NCCP-ICS joint consensus-based clinical practice guidelines on medical thoracoscopy

ABSTRACT

Medical Thoracoscopy (MT) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. The aim of the study was to provide evidence-based information regarding all aspects of MT, both as a diagnostic tool and therapeutic aid for pulmonologists across India. The consensus-based guidelines were formulated based on a multistep process using a set of 31 questions. A systematic search of published randomized controlled clinical trials, open labelled studies, case reports and guidelines from electronic databases, like PubMed, EmBase and Cochrane, was performed. The modified grade system was used (1, 2, 3 or usual practice point) to classify the quality of available evidence. Then, a multitude of factors were taken into account, such as volume of evidence, applicability and practicality for implementation to the target population and then strength of recommendation was finalized. MT helps to improve diagnosis and patient management, with reduced risk of post procedure complications. Trainees should perform at least 20 medical thoracoscopy procedures. The diagnostic yield of both rigid and semirigid techniques is comparable. Sterile-graded talc is the ideal agent for chemical pleurodesis. The consensus statement will help pulmonologists to adopt best evidence-based practices during MT for diagnostic and therapeutic purposes.

Evaluation of practice change following SAFE obstetric courses in Tanzania: a prospective cohort study

Anaesthesia has been shown to contribute disproportionately to maternal mortality in low-resource settings. This figure exceeds 500 per 100,000 live births in Tanzania, where anaesthesia is mainly provided by non-physician anaesthetists, many of whom are working as independent practitioners in rural areas without any support or opportunity for continuous medical education. The three-day Safer Anaesthesia from Education (SAFE) course was developed to address this gap by providing in-service training in obstetric anaesthesia to improve patient safety. Two obstetric SAFE courses with refresher training were delivered to 75 non-physician anaesthetists in the Mbeya region of Tanzania between August 2019 and July 2020. To evaluate translation of knowledge into practice, we conducted direct observation of the SAFE obstetric participants at their workplace in five facilities using a binary checklist of expected behaviours, to assess the peri-operative management of patients undergoing caesarean deliveries. The observations were conducted over a 2-week period at pre, immediately post, 6-month and 12-month post-SAFE obstetric training. A total of 320 cases completed by 35 participants were observed. Significant improvements in behaviours, sustained at 12 months after training included: pre-operative assessment of patients (32% (pre-training) to 88% (12 months after training), p < 0.001); checking for functioning suction (73% to 85%, p = 0.003); using aseptic spinal technique (67% to 100%, p < 0.001); timely administration of prophylactic antibiotics (66% to 95%, p < 0.001); and checking spinal block adequacy (32% to 71%, p < 0.001). Our study has demonstrated positive sustained changes in the clinical practice amongst non-physician anaesthetists as a result of SAFE obstetric training. The findings can be used to guide development of a checklist specific for anaesthesia for caesarean section to improve the quality of care for patients in low-resource settings.

The Role of Surgery in Patients with COVID-19-Related Thoracic Complications

Objective

Patients with several thoracic complications induced by SARS-CoV-2 infection may benefit from surgery, but its role in this condition is largely unknown, and many surgeons’ advice against any surgical referrals. Our aim is to investigate the efficacy and safety of surgery in COVID-19 patients with thoracic complications requiring surgery.

Methods

We designed a multicenter observational study, involving nine thoracic surgery departments, evaluating patients who developed thoracic complications in hospital, surgically managed from March 1, 2020, to May 31, 2021. An overall 30-day mortality was obtained by using the Kaplan–Meier method. Multivariable Cox regression model and logistic models were applied to identify the variables associated with mortality and postoperative complications.

Results

Among 83 patients, 33 (40%) underwent surgery for complicated pneumothorax, 17 (20.5%) for pleural empyema, 13 (15.5%) for hemothorax, 8 (9.5%) for hemoptysis, 5 patients (6%) for lung abscess, 4 (5%) for infected pneumatoceles, and 3 (3.5%) for other causes. Within 30 days of surgery, 60 patients (72%) survived. At multivariable analysis, age (HR 1.05 [95% CI, 1.01, 1.09], p = 0.022), pulmonary hypertension (HR 3.98 [95% CI, 1.09, 14.5], p = 0.036), renal failure (HR 2.91 [95% CI, 1.19, 7.10], p-value 0.019), thoracotomy (HR 4.90 [95% CI, 1.84, 13.1], p-value 0.001) and infective affections (HR 0.17 [95% CI, 0.05, 0.58], p-value 0.004) were found to be independent prognostic risk factors for 30-day mortality. Age (OR 1.05 [95% CI, 1.01, 1.10], p = 0.023) and thoracotomy (OR 3.85 [95% CI, 1.35, 12.0] p = 0.014) became significant predictors for 30-day morbidity.

Conclusion

Surgical management of COVID-19-related thoracic complications is affected by high mortality and morbidity rates, but a 72% survival rate still seems to be satisfactory with a rescue intent. Younger patients without pulmonary hypertension, without renal insufficiency and undergoing surgery for infectious complications appear to have a better prognosis.

The transCampus Metabolic Training Programme Explores the Link of SARS-CoV-2 Virus to Metabolic Disease

Currently, we are experiencing a true pandemic of a communicable disease by the virus SARS-CoV-2 holding the whole world firmly in its grasp. Amazingly and unfortunately, this virus uses a metabolic and endocrine pathway via ACE2 to enter our cells causing damage and disease. Our international research training programme funded by the German Research Foundation has a clear mission to train the best students wherever they may come from to learn to tackle the enormous challenges of diabetes and its complications for our society. A modern training programme in diabetes and metabolism does not only involve a thorough understanding of classical physiology, biology and clinical diabetology but has to bring together an interdisciplinary team. With the arrival of the coronavirus pandemic, this prestigious and unique metabolic training programme is facing new challenges but also new opportunities. The consortium of the training programme has recognized early on the need for a guidance and for practical recommendations to cope with the COVID-19 pandemic for the community of patients with metabolic disease, obesity and diabetes. This involves the optimal management from surgical obesity programmes to medications and insulin replacement. We also established a global registry analyzing the dimension and role of metabolic disease including new onset diabetes potentially triggered by the virus. We have involved experts of infectious disease and virology to our faculty with this metabolic training programme to offer the full breadth and scope of expertise needed to meet these scientific challenges. We have all learned that this pandemic does not respect or heed any national borders and that we have to work together as a global community. We believe that this transCampus metabolic training programme provides a prime example how an international team of established experts in the field of metabolism can work together with students from all over the world to address a new pandemic.

The Cutaneous Manifestations Associated with COVID-19: A review

IMPORTANCE

As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic spreads, increasing cases of dermatologic manifestations of the disease continue to be reported.

OBSERVATIONS

In this general review of the case reports, case series, and other systematic reviews on this subject, several patterns of cutaneous lesions have been compiled. These include viral exanthems, papulovesicular, pernio-like, vasculopathy-related, and other miscellaneous rashes.

CONCLUSIONS AND RELEVANCE

While clinical observations and subjective cases of rashes associated with SARS-CoV-2 are important to furthering our research and study of this viral disease, we as clinicians must be cautious in attributing causation with correlation. Continued research and study are needed before we can attribute a source for these dermatologic manifestations.

Experimental assessment of the performance of reinforced concrete beams strengthened with carbon fiber reinforced polymer laminates

In this study, experimental research is carried out to assess the flexural performance of RC beams strengthened with different amount of CFRP laminates at the tension face. Twelve rectangular RC beams were fabricated and three are un-strengthened and used as reference beams and the remaining nine are strengthened with different amount of CFRP varying from single to triple layers and all are tested to failure under three points bending test. The increase of ultimate strength provided by the bonded CFRP laminates is assessed and failure modes is identified and compared to the un-strengthened RC beams. The results indicated that the flexural capacity of the beams was significantly improved as the amount of the laminates increases that ranged from 20% to 52% increased for single to triple layers laminates. It is concluded that the attachment of CFRP laminates has substantial influence on the performance of CFRP strengthened RC beams. Based on the observed results, recommendations are made that externally application of CFRP laminates can be used for a significant enhancement of the strength deficient RC beams in increasing the ultimate load carrying capacity. Keywords: CPRP laminate, Reinforced concrete, ductility, index, epoxy resin, flexural strengthening

Effects of Pollination by the Indo-Malaya Stingless Bee (Hymenoptera: Apidae) on the Quality of Greenhouse-Produced Rockmelon

Rockmelon (Cucumis melo Linnaeus (Cucurbitales: Cucurbitaceae)) is a novel commercialized fruit in Malaysia and has great potential to become an important horticultural crop for the international market. In this study, we investigated the effects of pollination by the Indo-Malaya stingless bee Heterotrigona itama Smith (Hymenoptera: Apidae) on measures of yield and quality of rockmelon cultivated in the greenhouse, compared with hand cross-pollination and self-pollination. Results showed that rockmelon produced from plants pollinated by stingless bees and hand cross-pollination had higher fruit set, were heavier and larger, and contained higher numbers of seed per fruit compared with those produced by self-pollination. Pollination by stingless bees produced fruit with greater sweetness than either hand cross-pollination or self-pollination. This study demonstrated that stingless bee pollination produced rockmelon fruit of similar quality, but better yields compared to the other pollination treatments. We showed that stingless bees should be considered as an alternative, effective pollinator for the improved production of high quality rockmelon in commercial greenhouse cultivation.

Air leak: An unusual manifestation of organizing pneumonia secondary to bleomycin

Organizing pneumonia (OP) is a less common interstitial lung disease with varying clinical picture. The development of pulmonary air leak in a case of OP is an extremely rare complication. Here, we report the case of a 46-year-old female with carcinoma ovary, postchemotherapy who developed respiratory distress with pneumomediastinum, and subcutaneous emphysema. Lung biopsy showed evidence of OP. This turned out to be a rare case of OP, secondary to bleomycin chemotherapy, presenting with pulmonary air leak.

Biological properties of carbon powders synthesized using chemical vapour deposition and detonation methods

Carbon powders can be synthesized using variety of CVD and detonation methods. Several interesting properties of carbon powder particles make them a very attractive material examined in many laboratories all over the world. However there is a lack of information discussing investigation of carbon powders directed to its application in pharmaceutical-cosmetic industry and medicine. Earlier investigation results proved that diamond powders present properties fighting free radicals. Presented work discusses the influence of carbon powder particles manufactured using MW/RF PACVD, RF PACVD and detonation methods onto hydro-lipid skin coat. Before the biological examinations physicochemical properties of carbon powders were determined. Grain size, shape and chemical composition of carbon powders were determined using the scanning electron microscopy. Surface functional groups were characterized by IR Fourier-transform spectroscopy and X-ray photoelectron spectroscopy. Structure and phase composition were investigated by means of the Raman spectroscopy. Results of allergy tests performed on laboratory mice proved that carbon powder particles synthesized using different methods do not cause allergy. In the following stage, the group of 20 patients applied the formula including carbon powder on their face skin. The influence of carbon powder onto hydro-lipid skin coat was determined by measurement of such parameters as: pH reaction, skin temperature, lipid fotometry and level of hydration. Additionally, macro pictures of places where the cream had been applied were registered. As the result of the investigation it was found that powders synthesized using various methods present different physicochemical properties which may individually affect the face skin parameters. The noticeable improvement of hydro-lipid skin coat kilter was observed.

The prevalence of strabismus in schizophrenic patients in Durban, KwaZulu Natal

Purpose:    The psychosocial implications of a strabismus have not received sufficient attention and yet may have a significantly negative effect on a person’s life.  Schizophrenia is the fourth leading cause of mental disability in the developed world.  Both schizophrenia and strabismus appear to share a genetic and neurological origin.  This study thus set out to assess the prevalence of strabismus in a sample of schizophrenic subjects. Setting:  The study was carried out in Durban, Kwazulu-Natal inSouth Africa specifically at the Durban and Coastal Mental Health Institution. Method:  Fifty schizophrenic subjects residing at the Durban and Coastal Mental Health (DMH) Institution were assessedfor the presence of strabismus using the cover test and modified Krimsky test.  The inclusion criteria were all subjects diagnosed with schizophrenia, of both genders and any race.  The subjects werebetween fifteen to seventy years of age.  The exclusion criteria included any other mental illness, systemic disease or medication other than that usedon schizophrenic patients.  Results:   The prevalence of strabismus in this sample was found tobe 74% which was considerably higher than thatreported by other studies1,2.  There was a greater incidence of exotropia as opposed to esotropia.  The mean distance exotropia as detected with the cover test was 33 prism dioptres.  Similarly, the near cover test indicated a mean of 11 prism dioptres exotropia, and with the modified Krimsky test a mean of 9 prism dioptres exotropia.   Most of the strabismic subjects (86.5%) presented with a strabismus when fixating a near target.  Generally the strabismus was found to be constant and unilateral and no gender bias was found.  Conclusion:There appears to be a strong relationship between strabismus and schizophrenia.  Health care professionals, especially those dealing with paediatric care, parents and the public should be made awareof this relationship so that psychological adviceand early intervention can be sought for strabismic children. (S Afr Optom 2011 70(3) 101-108)

Serum ascorbic acid and protein calorie malnutrition in continuous ambulatory peritoneal dialysis patients

Protein calorie malnutrition (PCM) is a major predictor of morbidity and mortality in continuous ambulatory peritoneal dialysis (CAPD) patients. Oxidative stress has been implicated as a contributory cause. The relative lack of ascorbic acid, a plasma antioxidant, has been reported in CAPD patients. We therefore examined the correlation between serum ascorbic acid (SAA) and parameters of PCM in a cross-sectional study of 50 clinically stable adult CAPD patients. The mean age of the study group was 61 +/- 11 years; 48% of the patients were male; and 64% had diabetes. The parameters assessed were SAA, serum albumin (S Alb), body mass index (BMI), subjective global assessment (SGA), and lean body mass (LBM). The results (mean +/- standard deviation) were: SAA, 9.44 +/- 8.79 mg/L; S Alb, 31.6 +/- 4.9 g/L; BMI, 24.4 +/- 3.4; LBM, 0.66 +/- 0.14 kg/kg body weight; SGA, 9 of 50 were considered mildly-to-moderately malnourished (the rest were well-nourished). A significant correlation (p < 0.001) was found between SAA and S Alb only with SAA < or = 9 mg/L. No correlation was seen between SAA (at any level) and BMI or LBM. The SAA was not significantly different between the groups as graded by SGA. The data suggest that the mechanisms for low serum albumin in these patients may be related to the role of ascorbic acid as a plasma antioxidant.

Oral intake and serum levels of ascorbic acid in continuous ambulatory peritoneal dialysis patients

Oral intake of ascorbic acid is essential for optimum health in human beings. Continuous ambulatory peritoneal dialysis (CAPD) patients have an increased need for ascorbic acid, because of increased loss through dialysate, reduced intake owing to nausea and loss of appetite, and increased oxidative stress. However, optimum intake is still controversial. We studied 50 clinically stable patients to determine the relationship between oral ascorbic acid intake and serum ascorbic acid (SAA) level. Total oral intake ranged from 28 mg daily to 412 mg daily. Only one patient had an oral intake of ascorbic acid below 60 mg per day. The SAA levels ranged from 1 mg/L to 36.17 mg/L. Although a strong correlation existed between intake and SAA (p < 0.001, R2 = 0.47), the variation in SAA at any given intake level was wide. Of the studied patients, 62% had an SAA < 8.7 mg/L, 40% had an SAA < 5.1 mg/L (below the level in a healthy population), and 12% had a level below 2 mg/L (scorbutic). None of the patients demonstrated clinical manifestations of scurvy. Our results show that, in CAPD patients, ascorbic acid deficiency can be reliably detected only with SAA measurements, and oral intake may influence SAA level. To maintain ascorbic acid in the normal range for healthy adults, daily oral intake needs to be increased above the U.S. recommended dietary allowance to 80-140 mg.

Diabetes insipidus: a postpartum complication

Sheehan's syndrome and diabetes insipidus were diagnosed in a 31-year-old woman seven months after postpartum bleeding with a short duration of hypotension. The diagnosis of diabetes insipidus was established by the inability to concentrate urine during water deprivation and the marked increase in urinary osmolality after administration of 1-Desamino-8-D-arginine-vasopressin (DDAVP). Obstetricians should be aware of diabetes insipidus as a postpartum complication.

Early detection of cervical intraepithelial lesions by simple visual inspection after acetic acid among women in Rajshahi medical college hospital

Aim: To evaluate the performance of visual inspection of acetic acid (VIA) in the detection of precancerous and early cancerous lesions of cervix. Materials and methods: Total 5593 eligible women who randomly came to the Gyenae out patient department (OPD) of RMCH (Rajshahi Medical College Hospital) were examined by VIA. Detection of well defined, opaque, acetowhite lesions close to the squamocolumner junction or in transitional zone or dense acetowhitening of ulceroproliferative growth on the cervix constituted a positive VIA. Those who had abnormal results in screening test & those who had clinically suspicious lesions were sent for colposcopic evaluation (n= 442) & directed biopsy were taken from colposcopically suspected areas (n=214). The final diagnosis was based on histology. Results: Out of 5593 patients, 442 (7.20%) were VIA positive. 442 patients were colposcopically evaluated .Among them, 228 (51.58%) were normal and 202(45.70%) had different stages of cervical intraepithelial lesions (CIN) and 12 ( 2.71 % ) had carcinoma of cervix. Out of 214 patients biopsied, 23.36 % patients had a final diagnosis of CIN lesions, 5 (2.33%) had carcinoma in-situ & 17 cases (7.94%) had invasive carcinoma. Besides to find out the predictable factors of cervical lesions data have been collected from VIA positive patients regarding age of first coitus and first delivery, history of extra marital exposure and STI, use of contraceptive methods and family history of cancer. Age of first coitus between 12 to 15 years and 16 to 20 years were observed among 203 (46 %) and 40 % (177) women respectively. More than half of the patients (62%) were experienced with their first delivery within the age 15-20 years which was below 15 years of 12 % (53) patients. Fifty four percent patients used OCP and barrier methods used were only 10 %. Family history of cancer was observed among 09 % women. 58% patients were belonged to lower middle class and upper group were only 9% (table 1) Conclusion: In our study detection of different grades of intraepithelial lesions (CIN-I, CIN-II, CIN-III, invasive carcinoma) of cervix by VIA was comparable to that of colposcopy. So VIA is suitable for detection of precursor lesions of cervical cancer in low resource settings and also for diagnosis, follow up treatment and epidemiological studies of cervical cancer. Key words: Visual inspection; VIA; cervical carcinoma; colposcopy; screening; epidemiological studies. DOI: http://dx.doi.org/10.3329/bjms.v10i4.9494 BJMS 2011; 10 (4): 240-244