An Observational Study Evaluating the Performance of LENT Score in the Selected Population of Malignant Pleural Effusion from Lung Adenocarcinoma in Singapore.

BACKGROUND: Patients with malignant pleural effusion (MPE) secondary to lung cancer have been associated with poor prognosis historically. LENT score developed to risk-stratify unselected patients with MPE predicts prognosis of < 6 months in patients with lung cancer. OBJECTIVE: To assess the performance of LENT score in predicting prognosis in selected population of MPE secondary to lung adenocarcinoma alone. METHODS: A retrospective observational study was conducted by reviewing the medical records of patients managed for MPE in the year 2012. RESULTS: Seventy patients with lung adenocarcinoma presenting with MPE were studied. The median (range) LENT score at initial diagnosis was 5 (2-7), and the median survival 7.9 (0.13-40) months. Thirty-nine patients received epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKIs). The median LENT score and median survival was 4 (2-7) and 14.4 months, respectively, in this group. Those in high-risk category by LENT in this group (n = 19) had a median survival and 6-month survival of 17.4 months and 73.6%, respectively. Thirty-one patients were treated with conventional chemotherapy. The median LENT score and median survival was 5 (2-7) and 4.1 (0.13-34.3) months, respectively, in this group. The median survival and 6-month survival rate in patients in high-risk category and moderate-risk category by LENT score was 6.2 months and 52.7%, and 11.4 months and 70.5%, respectively. CONCLUSION: LENT score underestimates prognosis in patients having MPE secondary to lung adenocarcinoma. This disparity particularly applies to the lung adenocarcinoma patients carrying EGFR mutation. Hence, LENT score may not be applicable to, or may need modification before applying to such patients.

Experience With the Use of Single-Use Disposable Bronchoscope in the ICU in a Tertiary Referral Center of Singapore.

BACKGROUND: Flexible bronchoscopy is performed frequently in intensive care units (ICUs) for various indications using the reusable conventional bronchoscope (CB). Recently, "single-use disposable bronchoscope" (SB) was introduced into the health care industry. The purpose of this study was to compare the utility of SB with CB in ICU. METHODS: A retrospective review of medical records of patients undergoing flexible bronchoscopy in the ICUs in the year 2015. RESULTS: Ninety-three patients undergoing flexible bronchoscopy in the ICU were studied. Eighty-three bronchoscopies were performed using SB in 71 patients, and 24 using CB in 22 patients. The most common indications for using the SB were percutaneous tracheostomy [n=37 (44.6%)] in neuro-ICU, followed by collecting specimens for microbiological evaluation [n=20 (24.1%)] in the medical ICU. Airway inspection [8 (9.6%)], bronchial toilet [8 (9.6%)], hemoptysis [5 (6%)], and intubation [3 (3.6%)] were other indications for which SB was used. Microbiological yield of SB was 70% (14/20) versus 70% (7/10) for CB (P=1.0). The median interval between identification of the need-to-start of the procedure was shorter with SB (10 min) versus CB (66 min, P=0.01), whereas the cost was similar, SGD450 versus SGD472, respectively. In addition, less (3 personnel) were needed to perform bronchoscopy with SB versus 5 with CB with additional resource sparing effect in terms of nursing personnel having to wheel the CB equipment to ICU. CONCLUSIONS: SB is equivalent in performance to CB in ICU. In addition, the SB may confer clinical, economic, and logistical advantages over the CB.

Significance of coexistent granulomatous inflammation and lung cancer.

AIMS: Coexistence of lung cancer and granulomatous inflammation in the same patient confuses clinicians. We aimed to document the prevalence, clinicopathological features, treatment outcomes and prognosis in patients with coexisting granulomatous inflammation undergoing curative lung resection for lung cancer, in a tuberculosis (TB)-endemic country. METHODS: An observational cohort study of patients with lung cancer undergoing curative resection between 2012 and 2015 in a tertiary centre in Singapore. RESULTS: One hundred and twenty-seven patients underwent lung resection for cancer, out of which 19 (14.9%) had coexistent granulomatous inflammation in the resected specimen. Median age was 68 years and 58.2% were males. Overall median (range) survival was 451 (22-2452) days. Eighteen (14%) patients died at median duration of 271 days after surgery. The postsurgery median survival for those alive was 494 (29-2452) days in the whole group. Subgroup analysis did not reveal any differences in age, gender, location of cancer, radiological features, type of cancer, chemotherapy, history of TB or survival in patients with or without coexistent granulomatous inflammation. CONCLUSIONS: Incidental detection of granulomatous inflammation in patients undergoing lung resection for cancer, even in a TB-endemic country, may not require any intervention. Such findings may be due to either mycobacterial infection in the past or 'sarcoid reaction' to cancer. Although all patients should have their resected specimen sent for acid-fast bacilli culture and followed up until the culture results are reported, the initiation of the management of such patients as per existing lung cancer management guidelines does not affect their outcome adversely.

Differentiating Malignant from Tubercular Pleural Effusion by Cancer Ratio Plus (Cancer Ratio: Pleural Lymphocyte Count).

Background. We performed prospective validation of the cancer ratio (serum LDH : pleural ADA ratio), previously reported as predictive of malignant effusion retrospectively, and assessed the effect of combining it with "pleural lymphocyte count" in diagnosing malignant pleural effusion (MPE). Methods. Prospective cohort study of patients hospitalized with lymphocyte predominant exudative pleural effusion in 2015. Results. 118 patients, 84 (71.2%) having MPE and 34 (28.8%) having tuberculous pleural effusion (TPE), were analysed. In multivariate logistic regression analysis, cancer ratio, serum LDH : pleural fluid lymphocyte count ratio, and "cancer ratio plus" (ratio of cancer ratio and pleural fluid lymphocyte count) correlated positively with MPE. The sensitivity and specificity of cancer ratio, ratio of serum LDH : pleural fluid lymphocyte count, and "cancer ratio plus" were 0.95 (95% CI 0.87-0.98) and 0.85 (95% CI 0.68-0.94), 0.63 (95% CI 0.51-0.73) and 0.85 (95% CI 0.68-0.94), and 97.6 (95% CI 0.90-0.99) and 94.1 (95% CI 0.78-0.98) at the cut-off level of >20, >800, and >30, respectively. Conclusion. Without incurring any additional cost, or requiring additional test, effort, or time, cancer ratio maintained and "cancer ratio plus" improved the specificity of cancer ratio in identifying MPE in the prospective cohort.

Water pipes and E-cigarettes: new faces of an ancient enemy.

In a world grappling with tobacco addiction, the hookah (water-pipe) and the electronic cigarette (e-cigarette) are creating new problems. Apart from posing the inherent danger of nicotine addiction, they both seem to be wolves cloaked in the sheep-skin of consumer-perceived safety, at least in comparison to the cigarette. However it seems that the e-cigarette may have a role in a nicotine-replacement therapy. There has been a wave of interest around the world in analysing these phenomena. The following review discusses the current data regarding the hookah and the e-cigarette. A PubMed, Medline and Google search using the keywords'sheesha', 'hookah', water-pipe', 'electronic cigarette', 'e-cigarette', 'vapers' was carried out.The studies carried out between 2007-2013 were included in this review. Information available in the public domain on internet websites was included to study the perception of the lay consumer regarding the hookah and the e-cigarette.

Fatal nitrofurantoin lung.

Nitrofurantoin is a drug commonly used for urinary tract infections. It acts by damaging bacterial DNA. It is given in dose of 50-100 mg orally and is generally considered a safe drug but has occasionally been known to cause pulmonary toxicity which is usually reversible and only rarely fatal. We present a case of an elderly lady receiving nitrofurantoin for her urinary tract infection who developed sudden acute lung injury to which she finally succumbed within a few weeks.

Disseminated tuberculosis with immune thrombocytopenic purpura.

Tuberculosis has a variety of hematological manifestations. Immune thrombocytopenic purpura is an uncommon manifestation of tuberculosis. We present a case of disseminated tuberculosis with isolated thrombocytopenia. While TB granulomas in the bone marrow can themselves cause hematological abnormalities, persistent thrombocytopenia refractory to anti-TB therapy may be ITP associated with TB.

Primary immune deficiency in the intensive care unit: It is never too late to diagnose and treat.

Common variable immunodeficiency disorders (CVIDs), a heterogeneous group of primary immune deficiencies, can present at all age. Our patient with a hitherto undiagnosed CVID, symptomatic since middle ages, presented with severe pneumonia. Specific management of his CVID in addition to standard therapy was life-saving.