Bronchoscopic Electrocautery Versus Adrenaline and Cold Saline Instillation for Prophylactic Haemostasis Prior to Biopsy of Endobronchial Lesions (BEVACS): A Randomized Controlled Trial.

BACKGROUND: Flexible bronchoscopy-guided endobronchial biopsy (EBB) is routinely performed as an outpatient daycare procedure. Bleeding after EBB is a common complication, that at times disrupts the procedure and can rarely lead to a catastrophe. We aimed to compare the efficacy of prebiopsy prophylactic bronchoscopic electrocautery with adrenaline and cold saline instillation in achieving hemostasis in patients with endobronchial lesions with a higher risk of bleeding during EBB. METHODS: In this open-label, randomized controlled trial, 60 patients with endobronchial lesions were randomized to either the prophylactic electrocautery arm or the adrenaline and cold saline arm. Postbiopsy endobronchial bleed was quantified in millimeters using the Visual Analog Scale (VAS) and graded as per the British Thoracic Society grading system. Electrocautery-induced tissue damage was graded by the pathologist as "no damage," "mild," "moderate," and "severe." RESULTS: The median VAS score of bleeding was 6.14 mm (interquartile range: 8 mm) in the electrocautery arm and 10.17 mm (interquartile range: 7 mm) in the adrenaline and cold saline arm. Though the difference in the VAS score of bleeding between the two groups was statistically significant, there was no significant difference in the proportion of grade 2 or higher bleeding. CONCLUSION: No difference in postbiopsy bleed was observed between the application of electrocautery or instillation of cold saline plus adrenaline before biopsy of those endobronchial lesions which were likely to bleed more after biopsy. Although controlled prophylactic electrocautery using 15 watts did not impair the quality of EBB specimens, a higher wattage may change this observation, as well as the bleeding quantity.

Programmed cell death ligand 1 (PD-L1) expression in non-small cell lung cancer: Findings from a tertiary care institute in western part of India.

BACKGROUND: Immune checkpoint inhibitors targeting either programmed cell death protein 1 (PD-1) or programmed cell death ligand 1 (PD-L1) have been established as a novel target for immunotherapy in non-small cell lung cancer (NSCLC). Prevalence of PD-L1 expression in NSCLC varies from 13% to 70%, with sparse data from the Indian subcontinent. In this study, we looked at PD-L1 expression and its association with demographic, clinical, radiologic and pathologic parameters in NSCLC patients. METHODS: This was an observational study carried over a period of 18 months in which 65 patients of NSCLC were included. Immunohistochemistry (IHC) for PD-L1 was done using an automated IHC stainer and testing was performed using PD-L1 IHC CAL10. For statistical analysis, unpaired t test, Chi square test, Fisher's exact test and binomial logistic regression were used. P < 0.05 was taken to be statistically significant. RESULTS: Mean age of the patients was 62.9 ± 9.2 years, and majority (87.3%) of them were males. Seventeen (26.2%) patients expressed PD-L1, among whom 10 had high PD-L1 expression (≥50%) and 7 had low PD-L1 expression (1-49%). PD-L1 expression was seen in 13 out of 43 cases of squamous cell carcinoma (SCC) and 4 out of 15 cases of adenocarcinoma. On applying binomial logistic regression analysis, association between smoking and PD-L1 expression was found to be insignificant. CONCLUSION: Almost a quarter of NSCLC cases were PD-L1 positive without any difference in expression between SCC and adenocarcinoma. PD-L1 status was not associated with any specific demographic, clinical or radiologic parameter including the histologic subtype.

Study of factors leading to treatment delay in new sputum positive pulmonary tuberculosis patients and its impact on sputum conversion.

Our study was done to identify patient or health system related delay in diagnosis of treatment naïve sputum positive PTB patients and its impact on sputum conversion at 2 months. A total of 280 patients were enrolled and followed up for 2 months following which repeat sputum examination was done. Detailed clinical history was taken with emphasis on duration of symptoms, day of presentation, diagnosis and starting of therapy. The median(range) of delay in treatment initiation was 15 (0-82) days, most commonly because of delay due to the health system. Patients with positive sputum at the end of two months had significantly higher delay in treatment initiation (p < 0.05). Being remote (>5 km) from a health provider, being an unskilled labourer, and visiting a private practitioner were associated with delay in diagnosis. Eradication of tuberculosis in India requires training of health professionals, intersectoral cooperation and better public outreach.

Mortality and Its Predictors in COVID-19 Patients With Pre-existing Interstitial Lung Disease.

Background The data on the impact of coronavirus disease 2019 (COVID-19) on interstitial lung disease (ILD) is still limited. To the best of our knowledge, there has been no study from India to date to assess the impact of COVID-19 in patients with preexisting ILD. We undertook this study to assess the clinical outcome of ILD patients admitted to our hospital with COVID-19. Methods In this retrospective observational study, records of reverse transcription polymerase chain reaction (RT-PCR)-confirmed COVID-19 patients with preexisting ILD who were admitted to the hospital in the period from May 1, 2020, to April 30, 2021, were obtained from the hospital database. The clinical outcomes of the patients were recorded. Univariate analysis was performed to find relation between various predetermined risk factors for mortality and those with significant p values (p<0.05) were subjected to multiple logistic regression to determine independent risk factors. Results In our study of 28 patients, the overall mortality was 35.7%. On comparing the parameters associated with increased mortality, there was no effect of age, gender, comorbidities, type of ILD, CT thorax findings on diagnosis, use of corticosteroids and antifibrotics in the past, spirometric findings on mortality. On multivariate analysis, the significant parameters were interleukin 6 (IL-6), p=0.02, OR=1.020 (1.006-1.043) and D-dimer, p=0.04, OR=2.14 (5.55-1.14). Conclusion COVID-19 in patients with pre-existing ILD has a comparatively higher mortality. D-dimer and IL-6 are significant predictors of mortality in ILD patients infected with COVID-19.

Sleep-Disordered Breathing in Newly Diagnosed Patients of Lung Cancer.

Sleep-disordered breathing (SDB) is highly prevalent in patients with cancer and affects their prognosis. However, data on SDB in lung cancer patients are lacking, and few studies have conducted level I polysomnography (PSG) in this patient population. This study aimed to measure SDB in newly diagnosed lung cancer patients at the sleep clinic of a tertiary respiratory institute in New Delhi, India, for eight months. This study included 30 patients. Participants received a clinical examination, completed a sleep questionnaire, and then underwent overnight PSG. We scored sleep parameters according to the American Academy of Sleep Medicine guidelines. Both descriptive and inferential statistics were used to analyze the data. We used univariate analysis with chi-square testing, and p<0.05 was considered significant. SDB and obstructive sleep apnea (OSA) were found in 66.6% and 56.6% of patients, respectively. Mild, moderate, and severe OSA were seen in 26.6%, 16.6%, and 13.3% of patients, respectively. Nocturnal oxygen desaturation (NOD) or NOD90 (i.e., when >30% of sleep time was spent with oxygen saturation levels <90%) was seen in 13.3% of patients. Adenocarcinoma was the most common histological variant of cancer. Tumor-node-metastasis staging was significantly associated with the presence of OSA (p=0.045). Lung cancer patients should receive routine PSG to identify and manage patients with SDB, especially given that symptoms of SDB such as easy fatigability and non-refreshing sleep are overlooked as symptoms of lung cancer. Proper management of SDB or OSA would help improve patients' quality of life and improve their overall prognosis.

Study of spectrum of fungal isolates in the sputum of newly diagnosed pulmonary tuberculosis patients.

Tuberculosis is a state of immunosupression which exposes the patients to further opportunistic pathogens like fungus. Methods: 102 newly diagnosed sputum positive pulmonary tuberculosis cases were enrolled. Significant fungal isolates were seen in 31/102 (30.4%) patients. Aspergillus spp. were isolated in 13/31(41.9%) of the positive fungal cultures while Candida spp. were isolated in 15/31 (48.4%). Low body mass index, duration of symptoms, haemoptysis, severity of radiological features and IgG Aspergillus antibodies were independent risk factors for positive fungal culture. Significant proportion of patients with PTB have fungal colonisation of their airways which can lead to poor clinical outcomes. Few easily ascertained clinical parameters can help the clinician to determine patients who are at a higher risk of fungal colonisation.

Role of blood urea nitrogen and serum albumin ratio in predicting severity of community acquired pneumonia (CAP).

Blood urea nitrogen and serum albumin levels are independent risk factors for poor clinical outcome in CAP. However, there is a paucity in the literature on the role of Blood urea nitrogen and albumin ratio(B/A) in CAP. This was a prospective observational study in which 112 admitted patients with the diagnosis of CAP underwent routine blood examinations, ABG, procalcitonin and Chest X-ray. Univariate analysis among various risk factors, CURB-65 scores, blood parameters including B/A ratios and clinical outcomes were carried out followed by multiple logistic regression. Cox regression was done to look at B/A values and time to mortality. In the logistic regression, age, CURB -65 score, B/A ratio and procalcitonin came out to be independent risk factors for ICU admission and mortality. Odds ratio of B/A in predicting mortality and ICU admission came out to be 67.8 (49.2-95.4) and 11.2 (8.4-14), respectively. Cox regression showed B/A values were also found to have a statistically significant relationship with time to mortality (p=0.001). B/A ratio has the potential to become a veritable predictor of poor clinical outcomes in patients with CAP.

A Prospective Study of Fungal Colonization and Invasive Fungal Disease in Long-Term Mechanically Ventilated Patients in a Respiratory Intensive Care Unit.

BACKGROUND: Long-term mechanical ventilation in an Intensive Care Unit (ICU) exposes the patient to fungal colonization and invasive fungal disease due to the presence of indwelling catheters, administration of broad-spectrum antibiotics, and intravenous corticosteroids. A study is hence required to study the risk factors and incidence of fungal infection in these patients. METHODS: A prospective observational study was carried out in the respiratory ICU of a tertiary care hospital for a period of approximately 1 year in which patients on mechanical ventilation (>7 days) were enrolled. Blood, urine, and endotracheal aspirate (ETA) of these patients were sent for fungal culture on day 1 and day 7 of mechanical ventilation. Fiberoptic bronchoscopy was done on day 7 and bronchoalveolar lavage along with transbronchial lung biopsy (TBLB) were sent for fungal culture. RESULTS: During 7 days of ventilation, there was a statistically significant increase in the proportion of culture-positive ETA and urine samples. Overall, Candida albicans emerged as the most common colonizer. Blood candidemia was seen in 10% of patients on day 7 of mechanical ventilation. Fungal invasion of the lung, as evidenced by fungal culture-positive TBLB specimens, was seen in 17% of patients. Diabetes was found to be a statistically significant risk factor for respiratory and urinary tract colonization as well as invasive fungal disease. CONCLUSION: Long-term mechanical ventilation (>7 days) is strongly associated with fungal colonization of the respiratory tract and urinary tract. Appropriate prophylactic antifungals may be given and infection control practices to be observed to ensure minimum colonization and therefore infection in such settings.

Subclinical haemorrhagic tendency exists in patients with ß-thalassaemia major in early childhood.

BACKGROUND: Alterations of coagulation profile have been reported in patients with ß-thalassaemia major (ß-TM). METHOD: To investigate this in the paediatric population, we studied haemostatic parameters in pre-transfusion blood samples from 50 non-splenectomised transfusion-dependent children with ß-TM (mean age 6±2.5 years) and in blood from 25 healthy controls. RESULTS: Laboratory evaluation showed thrombocytopenia in 40%, prolongation of prothrombin time (PT) in 12% and prolongation of activated partial thromboplastin time (APTT) in 6% of the patients. Mean values for PT, APTT and platelet count (PC) were all raised in the patient population compared with the controls. The alteration of coagulation status was significant for PT (p value <0.005) and APTT (p value <0.0001). However, the change for PC was not significant (p value <0.05). No significant liner correlation could be identified between PT, APTT, PC of the patients and interval between transfusions (in days) or days since last transfusion. CONCLUSION: The findings from this study suggest that a subclinical haemorrhagic tendency exists in patients with ß-TM at a very early age. The intrinsic pathway appears to be more affected than the extrinsic pathway.