A Study of Role of Medical Thoracoscopy in Undiagnosed Pleural Effusion

Aim and objectives: To know the diagnostic yield of pleuroscopy (medical thoracoscopy) in cases of pleural effusions which remain undiagnosed after routine initial investigations. To notice the different gross pleuroscopic findings during the procedure. To observe various histopathological reports of pleural biopsy taken through medical thoracoscopy. To know the various complications of pleuroscopy in patients undergoing this procedure. Materials and methods: A total of 56 patients having undiagnosed pleural effusion were taken for study after informed written consent. All patients underwent medical thoracoscopy. The clinical, demographic, and radiological profile of patients was recorded. Gross pleuroscopic findings and histopathological reports of the pleural biopsy were noted. All patients were observed for any complications that occurred during or after the procedure. Result: Diagnostic yield of thoracoscopy in the present study was 91.07% (malignant pleural effusion 75% and tuberculous pleuritis 12.5%). Adenocarcinoma was the commonest malignancy in 60.71% of patients amongst malignant pleural effusion in the present study. Very few complications were recorded. The most common postprocedure complication was subcutaneous emphysema (12.5%) followed by pneumothorax (10.78%). Conclusion: Thoracoscopy gives excellent diagnostic yield in undiagnosed pleural effusion without major complications, and should be utilized wherever feasible.

Intranasal glioma (Nasal heterotopia): A rare cause of nasal polyp in neonates

A 3-month-old boy presented with an intranasal polypoidal mass protruding out of the nostril which was present since birth and growing slowly. The mass was non-pulsatile and soft to firm in consistency. It did not increase in size on coughing, crying, or compression of the jugular vein. Magnetic resonance imaging and contrast-enhanced computed tomography (CT) revealed a lobulated well-circumscribed soft tissue mass in the left nasal cavity with no intracranial communication. Complete surgical excision of the mass was carried out via an intranasal endoscopic approach. Histopathological examination confirmed the diagnosis of intranasal glioma.

Executive Summary of the Recommendations on the Management of Asthma In Primary Care (2022) – New Updates

Background : Asthma is a heterogenous disease defined by the history of respiratory symptoms (shortness of breath, wheezing, cough, and chest tightness) that vary over time and in intensity, along with variable expiratory airflow limitation. Despite an ever-increasing prevalence of asthma across all age groups, this condition remains poorly managed in India. Majority of the Indian patients remain undiagnosed or wrongly diagnosed in general clinical practice and even those who get diagnosed, remain poorly or inadequately treated1,2. Since the last published 2020 Indian Medical Association (IMA) recommendations on the management of asthma in primary care, noteworthy critical changes have been recommended in relation to the diagnosis/management of asthma in international guidelines. Hence, there was a need to update the existing IMA recommendations. For the same, an expert group meeting was organized with family physicians having clinical experience in managing patients with asthma along with chest physicians and pediatricians. Important updates related to asthma diagnosis and its management were discussed and the final recommendation decisions were derived from the joint group discussion. Some of the key points derived from the discussion are mentioned below in the executive summary. For a detailed version of the new recommendations please click on the url.

Isolated pancreatic myeloid sarcoma: A potential mimicker of pancreatic adenocarcinoma

Myeloid sarcoma (MS) is an extramedullary proliferation of immature myeloid cells which may occur as a progression of myelodysplastic syndrome (MDS), myeloproliferative neoplasm (MPN), or myelodysplastic syndrome/myeloproliferative neoplasm (MDS/MPN) and as acute myeloid leukemia (AML) relapse. Rarely may it be de novo. Lymph nodes, skin, lungs, intestine are the commonly involved sites. However, an isolated pancreatic MS is seldom reported in the literature. Herein, we report one such case which was misdiagnosed as pancreatic adenocarcinoma on the clinico-radiological examination which misled us away from preoperative diagnostic sampling, and a Whipple pancreaticoduodenectomy was performed. Histopathological examination in conjunction with immunohistochemistry revealed the final diagnosis of isolated MS of the pancreas. We emphasize that although rare, a clinical suspicion along with preoperative histopathological examination may lead to early diagnosis, targeted management, and a better clinical outcome in such cases.

The Study of Correlation Between Bronchiectasis Severity Index and FACED Score for Assessment of Severity of Bronchiectasis

Introduction: Two different validated scores are currently used to assess the severity of bronchiectasis: the FACED score and the Bronchiectasis Severity Index (BSI). The study was conducted to evaluate clini-cal etiology in bronchiectasis patients. And to compare the results of the assessment of bronchiectasis severity obtained via FACED and BSI scores. Methods: The study was conducted at a tertiary care hospital in the outpatients of the department of respiratory medicine. Detailed clinical history and necessary investigations were done. BSI and the FACED score were calculated. Statistical analysis was performed using the SPSS package. Results: According to the FACED score, we found 28 patients with mild bronchiectasis, 17 with moder-ate, and 5 with severe bronchiectasis. The frequency of patients with low, intermediate, and high BSI was 24, 21, and 5, respectively. Moreover, we observed a weak but statistically significant association of 43% agreement between FACED and BSI scores: Fisher’s exact test(p=0.399), tau-b de Kendall (-0.123; p = 0.337) and kappa test (0.032; p = 0.878). Conclusions: There is a small but significant correlation between the two scales (BSI and FACED). a ten-dency is observed for patients to be classified with a higher BSI compared to the FACED score.

Correlation Of Spirometry And Six Minute Walk Test (6MWT) In Patients Of Stable COPD

Background: Spirometryis the GOLD standard for the diagnosis of COPD. This test also grades the severity of the disease which helps in the management of patients.Many times Spirometry is not available in remote areas. In these situations 6MWT can be done. 6 minute walk test (6MWT) is a simple test to assess patient’s functional capacity (ability for day to day activities).Material And Methods:A prospective study was conducted in the department of Respiratory Medicine, AMC MET MEDICAL COLLEGE, L.G. HOSPITAL, AHMEDABAD for 6 months from date of Confirmation of IRB.The patient who was a confirmed and stable case of COPD and who gave consent was taken for the study.Conclusion:The 6MWT plays a major role in measuring the functional status and disease tolerance of COPD patients.Also, it is observed that as severity of FEV1 increses 6MWD decreses.This suggests that in the absence of spirometry 6MWT is a reasonable tool for the assessment of disease severity and functional status in COPD Patients.

Low-dose Perioperative Dexamethasone Improves 24-hour Post-Operative Pain after Anterior Cruciate Ligament Reconstruction

@#Introduction: Post-operative pain following anterior cruciate ligament reconstruction remains an important challenge. Steroids are used in various surgical procedures to decrease post-operative nausea, vomiting and pain. However, only a few studies have reported the effect of systemic administration of steroids in controlling postoperative pain after anterior cruciate ligament surgery. Materials and methods: We have conducted a prospective randomised trial with 109 patients divided into two groups to determine if administration of dexamethasone in the perioperative period improves pain in the post-operative period. The patients were divided into two groups: D, treatment (dexamethasone) and P, control placebo (saline). Patients in the D treatment group were given the first dose of 10mg of intravenous dexamethasone intravenously intraoperatively and the second dose on transferring of the patient to the inpatient department. The patients in the placebo P group, were administered normal saline in the perioperative period in a similar manner. Result: Post-operative pain was significantly less in the dexamethasone group at rest and on walking (p<0.001) for the first 24 hours after surgical procedure. Subsequently, the VAS pain scores were almost similar in both groups at 48 and 72 hours. The administration of dexamethasone resulted in less requirement of antiemetic and rescue analgesia medication There was no difference in range of motion and wound complications rate during the follow-up period at six months. No adverse side effect, like osteonecrosis of the hip, was detected. Conclusion: The pain following anterior cruciate ligament reconstruction is severe during the first 24 hours and perioperative administration of dexamethasone can decrease the post-operative pain substantially.

Assessment of Microbiological Profile of Infection Keratitis: An Institutional Based Prospective Study

Background: The incidence of infectious keratitis has risen inthe last decade, partially due to an increasing number ofcontact lens users and immune-compromised patients. Hence;the present study was undertaken for assess themicrobiological profile of patients with infection keratitis.Materials & Methods: A total of 96 patients of infectionkeratitis were enrolled in the present study. Completedemographic and clinical details of all the patients wereobtained. Slit-lamp biomicroscope examination of all thepatients was done. This was followed by collection of cornealscrapings under septic conditions by experienced and skilledophthalmologist. Inoculation of the material directly on the solidmedia was done. The media used were blood agar, chocolateagar and Sabouraud dextrose agar (SDA). Overnightincubation of seeded media was done. Assessment of cultureand colonies was done by skilled and experiencedmicrobiologists.Results: Only bacterial isolates were found to be present in54.2 percent of the patients. Only fungal isolates were foundto be 39.6 percent of the patients. Mixed infection wasfound to be present in 6.2 percent of the patients. Fusarium,Aspergillus, Hyalohyphomycetes, Curvularia and Candida werethe most common fungal species encountered. S.aureus,S.pneumoniae, Pseudomonas aeruginosa and Klebsiellapneumonia were the most common bacterial speciesencountered.Conclusion: Infection keratitis comprises of mixed spectrum ofbacteria and fungi.

Research in Clinical Sciences.

The scope and spectrum of medical research, including that in clinical sciences has tremendously expanded. It now extends from simple clinical observations to gathering of epidemiological data to the study of molecular mechanisms of diseases to evaluation of effects of therapeutic interventions. It is more meaningful to engage in multi-disciplinary and collaborative arrangements for the better achievements in health research. Translational approach involves the direct application of results of laboratory experiments to clinical use for benefit of patients. Besides clinical and experimental research, it is equally important to strengthen operational research for efficient implementation of health programmes and policies in the hospitals as well as in the community. There are several difficulties and constraints related to ethical principles, patient’s safety, confidentiality and costs. It is critically important to adhere to ethical principles and guidelines to maintain the moral and social perspectives. It is equally important to follow the scientific research methodology for the maximum gains from research experiments and projects. Interpretation of results of clinical experiments are hardly ever unequivocal, hence, there is a need for repetitive studies, systematic reviews and meta-analyses to reach definitive conclusions. It is important for busy physicians to adopt a scientific temper of logic and engage themselves in searching for answers to different research questions. It is always gainful to spare some time and resources for research out of a busy clinical practice. It is also worthwhile to go through a formal training programme in research methodology to improve capacity and competence to conduct meaningful research.

Medical thoracoscopy for undiagnosed pleural effusions: Experience from a tertiary care hospital in north India.

Background and Aims. Medical thoracoscopy, also called pleuroscopy, has received renewed interest in the recent past for diagnostic as well as therapeutic uses. In this study, we describe our experience with thoracoscopy for undiagnosed pleural effusions. Methods. In a retrospective analysis of thoracoscopic procedures we performed between January 2007 and December 2008, yield of thoracoscopic pleural biopsy for achieving a diagnosis in undiagnosed pleural effusions, defined as pleural effusions with adenosine deaminase (ADA) levels less than 70 IU/L and negative pleural fluid cytology for malignancy on three occasions was evaluated. Complications of thoracoscopy were also analysed. Results. Overall diagnostic yield of thoracoscopic pleural biopsy was 74.3% in patients with undiagnosed pleural effusions. Pleural malignancy was diagnosed in 48.6% of patients. There was only one case of mesothelioma and the rest were due to pleural metastasis. Lung cancer and breast cancer were the most common sites of primary malignancy. Tuberculosis was diagnosed with pleural biopsy in 22.8% of patients. We had low complication rate after thoracoscopy. Only two cases of empyema were observed. Conclusion. Medical thoracoscopy is a safe procedure and has good diagnostic yield in patients with undiagnosed pleural effusions.

Computed tomographic pulmonary angiography: Utility in acute pulmonary embolism in providing additional information and making alternative clinical diagnosis.

Objective: To evaluate the role of computed tomographic (CT) pulmonary angiography (CT-PA) in detecting additional information that may help in making an alternative clinical diagnosis in patients referred to CT for a suspected acute pulmonary embolism (PE). Materials and Methods: 50 patients (34 males, 16 females) in the age group of 18-72 years (mean 42.3 years), having high clinical suspicion of PE, underwent CTPA over a 2 year period. Chest x-ray, arterial blood gas (ABG) analysis, echocardiography were done in all patients. All patients underwent at least one other imaging examination besides CTPA: ventilation perfusion scan, Doppler ultrasound or compression ultrasound (for DVT). All patients were followed for 3 months after completion of the diagnostic work up at baseline. The final diagnosis was achieved by a combination of clinical, imaging, and laboratory analysis, after adequate imaging, laboratory tests, and follow up. Result: CTPA helped correctly identify 29 of 30 patients with PE. In the remaining 20 patients (with no evidence of PE), CT-PA provided additional information (that suggested or confirmed alternate clinical diagnosis) in 15 patients (75%): pleural effusion (n=8), mediastinal or hilar lymphadenopathy (6), pneumonia/airspace consolidation (5), atelectasis/collapse (2), aspergilloma (1), malignancy (1), and others (2). Conclusion: CT-PA is highly specific and sensitive for diagnosis of PE. In addition, in a majority of patients who do not have PE, it also provides important ancillary additional information and helps in making an alternative clinical diagnosis.