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.

Dissecting an Outbreak: A Clinico-epidemiological Study of Nipah Virus Infection in Kerala, India, 2018.

BACKGROUND: An outbreak of Nipah virus infection was confirmed in Kerala, India in May 2018. Five out of 23 cases including the first laboratory-confirmed case were treated at Baby Memorial Hospital (BMH), Kozhikode. The study describes the clinical characteristics and epidemiology of the Nipah virus outbreak at Kozhikode during May 2018. OBJECTIVE: To study the clinical and epidemiological profile of Nipah virus epidemic that occurred in Kerala in May 2018. METHODS: A collaborative team of physicians and epidemiologists from BMH, Medical College Hospital (MCH) Kozhikode and from the Indian Medical Association (IMA) conducted this study. The clinical and exposure history and the data on outbreak response were gathered from hospital medical records and through interviewing patient relatives and health workers using questionnaires. RESULTS: It was identified that out of the 23 patients with Nipah virus infection, 21 (91.3%) expired. Out of the 21 patients, 18 tested positive for Nipah virus by Real Time polymerase chain reaction (RT-PCR). It has been found that only the index case was infected in the community from fruit bats. Rest of the cases were due to transmission of the virus at three public hospitals. Median age was 45 years. 65% of them were males. Median incubation period was 9.5 days. Fever (100%), altered sensorium (84.2%), tachycardia (63.1%), hypertension (36.8%), segmental myoclonus (15.7%), segmental sweating (15.7%) and shortness of breath (73.6%) were common features. Mean duration of illness was 6.4 days. CONCLUSION: The rapid spread of infection uncovered the miserable state of health care system in implementing infection control measures. The case fatality and the socio-economic burden warrant developing appropriate treatments, vaccines and diagnostics.

Aspergillus sensitization in bronchial asthma: A separate phenotype.

Background: Bronchial asthma is one of the common chronic respiratory illnesses worldwide, with a global disease burden that affects approximately 300 million individuals. It affects 5-10% of the population in developed countries. India constitutes approximately one-tenth of the global disease burden, where an estimated 7 million children are affected by this illness. Airway hyperresponsiveness or bronchial hyperreactivity in asthma is an exaggerated response to numerous exogenous and endogenous stimuli. In India, the most important endogenous stimuli is considered to be fungal antigens from the genus, Aspergillus. Positive skin reactions to Aspergillus fumigatus among individuals with atopic asthma is 10 to 20%; however, a causal relationship is yet to be established. A separate entity, termed "severe asthma with fungal sensitivity," is often used to describe milder allergic reactions to fungal aeroallergens that has fungal sensitization as the starting point of pathogenesis than allergic bronchopulmonary aspergillosis. Methods: A total of 57 patients with bronchial asthma were prospectively enrolled and evaluated for Aspergillus sensitization and its impact on asthma control. Results: Symptoms were well controlled in a majority of patients (57.89%) and partly controlled in 14.04%. Uncontrolled symptoms were observed in only 28.07% of patients. The proportion of patients with uncontrolled symptoms was higher among patients who were sensitized (45.00%) compared with patients who were not sensitized (18.92%). The proportion of patients with well-controlled symptoms was higher in individuals who were not sensitized compared with individuals who were sensitized (62.16% versus 50.00%). Conclusion: The severity of asthma was associated with fungal sensitization, with sensitization to Aspergillus as a part of the pathogenesis. Aspergillus sensitization is significantly associated with bronchiectasis, even in the absence of clinical features.

Curious case of primary pulmonary mucoepidermoid carcinoma.

Pulmonary mucoepidermoid carcinoma (MEC) is an uncommon tumor constituting only 0.1% to 0.2% of all lung carcinoma. It is classified under "salivary gland type" tumors in the World Health Organization (WHO) classification of lung cancers. It generally carries a better prognosis than the more common small cell and nonsmall cell lung carcinomas. It is pathologically classified into high-grade and low-grade tumors. High-grade tumors are usually unresectable at presentation. However, surgery is the mainstay of treatment, which aims at surgically negative margins for a complete cure. In our patient, pulmonary MEC presented with intrathoracic mass with pericardial effusion. It came out to be low-grade neoplasm, which was treated with platinum-based doublet chemotherapy and responded well with near-total disappearance of tumor, like a vanishing lung tumor.

Identification of pheromone-carrying protein in the preorbital gland post in the endangered Indian male Blackbuck Antelope cervicapra L.

In mammals, a low molecular mass protein (17-20 KDa) reported from the pheromone sources such as urine, saliva, glandular secretion, etc., as ligand-carrier (pheromone carrier) has been associated with chemo-communication. Since the preorbital gland post is one of the major pheromone sources in Indian Blackbuck, an endangered species, we assumed that it possibly contains low molecular mass protein for chemical communication. Hence, we investigated the preorbital gland post in territorial and non-territorial male blackbucks for such low molecular mass proteins adopting SDS-PAGE and LC-MS/MS analysis. The total content of protein was higher in the post of territorial males than non-territorial males of adult and sub-adult. In fact, the protein profiles such as 17, 21, 25, 42 and 61 kDa were noted in the gland secretion of territorial and non-territorial males. The intensity of the 17 kDa protein band was higher in territorial males than non-territorial males. In-gel trypsin digestion of the 17 kDa band was processed and subjected to LC-MS/MS and SEQUEST analyses. The results of LC-MS/MS and SEQUEST search showed the presence of α(2u)-globulin in the 17 kDa band. In addition, the identified α(2u)-globulin sequence possessed GDW residues, which are the characteristic signature for lipocalin family. Since the α(2u)-globulin has been reported from the pheromone-carrying proteins in some mammals, this protein may carry the volatiles (pheromone compounds) in male Blackbucks preorbital gland to evoke the scent marking for maintaining territoriality (home range) and attraction towards female, through the secretion of glandular protein.

Effect of timing of surgery on neurological outcome and survival in metastatic spinal cord compression.

PURPOSE: Metastatic spinal cord compression (MSCC) requires expeditious treatment. While there is no ambiguity in the literature about the urgency of care for patients with MSCC, the effect of timing of surgical intervention has not been investigated in detail. The objective of our study was to investigate whether or not the 'timing of surgery' is an important factor in survival and neurological outcome in patients with MSCC. METHODS: All patients with MSCC presenting to our unit from October 2005 to March 2010 were included in this study. Patients were divided into three groups-those who underwent surgery within 24 h (Group 1, n = 45), between 24 and 48 h (Group 2, n = 23) and after 48 h (Group 3, n = 53) from acute presentation of neurological symptoms. The outcome measures studied were neurological outcome (change in Frankel grade post-operatively), survival (survival rate and median survival in days), incidence of infection, length of stay and complications. RESULTS: Patients' age, gender, revised Tokuhashi score, level of spinal metastasis and primary tumour type were not significantly different between the three groups. Greatest improvement in neurology was observed in Group 1, although not significantly when compared against Group 2 (24-48 h; (p = 0.09). When comparisons of neurological outcome were performed for all patients having surgery within 48 h (Groups 1 and 2) versus after 48 h (Group 3), the Frankel grade improvement was significant (p = 0.048) favouring surgery within 48 h of presentation. There was a negative correlation (-0.17) between the delay in surgery and the immediate neurological improvement, suggesting less improvement in those who had delayed surgery. There was no difference in length of hospital stay, incidence of infection, post-operative complications or survival between the groups. CONCLUSIONS: Our results show that surgery should be performed sooner rather than later. Furthermore, earlier surgical treatment within 48 h in patients with MSCC resulted in significantly better neurological outcome. However, the timing of surgery did not influence length of hospital stay, complication rate or patient survival.

Gemella haemolysans spondylodiscitis: a report of two cases.

We report on two cases of infective spondylodiscitis caused by Gemella haemolysans in otherwise healthy patients. This organism has only rarely been identified as a cause of bone and joint infection, with only two previous reports of infective spondylodiscitis. We describe the clinical features, investigations and treatment options.

Diversity and community structure of butterfly of Arignar Anna Zoological Park, Chennai, Tamil Nadu.

Investigation was carried out on the diversity of butterfly fauna in selected localities of conservation and breeding center of Arignar Anna Zoological Park (AAZP), Chennai, Tamil Nadu. Atotal of 56 species were recorded, 15 of them belonged to Pieridae, 12 Nymphalidae, 9 Satyridae, 8 Papilionidae, 7 Danaidae, 3 Lycaenidae and 1 species each belonged to the families Acraeidae and Hesperidae. Qualitatively and quantitatively Pieridae family were comparatively dominant than that of other families. The notable addition to the 25 more species listed during this observation were compared to previous field survey. Comparison of butterfly species distribution between the different localities revealed that butterfly species richness was higher at mountain region with 52 species and lowest of 25 species at public visiting areas. Visitor's activities may be that reason for effects on butterfly distribution and lack of vegetation. Each five endemic and protected species (i.e. endangered) listed under the Wildlife (Protection)Act were highlighted greater conservation importances of the AAZP. It is suggest that butterfly species diversity generally increase with increase in vegetation and declines with the increase in disturbance.

Can interepicondylar distance predict joint line position in primary and revision knee arthroplasty?

Restoration of the position of the prosthetic joint line (JL) to the same level as the original JL is a challenging problem in primary adn revision knee arthroplasty, and there is no reliable method for achieving this objective. We hypothesized that there is a constant ratio between the interepicondylar distance (IED) and the perpendicular distance from this interepicondylar line to the JL and analyzed 100 computed tomography scans of the knee to study this relationship. The IED and the perpendicular distance from this interepicondylar line to the JL was measured using both the clinical epicondylar axis (CEA) and the surgical epicondylar axis (SEA). Results showed that the ration between the IED adn the perpendicular distance from the interepicondylar line to the JL was 3.0 using the CEA and 3.3 using the SEA. The ratio was found to be constant, irrespective of the patient's sex or height. We suggest using the CEA because of the ease in localizing epicondyle peaks and conclude that the position of the JL from the interepicondylar line is one-third the IED using the CEA. This will prove to be a valuable aid in restoring the JL position during knee arthroplasty.

Zooplankton diversity and physico-chemical conditions in three perennial ponds of Virudhunagar district, Tamilnadu.

Plankton diversity and physico-chemical parameters are an important criterion for evaluating the suitability of water for irrigation and drinking purposes. In this study we tried to assess the zooplankton species richness, diversity and evenness and to predict the state of three perennial ponds according to physico-chemical parameters. A total of 47 taxa were recorded: 24 rotifers, 9 copepods, 8 cladocerans, 4 ostracods and 2 protozoans. More number of zooplankton species were recorded in Chinnapperkovil pond (47 species) followed by Nallanchettipatti (39 species) and Kadabamkulam pond (24 species). Among the rotifers, Branchionus sp. is abundant. Diaphanosoma sp. predominant among the cladocerans. Among copepods, numerical superiority was found in the case of Mesocyclopes sp. Cypris sp. repeated abundance among ostracoda. Present study revealed that zooplankton species richness (R1 and R2) was comparatively higher (R1: 4.39; R2: 2.13) in Chinnapperkovil pond. The species diversity was higher in the Chinnapperkovil pond (H': 2.53; N1: 15.05; N2: 15.75) as compared to other ponds. The water samples were analyzed for temperature, pH, electrical conductivity alkalinity salinity, phosphate, hardness, dissolved oxygen and biological oxygen demand. Higher value of physico-chemical parameters and zooplankton diversity were recorded in Chinnapperkovil pond as compared to other ponds. The zooplankton population shows positive significant correlation with physico-chemical parameters like, temperature, alkalinity phosphate, hardness and biological oxygen demand, whereas negatively correlated with rainfall and salinity. The study revealed that the presence of certain species like, Monostyla sp., Keratella sp., Lapadella sp., Leydigia sp., Moinodaphnia sp., Diaptomus sp., Diaphanosoma sp., Mesocyclopes sp., Cypris sp. and Brachionus sp. is considered to be biological indicator for eutrophication.

Treatment of idiopathic club foot using the Ponseti method. Initial experience.

We report our initial experience of using the Ponseti method for the treatment of congenital idiopathic club foot. Between November 2002 and November 2004 we treated 100 feet in 66 children by this method. The standard protocol described by Ponseti was used except that, when necessary, percutaneous tenotomy of tendo Achillis were performed under general anaesthesia in the operating theatre and not under local anaesthesia in the out-patient department. The Pirani score was used for assessment and the mean follow-up time was 18 months (6 to 30). The results were also assessed in terms of the number of casts applied, the need for tenotomy of tendo Achillis and recurrence of the deformity. Tenotomy was required in 85 of the 100 feet. There was a failure to respond to the initial regimen in four feet which then required extensive soft-tissue release. Of the 96 feet which responded to initial casting, 31 (32%) had a recurrence, 16 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The remaining 15 required extensive soft-tissue release. Poor compliance with the foot-abduction orthoses (Denis Browne splint) was thought to be the main cause of failure in these patients.

Using a custom mega prosthesis to treat hydatidosis of bone: a report of 3 cases.

Three cases of hydatidosis of bone with pathological fracture were treated by wide resection, custom mega prosthesis replacement, and chemotherapy. Two patients were females and one was male, with a mean age of 47 years (range, 38-55 years). Two of them had a pathological fracture of the proximal femur, and one had a pathological fracture of the distal femur. All patients were treated postoperatively with albendazole 400 mg, twice daily, for 12 weeks. During the mean follow-up period of 4.5 years, no recurrence of Echinococcal infection was noticed. The use of the custom mega prosthesis technique has not been reported elsewhere, and hydatid disease of the bone can now be considered an extended indication for custom mega prosthesis in addition to its application in surgery for tumours and massive trauma.

The Saddle prosthesis in periacetabular tumours.

The Saddle endoprosthesis provides a means of establishing a stable and mobile articulation between the femur and a partially resected pelvis. Six patients with malignant or aggressive benign bone tumours underwent resection and replacement with custom-made Saddle endoprosthesis. Wide margin was achieved in four cases and marginal margin in two. Follow-up ranged from 24 to 41 months. All the six patients were then alive, five being disease-free. One patient developed deep infection and local recurrence necessitating removal of the prosthesis. The functional results were either excellent or good in five patients.

Limb salvage in distal tibial osteosarcoma using a custom mega prosthesis.

We have assessed the oncological and functional results of limb salvage surgery using a custom-made endoprosthetic replacement in six patients (mean age 17 years) with distal tibial osteosarcoma (stage IIB). A wide margin excision was possible in three, marginal in two and contaminated in one. Skeletal reconstruction was performed using a locally designed and manufactured custom-made distal tibial and ankle replacement prosthesis. Two patients developed local recurrence and one necrosis of the flap and deep infection. In three in whom the prosthesis remained in place the mean functional score according to the rating system of the Musculoskeletal Tumour Society was 24.3/30. In carefully selected patients limb salvage with prosthetic replacement is possible for distal tibial osteosarcomas.

A giant schwannoma of cauda equina.

A case of giant schwannoma occurring in a woman 23 years of age with deformity of the foot developing at the age of five years is reported. The gross radiological changes of increased interpedicular distance and erosion of the posterior surface of the vertebra suggested the massive size of the tumour (6'' x 21/2'' x 11/2''). Successful surgical excision of such a large size schwannoma has not been reported previously.