Pleural effusion guidelines from ICS and NCCP Section 1: Basic principles, laboratory tests and pleural procedures.

Pleural effusion is a common problem in our country, and most of these patients need invasive tests as they can't be evaluated by blood tests alone. The simplest of them is diagnostic pleural aspiration, and diagnostic techniques such as medical thoracoscopy are being performed more frequently than ever before. However, most physicians in India treat pleural effusion empirically, leading to delays in diagnosis, misdiagnosis and complications from wrong treatments. This situation must change, and the adoption of evidence-based protocols is urgently needed. Furthermore, the spectrum of pleural disease in India is different from that in the West, and yet Western guidelines and algorithms are used by Indian physicians. Therefore, India-specific consensus guidelines are needed. To fulfil this need, the Indian Chest Society and the National College of Chest Physicians; the premier societies for pulmonary physicians came together to create this National guideline. This document aims to provide evidence based recommendations on basic principles, initial assessment, diagnostic modalities and management of pleural effusions.

Impact of Comorbidity Scores on the Overall Survival of Patients With Advanced Non-small Cell Lung Cancer: A Real-World Experience From Eastern India.

Introduction Lung cancer is the most common cancer, and it is the leading cause of cancer-related death. Smoking is the most common risk factor for the development of lung cancer. There is a lack of data on the comorbidities and outcomes of advanced non-small cell lung cancer (NSCLC) in the eastern part of India. This prospective study evaluated the impact of comorbidity scores on overall survival (OS) in these patients. Method This prospective cohort study was conducted on newly diagnosed advanced NSCLC patients between June 2020 and April 2021. These patients were given platinum-based doublet chemotherapy guided by histology and targeted therapy based on molecular studies. Comorbidities were assessed using the Charlson Comorbidity Index (CCI), Simplified Comorbidity Score (SCS), and Adult Comorbidity Evaluation-27 (ACE-27). The outcome assessed was OS. Overall survival was calculated in days from the date of start of anticancer therapy to the date of last follow-up or date of death. All enrolled patients were followed at regular intervals whenever they visited the hospital and telephonically until April 2022. The patients who were alive on April 30, 2022, were censored. The survival probability and median OS were calculated by Kaplan-Meier analysis, and group differences in comorbidity scores were analyzed with the log-rank test. A Cox proportional hazard analysis was performed to look for factors affecting overall survival. Results A total of 114 patients were enrolled in the study period, and the mean age of patients was 56.54 ± 11.03 years. Most of the patients were males (68.4%), and 52.6% were smokers. Adenocarcinoma was the most common histology (73.7%), followed by squamous cell carcinoma (25.4%). The median OS was 127 days (95% CI, 60-193 days). 33.4% of the patients had a CCI score of 0, a CCI score of 1 was seen in 57%, and ≥2 scores in 9.6%. SCS scores ≤9 and >9 were seen in 92.1% and 7.9% of patients, respectively. The ACE-27 score was none in 41 subjects, mild in 59, moderate in 12, and 2 NSCLC subjects had severe ACE-27 scores. The median OS for patients with a CCI score of 0 was 275 days (95% CI, 7-543 days), 114 days (95% CI, 85-142 days) for subjects with a CCI score of 1, and 402 days (95% CI, 0-844 days) for patients with a CCI score ≥2 (log-rank p = 0.215). Individuals with an SCS score ≤9 had a median OS of 175 days (95% CI, 91-258 days), and the median OS was 92 days (95% CI, 80-103 days) for patients with an SCS score >9 (log-rank p = 0.302). Median OS of the patients with ACE-27 score 0,1,2,3 were 297 days (95% CI, 76- 517 days), 117 days (95% CI, 81-152 days), 87 days (95% CI, 49-124 days) and 66 days, respectively (log-rank p=0.457). There was no statistical significance between comorbidity scores and OS. Worse OS was independently associated with poor performance status Eastern Cooperative Oncology Group (ECOG) ≥2 (hazard ratio [HR] 3.266; 95% CI 1.785-5.978; p = 0.00), neutrophil-to-lymphocyte ratio (NLR) <3 (HR, 2.35 95% CI 1.18-4.702; p = 0.015) and patients who were given compassionate tyrosine kinase inhibitors (TKIs) (HR, 7.396 95% CI 3.531-15.490; p = 0.000). Conclusions In our study, the advanced NSCLC patients who were given chemotherapy or oral TKIs showed no significant influence of comorbidities on overall survival. Factors independently associated with the worst survival were poor performance status (ECOG ≥ 2), NLR < 3, and patients who were given TKIs on a compassionate basis.

Comparison of Diagnostic Yield and Complications in Ultrasound-Guided Closed Pleural Biopsy Versus Thoracoscopic Pleural Biopsy in Undiagnosed Exudative Pleural Effusion.

Introduction Malignancy, tuberculosis, and non-tubercular pleural infections account for most exudative pleural effusion. Pleural fluid cytology, biochemical tests and even pleural fluid cell block studies may fail to yield a diagnosis in certain cases. Medical thoracoscopy is the gold standard for the diagnosis of unexplained pleural effusions. However, access to medical thoracoscopy may be limited, particularly in developing countries. Also, certain patients may not be fit to undergo the procedure because of medical conditions. An ultrasound-guided pleural biopsy is an option in such conditions. The present study is intended to compare the diagnostic yield and complications of both methods of pleural biopsy in undiagnosed exudative pleural effusion under a randomized controlled trial. Method After fulfilling all the inclusion criteria, participants were randomized to either ultrasound-guided closed pleural biopsy or thoracoscopic-guided pleural biopsy groups. The primary outcome was to compare the diagnostic yield of ultrasound-guided Tru-Cut® (Newtech Medical Devices, Faridabad, India) closed pleural biopsy versus thoracoscopic pleural biopsy, and the secondary outcomes were to compare the complications rate, duration of the procedure, and hospital stay in the patients undergoing ultrasound-guided pleural biopsy versus thoracoscopic pleural biopsy, and predictors of a positive biopsy result in both groups. Result A total of 118 patients with pleural effusion were screened; 39 of them who were eligible, randomized into the ultrasound group (20 patients) and the thoracoscopic group (19 patients). The median age of participants was 53.5 (50-58) years and 55 (45-64) years in the ultrasound and thoracoscopic groups, respectively. Pleural fluid cell count, protein, adenosine deaminase (ADA), and lactate dehydrogenase (LDH) were similar in both groups, although pleural fluid glucose was low in the ultrasound group. Diagnostic yield was 90% (18/20) and 94.7% (18/19) in the ultrasound and thoracoscopic groups, respectively, which was statistically non-significant (p=0.963). The median duration of hospital stay was 9.5 (5.3-27) days and 15 (12-22) days in ultrasound and thoracoscopic groups respectively. The thoracoscopic group had a more prolonged stay compared to the ultrasound group, but it was statistically non-significant (p=0.09). The duration of the procedure was significantly longer in the thoracoscopic group 90 (85-105) minutes, in comparison to ultrasound 47.5 (41.3-55) minutes (p=0.001). No major complications were seen in both groups. Subcutaneous emphysema was the most common complication in the thoracoscopic group (10%), followed by hemorrhage (5.3%), and respiratory failure (5.3%). Hypotension was the only complication in the ultrasound group (5%). The rate of complications was significantly higher in the thoracoscopic group (p<0.01). Conclusion Ultrasound-guided closed pleural biopsy is as good as thoracoscopic pleural biopsy in undiagnosed exudative pleural effusion. It was associated with a shorter procedure duration, a shorter hospital stay, and fewer complications as compared to thoracoscopic biopsy. Both the procedures were safe in experienced hands and a hospital setup, but the thoracoscopic pleural biopsy was associated with complications.

Prophylactic Role of Ivermectin in Severe Acute Respiratory Syndrome Coronavirus 2 Infection Among Healthcare Workers.

Introduction Healthcare workers (HCWs) are vulnerable to getting infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Preventing HCWs from getting infected is a priority to maintain healthcare services. The therapeutic and preventive role of ivermectin in coronavirus disease 2019 (COVID-19) is being investigated. Based on promising results of in vitro studies of oral ivermectin, this study was conducted with the aim to demonstrate the prophylactic role of oral ivermectin in preventing SARS-CoV-2 infection among HCWs at the All India Institute of Medical Sciences (AIIMS) Bhubaneswar. Methods A prospective cohort study was conducted at AIIMS Bhubaneswar, which has been providing both COVID and non-COVID care since March 2020. All employees and students of the institute who provided written informed consent participated in the study. The uptake of two doses of oral ivermectin (300 µg/kg/dose at a gap of 72 hours) was considered as exposure. The primary outcome of the study was COVID-19 infection in the following month of ivermectin consumption, diagnosed as per Government of India testing criteria (real-time reverse transcriptase polymerase chain reaction [RT-PCR]) guidelines. The log-binomial model was used to estimate adjusted relative risk (ARR), and the Kaplan-Meier failure plot was used to estimate the probability of COVID-19 infection with follow-up time. Results Of 3892 employees, 3532 (90.8%) participated in the study. The ivermectin uptake was 62.5% and 5.3% for two doses and single dose, respectively. Participants who took ivermectin prophylaxis had a lower risk of getting symptoms suggestive of SARS-CoV-2 infection (6% vs 15%). HCWs who had taken two doses of oral ivermectin had a significantly lower risk of contracting COVID-19 infection during the following month (ARR 0.17; 95% CI, 0.12-0.23). Females had a lower risk of contracting COVID-19 than males (ARR 0.70; 95% CI, 0.52-0.93). The absolute risk reduction of SARS-CoV-2 infection was 9.7%. Only 1.8% of the participants reported adverse events, which were mild and self-limiting. Conclusion Two doses of oral ivermectin (300 µg/kg/dose given 72 hours apart) as chemoprophylaxis among HCWs reduced the risk of COVID-19 infection by 83% in the following month. Safe, effective, and low-cost chemoprophylaxis has relevance in the containment of pandemic alongside vaccine.

Small Sample Lung Biopsy Findings in Patients With Clinicoradiologic Suspicion of Pulmonary Venoocclusive Disease-Pulmonary Capillary Hemangiomatosis.

Pulmonary venoocclusive disease (PVOD) and pulmonary capillary hemangiomatosis (PCH) form a sinister subgroup of pulmonary arterial hypertension where the predominant pathology lies in the pulmonary veins and capillaries, thus making the use of pulmonary vasodilators potentially dangerous in these patients. Radiologically, the presence of centrilobular nodules, interlobular septal thickening, and significant mediastinal adenopathy are useful in identifying this subgroup from patients with pulmonary arterial hypertension. The combination of all three has a sensitivity of 66% and a specificity of 100% in identifying this subgroup. We present a case series of 3 patients who were radiologically suspected to have PVOD or PCH and in whom pathologic corroborative evidence suggestive of PVOD and PCH was found in small sample lung biopsy specimens: transbronchial lung biopsy (2 patients) and trucut biopsy of the postmortem lung (1 patient). Histopathology, in our patients, showed pulmonary arteriole smooth muscle proliferation and narrowing, capillary proliferation, intimal fibrosis of pulmonary veins and arteries, interstitial fibrosis, interstitial foreign body type of multinucleate giant cells, and aggregates of alveolar and interstitial hemosiderophages. In conclusion, histopathology of small lung biopsy samples can provide useful corroborative pathologic evidence in patients with clinicoradiologic suspicion of PVOD-PCH.