forced vital capacity (FVC), diffusing capacity (DLCO), and six-minute walk distance (6-MWD) at 6 and 12 months were compared between GCP and GNCP. Results: After screening 720 participants, 425 treatment-naïve ILD patients (56.7% female; mean age 51.7 years) were included. Connective tissue associated-ILD (CTD-ILD) was the most common diagnosis (36.2%), followed by hypersensitivity pneumonitis (17.4%), idiopathic pulmonary fibrosis (IPF, 13.9%), interstitial pneumonia with autoimmune features (13.9%), and sarcoidosis (8.2%). GCP rates for ILD specific pharmacotherapy were 83%, 74.7%, and 93.5% for IPF, CTD-ILD, and sarcoidosis, respectively. In IPF, patients with GCP had significantly lower FVC decline at 12 months compared to the GNCP (0.06 L vs. 0.25 L; p = 0.02). There was huge care-gap in non-pharmacological advice with 13.2%, 7.1%, 10.2% and 4.2% of eligible cases were advised vaccination, pulmonary rehabilitation, antigen avoidance, and lung transplantation counselling, respectively. Interpretation and conclusions: India-ILD care study revealed a huge care gap with significantly under-prescription of non-pharmacological components. These results highlight the urgent need for organized implementation strategies including dissemination of guidelines, and a greater emphasis on a structured management protocol that includes both pharmacological and non-pharmacological treatment to optimize outcomes for ILD in India.

A young male with dyspnoea after placement of a pleural drain

Setting: Uncontrolled asthma patients at a university teaching hospital in India. Objective: To determine the prevalence, endotypes, and need for add-on therapies in severe asthma. Methods: This prospective study screened all patients with uncontrolled asthma, and those with uncontrolled asthma while on moderate-to-high dose inhaled corticosteroids with long-acting beta agonists (ICS + LABA) were further assessed. Endotyping and optimisation of therapy for all potentially modifiable factors were performed, followed by reassessment at 3 months of optimised treatment. Uncontrolled patients at 3 months were classified as having severe asthma and assessed for eligibility for add-on therapies. Results: After screening 261 uncontrolled asthma patients, 160 patients with uncontrolled asthma on moderate-high dose ICS + LABA were included in the study (prevalence of difficult-to-treat asthma: 61.2%). On endotyping, 134 (83.75%) had T2-high endotype and 26 (16.25%) had T2-low endotype asthma. Severe asthma prevalence was 20% (32 out of 160) in this subgroup, and they were assessed for eligibility for guideline-directed add-on therapy: 12 (37.5%) were eligible for omalizumab; 18 (56.25%) were eligible for mepolizumab, benralizumab, or dupilumab; and seven (21.87%) were not eligible for any add-on therapy. Conclusion: T2-high asthma is five times more common than T2-low asthma, and the prevalence of severe asthma is 20% among uncontrolled asthmatics.

Polysomnography (PSG) is the gold standard for diagnosing obstructive sleep apnea (OSA), but it poses significant barriers in resource-limited settings. The Belun Ring, a new home sleep apnea testing device utilising photoplethysmography and deep learning analysis, offers an alternative approach for diagnosing OSA. Herein, we present our initial experience with this device. Simultaneous in-lab PSG and Belun Ring assessments were conducted in six consecutive adults with suspected OSA undergoing PSG. Diagnostic performance was assessed by comparing the apnea-hypopnea index (AHI) and oxygen desaturation index (ODI) derived from both modalities. Belun Ring demonstrated a strong correlation with PSG AHI and ODI (Pearson’s r = 0.98 for both; P < 0.001), but misclassified OSA severity in 50% of cases, mainly underestimating moderate disease. The device had a sensitivity of 83% for diagnosing OSA. This case series demonstrates the feasibility of Belun Ring use in an Indian population, but frequent severity misclassification is a concern, limiting its diagnostic applicability.

Purpose Level 1 polysomnography (PSG) is considered the gold standard test for diagnosing obstructive sleep apnea (OSA). The Belun Ring platform, a recently FDA-approved wearable device, is a potential alternative to PSG for diagnosing OSA. We conducted this systematic review and meta-analysis to assess the diagnostic accuracy of the Belun Ring Platform compared to PSG in adults. Methods A systematic search of PubMed and Embase was conducted from database inception till 8th July 2025 to identify studies comparing the Belun Ring Platform with PSG in adults. A meta-analysis was performed to estimate the pooled diagnostic test characteristics. Results Four prospective studies involving 339 patients (mean age 54.6 years; 62% males) were included. For diagnosing moderate-to-severe OSA (AHI ≥ 15), the Belun Ring showed pooled sensitivity of 0.92 [95% confidence interval (CI): 0.86–0.96], specificity of 0.81 [95% CI: 0.73–0.87], positive likelihood ratio of 4.84 [95% CI: 3.33–7.03], negative likelihood ratio of 0.10 [95% CI: 0.05–0.17], and diagnostic odds ratio of 50.36 [95% CI: 24.7–102.65]. For AHI ≥ 5, sensitivity was 0.97 [95% CI: 0.91–0.99], but specificity was lower at 0.18 [95% CI: 0.05–0.50]. For severe OSA (AHI ≥ 30), sensitivity was 0.66 [95% CI: 0.40–0.85], with a high specificity of 0.95 [95% CI: 0.91–0.97]. Conclusion We conclude that the Belun Ring platform demonstrates high sensitivity for detecting OSA and excellent specificity (though poor sensitivity) for severe OSA, supporting its utility as an effective tool for diagnosing OSA in adults with suspected moderate to severe disease. It shows good diagnostic accuracy for moderate-to-severe OSA, but limited specificity for mild OSA, supporting its use as an adjunct to type I PSG for diagnosis of OSA.

Pulmonary rehabilitation (PR) in chronic respiratory diseases improves symptoms, quality of life, and exercise capacity and has an integral role in lung transplantation (LT). Virtual PR has recently emerged to cater to patients who otherwise may not have regular access to PR. However, little is known about the effect of virtual PR strategies on candidates for LT. The primary objective was to study the effect of a protocolized hybrid PR program on performance status using the Karnofsky Performance Status (KPS) score. Secondary objectives were Eastern Cooperative Oncology Group (ECOG) status, quality of life, symptom severity, sarcopenia, spirometry (pulmonary function test and diffusing capacity of the lung for carbon monoxide), 6-minute walk distance, and eligibility for LT waitlisting. This is a prospective, single-arm, interventional study on patients with end-stage lung disease, meeting referral criteria for LT. A protocolized 12-week hybrid hospital and home-based virtual PR intervention was conducted, and all outcomes were assessed at baseline and at completion of the intervention. A total of 75 patients were enrolled, and the intervention was completed by 51 patients (68%). A total of 35 patients met LT listing criteria, 27 being “unfit” for LT at baseline, 18 of whom completed the intervention. Significant improvement was seen in KPS, ECOG, St. George’s Respiratory Questionnaire score, visual analog scale score for cough and dyspnea, and sarcopenia for all 51 patients. Of the 18 patients unfit for waitlisting, 12 became fit, and 7 were waitlisted for LT. Patients eligible for LT who do not have access to regular PR may benefit from a hybrid (virtual and hospital-based) PR program, with improvement in KPS, quality of life, sarcopenia, and eligibility for LT waitlisting.